Saturday, 4 April 2020

The WACEM-ACAIM Joint 3rd Special Global Web Conference on Case Based Lessons from COVID19 patients across the World

4th April 2020


Telemedicine for home monitoring of discharged patients and other complaints is in full use as numbers in Italy start to trend south.


Point of Care Pulse Ox assessment at triage should identify silent Hypoxia Assessment via rest and stress check after one-minute walk.

Order Labs and X-ray Chest.

An inconclusive chest X-ray should prompt plain CT of the chest. If the CT is positive then the patient is admitted.

Negative CT Chest should prompt an evaluation to rule out COVID Myocarditis / PE as COVID has shown to have cardiac effects and thrombotic tendencies.

CTA is done when there is a high suspicion for PE. Additional POCUS Cardiac exam is done. D-Dimer routinely is high in COVID patients.

The PE algorithm should be followed keeping in mind that AKI and dehydration can be present.

Kidney Dysfunction

GFR and trending the creatinine in last 7 weeks is good enough to evaluate the kidney status in addition to creatinine.

High Sensitivity Troponin is an efficient marker to r/o myocarditis.

Non-COVID Pathologies:
The emphasis was that other pathologies do exist and we have to keep that in mind as we evaluate COVID patients and vice versa.

Hematological / Metabolic Markers
Neutropenia, Lymphopenia, Hypokalemia and High Fibrinogen levels have been found in COVID19 patients.

Routine dosing that the experts recommended for patients admitted.

Extra-Pulmonary manifestations of COVID19
AMS / Seizures / Delirium / Encephalopathy / Myocarditis / N / V/ D / Rhabdomyolysis / AKI / Thrombosis / Embolism were the major manifestations mentioned by experts.   

Saturday, 28 March 2020

The WACEM Second Special Global Web Conference on “ Emergency Shock , Resuscitation in COVID19”

Date: 28/3/20

With gratitude to all our global participants today for sharing your experiences and advice.

1) Multi-use Ventilator-Patient Dyssynchrony : 
Consider the major problem of ventilator triggers when optimizing use for multiple patients. Adequate sedation is key.

- Should be used in conjunction with CVTS and experienced team/units.
- Consider outcome potential, with best potential in young, otherwise fit individuals. Older patients with co-morbidities and multi-organ failure are poor candidates for consideration of this limited resource.

3) Aggressive Diagnostic CT
Consider balancing the use of your CT resources with the time and resource limiting factors. 

Bedside POCUS use by trained operators.

5) CRP/Procalcitonin 
There are of more value in serial measurements than to use as absolute diagnostic or discharge criteria.

6) Neutrophil to Lymphocyte ratio

7) Co-infection
COVID-19 is being diagnosed as either the primary or the co-infection in cases of Sepsis / Trauma / Cardiology presentations. To be kept in mind. ACLS / ATLS should be done as per protocol.
Broad spectrum antibiotics for at-least 48 hours until negative cultures obtained if Sepsis protocol is being followed. Do not forget Non COVID19 Sepsis and other pathologies continue to exist and cannot be missed. Fluid management and Ventilator support should follow ARDS protocols.  

8) PCR sampling 
Of more use in milder infections and targeting health care professionals than a wider use screening tool. 

9) OP/NP sampling
Moderate sensitivities shown. Potential for late positives. Efforts should be made to reduce sampling errors.

10) Disaster preparedness
Countries/regions with good disaster preparedness protocols and experience are fairing better than those without. Successful models or successful features from developing models should be shared and inculcated into global practice.

10) Discharge Criteria
Silent Hypoxia is the major factor which can impede discharge from ED. Other factors like Fever and Low Lymphocyte count should take presence / Absence of Hypoxia as a Major criteria to discharge or admit the patient.

Please read post covering previous meeting talking points for completeness.  

Sunday, 22 March 2020

The WACEM Compilation of Open Access Resources for COVID-19 (Updated 28th March 2020)

Compilation of Open Access Resources for COVID-19

(With gratitude to all contributors for sharing your wisdom, resources, experiences and ideas)
The disease is new, thus the knowledge evolving and dynamic.

I'll be updating the list as time permits.

1) Website: OnepagerICU: by

2) Website: Propofology: UK-based FOAMed; (twitter user Gas_Craic)

3) Society of Critical Care Medicine…/Surviving-Sepsis-Campaign-Guidelines-on-…… Guidelines for management of the acutely unwell with COVID-19

4) Blog: New to ITU by (twitter user SamIAm_UK)
ICU basics for to ICU.

Guide to Chest CT in COVID-19 (twitter profile PulmCCM)

CDC's Infection Control Guidance

7) Website: CDC posters on how to don/doff PPE:

8) Summary thread of SCCM guidelines by twitter user @virenkaul (New York based Pulmonologist/ICM doctor)

9) Simulations resource and experience sharing by twitter user @cliffreid (Sydney based EM/ICM/PHEM doctor)

10) Nitrates in acute pulmonary edema secondary to LVF by @cliffreid (Sydney based EM/ICM/PHEM doctor)
11) Influenza vs. COVID19 infographic by @CPSolvers

12) Airway Pressure Release Ventilation by @eddyjoemd (Intensivist, unsure where) *also has resource rich Instragram account

13) Optimizing ventilator capacity by @SJH_EM (Detroit based EM)

+ Published journal article: 
Increasing Ventilator capacity By Lorenzo Paladino et. al 

14) Innovation: Plexiglass barrier, by twitter user @alison4WI…

15) Experience: From Madrid, by twitter user @mgalandejuana

16) Innovation: 3D printed ventilator, by twitter user @sonalasthana

17) Experience: Document shared by Italian College of Anaesthesia/Analgesia/Resuscitation/Intensive Care, by twitter user @Yascha_Mounk

18) Indo-Pacific Management guidelines by Australasian College of Emergency Medicine:…/Managing-COVID-19-across-the-Indo-Pac… 

19) COVID-19 and Children, Website: Don't Forget The Bubbles:…/Managing-COVID-19-across-the-Indo-Pac…

20) Experience/Innovation: Extubation in COVID-19 by twitter user @StephenLap

21) Journal: Treatment of severed ARDS, in The Lancet:…/PIIS2213-2600(20)30127…/fulltext

22) Website: COVID-19 prevention, REBELEM (laid out neatly!)

23) Twitter: Mask Basics (From REBELEM) by twitter user: @ srrezaie

24) Mass General Hospital guidelines for management of COVID-19 shared by twitter user @HarvardPulm

24) Important Reminder re: caution in using Chloroquine shared by twitter user @CMichaelGibson 25) NEJM Paper: SARS – COV – 2 Infection in Children
26) REBEL EM’s Airway Management (with further resources scouted within)
27) FOAMcast’s COVID Timeline: 28) NHS COVID-19 Admission Guidance 29) NebraskaMed N95 decontamination process:
--- Originally published: 22/3/20 ---
--- Updated: 28/3/20 ---

Saturday, 21 March 2020

The WACEM Inaugural Special Global Web Conference on “The Emergency Physicians Response to COVID19 across the World”

21st March 2020

The WACEM Special Global Web Conference on
“The Emergency Physicians Response to COVID19 across the World”

Eminent Academic Experts from USA, Italy, UK, Netherlands, Qatar, India and many other places participated in this specially convened Web Conference.  

The Key Take Home Points:

The Patient Care Paradigm will be the most defining as number of patients mount up.

Non-COVID19 sick patients and health care providers need protection ASAP.

Viral Load and virulence is variable across patient population. Greater the co-morbidity greater the severity even though there are healthy sick patients.

Few of the leaders on the Conference are infected and have signs of severe weakness, Diarrhea, Nausea, Vomiting and extreme myalgia and fatigue. They are healthy!

“SILENT HYPOXIA” needs to be recognized. Patients look fatigued and are low temp but are Hypoxic.

Hospitals need to consider being locked down. Exit Doors open to EXIT ONLY, no visitors, and one point entry outside the hospital in a separate tent where fully gowned personnel check vitals temperature and recognize high-risk patients for further testing in a special area in isolation.

Airborne and Droplet precautions are important.

Health Providers need PPE and that demand will rise and is paramount.

Hospitals Need for Ventilators and Critical Care beds will rise.

Qatar Model of Erecting Field Hospitals, Quarantining in Hotels and ramping up of critical Care beds was applauded.

Telemedicine to care for the STABLE SICK is recommended.

Antimalarial Chloroquine, Antibiotic Azithromycin and Anti-Viral Remesdivir are all being recommended but we still need outcomes data. THEY ARE NOT FOR PROPHYLAXIS.

POCUS Lung Ultrasound, HsTrop and D Dimer can be used to predict mortality.

Provider Safety and in-patient safety and surge management are all key.

Sharing of all protocols for Triage, Isolation, Discharge, Admission, NIV, Ventilation, and Resuscitation is needed.

Be Safe and God Bless Everyone !

Get well Soon Leaders !

Next Update very soon !

The World Academic Council of Emergency Medicine

Sunday, 12 August 2018

Self-Study Path for MD/DNB PG Residents in Emergency Medicine in India

Path to Success Lies with the one who succeeds

After nearly a decade in Academics and the struggle to standardize Emergency Medicine Post Graduate Training in India I have come to realize that the only way  Residents in MD/DNB can succeed is Standardize Themselves to a Discipline which will build their knowledge and skills.

I am laying out a Plan which the residents can follow to help them achieve their goals.

Studying Hard is key and following the plan is vital.
It is similar to a weight loss plan and I call it Ignorance Loss Plan in EM…

Ground Rules:

Residents have a 1000 days to learn, commit mistakes and correct them.

Using every day , every moment is key.

Residents don’t need a Degree to Learn and should not think that they can learn after MD/DNB because that takes away few years from the life of performance.


PGY 1:

Finish ATLS ACLS PALS AUTLS within the first three months of starting. It’s crucial because having Resuscitation mastered is key to building on knowledge.

Start Read 10 pages a day of Tintinalli RELIGIOUSLY and that’s easy.

ACEE-INDIA has set up monthly tests which will guide Residents in knowing whether they are reading the correct clinical perspectives.

Finishing the tests in year one will help you build a thinking capacity to build your deeper knowledge on.

This is a Tested model since last 10 years and many have used and benefited from it including many residents who took it up during their training.

Try to find an Ophthalmologist who can train you on how to use a Slit lamp and also do Fluorescein Testing and use the Tonometer.

Try to do some Pelvic Exams with OB/GYN Experts so you know what to look for.
Try and Learn Suturing and also ENT Exam from ENT Colleagues. Everyday Cases are done in Operating Room.

Go at 6 am and Intubate with an anesthetist.

See all Procedural YouTube Videos.

Master Clinical Exam in Cunningham’s (Medicine); Love&Baily (Sx); Dutta (OB) and Nelson (Peads): Mastering The clinical Exam is key.



Repeat the 10 pages a day cycle and start reading Journals

Start Mastering EKG-Suturing-Splinting

Start work on a Publishable Research Project


 Repeat the 10 pages a day cycle and continue reading Journals

Go on to read FOAMED and data on websites because by this time you have read the book twice and seen tons of cases to be able to master to the subject.

Start Preparing for Exams

Complete the Thesis.

Attending The National Emergency Medicine Board Review of India Course. NEMBRIC held at National Board of Examinations / New Delhi every year.

Attend the EXAMATHALON which is held in Kerala every year in First half of the year which helps you using Mock Examination patterns for training.


Disclaimer: Many Residents are forced to attend Conferences. Remember You don't go to a conference to gain Resident Level Knowledge...That's done in your PG Training.

Be smart and Know who is speaking on the stage ... Realize whether that person who claims to be an Expert Specialist is really qualified to speak...Time is crucial don't waste it and gain knowledge from someone who is not qualified.

I have laid out a Conference which is called EMINDIA held every July and focusses on a Model where Patient Cases are Presented by Residents and Faculty and both equally discuss and debate patient care. Its a Case Based Learning Conference :

The Conference Model is ACADEMIC MODEL with low Registration fee and totally disregards the Cut Paste Lecture Format and 5 Star Conferencing Tourism Registration Model which is being practiced.

Below are few papers which will help the residents:

Pediatric Fever:

Chest Pain:

Developing a Department of Academic EM:


I want you all to realize that I want you all to succeed. I am a hard core academician and respect and worship The Goddess of Knowledge. I believe that this is the knowledge which brings food to my table and this is the knowledge which gives power to practice patient care.

I take this education seriously and plead that you do so too.

Remember the fact that Emergency Medicine in India is One HOD Model and not like the west where many consultants work. This job market has shrunken with fake Degree Manufacturing process set up.

The Consultants from other department will respect you when you have the knowledge and participate in discussions as an equal.

They have to respect you not as a CMO but as a Specialist.

We will have to work hard on creating jobs, meanwhile you the NEET Selected MCI Recognized MD/NBE Legitimate Residents have to work hard to accomplish the goals.

Passing Exams is just one step , having the knowledge and skills is step two and become a good specialist is the last never ending step.

I wish you the best and you can contact me at anytime.

God Bless You All
Sagar Galwankar

Thanks to Bing Images