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The industrial manufacturing sector is the biggest final usage sector when speaking of both final energy consumption and emission of greenhouse gases (accounting for over 30% of the total); the industry's expansion is fast modifying the climate of the whole globe. Energy conservation is one of the key components of success for sustainable production because of the pressing need to reduce the negative effects that industrial operations have on the surrounding environment. As a direct consequence of this, the scientific community's involvement in energy management has significantly increased, which has resulted in a number of literature evaluations being conducted on methodologies. However, there is a dearth of both a detailed study of the techniques and tools that attempt to improve energy awareness as well as an assessment of the impact that these methods and tools have on energy efficiency. To try to fill this void, the author of this work conducts an extensive literature study on the various energy assessment methodologies and tools with their microstructures. After examining the databases of scientific literature, a total of 1366 publications were retrieved; however, it might be of use to industry practitioners in the field of energy management. In accordance with the guidelines provided by ISO 50001, the procedures and instruments were categorized into three primary areas (namely, AAM which means analysis, assessment, and saving measures), and the particular results important to each category were then synthesized as the outcome of study. In its concluding section, the article discusses problems and topics that still need to be addressed and offers proposals for new lines of inquiry.

Green machining is an emerging field that focuses on reducing the environmental impact of machining processes while maintaining or improving their economic efficiency. Cutting fluids are commonly used in machining operations to reduce friction and heat generated during cutting, but they can also cause negative environmental and health impacts. This paper reviews the environmental and economic impacts of cutting fluids in machining processes and presents various green machining techniques that can be used as alternatives to traditional cutting fluids. The paper also discusses the challenges associated with implementing green machining techniques and the main outcome is the potential benefits for both the environment and the economy.

In healthcare professions, soft skills contribute to critical thinking, decision-making, and patient-centered care. While important to the delivery of high-quality medical care, soft skills are often underemphasized during healthcare training in low-and-middle-income countries. Despite South Asia's large population, the efficacy and viability of a digital soft skills curriculum for South Asian healthcare practitioners has not been studied to date. We hypothesized that a web-based, multilingual, soft skills course could aid the understanding and application of soft skills to improve healthcare practitioner knowledge, confidence, attitudes, and intent-to-change clinical practice.In September 2019 a needs assessment observing soft skills practices was conducted in several Indian states. We developed a communication-focused soft skills curriculum that comprised seven 10-minute video lectures, recorded in spoken English and Hindi. Participants consisted of any practicing healthcare professionals and trainees in select South Asian countries age 18 and over. Participant knowledge, confidence, attitudes, and intent-to-change clinical practice were evaluated using pre- and post-course tests and surveys. Statistical analyses were performed using STATA and SPSS.From July 26, 2021 to September 26, 2021, 5750 registered and attempted the course, 2628 unique participants completed the pre-test, and 1566 unique participants completed the post-test. Participants demonstrated small but statistically significant gains in confidence (𝑝<0.001), attitudes toward course topics relevance (𝑝<0.001), and intent-to-change clinical practice (𝑝<0.001). There was no statistically significant gain in knowledge. A digital soft-skills massive open online course for healthcare practitioners in South Asia could serve as a viable approach to improve the quality of soft skills training in low-to-middle income countries., (© 2024. The Author(s).)

Background: Millions of children in low- and middle-income countries (LMICs) experience illness or trauma amenable to emergency medical interventions, but local resources are not sufficient to treat them. Emergency medical services (EMS), including ambulance transport, bridge the gap between local services and higher-level hospital care, and data collected by EMS could be used to elucidate patterns of paediatric health care need and use. Here we conducted a retrospective observational study of patterns of paediatric use of EMS services by children who used EMS in India, a leader in maternal and child EMS development, to inform public health needs and system interventions to improve EMS effectiveness., Methods: We analysed three years (2013-2015) of data from patients <18 years of age from a large prehospital EMS system in India, including 1 101 970 prehospital care records across 11 states and a union territory., Results: Overall, 38.3% of calls were for girls (n = 422 370), 40.5% were for adolescents (n = 445 753), 65.9% were from rural areas (n = 726 154), and most families were from a socially disadvantaged caste or lower economic status (n = 834 973, 75.8%). The most common chief complaints were fever (n = 247 594, 22.5%), trauma (n = 231 533, 21.0%), and respiratory difficulty (n = 161 120, 14.6%). However, transport patterns, including patient sex and age and type of destination hospital, varied by state, as did data collection., Conclusions: EMS in India widely transports children with symptoms of the leading causes of child mortality and provides access to higher levels of care for geographically and socioeconomically vulnerable populations, including care for critically ill neonates, mental health and burn care for girls, and trauma care for adolescents. EMS in India is an important mechanism for overcoming transport and cost as barriers to access, and for reducing the urban-rural gap found across causes of child mortality. Further standardisation of data collection will provide the foundation for assessing disparities and identifying targets for quality improvement of paediatric care., Competing Interests: Disclosure of interests: All authors have completed the ICMJE Disclosure of Interest Form (available on request from the corresponding author) and declare: Stanford Department of Emergency Medicine funded this work, GR is the Director of the Emergency Medicine Learning Center for GVK EMRI and the Stanford Department of Emergency Medicine is an academic partner to GVK EMRI advising on education and research endeavours., (Copyright © 2022 by the Journal of Global Health. All rights reserved.)

Background: Advanced Trauma Life Support field triage utilizes the Glasgow Coma Scale (GCS) to assess the level of consciousness. However, prehospital care providers in low- and middle-income countries (LMICs) often use the Alert, Verbal, Pain, and Unresponsive (AVPU) scale to assess the level of consciousness. This study aimed to determine whether prehospital AVPU categorization correlates with mortality rates in trauma victims, similarly to GCS., Methods: In this cross-sectional study conducted between November 2015 and January 2016, we enrolled a convenience sample of prehospital trauma-related field activations. The primary outcome measure was the probability of death within 48 h for each category of AVPU., Results: In a convenience sample of 4514 activations, 1606 (35.6%) met exclusion criteria, four did not have AVPU, and four did not have GCS, leaving 2900 (64.2%) trauma activations with both AVPU and GCS available for analysis. Forty-eight-hour follow-up data were available for 2184 (75.3%) activations out of these 2900. The 48-h mortality rates for each category of AVPU were 1.1% (Alert), 4.3% (Verbal), 17.9% (Pain), 53.2% (Unresponsive); and, for each GCS-based injury severity category, they were 0.9% (Mild, GCS 13-15), 8.1% (Moderate, GCS 9-12), 43.5% (Severe, GCS ≤ 8). Overall, there was a statistically significant difference in GCS for each category of AVPU (p < 0.001) except between patients responding to verbal commands and those responding to pain (p = 0.18). The discriminative ability of AVPU (AUC 79.7% (95% CI 73.4-86.1)) and GCS (AUC 81.5% (95% CI 74.8-88.2)) for death within 48-h following hospital drop-off were comparable., Conclusion: EMT assessments of AVPU and GCS relate to each other, and AVPU predicts mortality at 48 h. Future studies using AVPU to assess the level of consciousness in prehospital trauma protocols may simplify their global application without impacting the overall quality of care., Competing Interests: Declaration of Competing Interest SAM, SRJ, MCS, MAK, and JAN do not have any conflict of interest to disclose. GVR is a full-time employee of the GVK Emergency Management Research Institute, which operates the ambulance services studied here., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Paediatric out-of-hospital cardiac arrest (OHCA) results in high mortality and poor neurological outcomes. We conducted this study to describe and compare the effects of pre-hospital airway management on survival outcomes for paediatric OHCA in the Asia-pacific region., Methods: We performed a retrospective analysis of the Pan Asian Resuscitation Outcomes Study (PAROS) data from January 2009 to June 2018. PAROS is a prospective, observational, multi-centre cohort study from eleven countries. The primary outcomes were one-month survival and survival with favourable neurological status, defined as Cerebral Performance Category1 or 2. We performed multivariate analyses of the unmatched and propensity matched cohort., Results: We included 3131 patients less than 18 years in the study. 2679 (85.6%) children received bag-valve-mask (BVM) ventilations, 81 (2.6%) endotracheal intubations (ETI) and 371 (11.8%) supraglottic airways (SGA). 792 patients underwent propensity score matching. In the matched cohort, advanced airway management (AAM: SGA and ETI) when compared with BVM group was associated with decreased one-month survival [AAM: 28/396 (7.1%) versus BVM: 55/396 (13.9%); adjusted odds ratio (aOR), 0.46 (95% CI, 0.29 - 0.75); p = 0.002] and survival with favourable neurological status [AAM: 8/396 (2.0%) versus BVM: 31/396 (7.8%); aOR, 0.22 (95% CI, 0.10 - 0.50); p < 0.001]. For SGA group, we observed less 1-month survival [SGA: 24/337 (7.1%) versus BVM: 52/337 (15.4%); aOR, 0.41 (95 %CI, 0.25-0.69), p = 0.001] and survival with favourable neurological status., Conclusion: In children with OHCA in the Asia-Pacific region, pre-hospital AAM was associated with decreased one-month survival and less favourable neurological status., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: MEH Ong reports funding from the Zoll Medical Corporation for a study involving mechanical cardiopulmonary resuscitation devices; grants from the Laerdal Foundation, Laerdal Medical, and Ramsey Social Justice Foundation for funding of the Pan-Asian Resuscitation Outcomes Study; an advisory relationship with Global Healthcare SG, a commercial entity that manufactures cooling devices; and funding from Laerdal Medical on an observation program to their Community CPR training Centre Research Program in Norway. MEH Ong has a licensing agreement and patent filed (Application no: 13/047,348) with ZOLL Medical Corporation for a study titled “Method of predicting acute cardiopulmonary events and survivability of a patient. He is also the co-founder and scientific advisor of TIIM Healthcare, a commercial entity which develops real-time prediction and risk stratification solutions at triage. All other authors have no conflict of interest to declare., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Women in South Asia face the highest lifetime prevalence of intimate partner violence in the world, which is just one form of violence against women (VAW). In India, few women seek help after experiencing violence, particularly from formal resources, such as physicians or the police. While many studies have investigated the impact of survivor characteristics and patterns of violence on help-seeking behaviors, there is scant research on support service characteristics and their impact on help-seeking. The introduction of a novel crisis helpline in Gujarat, India provided an opportunity to better understand how successful help-seeking can be driven by the perceived and experienced characteristics of the helpline. We conducted in-depth interviews with helpline users to identify factors and pathways that promoted or discouraged help-seeking in general, help-seeking from a formal source, and help-seeking from this particular helpline. We analyzed 32 interviews of women who used the helpline. Participants were from eight districts across the state, representing a diverse range of sociodemographic backgrounds. After conducting a thematic analysis, we found that action-oriented service, timeliness, and women-focused staff influenced (positively and negatively) participants' feelings of safety, empowerment, and trust in the helpline, which ultimately impacted their decision to seek help from the helpline or even to seek help at all. This study illuminates how service characteristics, in and of themselves, can influence the likelihood that survivors will seek help, emphasizing the need for survivors to have a voice in the growth and refinement of VAW support services. Consequently, these areas must be a focus of future research and initiatives to improve help-seeking by VAW survivors.

Mental health is a major public health issue that calls for immediate steps by individuals and societies around the globe. Talking about mental health issues has always been considered a taboo, especially in lower-middle income countries. This paper assesses the role of GVK Emergency Management Research Institute (GVK EMRI) 108 Ambulance Services in the management of behavioral emergencies in the state of Telangana, India. Primary data collection was carried out in Devaryamjal village of Medchal District with people from both rural and urban setting. The use of management services for behavioral emergencies are described, and knowledge attitude and practices in communities regarding the use of these services are identified. The impact of the Covid-19 pandemic on the mental health of individuals is considered as well, and recommendations to strengthen 108 services for managing behavioral emergencies are suggested. As GVK EMRI is a first responder organization, understanding its role in the field of behavioral emergencies can fundamentally impact several lives. Findings indicate that mental health problems exist in communities, but individuals are reluctant to seek help. People from the urban setting were more open to talk about the topic. The awareness of 108 as an emergency response service was immaculate and a positive view was held about the services and the organization., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Bystander cardiopulmonary resuscitation (BCPR) is a critical component of the 'chain of survival' in reducing mortality among out-of-hospital cardiac arrest (OHCA) victims. Inconsistent findings on gender disparities among adult recipients of layperson BCPR have been reported in the literature. We aimed to fill this knowledge gap by investigating the extent of gender disparities in a cross-national setting within Pan-Asian communities., Methods: We utilised data collected from the Pan-Asian Resuscitation Outcomes Study (PAROS), an international, multicentre, prospective study conducted between 2009 and 2018. We included all OHCA cases with non-traumatic arrest aetiology transported by emergency medical services and excluded study sites that did not consistently collect information about the location of cardiac arrest. Logistic regression was used to analyse the association between gender and BCPR, stratified by location., Findings: We analysed a cohort of 56,192 OHCA cases with an overall BCPR rate of 36.2% (20,329/56,192). At public locations, the BCPR rate was 31.2% (631/2022) for female and 36.4% (3235/8892) for male OHCA victims; while at home, the rate was 38.3% (6838/17,842) for females and 35.1% (9625/27,436) for males. Controlling for site differences and several factors in multivariable logistic regression, we found females less likely to receive BCPR than males in public locations (odds ratio [OR]=0.89, 95% confidence interval [CI]: 0.70-0.99), but more likely to receive BCPR at home (OR=1.16, 95% CI: 1.11-1.21)., Interpretation: In Pan-Asian communities, gender differences exist in adult recipients of BCPR and differ between home and public locations. Future studies should account for additional information on bystanders and societal factors to identify targets for interventions., Funding: The study was supported by grants from the National Medical Research Council (NMRC/CSA/0049/2013) and Laerdal Foundation (20040)., Competing Interests: MEH Ong reports funding from the ZOLL Medical Corporation for a study involving mechanical cardiopulmonary resuscitation devices; grants from the Laerdal Foundation, Laerdal Medical, and Ramsey Social Justice Foundation for funding of the Pan-Asian Resuscitation Outcomes Study; an advisory relationship with Global Healthcare SG, a commercial entity that manufactures cooling devices; and funding from Laerdal Medical on an observation program to their Community CPR raining centre Research Program in Norway. MEH Ong has a licensing agreement and a patent filed (Application no: 13/047,348) with ZOLL Medical Corporation for a study titled "Method of predicting acute cardiopulmonary events and survivability of a patient. All other authors have no conflict of interests to declare., (© 2022 The Authors.)

Aims and Objectives: The objective of this study is to study, assess and compare the socio-demographic profile, psychiatric morbidity, cognitive functioning, quality of life and social support of senior citizens in care homes as well as in the communities., Material and Methods: Hundred subjects (50 were from old-age home and the rest were from the community) were assessed using intake pro forma details and an interview questionnaire. The Geriatric Mental Status questionnaire, Mini-Mental Status Examination, Quality of Life Support, and Multidimensional Scale of Perceived Social Support scales were then performed on each subject from the two groups in that order, and they were rated on all scales., Results: Individuals with lack of spouse and lack of children were higher and common attitude was death in old-age homes. Past history of psychiatric illnesses was more in the inmates of old-age homes. Memory disturbances, concentration problems, hypochondriasis, somatic dysfunction, error behaviour, thought disturbances, perceptual disturbances, persecution, expressed happiness and satisfaction were greater in the inmates of old-age care homes. The quality of life was poor in community group than in old-age home group., Conclusion: There is a need to increase community and health-care professional awareness of mental health problems in later life, as well as improve access to appropriate geriatric and mental healthcare., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Family Medicine and Primary Care.)

Background: Emergency medical services (EMS) in India face enormous challenges in providing care to a geographically expansive and diverse patient population. Over the last decade, the public-private-partnership GVK EMRI (Emergency Management and Research Institute) has trained over 100,000 emergency medical technicians (EMTs), with greater than 21,000 currently practicing, to address this critical gap in the healthcare workforce. With the rapid development and expansion of EMS, certain aspects of specialty development have lagged behind, including continuing education requirements. To date, there have been no substantial continuing education EMT skills and training efforts. We report lessons learned during development and implementation of a continuing education course (CEC) for EMTs in India., Methods: From 2014 to 2017, we employed an iterative process to design and launch a novel CEC focused on five core emergency competency areas (medicine and cardiology, obstetrics, trauma, pediatrics, and leadership and communication). Indian EMT instructors and providers partnered in design and content, and instructors were trained to independently deliver the CEC. Many challenges had to be overcome: scale (>21,000 EMTs), standardization (highly variable skill levels among providers and instructors), culture (educational emphasis on rote memorization rather than practical application), and translation (22 major languages and a few hundred local dialects spoken nationwide)., Lessons Learned: During the assessment and development phases, we identified five key strategies for success: (1) use icon-based video instruction to ensure consistent quality and allow voice-over for easy translation; (2) incorporate workbooks during didactic videos and (3) employ low-cost simulation and case discussions to emphasize active learning; (4) focus on non-technical skills; (5) integrate a formal training-of-trainers prior to delivery of materials., Conclusion: These key strategies can be combined with innovation and flexibility to address unique challenges of language, system resources, and cultural differences when developing impactful continuing educational initiatives in bourgeoning prehospital care systems in low- and middle-income countries., Competing Interests: The authors report no conflicts of interest for this work., (© 2020 Lindquist et al.)

Background: In India, acute respiratory illnesses, including pneumonia, are the leading cause of early childhood death. Emergency medical services are a critical component of India's public health infrastructure; however, literature on the prehospital care of pediatric patients in low- and middle-income countries is minimal. The aim of this study is to describe the demographic and clinical characteristics associated with 30-day mortality among a cohort of pediatric patients transported via ambulance in India with an acute respiratory complaint., Methods: Pediatric patients less than 18 years of age using ambulance services in one of seven states in India, with a chief complaint of "shortness of breath", or a "fever" with associated "difficulty breathing" or "cough", were enrolled prospectively. Patients were excluded if evidence of choking, trauma or fire-related injury, patient was absent on ambulance arrival, or refused transport. Primary exposures included demographic, environmental, and clinical indicators, including hypoxemia and respiratory distress. The primary outcome was 7 and 30-day mortality. Multivariable logistic regression, stratified by transport type, was constructed to estimate associations between demographic and clinical predictors of mortality., Results: A total of 1443 patients were enrolled during the study period: 981 (68.5%) were transported from the field, and 452 (31.5%) were interfacility transports. Thirty-day response was 83.4% (N = 1222). The median age of all patients was 2 years (IQR: 0.17-10); 93.9% (N = 1347) of patients lived on family incomes below the poverty level; and 54.1% (N = 706) were male. Cumulative mortality at 2, 7, and 30-days was 5.2%, 7.1%, and 7.7%, respectively; with 94 deaths by 30 days. Thirty-day mortality was greatest among those 0-28 days (N = 38,17%); under-5 mortality was 9.8%. In multivariable modeling prehospital oxygen saturation <95% (OR: 3.18 CI: 1.77-5.71) and respiratory distress (OR: 3.72 CI: 2.17-6.36) were the strongest predictors of mortality at 30 days., Conclusions: This is the first study to detail prehospital predictors of death among pediatric patients with shortness of breath in LMICs. The risk of death is particularly high among neonates and those with documented mild hypoxemia, or respiratory distress. Early recognition of critically ill children, targeted prehospital interventions, and diversion to higher level of care may help to mitigate the mortality burden in this population., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Professional wellness is critical to developing and maintaining a health care workforce. Previous work has identified burnout as a significant challenge to professional wellness facing emergency medical technicians (EMTs) in many countries worldwide. Our study fills a critical gap by assessing the prevalence of burnout among emergency medical technicians (EMTs) in India., Methods: This was a cross-sectional survey of EMTs within the largest prehospital care organization in India. We used the Maslach Burnout Inventory (MBI) to measure wellness. All EMTs presenting for continuing medical education between July-November 2017 from the states of Gujarat, Karnataka, and Telangana were eligible. Trained, independent staff administered anonymous MBI-Medical Personnel Surveys in local languages., Results: Of the 327 EMTs eligible, 314 (96%) consented to participate, and 296 (94%) surveys were scorable. The prevalence of burnout was 28.7%. Compared to EMTs in other countries, Indian EMTs had higher levels of personal accomplishment but also higher levels of emotional exhaustion and moderate levels of depersonalization. In multivariate regression, determinants of burnout included younger age, perceived lack of respect from colleagues and administrators, and a sense of physical risk. EMTs who experienced burnout were four times as likely to plan to quit their jobs within one year., Conclusion: This is the first assessment of burnout in EMTs in India and adds to the limited body of literature among low- and middle-income country (LMIC) prehospital providers worldwide. Burnout was strongly associated with an EMT's intention to quit within a year, with potential implications for employee turnover and healthcare workforce shortages. Burnout should be a key focus of further study and possible intervention to achieve internationally recognized targets, including Sustainable Development Goal 3C and WHO's 2030 Milestone for Human Resources., Competing Interests: The authors have declared that no competing interests exist.

Introduction Miscommunication during patient handoff contributes to an estimated 80% of serious medical errors and, consequently, plays a key role in the estimated five million excess deaths annually from poor quality of care in low- and middle-income countries (LMICs). Objective The objective of this study was to assess signout communication during patient handoffs between prehospital personnel and hospital staff. Methods This is a cross-sectional study, with a convenience sample of 931 interfacility transfers for pregnant women across four states from November 7 to December 13, 2016. A complete signout, as defined for this study, contains all necessary signout elements for patient care exchanged verbally or in written form between an emergency medical technician (EMT) and a physician or nurse. Results Enrollment of 786 cases from 931 interfacility transfers resulted in 1572 opportunities for signout. EMTs and a physician or nurse signed out in 1549 cases (98.5%). Signout contained all elements in 135 cases (8.6%). The mean percentage of signout elements included was 45.2% (95% CI, 43.9-46.6). Physician involvement was correlated with a higher mean percent (63.4% [95% CI, 62-64.8]) compared to nurse involvement (23.6% [95% CI, 22.5-24.8]). With respect to the frequency of signout communication, 63.1% of EMTs reported often or always giving signout, and 60.5% reported often or always giving signout; they reported feeling moderately to very comfortable with signout (73.7%) and 34.1% requested further training. Conclusions Physicians, nurses, and the EMTs conducted signout 99% of the time but often fell short of including all elements required for optimal patient care. Interventions aimed at improving the quality of patient care must include strengthening signout communication., Competing Interests: GV Ramana Rao and Aruna Gimkala, two co-authors, are employees of GVK Emergency Management and Research Institute where this study is conducted., (Copyright © 2020, Janagama et al.)

Background: Dispatch services (DS's) form an integral part of emergency medical service (EMS) systems. The role of a dispatcher has also evolved into a crucial link in patient care delivery, particularly in dispatcher assisted cardio-pulmonary resuscitation (DACPR) during out-of-hospital cardiac arrest (OHCA). Yet, there has been a paucity of research into the emerging area of dispatch science in Asia. This paper compares the characteristics of DS's, and state of implementation of DACPR within the Pan-Asian Resuscitation Outcomes (PAROS) network., Methods: A cross-sectional descriptive survey addressing population characteristics, DS structures and levels of service, state of DACPR implementation (including protocols and quality improvement programs) among PAROS DS's., Results: 9 DS's responded, representing a total of 23 dispatch centres from 9 countries that serve over 80 million people. Most PAROS DS's operate a tiered dispatch response, have implemented medical oversight, and tend to be staffed by dispatchers with a predominantly medical background. Almost all PAROS DS's have begun tracking key EMS indicators. 77.8% (n = 7) of PAROS DS's have introduced DACPR. Of the DS's that have rolled out DACPR, 71.4% (n = 5) provided instructions in over one language. All DS's that implemented DACPR and provided feedback to dispatchers offered feedback on missed OHCA recognition. The majority of DS's (83.3%; n = 5) that offered DACPR and provided feedback to dispatchers also implemented corrective feedback, while 66.7% (n = 4) offered positive feedback. Compression-only CPR was the standard instruction for PAROS DS's. OHCA recognition sensitivity varied widely in PAROS DS's, ranging from 32.6% (95% CI: 29.9-35.5%) to 79.2% (95% CI: 72.9-84.4%). Median time to first compression ranged from 120 s to 220 s., Conclusions: We found notable variations in characteristics and state of DACPR implementation between PAROS DS's. These findings will lay the groundwork for future DS and DACPR studies in the PAROS network.

Objectives: The purpose of this study was twofold: (1) establish the prevalence of safety threats and workplace violence (WPV) experienced by emergency medical technicians (EMTs) in a low/middle-income country with a new prehospital care system, India and (2) understand which EMTs are at particularly high risk for these experiences., Setting: EMTs from four Indian states (Gujarat, Karnataka, Tamil Nadu and Telangana) were eligible to participate during the study period from July through November 2017., Methods: Cross-sectional survey study., Participants: 386 practicing EMTs from four Indian states., Results: The overall prevalence of any WPV was 67.9% (95% CI 63.0% to 72.5%). The prevalence of physical assault was 58% (95% CI 52.5% to 63.4%) and verbal assault was 59.8% (95% CI 54.5% to 65%). Of physical assault victims, 21.7% were injured and 30.2% sought medical attention after the incident. Further, 57.3% (n=216) of respondents reported they were 'somewhat worried' and 28.4% (n=107) reported they were 'very worried' about their safety at work., Conclusion: WPV and safety fears were found to be common among EMTs in India. Focused initiatives to counter WPV in countries developing prehospital care systems are necessary to build a healthy and sustainable prehospital healthcare workforce., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

We studied the pregnant women, who requested a '108' ambulance in two Indian states (Andhra Pradesh (AP) and Himachal Pradesh (HP)). We conducted a cross-sectional telephone survey to study the characteristics and outcomes of those who (1) were transported using '108' ambulance, (2) were sent '108' ambulance but did not use it and (3) were not assigned a '108' ambulance. We conducted interviews within 24 hours of clients' call and followed them up at 48 hours, on the 7th and 28th day. 90% of pregnant women callers in AP and only 16% in HP were from poorer socioeconomic circumstances. 22.5% of women who were not provided an ambulance in HP lived in tribal areas. A higher proportion of women who were transported using '108' reported either a high-risk condition (AP, 22%; HP, 27%) or an early complication in pregnancy (AP and HP, 16%), compared with the other groups (AP, 18% and 8%; HP, 19% and 16%). In AP, women who were sent an ambulance but did not use it had higher prevalence of obstetric emergency (9.8%) compared with the other groups (ambulance used, 7.4%; not assigned, 4.1%). One-fifth of women in AP and one-seventh in HP delivered by caesarean section. One woman who called, but was not transported by '108', died in AP. Ten stillbirths and 22 neonatal deaths were reported in AP and 17 and 16, respectively, in HP. Strategies are required to improve '108' service for tribal areas in HP. The '108' services should be improved to reduce non-use of ambulance, especially for women who report obstetric emergencies., Competing Interests: Competing interests: None declared.

Objectives: To describe the demographic characteristics and clinical outcomes of neonates born within 7 days of public ambulance transport to hospitals across five states in India., Design: Prospective observational study., Setting: Five Indian states using a centralised emergency medical services (EMS) agency that transported 3.1 million pregnant women in 2014., Participants: Over 6 weeks in 2014, this study followed a convenience sample of 1431 neonates born to women using a public-private ambulance service for a 'pregnancy-related' problem. Initial calls were deemed 'pregnancy related' if categorised by EMS dispatchers as 'pregnancy', 'childbirth', 'miscarriage' or 'labour pains'. Interfacility transfers, patients absent on ambulance arrival, refusal of care and neonates born to women beyond 7 days of using the service were excluded., Main Outcome Measures: death at 2, 7 and 42 days after delivery., Results: Among 1684 women, 1411 gave birth to 1431 newborns within 7 days of initial ambulance transport. Median maternal age at delivery was 23 years (IQR 21-25). Most mothers were from rural/tribal areas (92.5%) and lower social (79.9%) and economic status (69.9%). Follow-up rates at 2, 7 and 42 days were 99.8%, 99.3% and 94.1%, respectively. Cumulative mortality rates at 2, 7 and 42 days follow-up were 43, 53 and 62 per 1000 births, respectively. The perinatal mortality rate (PMR) was 53 per 1000. Preterm birth (OR 2.89, 95% CI 1.67 to 5.00), twin deliveries (OR 2.80, 95% CI 1.10 to 7.15) and caesarean section (OR 2.21, 95% CI 1.15 to 4.23) were the strongest predictors of mortality., Conclusions: The perinatal mortality rate associated with this cohort of patients with high-acuity conditions of pregnancy was nearly two times the most recent rate for India as a whole (28 per 1000 births). EMS data have the potential to provide more robust estimates of PMR, reduce inequities in timely access to healthcare and increase facility-based care through service of marginalised populations., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)