What went well, what didn’t,” is a common post-event mantra for disaster planners, football coaches, and most recently, the Stanford leaders of the first in-depth advanced prehospital course in India’s history.

The team, led by two emergency medicine faculty members, Swaminatha “Maha” Mahadevan and Matt Strehlow, said if they go back to South Asia, they probably would focus on making sure they left behind some local instructors who could carry on the training of prehospital workers. But for the most part, Mahadevan and Strehlow said most things worked well during the one-year program that ended with the certification of 16 advanced prehospital care providers in Chennai, India’s fourth largest city (at about 7 million) and Hyderabad, city No. 5.

True, 16 new well-trained paramedics offer a service ratio of 1 to 63 million in a country of more than 1 billion people, but “these guys will plant the seed and serve as role models for the entire country,” said Mahadevan, assistant professor of surgery/emergency medicine and medical director of the SHC Emergency Department. Moreover, he said, they’ll reinforce the concept that accident victims should expect to be cared for quickly and not left in the road as can happen where there is little first responder infrastructure.

India, said Strehlow, is an ideal nation for Stanford to offer an advanced prehospital care course, because despite a shortage of paramedics, “they do have facilities to take care of people once they get to the hospital.” That’s unlike some nations, where, sadly, few modern interventions are available at the end of an ambulance ride. For example, Mahadevan said, in Chennai, state-of-the-art equipment, such as 64-slice CT scanners were available throughout the city. (The Stanford ED will soon have access to its first such unit). Ambulances, said Strehlow, were well equipped, just waiting for trained personnel to staff them.

The recent training, which included half hands-on, half classroom, instruction was based on the U.S. advanced EMT curriculum but included some localized modifications, such as information on indigenous venomous snakebites (after all, cobra bites are more frequent in India than the Bay Area) and material on how to deal with pesticide poisonings.

Mahadevan and Strehlow rotated back and forth to the Indian classrooms for two-week stints as part of a teaching team of 13 Stanford faculty, residents and one paramedic educator. The Stanford emergency medicine instructors included two attending physicians, Greg Gilbert and Ingrid Lim; six emergency medicine residents, Peter D’Souza, Ketan Patel, Nishant Anand, Suzanne Miller, Alice Chiao and Carmie Chan; and one EMT-P instructor, Mary Green. “These dynamic and talented instructors put in long hours creating instructional materials and then delivered the educational curriculum to the trainees,” Mahadevan said.

Strehlow participated as an international emergency medicine fellow and has recently joined the faculty as a clinical instructor surgery/emergency medicine.

Mahadevan, who with Strehlow, directs Stanford Emergency Medicine International, said the course stemmed from a chance meeting with a hospital CEO in Hyderabad. The hospital, owned by the Indian for-profit Apollo chain, agreed to sponsor the course — subsidizing transportation and housing for the instructors.There were challenges. “You’re teaching some pretty complicated medicine to young kids, 20-year-olds, some with no medical background and all speakers and readers of English as a second or third language,” said Mahadevan. “There were times when we thought, ‘There is no way they are going to absorb all this information’.” But, said the two course leaders, most students passionately absorbed the material. They had to.

Apollo and Stanford agreed that the instructors would only issue certificates of completion (India doesn’t yet have first responder licensing) to students who passed the course and were qualified. While attrition, usually for academic reasons, was high — 50 percent in Chennai, lower in Hyderabad — those who completed the course typically did impressively well on an exam similar (less some U.S.-specific regulatory information) to tests given to U.S. EMT students.“A couple students got 99 percent on the written exam — Matt and I joked that we couldn’t score that high,” said Mahadevan.At graduation, the students put on ties — “some probably for the first time,” Strehlow said, and thanked their instructors who came from what many of the students for some undefined reason called “the sixth best university in the world.” Then soon afterward they received pay raises, and then went out on ambulance call as part of their new career.Among the early success stories: One of the graduates was called to a physician’s office to rescue a patient who had collapsed; the trainee defibrillated the patient right in front of the physician. After one graduate intubated a trauma patient with significant oral bleeding— impressing the patient’s father, a local doctor — Mahadevan said the local medical community began to see that these advanced prehospital care providers filled a needed niche because of their independence of practice (nurses and others don’t usually initiate such procedures in India) and specialized skills. “Even physicians find it difficult to intubate an orally bleeding patient. Our trainee had it nailed.”

Mahadevan noted that the state of Andhra Pradesh, which includes Hyderabad, had recently launched a public ambulance service, but that most ambulances in India are operated by hospitals, including the Apollo facilities where the Stanford trainees work. Cost is an issue. Patients are asked in the field where they want to be taken. If they cannot pay for the ambulance or their hospitalization, Mahadevan said they will be transported at no charge to the free, albeit less well equipped, public hospitals.

The program was the first prehospital effort for both Stanford Emergency Medicine International and for India. Other recent efforts included partnering with UCLA’s international medicine program to teach trauma care to physicians in both Egypt and China, countries where emergency medicine is not a specialty and where few physicians have relevant training. Stanford EM International also hosts visiting international physicians for faculty development and hands-on ED experience and has trained 12 physicians since 2001.

Strehlow notes that the Indian “graduates are all going to be leaders at whatever hospital or program they go to.” Mahadevan said that the team is currently exploring the creation of a paramedic instructor’s course. In any case, said Mahadevan, future courses will focus on instructor training so that programs can carry on. This time the Stanford team left behind the course material — including the extra material on how to care for snake bites. What did the Stanford team bring back besides satisfaction of launching a program? Mahadevan points out: “The best way to make sure you learn something is to teach it.”

Students demonstrate immobilization
of a potential cervical spine injury under simulated field conditions.