Hardlook: In need of an ambulancehttps://indianexpress.com/article/cities/delhi/delhi-ambulances-cats-primary-healthcare-hardlook-in-need-of-an-ambulance-4966589/

Hardlook: In need of an ambulance

The first responders to any medical emergency, the capital’s 265 CATS ambulances are in a bad shape, with 60 vehicles unfit for use and over 100 outdated. Kaunain Sheriff M tracks the fleet for five days to uncover the many problems — from lack of medical equipment to faulty technology.

An ambulance that caught fire four months ago, parked outside the Najafgarh base; during their strike in November. (Express Photo by Gajendra Yadav)

Next to the primary health centre in Najafgarh, on the outskirts of Delhi, is a 10×10 feet room which serves as one of the ‘bases’ for the Centralised Accident & Trauma Services (CATS) — the backbone of the capital’s emergency medical services. Each base is assigned an ambulance pilot, or driver, and a CATS paramedic. Every time a call comes in, they rush to address the medical emergency.

But around 3.30 pm on Wednesday, the room is locked. There is no pilot, no paramedic and no calls. Speaking to The Indian Express over the phone, a pilot who works at the base said, “The ambulances in Najafgarh, in the Southwest zone, are not mechanically fit for operation. There is no work here, so we have to sit idle. All the calls from this zone are routed to ambulances in other zones.”

Parked outside the base is one such mechanically unfit ambulance — Beta 52, an advanced life support (ALS) vehicle. At first glance, the ambulance looks like someone torched it. But a staffer at the base explained, “The ambulance had just come back from the hospital. The pilot parked it and went for a break. Within minutes, it burst into flames. This was almost four months ago. Since then, no one has bothered to repair the vehicle. The servicing is to be done near the Badarpur border, but authorities are not willing to transport it. This ambulance is the most advanced one, meant for critical cases. But it has been dumped here for so long.”

Beta 52 is not the only ambulance that has been “dumped” in Najafgarh. The Indian Express found that at least 20 ambulances in the Southwest zone are “non call worthy (NCW)”, which means they are non-operational due to mechanical reasons.

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Even more alarming is the fact that only six of 26 ambulances are operational in the zone for approximately 22 lakh people. For each day an ambulance is non-operational, a penalty of Rs 1,500-Rs 4,500 is imposed on the company running the services.

CATS employees had set on fire an ambulance outside CM Arvind Kejriwal’s home. (Express Photo)

But it’s not just the Southwest zone that is suffering. The Indian Express tracked the functioning of ambulances in the capital’s 11 zones between November 27 and December 1, and discovered that at least 60 ambulances of a fleet of 265 were non-operational due to mechanical faults. Only one zone, East, which has 17 ambulances, is operating in full strength. Southwest is the worst hit, with 77% of its ambulances in the NCW category.
Of the 60 NCW ambulances, at least 40 are mechanically unfit for operation and require urgent repairs. The Indian Express also found that at least two ALS, as well as four basic life support (BLS) ambulances, have caught fire in the last two years.

Beset by strikes

In 2015, the Aam Aadmi Party government had procured 110 new ambulances, taking its fleet to 265. More importantly, the government had also decided to outsource the operation and maintenance of its ambulance services in order to reduce response time. In 2016, the UK Specialist Ambulance Services (UKSAS) tied up with the Indian firm, BVG group, and took over CATS services in the city.

Prior to this, CATS, an autonomous body under the Delhi government, ran operations. The service responds to calls of accidents and medical emergencies received by Delhi Police, Delhi Fire Services, Delhi Disaster Management Authority, government hospitals, Delhi Secretariat as well as anyone who calls the 102 helpline. On an average, CATS receives 13,000 calls every month.

Less than two years after operations were outsourced, things seem to have gone from bad to worse. CATS operations have come under scanner after contractual staff went on strike at least nine times this year, demanding that they be regularised. They also demanded 2.5 days leave per month, and that their salary be calculated on a monthly basis.

On November 4, the Delhi government cracked down on agitating employees by classifying them as “essential service” for six months, which means they cannot go on strike anymore. BVG UKSAS EMS Pvt Ltd also terminated 45 employees for damaging ambulances during the strike in November.
According to the company, during the strike between November 1 and 8, 120 ambulances were allegedly damaged. The Delhi Police had registered an FIR in the matter.

But frequent strikes are just part of the problem for CATS. The Indian Express spoke to stakeholders, examined documents and accessed key communications to find glaring discrepancies in the functioning of  CATS ambulances in the city.

Faulty response system

At a base in Janakpuri, the pilot received a call from Dwarka Mor, around 9 km away. “The Dwarka base should have received the call. But because of a faulty system, an ambulance from any zone can be assigned. It will take at least 40 minutes to reach the spot. The response time has to be within 20 minutes. But the central control room randomly assigns anyone. Also, a BLS vehicle should have been assigned as it is a minor accident. But an ALS — required for critical cases — has been assigned. This is how the system works,” the pilot said.

 

Over the next 50 minutes, between 8.25 pm and 9.15 pm, the pilot received three calls — road accident, delivery and abdominal pain — from the central server. “In 50 minutes, I have received three calls from three different locations. How can one ambulance deliver services to three patients in 50 minutes? This is the state of the system,” he said.

When contacted, company officials admitted that “multiple calls are being dispatched to one vehicle at the same time and the staff faces problems”. The Indian Express also accessed documents that show how “calls of Narela (North zone) were being received by East zone ambulances”. “The main reason is that non-technical staff of CATS are deployed in the control room. They are staffers recruited as paramedics, with no technical knowledge. Even though they received training, glitches creep in. We have moved to a different technology, but operations continue to be hampered due to inadequate technical staff,” an official said.

Critical equipment missing

Each ambulance is mandated to have 46 crucial equipment. But when The Indian Express visited a base in Northwest Delhi and examined logbooks, it discovered that, on an average, at least 30 equipment were missing for at least a month. This includes basic equipment for resuscitation and airway management, a wheelchair, a pulse oximeter to monitor oxygen levels, and a blanket to cover the patient.

The BLS even lacked a bleeding control kit comprising pads, bandages, tourniquets and air splints — essential for accident cases. Ambulance staff are also provided with a mobile data terminal (MDT), which is like a tablet, to accept calls from the central server. The tablet is also supposed to display and automatically update medicine count, equipment list, fluid count and consumable count.

However, the tablet in the BLS ambulance did not have any automatic updates. “We cannot update anything on the tablet as it has not been made functional. We have to manually check the actual status of medicines and equipment. In fact, many times, even oxygen cylinders are not available in the storeroom. There is no round-the-clock monitoring of any medical requirement,” a staffer said.

Officials admitted that online tracking of medical equipment is not functional through the tablet. “Managers have to check this. It is a learning process, but it should be fixed soon,” an official said.

Faulty tablets

The Indian Express also accessed documents which showed that many tablets were “non-functional”. In such a scenario, the server cannot calculate response time of the ambulance. A letter written by the company to the CATS authority in February said it was unable to “generate uptime report based on the MDT” as the tablets were “non-functional”. In another communication in June, the company informed the CATS authority about the “delay in delivering of call dispatch”. “Every day, there is a delay in delivering of call dispatch (or) failure of call dispatch… (else) the server is unable to take the load of such voluminous calls… We all are aware of such critical services and the software being used has been tried, tested… Therefore, we request a permanent solution, wherein there is zero tolerance concerning MDTs, so that the lives of general public are not at stake,” the communication read.

Outdated ambulances

While at least 40 ambulances are mechanically unfit, sources said 155 are older than six years, which hampers services. In fact, the company struggled to deploy just 20 ALS vehicles for the Independence Day parade. The reason: problems with the defibrillator, used in a medical emergency to artificially provide electric current to the heart.

“We are rectifying most of the issues in the ALS, but the defibrillator is a major concern… We trying to resolve maximum issues. But if any issue still persists, (we) request you to remove the ambulance from the deployment list,” the company told the CATS authority.  Asked about breakdowns, an official said, “Getting spare parts for the old fleet continues to be a problem. Even the battery to charge the defibrillator is not available in India. We are yet to receive the batteries. The tender clearly states that no ambulance can be replaced within three years.”

The company and the CATS authority, meanwhile, have found themselves at odds. With the authority yet to pay the company Rs 28 crore for the operation of ambulances, BVG has moved arbitration proceedings. Dr Nivedita Patnaik, Manager, Operations, BVG UKSAS EMS Pvt Ltd, told The Indian Express: “Our objective is to provide daily, round-the-clock transportation services for critical and emergency patients. Since the beginning of the contract, we have faced contractual manpower problems, decrepit vehicle condition and unreasonable uptime penalty conditions. There has been no payments from CATS despite constant upward improvement month after month. There has been no replacement of old ALS ambulances, which are extremely prone to breakdowns. Also, strikes caused by contractual employees are not attributable to BVG-UKSAS, which has tried its best to sort out the issues.”

The Additional Secretary (Health and Family Welfare), meanwhile, has written to the company, stating that BVG “shall release the monthly remuneration of contractual ambulances engaged by them by the 7th of every month”, and that for “smooth operations and maintenance of CATS ambulances, and to deal with the emergency situation, CATS zonal representatives will be deployed”.

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The government has also given the company 89 days to replace terminated staff. “BVG UKSAS EMS Pvt Ltd should start recruitment process for engagement of ambulance paramedics as per qualification in the agreement and start training to ensure the availability of qualified and trained manpower within 89 days,” the government said.