Proposed emergency medical service: The views of a senior surgeon

Q: Dr. Goonetilleke, whilst thanking you for agreeing to speak on the proposed emergency medical care and ambulance service, why do you think that such a service is needed? 

A: Soon after my return from the United Kingdom since obtaining the FRCS in 1981, I opted to work in Polonnaruwa. Working in the Polonnaruwa Base Hospital gave me the opportunity to obtain first-hand experience in treating patients who had to suffer unusual traumatic conditions. 

The Base Hospital in Polonnaruwa at the time lacked several facilities including shortage of medical personnel. The doctors working there had to improvise treatment methods, especially surgical operations. In addition, the Polonnaruwa Base Hospital had to undertake treatment of armed services personnel injured from confrontations with the LTTE in the east and certain areas in the North Central Province. Anuradhapura General Hospital catered to the treatment of injured armed services personnel in the north. 

As a result I had the exposure to treat very extreme cases of trauma. In many instances, the patients were transported to the nearest hospital in two wheel tractor trailers, vans or even buses. These victims did not have any first aid at all because of ignorance. They were not handled with due care and attention. 

If a trauma patient or one suffering from a heart attack or stroke is given initial first aid and quickly transported to a hospital within the first hour, he or she has a much better chance of survival. This is the function of an Emergency Medical Service which is practiced the world over. So if Sri Lanka is starting an Emergency Medical Service, commonly referred to as an ambulance service, it is fulfilling a long-felt need and will certainly help save lives. 

Q: You were talking enthusiastically about your service in Polonnaruwa. What was so significant about Polonnaruwa? 

A: At the time I started work at the Polonnaruwa Base Hospital in the 1980 period, the district was considered a difficult area. The people of the area were engaged mainly in paddy farming. In the healthcare sector, there was only the base hospital with one surgeon for the entire district. Others were very small hospitals. There were only two State banks in the Polonnaruwa town with a few smaller branches located in village centres. Transport was not properly organised and infrequent. The two main schools were situated in the Polonnaruwa town with a few smaller schools in the surrounding semi urban areas. Most farmers depended on man power for their cultivation activities. 

The area was gearing up for major development under the accelerated Mahaweli Project, with the construction of the Maduru Oya reservoir with an American and a Canadian firm engaged in the reservoir work and the construction of the canal system. As a result of this major development, businesses started to develop and the community had opportunities in employment. 

However despite this, the health services available in the area did not keep pace. Patients with serious conditions had to be transferred to Kandy. The Base Hospital had only one ambulance in service and you can imagine the hardship, the hospital management as well as the patients had to endure. Some of the patients were transported to Kandy in private vans by relatives who could afford. There were victims of major accidents especially the farmers using implements without safety devices. 

Once I had to treat a victim injured by a fan blade that catapulted itself out from a winnowing device connected to a two-wheel tractor engine. It cut his face and embedded itself in his head. Some fainted after seeing the victim. I with the help of my team performed an operation and removed the blade. Though he carries a noticeable scar on his face, he is healthy and getting about with his job. 

The medical support services then were very primitive. Many accident victims were brought to the hospital on two-wheel tractor trailers which were slow or in vans. The injured persons hardly received any first aid and had to survive hazardous travelling. The road network was hardly maintained. Under these conditions, I found that there was no proper pre-hospital emergency care and many a victim succumbed to unnecessary death, permanent disability or impairment as a result. 

I started collecting data and statistics of such victims injured by domestic or road accidents. The statistics of victims suffering from trauma resulting from armed strife were high. I made scientific presentations at many medical meetings to bring awareness of the need for an Emergency Medical System 

Q: You mentioned the initial stages of the war in the NCP and the east. Can you elaborate on this? 

A: When I was stationed at the Base Hospital in Polonnaruwa, sometime after 1983, there was an upsurge in LTTE terrorist activity and many of our armed services personnel were injured. The injuries sustained by them ranged from the effects of landmine blasts and sniper fire extending to direct confrontations with the terrorists. The armed services personnel so injured were transported in army trucks, CTB buses, tractors and vans, etc., and at times in helicopters when the condition of the patient was serious.

My surgical team and I were ready for a prolonged workday when the helicopters arrived. Our efforts then were focused mainly to save the life first and ‘repair’ the physical damage to body or limb thereafter. It was an arduous task to treat trauma victims who sustained injuries due to armed conflict. We were actually able to save many precious lives of our valiant soldiers and to mitigate the disabilities suffered by them in fighting for the country. 

The first major terrorist attack in Polonnaruwa occurred when the LTTE tried to overrun the Police post in Welikanda guarding the rail and road bridge over Mahaweli River. If I remember right, 12 Police personnel were seriously wounded and about three died. The town was engulfed in fear. I stayed at the hospital attending to the injured. After this period, the war was escalating and confrontations with the LTTE multiplied. I had travelled to the north with the Army to treat our injured soldiers at the Palay Base Hospital. I was able to treat many soldiers as a result and quite a number returned to active service. 

Q: Doctor, you mentioned trauma several times. I gather that you have done a lot of work in treating trauma and tried to bring it to the attention of authorities to consider it as a serious health impediment or illness. What exactly is trauma? 

A: Trauma refers to injury to the body, resulting from physical violence, an accident or even severe emotional or mental distress caused by an experience that results in trauma. My work concentrated mainly on physical nature of trauma caused by injuries sustained during accidents, domestic or external and by confrontations among humans. I took it upon myself to draw the attention of fellow medical professionals, the authorities and the general public. 

I have made a contribution to trauma care in Sri Lanka with presentations, publications, workshops, training programs, lectures, institutional development and also by serving in hospitals, providing volunteer services to the army in training personnel in trauma care and also education of the public via media. I had training in Israel on managing trauma victims and an Emergency Medical System or Service was their priority. I also had the opportunity to deliver lectures on trauma care in Australia, India. Pakistan, Nepal and other countries. But despite my relentless efforts, trauma care has not received the attention it deserves from the authorities in Sri Lanka but I will pursue my efforts continuously. 

Trauma is a major cause of death and disability throughout the world. In developed countries there are well-coordinated and well-managed plans for the control of this epidemic. However, in developing countries like ours, such plans do not exist. Here, physical injury is the commonest cause for admission to hospitals. Since 1995, the number of injured increased every year. According to the latest statistics available, at least 800,000 are admitted to hospitals at the present time resulting in an enormous burden on the health service in Sri Lanka.

Road accidents also result in at least six deaths every day. When compared to infectious conditions such as dengue fever about which most people and the health authorities talk so much, the burden of road accident trauma is much greater. Road accidents lead to 180 deaths per month, thus highlighting the importance and the need to prevent such accidents.

Trauma commonly affects the young, capable of an active and economically productive life. Trauma causes death, disability and a long period of hospitalisation with the result that the injured will be off work for days, months or years. This, no doubt, will affect the economy of our country not merely because of work hours lost but also the cost of treatment, rehabilitation, compensation, insurance, social benefits etc. 

Therefore health authorities must take action at least now to control this epidemic. First and foremost, we must consider trauma as a separate disease entity. Programmes to prevent trauma must be initiated as soon as possible. Training in first aid, training paramedics, a well-coordinated ambulance service with a state-of-the-art communication network, well-equipped and well-staffed trauma centres on regional basis, together with centres for rehabilitation of the injured are some of the requirements. Collection of data relating to trauma is of paramount importance in such a project as this will help in planning health care for patients. 

Q: In answer to my earlier question, you mentioned among other steps to be taken, establishment of a well-coordinated ambulance service with a state-of-the-art communication network. Now the Government is initiating just such a service with a substantial grant from India. What is your opinion about this? 

A: This certainly is a blessing, though we are a little too late in starting such a service. So far no country has come forward to help us in such a project. We should be grateful to India. According to available information, the service is to be established with the assistance of an institution in India which will come under the purview of the Ministry of Health and completely manned by Sri Lankan personnel who will undergo specialised training. 

According to the information that I gathered by browsing the web, the Indian institution entrusted with the task has made its mark by operating a state-of-the-art ambulance service in India. I also learn that the Indian ambulance service caters to about 750 million people in 17 States in India and conforms to standards stipulated by the Stanford University in the US. The number of lives saved during the last 10 years is said to be around a million. We could not have had a better partner to initiate the ambulance project in Sri Lanka than one with such a wealth of experience. 

The Indian ambulance service is provided free to its citizens. I believe Sri Lanka’s aim too is to provide the facility free to all citizens. With my experience as a surgeon, I believe thousands of lives may be saved. I am referring to victims of accidents as well as patients suffering from medical emergencies like heart attacks and strokes, etc. If planned and executed well, it is a good thing that could happen concerning the health service of our country. This is something I have been advocating for many years. 

Q: You are very enthusiastic about this project but there are concerns and reservations expressed by some professionals, mainly in the medical field and healthcare services. What is your comment? 

A: In Sri Lanka there are objections or protests for everything new, good or bad. People, professionals and politicians certainly have a right to express their opinions. They may or may not have genuine concerns and perhaps may feel threatened by illusive ‘career encroachments’ through the ambulance project. My personal feeling is that these apprehensions are baseless and I view this project as something useful because I have seen the problems due to a lack of a care system and service. Perhaps it may be because this project is coming out at the same time as the much-discussed ETCA. 

According to the Government announcements as reported in the press, the service is initiated through an MOU of the Health Ministry signed with the Indian organisation and it will be strictly under the supervisory control of the Ministry. Further, the service plans to deploy trained paramedics or medical technicians recruited here and trained. The doctor comes into play when the patient is handed over to the designated hospital by the ambulance staff. The exception is when a critically injured is transferred from one hospital to another when the patient will be accompanied by a doctor. 

There cannot be an influx of persons from India or other countries to work in the ambulance service, except perhaps a few in the initial stage for purposes of training and setting up the infrastructure. The Government grants work visas for a specific purposes and those responsible have mentioned that they will not allow an inflow of Indians for this purpose. So why fear? I personally feel that all citizens including the medical profession should support a well-planned and well executed emergency medical assistance system with a fully equipped ambulance service deploying trained emergency medical technicians and linked by a coordinated, state-of-the-art communication network.