Focus on emergency treatment in Homoeopathic Hospitals

Dr Puneet Kumar Misra

Abstract
At the rising state  of homoeopathy  the entire medical field lack the   uniform pattern of disease classification or  standard protocol of treatment , still originator of homoeopathy Dr Hahnemann have  strong vision regarding diseases  and its treatment , at that time he also  explain clear cut about acute  and chronic diseases with their treatment as per need of circumstance, periodic or shorter interval  or shorter with acutest condition . The present time acute medicine having separate status in the medical field and in the last decade homoeopathy system of medicine controlling authorities also focus on the emergency as a separate special unit in its hospitals,  its  description   under purview of NCH,NABH and  Clinical establishment rules are main aims .

Key words – Emergency, Acute, chronic, homoeopathy hospitals, NABH, NCH.

Introduction
As it is now no longer a matter of doubt that the diseases of mankind consist merely of groups of certain symptoms, and may be annihilated and transformed into health by medicinal substances, but only by such as are capable of artificially producing similar morbid symptoms (and such is the process in all genuine cures), hence the operation of curing is comprised in the three following points:
I. How is the physician to ascertain what is necessary to be known in order to cure the disease?
II. How is he to gain a knowledge of the instruments adapted for the cure of the  natural disease, the pathogenetic powers of the medicines?
III. What is the most suitable method of employing these artificial morbific agents (medicines) for the cure of natural disease? 1

With respect to the first point, the following will serve as a general preliminary view. The diseases to which man is liable are either rapid morbid processes of the abnormally deranged vital force, which have a tendency to finish their course more or less quickly, but always in a moderate time these are termed ACUTE diseases or they are diseases of such a character that, with small, often imperceptible beginnings, dynamically derange the living organism, each in its own peculiar manner, and cause it gradually to deviate from the healthy condition, in such a way that the automatic life energy, called vital force, whose office is to preserve the health, only opposes to them at the commencement and during their progress imperfect, unsuitable, useless resistance, but is unable of itself to extinguish them, but must helplessly suffer (them to spread and) itself to be ever more and more abnormally deranged, until at length the organism is destroyed; these are termed CHRONIC diseases. They are caused by dynamic infection with a chronic miasm.1

Under these conditions, the smallest doses of the best selected homoeopathic medicine may be repeated with the best, often with incredible results, at intervals of fourteen, twelve, ten, eight, seven days, and, where rapidity is requisite, in chronic diseases resembling cases of acute disease, at still shorter intervals, but in acute diseases at very much shorter periods – every twenty – four, twelve, eight, four hours, in the very acutest every hour, up to as often as every five minutes, – in every case in proportion to the more or less rapid course of the diseases and of the action of the medicine employed, as is more distinctly explained in the last note.1

Acute medicines is the part of general medicine that is concerned with the immediate and early management of medical patients who require urgent care. As a specialty, it is closely aligned with emergency medicine and intensive care medicine, but is firmly rooted within general medicine. 2

The decision to admit to hospital Every patient presenting to hospital should be assessed by a clinician who is able to determine whether or not admission is required. The requirement for admission is determined by many factors, including the severity of illness, the patient’s physiological reserve, the need for urgent investigations, the nature of proposed treatments and the patient’s social circumstances. In many cases, it is clear early in the assessment process that a patient requires admission. In such cases, a move into a medical receiving unit – often termed a medical admissions unit (MAU) or acute medical unit (AMU) – should be facilitated as soon as the initial assessment has been completed and urgent investigations and/or treatments have been instigated. In hospitals where such units do not exist, patients will need to be moved to a downstream ward once treatment has been commenced and they have been deemed sufficiently stable. In suspected cases of airborne-transmissible infectious diseases, patients should be isolated initially and may require cohorting in specific areas of the hospital once diagnoses have been confirmed. Following the initial assessment, it may be possible to discharge stable patients home with a plan for early follow-up (such as a rapid-access specialist clinic appointment)2

Ambulatory care In some hospitals, it is increasingly possible for patient care to be coordinated in an ambulatory setting, negating the need for a patient to remain in hospital overnight. In the context of acute medicine, ambulatory care can be employed for conditions that are perceived by either the patient or the referring practitioner as requiring prompt clinical assessment by a competent decision-maker with access to appropriate diagnostic resources. The patient may return on several occasions for investigation, observation, consultation or treatment.2

Presenting problems in acute medicine – Chest pain, acute breathlessness, Headache, Anaphylaxis, Syncope/pre syncope, Unilateral leg swelling & acute abdomen 2

Accident & Emergency service include Disaster Management (A & ED)

The department of emergency service is well equipped with necessary trained manpower, equipment and supplies are the first need of severe acutely ill / injured person which required immediate/Urgent medical care.  The definition of emergency by American College of Emergency Physicians (ACEP) emergency service as any health care service provided to evaluate and /or treat any medical condition such that a prudent layperson possessing an average knowledge of medicine and health, believes that immediate unscheduled medical care is required. But the concept of emergency department as a specialty within the hospital organization was first put forward by American College of Surgeons .The emergency department varied as per need of patient condition   and resource available in the hospitals i.e. accident & trauma, medical, surgical, poisoning, burn, obs & gyna, pediatric, etc. the emergency service in the hospital provide immediate care for ambulatory patient on OPD basis and critical ill and injured on IPD basis. The facility of ED in the hospital is easily accessible from main entry through proper signage and preferably ground floor in case of multistoried hospital.3

National Academy of Service, USA has classified emergency into four Major types.

Type I major emergency facility– This type of service seen in large hospital, teaching hospital & tertiary hospital which provided specialized facilities (diagnostic & therapeutic) with 24 hours availability of  specialist.

Type II basic emergency facility– This type seen in general hospital   and manage by medical officer (MO) round the clock & respective specialists are on call duty

Type III stand by emergency facility – This type seen in the PHC (Primary health center) or CHC (community health center) levels and manage by trained nurses round the clock and MO on call duty.

Type IV referral   emergency facility – This type typically seen at sub center level manage by ANMs or Trained nurses, only provided the first aid, and referred according  to severity &  needs of patient . 3

(12) (A) Collegiate hospital shall have dedicated emergency room with adequate man power. It should preferably have a distinct entry independent of out-patient Department main entry so that a minimum time is lost in giving immediate treatment to casualties arriving in the hospital. There should be an easy ambulance approach with adequate space for free passage of vehicles and covered area for alighting of patients. Signage of emergency must be displayed at the entry of the hospital. Separate emergency beds must be provided. Emergency unit to have all basic instruments required for examination of patient which shall include torch, thermometer, tongue depressor, knee hammer, B.P. apparatus, nebulizer glucometer, pulse oxymeter, needles, syringe, suturing material, scalpel, ryles tube, I.V. set, oxygen cylinder, mask with kit for inhalation and suction machine. 4

(B) Emergency unit shall be managed under the supervision of General Physician having qualification as specified in the Third Schedule. Duty roaster for doctors and nurses shall be displayed and maintained. 4

(C) Emergency Equipment shall be as per Appendix-15. Emergency Equipments S.no Name of the Equipment For  30bed, 31 to50bed,  51to100 bed

1. Emergency equipment box For first aid and Basic Life Support Skill Minimum1
2. Crash- Cardtrolley Minimum1
3. Portable defibrillator Optional or Minimum1
4. Disposable syringes As needed
5. Ambu Bag Minimum 1
6. Laryngoscope with cell Minimum 1
7. Sealed battery cell Minimum 1
8. Endotracheal tubes As needed
9. Monitor As needed .4

(D) Drugs segment includes the minimum essential drug which needs to be maintained in the facility.

(i) Anesthetics drugs shall be as per Appendix-16.

(ii) Emergency drugs shall be as per Appendix-17.4

STANDRED COP.3. Emergency services are guided by documented policies, procedures, applicable laws and regulations, if applicable.

Objective Elements

1. There shall be an identified area in the organization which is easily accessible to receive and manage emergency patients.
2. Policies and procedures for emergency care are documented and are in consonance with statutory requirements. *
3. This also addresses the handling of medico-legal cases. *
4. The patients receive care in consonance with the policies.
5. Documented policies and procedures guide the triage of patients for initiation of appropriate care. *
6. Staff are familiar with the policies and trained on the procedures for care of emergency patients.
7. Admission or discharge to home or transfer to another organization is also documented.
8. In case of discharge to home or transfer to another organization, a discharge note shall be given to the patient.
9. Quality assurance programmes are documented and implemented. *
10. The documented policies and procedures guide management of patients found dead on arrival to the hospital. *5

MINIMUM STANDARD REQUIREMENTS FOR HOMEOPATHY HOSPITALS. They shall register, under the respective State Govt. or Central Govt. in compliance of the Clinical Establishment (CENTRAL GOVT.) Rules 2012, through standard application form prior to establishment of the institutions. Respective State Govt. or Central Govt. shall provide the required registration and permission for continuation of the establishment on fulfillment of the terms and conditions as laid down in the Rule. 6

Emergency equipments with bed capacity of hospital 

A 11 to 25 bed

B 26 to 50 bed

C 51 to 100 bed

D Teaching hospital

Name of the Equipment 

1. Emergency equipment box for first aid & BLSS Minimum 1
2. Crash-Card trolley Minimum 1
3. Portable defibrillator Minimum 1or optional
4. Disposable syringes as need
5. Ambu Bag: Minimum 1
6. Laryngoscope Minimum 1
7. Sealed battery cell Minimum 1
8. Endo tracheal tubes as need
9. Monitor Minimum as need. 6

Categorization of Hospitals CEA/Hospital – 001  

Hospital Level 1 (A)- General Medical services with indoor admission facility provided by recognized allopathic medical graduate(s) and may also include general dentistry services provided by recognized BDS graduates.

Example: PHC, Government and Private Hospitals and Nursing Homes run by MBBS Doctors etc.7

Hospital Level 1(B) – This level of hospital shall include all the general medical services provided at level 1(A) above and specialist medical services provided by Doctors from one or more basic specialties namely General Medicine, General Surgery, Paediatrics, Obstetrics &Gynaecology and Dentistry, providing indoor and OPD services. Level 1(A) and Level 1(B) Hospitals shall also include support systems required for the respective services like Pharmacy, Laboratory, etc. Example: General Hospital, Single/ Multiple basic medical Specialties provided at Community Health Centre, Sub Divisional Hospital, and Private Hospital of similar scope, Nursing Home, Civil / District Hospital in few places etc.7

Hospital Level 2 (Non-Teaching) This level may include all the services provided at level 1(A) and 1(B) and services through other medical specialties given as under, in addition to basic medical specialty given under 1(B) like: a. Orthopaedics b. ENT c. Ophthalmology d. Dental e.  Emergency with or without ICU f.Anaesthesia g. Psychiatry h. Skin i.Pulmonary Medicine j.Rehabilitation, etc. And support systems required for the above services like Pharmacy, Laboratory, Imaging facilities, Operation Theatre etc. Example: District Hospital, Corporate Hospitals, Referral Hospital, Regional/ State Hospital, Nursing Home and Private Hospital of similar scope etc.7

Hospital Level 3 (Non-Teaching) Super-specialty services – This level may include all the services provided at level 1(A), 1(B) and 2 and services of one or more of the super specialty with distinct departments and/or also Dentistry if available. It will have other support systems required for services like pharmacy, Laboratory, and Imaging facility, Operation Theatre etc. Example: Corporate Hospitals, Referral Hospital, Regional/State Hospital, Nursing Home and Private Hospital of similar scope etc.7

Hospital Level 4 (Teaching) – This level will include all the services provided at level 2 and may also have Level 3 facilities. It will however have the distinction of being teaching / training institution and it may or may not have super specialties. Tertiary healthcare services at this level can be provided through specialists and may be super specialists (if available). It will have other support systems required for these services. It shall also include the requirement of MCI/other registering body for teaching hospitals and will be governed by their rules. However registration of teaching Hospitals will also be required under Clinical Establishment Act for purpose other than those covered under MCI such as, records maintenance and reporting of information and statistics, and compliance to range of rates for Medical and Surgical procedures, etc.7

CEA/Hospital – 001  EMERGENCY EQUIPMENT.

Name of Emergency Equipment

1. Resuscitation equipment including Laryngoscope, endotracheal tubes, suction equipment, xylocaine spray, oropharyngeal and nasopharyngeal airways, Ambu Bag- Adult & Paediatric (neonatal if indicated)
2. Oxygen cylinders with flow meter/ tubing/catheter/face mask/nasal prongs
3. Suction Apparatus
4. Defibrillator with accessories (Desirable)
5. Equipment for dressing/bandaging/suturing
6. Basic diagnostic equipment- Non mercury Blood Pressure Apparatus, Stethoscope, weighing machine, thermometer (Non mercury)
7. ECG Machine
8.  Pulse Oximeter (Desirable)
9. Nebulizer with accessories b. Other equipment and consumables 7

Categorization of Hospital CEA/Hospital- 003  

Hospital Level 1- Primary healthcare services provided by qualified doctors that include General Medicine, Pediatrics, First aid to emergency patient and Out Patient Services, Obstetrics & Gynecology Non-surgical and Minor Surgery and having a bed strength of not more than 30. The primary healthcare services can be provided through trained and qualified manpower; with support/supervision of registered medical practitioners with the required support systems for this level of care. 8

Hospital Level 2– This level may include all the services provided at level 1 plus also have facility for Surgery and Anesthesia. Secondary healthcare services can be provided through registered medical practitioner under supervision and with support of specialists; it will have other support systems required for these services like pharmacy, laboratory, diagnostic facility etc. 8

Hospital Level 3– This level may include all the services provided at level 1 and 2 plus the following: Multi-specialty clinical care with distinct departments, General Dentistry (this could be optional in case of independent Dental Hospital), Intensive Care Unit. Tertiary healthcare services can be provided through specialists; it will have other support systems required for these services like pharmacy, Laboratory, and Imaging facility. 8

Hospital Level 4 (Teaching) –This level will include all the services provided at level 3. It will however have the distinction of being teaching/ training institution and it will have multiple super specialties. Tertiary healthcare services that can be provided through specialists; It will have other support systems required for these services. It shall also include the requirements of MCI/other registering body.8

DISCUSSIN

• It is a known fact that the homoeopathy hospital having no existence in current medical scenario in the society for treatment  except teaching institution while in the other hand  the  hospital have  very capacious realm for treatment in the  allopathic or modern medicine
• As per Clinical Establishment Act allopathic or modern medicine hospital are categorized  into four group on the basis of its  scope of serving  treatment services, while in case of homoeopathy it based on the bed capacity maximum 100 beds and still  in the draft condition.
• Classification of  emergency service as per  National Academy of Service, USA the status of homoeopathy hospital attached to the college are capable to provide the emergency treatment stand  between the  Type III stand by emergency and Type IV referral   emergency facility.
• When compare the Minimum Essential Standards for Homoeopathic Colleges and Attached Hospitals Regulations, 2013 & 2024 then we found that protocol of emergency unit is the newly attached in the 2024 while it is not a part of the previous.
• As per Minimum Essential Standards for Homoeopathic Colleges Attached Hospitals Regulations, 2024, 12 A, B, C and D. the 12 A,B,C provide the complete infrastructure ,equipment and staffing pattern while 12D  shows the Drugs segment includes the minimum essential drug which needs to be maintained in the facility  Are (i) Anesthetics drugs shall be as per Appendix-16. (ii) Emergency drugs shall be as per Appendix-17. Both mentioned drug Appendix are not any single homoeopathy drug they all are part of allopathic or modern medicine   and for its administration institutes depend upon allopathic clinician.
• We go through Homoeopathy degree course 4^th year in theory of   practice of medicine  2003 regulation, acute emergencies including poisonings is a topic , but in 2015 regulation it is not included  and again draft  regulations 2022 having the topic  critical care medicine without description table  under the CBDC. The topic is included but presence of   skilled faculty is an unanswered questions .
• The NABH for homoeopathy hospital ^2nd edition 2016 also have the separate emergency standard with completely objectives

CONCLUSION
The lift up step toward the emergency service in the homoeopathy teaching hospital is an appreciated act , but due to the lack of  efficient man power or dependence on the  man power  of other branch of treatment of the society created  doubt in its success , because most of the man power in the homoeopathy teaching mainly clinical subject are uncomfortable  and hesitation feel in  skill of emergency issue,  therefore it is a need of time to  starts an pilot project to prepare the  trained  certified  man power in the homoeopathy for management of emergency issue, otherwise homoeopathy and homoeopath will pay very high cost of  loss in future.

Bibliography

1. Dr Dudgeon R E & Dr Boericke W. Organon of Medicine by Samuel Hahnemann combined 5^th & 6^th editions. 36^th impression B. jain Publishers (p) Ltd; 2018.149, Page 115-117,220-221.
2. Sir Stanley Davidson . Davidson’sPrincipal & Practice of medicine. 24^th  Edition. Elsevier Ltd; 2022. Page 178.
3. Theme IV Patient Care and Support Service, Block -1Patient Care Services –I National Institute of Health & Family welfare   New Delhi , March  2013, Page04- 06
4. The National Commission For Homoeopathy (Minimum Essential Standards For Homoeopathic Colleges And Attached Hospitals) Regulations,  New Delhi, 11th March, 2024 PAGE 108
5. National Accreditation Board for Hospitals and Healthcare Providers (NABH) ,Accreditation Standards for Homoeopathy Hospitals , 2^nd Edition. July 2016 Page, 15 .
6. Minimum Standard Requirements for Homeopathy Hospitals these shall be within the ambit of the Clinical Establishment (CENTRAL GOVT.) Rules 2012Clinical Establishment Rule.
7. Clinical Establishment Act Standards for Hospital (LEVEL 1A &1B)) CEA/Hospital – 001 PAGE NO 4-5, 15 ANNEXER 03
8. Clinical Establishment Act Standards for Hospital (LEVEL 3) CEA/Hospital- 003 ,Page 5

Dr Puneet Kumar Misra
Reder (Practice of Medicine)
Govt Pt JLNHMC Kanpur
Email : drpuneetmishra18@yahoo.com