Key Note Address- 1st Anniversary of ANGELS (18/02/2012)

Happy to participate in the 1^st anniversary of ANGELS (Active Network Group of Emergency Life Savers). It is nice to see that this is celebrated as Golden Hour 2012 with a caption: Caring for the people –bridging the gap”. We know that ANGELS is bringing a new culture in emergency medicine. It is bridging the gap-the gap between knowledge & practice.

I am only a fellow traveler of ANGELS, once in a while attending meetings like this. But I could palpate the pulse of this organization, the enthusiasm of its activists. It was evident when we experienced the mock drill at the air port.

I was thinking of pre angels era. Our attempt of emergency care was limited to hospital casualty. We know many patients are brought very late. They need management at spot, management at golden hour were we have to provide care for better outcome. Now at least we know that we could do something if not all.

Think of a cardiac arrest. It can happen at home, on the road, in the hospital. Those occurring in the hospital can be saved to an extent. What about others. Of the more than 300,000 cardiac arrests that occur annually in the United States, survival rates are typically lower than 10% for out-of-hospital events and lower than 20% for in-hospital events.^[When brought to the hospital the valuable time is already spoiled. Suppose we can give cardiac massage at site or defibrillate at site we could have saved the patient.

Targeted education and training regarding treatment of cardiac arrest directed at emergency medical services (EMS) professionals as well as the public has significantly increased cardiac arrest survival rates. Variation of CPR known as “hands-only” or “compression-only” CPR (COCPR) consists solely of chest compressions. This variant therapy is receiving growing attention as an option for lay providers. it is currently accepted that COCPR is superior to standard CPR in out-of-hospital cardiac arrest. The 2010 revisions to the American Heart Association (AHA) CPR guidelines state that untrained bystanders should perform COCPR in place of standard CPR or no CPR. Additionally, studies have shown that survival falls by 10-15% for each minute of cardiac arrest without CPR delivery. Bystander CPR initiated within minutes of the onset of arrest has been shown to improve survival rates 2- to 3-fold, as well as improve neurologic outcomes at 1 month.

Improvements in pre-hospital care have led to more rapid stabilization and transport of critically injured patients to definitive care. Despite this, cardiac arrest caused by trauma carries mortality rates of 81%-100%, even if managed early and aggressively. Increasingly, it has been recognized that continued CPR efforts on a trauma victim in the ED after failed pre-hospital resuscitation are futile and expensive. Study found that patients requiring CPR did not survive if they lost vital signs prior to hospital arrival.

Severely injured trauma victims are at high risk of development of the multiple organ dysfunction syndrome (MODS) or death. To maximize chances for survival, treatment priorities must focus on resuscitation from shock, including appropriate fluid resuscitation and rapid hemostasis. Inadequate tissue oxygenation leads to anaerobic metabolism and resultant tissue acidosis. The depth and duration of shock leads to a cumulative oxygen debt. Resuscitation is complete when the oxygen debt has been repaid, tissue acidosis eliminated, and normal aerobic metabolism restored in all tissue beds. Many patients may appear to be adequately resuscitated based on normalization of vital signs, but have occult hypoperfusion and ongoing tissue acidosis which may lead to organ dysfunction and death.

Another area is mass casualty and disaster management. At present this area is full of chaos. That is because of poor preparedness. There should be a disaster management team always. We know that they will not have any job for most of the time. But they can handle a situation much better than a naïve unit. Better training, available resources and good coordination are all important here. I am sure angels with its net work of life saving ambulances and dedicated team under able leadership can handle any situation what so ever

We are fortunate to have a unit like this in Calicut. Within one year it has spread its wings to whole of Malabar. More attempt at public awareness, targeted training to professionals and public are all need of the hour. In Medical College our attempt is to have a separate emergency medicine department with state of the art facilities and trained man power. We are looking forward to start MD in Emergency medicine and Critical care Medicine so that skilled man power will be siphoned out to this field. Medical College administration consider this as a challenge and a sizeable share of central fund under the scheme PMSSY will be utilized to improve emergency and trauma care. In this venture I request ANGELS to extend a helping hand to us for planning and executive at least in the initial years. Calicut medical College and ANGELS can have a mutually co operative and complimentary role in improving this particular discipline of medicine.

Thanking you and wishing you good luck

Dr C Ravindran