Following the joint Faculty of Pre-hospital Care (FPHC) workshop in India in October 2022 (see Surgeons’ News, March 2023) two inaugural Pre-Hospital Trauma Care (PHTC) Provider Courses were delivered at the Sri Ramachandra Institute of Higher Education and Research (SRIHER) in Chennai in April. Funding was provided by the UK-registered charity Saving Lives, which supports the Faculty of Disaster Medicine – India and Nepal (FDMIN). FDMIN aims to improve training in all phases of disaster response (mitigation, preparedness, response and recovery) and sees pre-hospital care (PHC) as having a key role in the initial response as well as contributing to reducing the wider, ongoing accident-related health burden in South Asia. 

India recorded just over 397,500 accidental deaths in 2021¹ of which 1.8% were due to forces of nature, such as flooding or earthquakes, while 98.2% were due to other causes defined as “deliberate or negligent conduct of human beings”, including falls, factory incidents, explosions, crowd stampedes, building collapses, traffic accidents and other incidents.

Two-day course

The PHTC Course is an established FPHC-endorsed course aimed at multidisciplinary candidates who work for the emergency services or the armed forces, and healthcare professionals who treat the seriously injured during the pre-hospital phase of care. The two-day course aims to give candidates the skills and knowledge to recognise the seriously injured patient, including mass casualties, and to provide appropriate interventions to manage patients in the pre-hospital environment, within their scope of professional practice. 

The UK version of the PHTC Course was adapted to take account of the current PHC capabilities and practice in India, guided by information from the October 2022 workshop and input from local practitioners. In addition, a folder of supporting administrative documentation was developed to allow the planned dissemination of the course to other approved training centres and maintain consistency of training. The FPHC Foundation Material for Immediate Care manual, in an e-format, was used as the reference text. 

The UK Faculty comprised myself, Lorraine Greasley² and Rob Russell³ and we were fortunate to be joined by Professor T V Ramakrishnan, who is Head of the Emergency Medicine Department at SRIHER and a key influencer in the development of PHC in India. Professor Ramakrishnan engaged with his PHC contacts to find a multidisciplinary group of candidates from across India. Peter Patel of Saving Lives and FDMIN invited candidates from Nepal. Ultimately, we had 41 candidates comprising 12 paramedics and 29 doctors, including four from Nepal, from a range of backgrounds.

The course focused on the <c>ABCDE paradigm of pre-hospital care and used a combination of presentations, skills stations, discussions and casualty simulations for training. There were also informal discussions about UK PHC developments and capabilities, with some that do not currently exist within Indian PHC introduced to stimulate discussion and progress. However, such proposed developments needed to be sensitive to the scale of the task and costs in India/Nepal, allied with the fact that structured PHC is at an early stage compared with that in the UK, and healthcare systems are not unified⁴.

The courses were very successful, and all candidates passed the final summative moulage. An MCQ paper was also part of the course and this proved to be more challenging; moreover, the results did not necessarily correlate with candidates’ performance throughout the wider course or during the final assessed moulage. Candidates from the first course who were unsuccessful in their MCQ exam were able to sit a different MCQ exam on 21 April, when they were attending a linked course on FDMIN Disaster Medicine. Candidates from the second course have also been offered a further opportunity to resit. 

Rethinking the MCQ

The suitability of an MCQ exam as a key element of final assessment in an overseas course, where candidates were focusing on practical skills and may have difficulties with language, was discussed with candidates and the Faculty. Interestingly, the role of MCQ examinations in PHC short courses was already being debated within the FPHC Training and Standards Committee having been raised by a UK training provider, which had highlighted that its candidates were practical learners and that MCQ results did not necessarily correlate with wider course performance. For overseas PHC courses, documented continuous assessment with a final summative moulage and clearly defined success outcomes may be a better model.

Feedback from all candidates was excellent and the Faculty was invited to deliver the course at other locations in India. However, to establish a firm foundation and local ‘ownership’ the ultimate aim is for the course to be delivered by selected local instructors at approved centres in India. Accordingly, candidates with Instructor Potential were selected across the two courses. 

More than 35% of the candidates were felt to have the correct attributes. This may seem high, compared with courses such at ATLS®, but it is unsurprising given that Professor Ramakrishnan had targeted PHC enthusiasts for the first courses. The next step is to hold an Instructor Course for the selected candidates, led by UK Faculty who will then oversee/guide their delivery of a further two-day Provider Course immediately afterwards. This will hopefully generate more candidates with Instructor Potential and generate an India-based group who can run courses at approved training centres using material from the FPHC within a Memorandum of Understanding. Quality assurance of courses will be carried out during periodic visits by a member of the FPHC and will depend on careful selection of training centres that will be required to meet the established FPHC overseas course-endorsement criteria.

The unwavering support of Professor Ramakrishnan, Peter Patel and all SRIHER staff, but particularly the BSc/MSc Trauma Care Management students, was fundamental to the success of the courses. In addition, I am grateful to Uma Sekar, Vice-Chancellor of SRIHER, for allowing us the use of the Institute.

Pam Hardy, Chair of the FPHC, said: “This is a fantastic international development for the FPHC and the culmination of a significant amount of work, aided by the support of RCSEd, following the success of the joint FPHC workshop run in parallel with the 2022 RCSEd Conference in Chennai.

“I am immensely grateful to David Bruce and the Faculty for all their work on this course and its inaugural delivery. The excellent feedback suggests this will be the first of many, extending the international reach of vital PHC education and building overseas relationships. My thanks to all at SRIHER, Professor Ramakrishnan and Peter Patel for your much-valued collaboration.”