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Many accident victims end up riding in what are essentially taxis masquerading as ambulances, said Dr. Shakti Kumar Gupta, who is helping the government draft a national code to standardize ambulances.

Emergency workers too are not properly trained. Rahul, 24, who uses just one name, is a high school dropout and failed mechanic who managed to find work as an ambulance assistant. His job is to load patients on and off the ambulance, and if needed, set up their oxygen supply. Often, he is the closest thing to a paramedic patients get.

There were no emergency medical technicians in India less than a decade ago, and only about 10,000 have been trained since 2005 in the nation of 1.2 billion, said Subodh Satyawadi, chief executive of the Emergency Management and Research Institute. By contrast, the United States has 240,000 for a population that is a fourth of India‘s.

EMRI is one of the largest contributors to India’s emergency workforce, but the government doesn’t recognize their courses or those of other such institutions. There is a Paramedical Council of India, but they train technicians in areas like dialysis and echocardiograms _ not emergency care.

Dr. Angel Rajan Singh, a member of the government’s workgroup on emergency medicine, said there is no standard to distinguish between trained paramedics and those off the street. He said a national emergency authority has been proposed.

Even emergency rooms suffer from a lack of specialized trauma training. Emergency medicine was recognized as a subject only in 2009, and the programs accredited by the Medical Council of India admit only 22 doctors every year. The first batch won’t even graduate until 2014.

“The government’s guidelines were, and still are, impractically stringent,” said Apollo HospitalsDr. Joshi. He said even non-accredited programs run by the private sector have trained less than 500 trauma physicians.

Most emergency rooms are overburdened, with three or four doctors and a couple of interns managing several dozen cases at a time, said Dr. Arshad Anjum, a professor at Aligarh’s university medical college.

At a packed emergency room in Delhi recently, patients with broken limbs, bleeding wounds, even burns kept piling up until they were forced to share beds, and when those ran out, stretchers.

Waiting for care can have tragic consequences, as it nearly did for Bharat Singh’s brother.

“If the delay had been any longer, we wouldn’t have been able to reattach the torn muscle,” said Dr. S.K. Das, the orthopedic surgeon who performed the operation. “In fact, he almost lost his leg.”