Capital – New Delhi
Land Size – 3,287,263 sq km
Population – 1,173,108,018
Language(s) – Hindi 41%, Bengali 8.1%, Telugu 7.2%, Marathi 7%, Tamil 5.9%, Urdu 5%, Gujarati 4.5%, Kannada 3.7%, Malayalam 3.2%, Oriya 3.2%, Punjabi 2.8%, Assamese 1.3%, Maithili 1.2%, other 5.9%



  • “Although injury is a major public-health problem, the government, medical fraternity, and the society are yet to recognize it as a significant public health challenge” (Joshipura, 1613)
    • “India has 1% of the motor vehicles in the world but bears the burden of 6% of the global vehicular accidents” (Joshipura, 1613)
    • “In India, pedestrians and motorcyclists constitute 70-80% of all road traffic deaths, while the larger automobile occupants constitute a mere 5%” (Roy, 148)
  • “Prehospital services in India are inequitable, with differences between urban/rural and paying/non-paying patients. Economics and the perceived paying-capacity of the victim of the victim are important triaging criteria, in a resource-poor setting” (Roy, 146)
    • “Currently, as a result of not having an EMS system, prehospital care is a citizen responsibility using societal networks” (Roy, 150)
  • “Despite significant overall progress in many other fields, trauma systems in India continue to remain at a formative stage for various reasons. A concerted effort from all the parties involved, as well as the society, is the need of the hour” (Joshipura, 1616)



  • Mumbai (Roy)
    • Most populous city in the world – 23,088 people/sq km
    • No organized prehospital EMS system
      • Private hospitals provide ambulance service to paying customers
      • Gov’t ambulances are “stand-alone vehicles attached to individual hospital”
        • No central coordination
        • Un-/Under-equipped with resuscitation equipment (ambulance personnel use and return hospital equipment)
        • Informal network for remainder of population
          • Inconsistent care and transportation to trauma center provided by police, fire, bystanders, taxis or NGOs
    • “The nature of transport and choice of trauma care provider are decided by financial constraints, among other factors”



  • “There is no central government agency to integrate policy-making, planning, financing, drafting legislation, or establishment of minimum standards for the performance of a trauma-care system” (Joshipura, 1614)
  • “Legislative provisions for the minimum qualification of ambulance personnel, the type and quality of ambulance equipment, and essential hospital capabilities are not in place” (Joshipura, 1614)
    • “Formal licensing to an ambulance service in India is not mandatory” (Joshipura, 1615)
  • “State governments of Andrha Pradesh and Gujarat have started prehospital systems through EMRI [Emergency Medical Research Institute], but the long-term success of this program is yet to be evaluated” (Joshipura, 1615)



  • Ambulance services
    • “run by a multitude of agencies that include the government, police, fire brigades, hospitals, and private agencies” (Roy, 149)
    • “One-third of ambulances serve only as transport vehicles with no paramedic staff. Only 28% of the ambulances have two or more paramedics” (Joshipura, 1615)
  • Treatment (Roy)
    • “Of the 48.3% who received some kind of first aid [in Roy study], most received inadequate care. The usual prehospital care consisted of tetanus toxoid, intravenous fluids, and an injectable analgesic”
      • Splinting, endotracheal intubation, and airway control rarely performed
    • “The reason for the provision of inadequate prehospital care was based on the economics rather than lack of available manpower”
      • Very low probability of recuperating consumables used and/or costs, which served as a deterrent
    • “Unfortunately, 5% dextrose was still the first intravenous fluid started in more than half of the victims. Most of these interventions, though inappropriate, served to reassure the victim that some treatment had been initiated, but indicated a lack of training”
  • Rural – “prehospital care is virtually nonexistent in most rural and semiurban areas in India” (Joshipura, 1615)
    • “Gross discrepancy is seen in prehospital services between urban and rural settings, as well as between paying and non-paying patients” (Joshipura, 1615)



  • “Emergency Medical Technician courses are offered in partnership with overseas institutions … but are few in number and insufficient to service” (Joshipura, 1614)
    • “The absence of minimal educational and training standards for paramedics promotes unskilled labor to handle the most delicate of tasks … Currently, only 4% of the ambulance personnel have any certified formal training.” (Joshipura, 1615)



  • “No national or regional guidelines exist for triage, patient-delivery decisions, prehospital treatment plans, and transfer protocol. Policies, procedures, and regulations governing medical directions are in place only in some city systems” (Joshipura, 1615)
  • “In the wake of the gross disparity between accessibility and affordability of trauma care, quality assurance is a major casualty. In the absence of a lead agency and with a poor information system, evaluation and research on trauma systems is a difficult proposition” (Joshipura, 1615)



  • “Only 14% of the systems have a dedicated central telephone number for incident reporting … Only 4% of systems have a comprehensive network operational between hospitals and ambulances” (Joshipura, 1615)
  • Private hospital-run ambulances have individual numbers to request ambulance services
    • Most are pre-booked, MD-equipped, fee-for-service “cardiac ambulances”
  • Bystander Transport (Roy)
    • In urban cities, “the injured victim is usually rescued by a Good Samaritan passer-by and, contrary to popular belief, helped by the police.”
      • “Almost immediately after rescue, the victim begins transport towards the hospital. No one waits for the EMS ambulance to arrive, as there is none”
      • “A taxi, though not ideal remains the most popular substitute for an ambulance”



  • “There are no dedicated trauma surgeons in India. Orthopedic surgeons lead the trauma response in 50% of facilities” (Joshipura, 1615)
  • “Though 80% of the hospitalized health care is catered by private, fee-for-service providers, public hospitals bear the brunt of the caseload of the injured” (Roy, 150)
    • “Most government [public] hospitals offer free care, but the quality of that care differs from one center to another. … [They] often lack trained staff, adequate infrastructure for management of polytrauma, and supply of consumables” (Joshipura, 1615)
    • “Private and corporate hospitals, located mostly in large cities, are equipped with modern diagnostic and imaging facilities, good operating environments, and intensive-care units. Some of them also run dedicated trauma services. However, there are no norms to govern their standards and their relations with the public trauma system” (Joshipura, 1615)



  • Disaster-prone country
    • Natural – earthquakes, floods, landslides and cyclones
    • Technological – Train accidents (vast train system)
    • Man-made – Terrorism (Nov. 2008 Mumbai Terrorist attacks)



  • Joshipura MK: “Trauma care in India: current scenarios.” World Journal of Surgery 2008;32:1613-17.
  • Joshipura MK, Shah HS, Patel PR, Divatia PA, Desai PM: Trauma care systems in India.” Injury, Int. J. Care Injured 2003;34:686-92.
  • Roy N, Murlidhar V, Chowdhury R, Patil SB, Supe PA, Vaishnav PD, Vatkar A: “Where there are no emergency medical services – Prehospital care for the injured in Mumbai, India.” Prehospital and Disaster Medicine 2010;25(2):145-51.
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