Discussion

To our knowledge, this is the first StB training in India.1 This initial study confirmed our suspicion that Indian healthcare providers, in both rural and urban settings, are given little to no formal hemorrhage control training but are very eager to receive it. As India continues its tremendous economic growth, the purchasing power of its citizens will lead to more automobiles and motorcycles on roads that are poorly equipped for such high capacity. In addition to the sheer volume of people (current population 1.2 billion), there was previously no official national emergency response phone number in India. In 2017, the Telecom Regulatory Authority of India (TRAI) proposed ‘112’ as a single number to be used for all emergency phone calls, including police, fire and emergency medical service (EMS)/ambulance services.8 It has yet to be widely implemented across the country.

Unfortunately, India also lacks ambulances. The WHO recommends that for every 100 000 people, there should be at least one ambulance. New Delhi, the capital of India, with a population of 22 million people and growing, has only 152 state-run ambulances.9 This is approximately one ambulance for every 144 736 people, well below the WHO threshold. According to a 2012 study by the All India Institute of Medical Sciences, 28% of the 70 768 emergency calls received between March 2009 and May 2010 in the city were refused due to a shortage of ambulances.9 The ambulances that do exist often lack basic life support, such as oxygen or medications, let alone advanced equipment. Many ‘ambulances’ are simply white vans containing stretchers. If an ambulance does arrive on scene, response times can vary significantly based on rural or urban setting. Major traffic delays coupled with a lack of training for drivers on giving an ambulance the right of way exacerbate poor response times. Making the problem even worse is a lack of prehospital personnel in India. There are currently no standardized prehospital training standards or curriculum for designating emergency medical technicians.

Given the lack of resources, it is imperative that courses such as StB be taught across the country to provide laypersons a basic skill set to save a life until EMS/prehospital staff arrive. Importantly, work by non-governmental agencies, such as SaveLIFE Foundation and Save a Life, Give a Life Foundation, have helped champion the importance of trauma care in India. SaveLIFE, for example, helped create legislation to safeguard bystanders, or ‘good samaritans’, who come forward during emergencies to help the injured.10 This was passed into law in 2016 by the Supreme Court of India. By initially training HCPs in both rural and urban settings, we aimed to enhance the capabilities of trainers who will in turn train others using a train-the-trainer model.

This study has several limitations. Importantly, the study analyzed data from a small sample of HCPs (n=88). The StB program is intended for widespread public education. To that end, the program’s effectiveness should be studied in larger groups that include Indian laypersons to determine what changes must be made to terminology, skills practice, and teaching pace. Notably, pre-training and post-training questionnaires were written in English; this was not the first language of most participants and therefore may have impaired data validity. The questionnaire was also first-person subjective: it asked participants to rate their ‘confidence’ level with their new hemorrhage control skills. Measuring training success by participants’ self-perceived competency introduces potential bias, as participants are inexperienced and may try to give responses that flatter trainers and validate the training. The training was taught entirely in English, which is the second or third language of most HCPs in India. The potential language barrier may have led to miscommunication between trainers and trainees, or even prevented participants from asking more technical or nuanced questions about the training material. Future trainings, particularly directed toward laypersons, should be offered in the local language.

Improvements to the training kit should be made. Over 90% of participants recommended the use of more realistic mannequins. ‘Realistic’ was not explicitly defined but may refer to anatomical accuracy (resembling an arm or leg) or hemorrhage feedback (bleeding that stops when enough pressure is applied). Trainers also noted the heaviness and bulkiness of the training kits as deterrents to traveling with them. The high cost of the official StB mannequin training kit (over US$900) is prohibitive to program adoption and uptake, particularly in low-income countries like India. It should be noted that the StB course does not currently mandate any one training kit. This enables opportunities to develop inexpensive models with local materials. In fact, several US-based trainers have successfully performed StB training with inexpensive ‘home-made’ kits rather than the high-cost commercial equipment. Jugaad, a word in Hindi and a concept taught in business schools around the world, captures the meaning of finding a low-cost solution to any problem in an intelligent way.11 Developing a cost-effective StB training kit, particularly for low-income and middle-income countries, would be an example of Jugaad innovation.

The inclusion of expensive specialty gauze in some kits provided no benefit over generic gauze and could potentially be replaced with cheaper alternatives. Consideration should be given to using lighter-weight, anatomically accurate mannequins and generic gauze.

During conversations with participants, questions frequently arose about the circumstances in which one should apply hemorrhage control skills. It may therefore be useful for future versions of StB to include additional guidelines for intervention. Though not discussed in the questionnaires, conversations with participants during trainings also revealed widespread skepticism about the usefulness of learning tourniquet application. Participants wondered if a tourniquet would be available during an emergency and expressed interest in learning how to create make-shift tourniquets from everyday objects. Another limitation is the lack of delayed reassessment of knowledge and skills to quantify how much information participants had retained over a set time period. Despite these limitations, Indian HCPs benefited from StB trainings and felt confident using and teaching the skills to others after just one hour of training.

Dissemination of life-saving basic hemorrhage control skills into both rural and urban settings in India has significant potential to increase the number of trauma patients who survive long enough to reach a trauma center. Much more work is needed to match the training required for the large population.