MEDICAL CARE IN INDIAN TRAINS

The Indian Railways shoulders the monumental responsibility of transporting over 2.3 crore passengers daily, a figure nearly double the projected population of Uttarakhand in 2022. While the Balasore train accident in June 2023 underscored the imperative of rail safety, it primarily addressed accident-related concerns. However, given the substantial passenger throughput, another critical facet often overshadowed is the Railways' responsibility towards addressing medical emergencies.

2. Passenger Load and Rail Safety Concerns

• The Balasore incident emphasized accident-related safety, but the Indian Railways, with its vast passenger volume, grapples with a distinct safety challenge — medical emergencies. The magnitude of this challenge came to light in 2017 at the Katpadi Junction railway station in Vellore, Tamil Nadu, where 1,076 medical emergencies were reported. These ranged from trauma-related incidents to minor ailments and life-threatening conditions, requiring prompt attention.
• A quarter of the reported emergencies at Katpadi Junction were trauma-related, while the rest spanned a spectrum from common ailments like fever to critical conditions such as low blood sugar. Notably, almost 10% of emergencies reported at the station's emergency help desk, managed by the Christian Medical College (CMC) Vellore, demanded urgent, life-saving interventions.
• India witnesses a surge in non-communicable diseases, with diabetes and hypertension on the ascent. The recent years have seen a marked increase in deaths attributed to heart attacks, indicating a shifting health landscape. The pertinent question arises: Is the Indian Railways adequately equipped to address the escalating wave of medical emergencies, particularly those arising from these prevalent health conditions?
• The landscape of health emergencies in India is transforming, with non-communicable diseases taking center stage. As heart attacks and other critical conditions become more pervasive, the preparedness of the Indian Railways to handle the medical fallout of these health challenges comes under scrutiny.
• Given the changing health dynamics, it becomes imperative for the Indian Railways to enhance its preparedness for medical emergencies. This involves not only addressing trauma-related incidents but also developing a comprehensive approach to tackle a spectrum of health issues, from minor ailments to life-threatening conditions.
• To meet the evolving health demands of its vast passenger base, the Indian Railways must consider reinforcing its medical infrastructure. This includes upgrading emergency help desks, ensuring the availability of trained medical personnel, and equipping stations to handle a diverse range of medical emergencies.
• Collaborations with healthcare institutions, exemplified by the partnership with Christian Medical College (CMC) Vellore, can serve as a model for augmenting medical support. Such partnerships bring specialized medical expertise to the forefront, ensuring prompt and efficient responses to emergencies.

3. Evolution of Medical Care in Indian Railways

• The provision of medical care in the Indian Railways has undergone significant evolution, extending beyond addressing accident-related emergencies to encompass a broader spectrum of medical conditions. This evolution is marked by initiatives and interventions aimed at enhancing emergency healthcare services for passengers.
• In 1995, a crucial milestone was achieved with the introduction of the 'special first aid box' in long-distance superfast trains, specifically Shatabdi and Rajdhani. This specialized kit, comprising 49 items, was designated for use by a doctor traveling on the train. Subsequently, an enhanced version known as the 'augmented first aid box' with 58 items was introduced for specific long-distance trains.
• As a pilot project in November 1996, the Railways stationed a medical team on two long-distance trains, including a medical officer, a male nurse, and an attendant. Over the next four years, challenges emerged as the team was predominantly idle, addressing only minor ailments. The inadequacy of resources in moving trains resulted in the loss of critically ill passengers' lives, leading to the discontinuation of the service.
• To ensure healthcare accessibility, the Railways implemented a discount incentive in which doctors traveling on trains received a 10% discount if they volunteered to provide medical services en route. Despite these measures, instances like the unfortunate death of Netrapal Singh in 2004 highlighted persistent inadequacies.
• A petition filed in the Rajasthan High Court in 1996 gained momentum following Mr. Singh's demise, prompting judicial scrutiny of medical care provisions in trains and railway stations. The 2005 judgment revealed a lack of awareness contributing to the underutilization of medical teams. The court directed the reservation of four berths in long-distance trains for medical care and mandated medical teams for trains covering more than 500 km.
• In 2017, the Supreme Court intervened, directing the Railways to establish a committee comprising experts from the All India Institute of Medical Sciences (AIIMS), New Delhi. The committee's task was to recommend further measures for enhancing medical care provisions in the Railways.
• Based on the Supreme Court's directive and the committee's recommendations, the Railways committed to modifying the contents of first aid boxes. These modified boxes are now provided at all railway stations and in all passenger-carrying trains. Additionally, the Railways mandated first-aid training for railway staff, both at the time of joining and at three-year intervals. The committee also recommended a periodic review of service utilization every three years.
• The ongoing commitment to periodic reviews and continuous improvement underscores the Railways' dedication to enhancing healthcare services. The multifaceted approach involves infrastructure enhancement, staff training, and awareness initiatives to ensure the effectiveness of emergency medical care provisions.

4. Implementation Status of AIIMS Expert Committee Recommendations (2018)

• In 2018, the Minister of State in the Ministry of Railways responded to a Lok Sabha query, stating that all recommendations put forth by the AIIMS expert committee had been implemented. This suggests a commitment to improving medical care provisions based on the expert committee's insights.
• In 2021, the Railways took a significant step by introducing an integrated helpline number, 139, designed to handle various queries related to railway services, including medical assistance. This centralized helpline aimed to streamline communication and address passenger concerns efficiently.
• In February 2023, Union Minister of Railways Ashwini Vaishnaw conveyed to the Lok Sabha that deputing a doctor at every railway station was deemed unnecessary. However, by December of the same year, the minister asserted that all recommendations of the committee, including those potentially impacting medical services, had been implemented. This shift in perspective raises questions about the ongoing assessment of medical care needs.
• Despite official statements, as of the latest available information, passenger complaints on social media platforms, including X (formerly Twitter), continue to highlight dissatisfaction with medical services on trains. This ongoing feedback suggests a gap between official claims and passenger experiences.
• On December 23, 2023, while traveling from Delhi to Dehradun on a Vande Bharat Express, one of the authors, Parth Sharma, encountered a medical emergency. The train staff urgently sought a doctor's assistance for a passenger experiencing symptoms suggestive of a heart attack. This real-time incident underscores the critical importance of immediate medical intervention during emergencies.
• During the medical emergency, it was revealed that the emergency kit on the train was inadequate. Key deficiencies included the absence of a blood pressure monitor and a glucometer. Furthermore, critical medications, such as aspirin, were near expiry. A closer inspection suggested that the train might be using an outdated medical kit list from 1995 instead of an updated version from 2017.
• The incident on December 23, 2023, and the identified shortcomings in the emergency kit highlight the ongoing need for continuous evaluation and enhancement of medical care provisions on trains. This involves not only implementing recommendations but also ensuring that onboard medical resources are regularly updated and aligned with contemporary healthcare standards.

5. Evaluation of Existing Medical Kit Lists (Post-2017)

• According to K.P.P. Abhilash, the head of emergency medicine at CMC Vellore, the medical kit list from 2017 is deemed inadequate. Drawing insights from cases at the emergency care center in Katpadi Railway station, Dr. Abhilash and his team identified essential medical items that were lacking in the existing stock. These include personal protective equipment for healthcare providers and a pulse oximeter.
• Recognizing the transformative impact of recent advancements in point-of-care diagnostics, experts suggest the inclusion of portable ECG devices and rapid diagnostic kits in the onboard medical kits. This addition aims to enhance the ability to identify and promptly address conditions such as heart attacks during train journeys.
• An urgent measure is to ensure the widespread implementation of the updated 88-item medical kit list recommended by the AIIMS expert committee. This involves verifying the presence of the updated kit in all trains and raising awareness among passengers about the availability of these services. Regular inspections are crucial to maintaining the quality and completeness of onboard medical care resources.
• The Railways should institute a system to capture comprehensive data on the healthcare needs of individuals traveling on trains. This data-driven approach can serve as a foundation for informed policy decisions. Understanding the prevalent health conditions among passengers enables proactive planning and resource allocation to meet evolving medical requirements.
• Conducting periodic training sessions for onboard staff is essential to ensure they are well-equipped to handle medical emergencies effectively. Additionally, awareness programs for passengers can inform them about the available medical services, emergency protocols, and how to access assistance when needed.
• Collaborating with medical professionals, organizations, and research institutions can contribute valuable insights to continuously refine and update medical care provisions. The Railways can benefit from ongoing dialogues with experts in emergency medicine, public health, and medical device development.
• Establishing a culture of continuous improvement is crucial. Regular assessments, feedback loops, and responsiveness to evolving medical standards should be ingrained in the healthcare provision framework on trains. Embracing an iterative approach ensures that the system adapts to changing healthcare dynamics and emerging technologies.