The 32nd WACEM-ACAIM Weekly Summit: Week 4 of e-EMINDIA2020

 

The 31st WACEM-ACAIM Weekly Summit: e-EMINDIA2020

 

 "Navratri Edition" of  e-EMINDIA2020 (Week 3)

 Dr. Nisanth Menon. 

The meeting began with the WACEM chief Dr.Sagar Galwankar's inspirational introduction. He touched upon the milestones laid by INDUSEM and insisted that Emergency Medicine be looked upon as a surgical specialty.

Failed Supply Chain in COVID and Solutions for Future

Dr. S. Venkataramanaiah

IIM, Kanpur

The International Speaker for the day began his insightful talk with historical perspectives surrounding the silk route and spice routes. As he slowly decoded the supply chain ecosystem, he took us along the supply chain masters and their survival tactics based upon resilient and quick responses of supply chains to meet demands. The SCOR model of supply chain resilience and digitization was highlighted wherein success of supply chains under uncertainty was touted as a solution during the current COVID scenario. Moderator for the session was Dr. Mohammed Haneef, EMA South Zone Secretary and Chief Emergency Physician, MTH, Kochi. This was followed by residency program Presentations.  

ED Administrative Challenges During COVID Times

Dr. Vimal Rohan, 

Government Medical College, Kannur

Dr. Vimal Rohan, Deputy Medical Superintendent and Assistant Professor of Emergency Medicine, Govt Medical College, Kannur, Kerala spoke about the unique experiences that were native to his work place. One such experience that led to a string of administrative reforms was about a trauma patient who came with history of jackfruit falling over him and turning COVID positive in ED that led them to screen every patient irrespective of classical symptoms for COVID! Patient flow changes to minimize cross infection, liaison with district and local hospitals to avoid ED boarding and infrastructural up hauling for surge were detailed out from his hospital point of view. The WACEM ventilator sparing protocol training for Emergency Physicians in association with Government of Kerala was an extremely important part of their adapted COVID protocol in ED, he observed. (The link for the landmark paper can be found here: http://www.indusem.org/wp-content/uploads/covid/Ventilator-Sparing-Protocol.pdf)

TWO MAN SHOW" ED RESUSCITATION - COVID 19

Dr. Ashmal, 

Junior Resident in Emergency Medicine, 

Government Medical College, Kannur

Following the faculty presentation was a presentation by his resident Dr. Ashmal K T about an interesting resuscitation sequence in ED developed at the time of COVID. In view of lack of literature, an indigenous COVID ED plan was devised by them to preserve frontline healthcare workers. He highlighted limiting the number of staff to two with the help of portable USG and a central camera in the COVID resuscitation area. Another important point highlighted was their use of LMA and use of video laryngoscope for intubation in crash patients along with other standard precautions.

Lung sonographic findings in COVID-19 Patients

Dr. Ankit Sahu, 

Emergency Medicine Department, 

AIIMS, New Delhi 

A prospective observational study from the Department of Emergency Medicine, AIIMS, New Delhi was presented in brief by Dr. Ankit and his mentor Prof. Sanjeev Bhoi. The study measured the incidence of lung Ultrasound findings among COVID patients and correlated it with severity of the disease. Their major finding was that findings tend to be bilateral, occurring more in the lower zones with common pleural line irregularities and B-profile. They observed that these findings were accentuated in those with severe disease as well.

Complete Heart Block: A Rare Presentation of COVID-19

Dr. Vaishnavi, 

Junior Resident in Emergency Medicine, 

AIIMS, New Delhi

An atypical case of COVID positive patient was discussed conveying the fact that Emergency Physicians need to be vigilant about out of the box presentations in COVID. AIIMS Residency Program Faculty Mentor Dr Sanjeev Bhoi summarized the presentations with a crisp note on their study and impressed the audience on point of care ultrasound being a far better option than other radiological investigations like X-rays or CT in COVID cases approaching the Emergency Department.

The 30th WACEM-ACAIM Weekly Summit: e-EMINDIA2020

 

The Effect of UV-C Radiation Against Different N95 Respirators Inoculated with SARS-CoV-2 

Dr. Shanthi Narla, MD

Dermatology Resident Physician

St. Luke's University Health Network, 

Pennsylvania, United States

Dr. Narla presented her topic of research on the UV-C Radiation on various N95 respirators. She emphasized that ultraviolet radiation degrades polymers, thus inducing DNA damage to prevent viral replication, rather than "eliminating" the virus. The topic of N95 mask reuse and PPE shortages became a topic of conversation early in the pandemic in both developed and developing countries. Without going into details of her fantastic study (available to read at: https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Narla%2C+Shanthi ), her presentation yielded some take-home points. UV-C at doses of 1.5 J/cm^2 to both sides is effective on some models of N95. Further consideration is required for disinfection of mask straps (alcohol swabs were found to be effective, with due caution not to allow dripping onto the mask itself). It's important to note that this decontamination for SARS-CoV-2 does not apply equally to all hospital respiratory pathogens, and that fit testing following irradiation should be considered.

Sree Gokulam Medical College, Thiruvananthapuram, Kerala

Accepting, Adapting, Awakening - Administrative Modifications During COVID-19 

Dr. Amrithanand V T, MD, 

Assistant Professor, 

Department of Emergency Medicine

Dr. Amrithanand gave us a look into the handling of COVID-19 by his department. Kerala, like other parts of India, and indeed the world, saw an alarming rise in coronavirus cases. Initially they faced bottlenecking due to a combination of insufficient knowledge of this new virus, supply-demand issues, the task of providing a safe working environment, pandemic hysteria, and existing disease burden. Their hospital administration was on their toes, carrying the memory of dealing with the Nipah outbreak, and were quick to establish a command center. They generated surge capacity and ensured up to date training. They followed a 2 - step (Questionnaire and Vitals) Triage system. They anticipated a mass casualty incidence following Attukal Pongala (a celebratory gathering of worship) and prepared themselves to face the worst. Floor plans were changed, and management steps thus far enacted only in simulated scenarios, were put into action. Their infection control department took charge of developing areas for safe donning/doffing, waste disposal and provision of PPE for all staff. They ran drills. Their "Break the Chain" campaign took the message of "our health, our responsibility" to the public. Engineering and administrative issues were quickly dealt with, and standard operating procedures were put into effect and communicated throughout their hospital. Importantly, they also partook in raising community awareness of the disease. Leading by example!

Unmasking COVID-19

Dr. Reshma Douglas and Dr. Nidhi Mohan

EM Residents

Dr. Douglas presented her case of a gentleman in his 60s who walked into their department, in the early days of the pandemic, with complaints of rhinitis, productive cough and fever, but no breathlessness. Their quick 2 step Triage revealed a silent hypoxia, with saturations in the mid 70s. She elicited a history of the patient having attended 4 funerals in the recent past with as many as 50 in-person contacts in that period. He was diagnosed with mild ARDS and had point of care ultrasound in department. The patient was referred early to the COVID center as a strongly suspected COVID case. His first PCR test was negative, however the patient was retested after he developed neurological features and needed intubation. The second test was positive. Her second case was that of syncope in a COVID patient, in whom troponins revealed myocardial involvement, and the patient succumbed to a myocardial infarction. Both her cases emphasized the unusual presentations of COVID-19. As we have come to learn with time, that initial symptom complex of flu-like symptoms can be fairly misleading when it come to COVID-19. 

Dr. Nidhi's case was in a similar vein. Her patient, too, initially tested negatively. However a high index of suspicion and evolution of symptoms called for serial testing with both imagining and RT-PCR which indeed then showed evidence of COVID-19. Her presentation reminds us all that though investigations have their place, they do not displace clinical gestalt. A high index of suspicion is necessary, which comes through knowledge, experience and instinct. Not are presentations of COVID-19 come solely with respiratory symptoms, and one must conduct a thorough assessment when it comes to unmasking diseases such as COVID-19.

P.E.S. Institute of Medical Sciences and Research, Kuppam, Andrapradesh

A comparative study on severity of pulmonary versus cardiac involvement in COVID-19

Dr. Befin K, MD

Assistant Professor, 

Department of Emergency Medicine

Dr. Befin said it best in his slide, "Heart and lungs are the two vital organs most commonly affected with COVID-19," which is what led him to conduct his interesting study. As a matter of routine, his department categorized the disease based on the degree of severity, and followed a well-laid out algorithm to determine investigations and management. Amongst the various biomarkers and imaging modalities, this study took a look at high sensitivity troponins (hs-troponins) and HRCT in COVID-patients. The HRCT findings, in keeping with other published data, were ground glass opacities and consolidation, with diffuse GGO being the most common early finding in patients who died. In several patients with positive hs-troponin values, HRCT revealed significant ground glass opacities and consolidatory changes. Though there might be other explanations for the hs troponin rise, and high mortality rates in certain patients, his study, and presentation generated interest in looking further into the topic of troponins, and other biomarkers in COVID-19. 

Emergency Medicine - A Game Changer

Dr. S. Prakash Babu, MD, 

Assistant Professor, 

Department of Emergency Medicine

Dr. Prakash's presentation highlighted the role of the emergency physician and the emergency medicine department in the management of a pandemic such as COVID-19. The pandemic brought along with it havoc and demoralization, alongside stringent government and state led guidelines, and political influences. Through step-wise implementation of changes early on, including role allocation, public awareness programs, division of blocks, while also considering non-COVID patients, the ED played a major role in excellent management. Emergency Medicine specializes in rapid assessment and stabilization. This is not limited only to individual patients but also to dynamic scenarios. Resident training includes disaster management and preparedness, which helps in times like this to draft protocols and more importantly, in their smooth implementation. Communication and management are core EM skills. Emergency Medicine is the game changer!

An Unusual Presentation of COVID-19

Dr. Rajeev, 

EM Resident

Dr. Rajeev presented his case of a gentleman in his 70s who attended the ED with fever, cough, and sudden onset dyspnea with unilateral pleuritic chest pain. Early in the course of his attendance, Dr. Rajeev suspected that this patient had a tension pneumothorax, and had features of COVID-19. His POCUS, fitting with his suspicions, revealed a pneumothorax, and an immediate needle decompression was carried out. A chest radiograph following the decompression also confirmed the pneumothorax, which still appeared large, therefore a tube thoracostomy was performed. The patient also underwent other routine investigations and tested positive for COVID. He was treated as per their local management algorithm. The likely pathogenesis is proposed to be inflammation induced pulmonary parenchymal injury and necrosis, and treatment in this case involved following routine management of pneumothoraces in combination with treatment initiated for COVID-19. 

Defeated COVID, Succumbed to Renal Failure

Dr. V. R Tejasvi, 

EM Resident

Dr. Tejasvi's case came with the unfortunately underlying diagnosis of chronic kidney disease. Her patient of COVID-19 who had an ongoing oxygen requirement and imaging findings consistent with ARDS, also required emergency dialysis which was arranged with due care following the COVID-19 positive report. Due to his precipitously worsening condition, he developed hyperkalaemia, reflected by typical changes of peaked tall T waves and wide complexes on his ECG. Through the course of his admission, careful respiratory management improved his lung function, with serial investigations showing pulmonary recovery. On the other hand, through the course of his admission, he developed recurrent hyperkalaemia and acidosis despite haemodialysis. His management proved difficult through fluctuating hypotension and hypertension. Finally, and tragically, he succumbed to his recurrent hyperkalaemia and renal failure. The message Dr. Tejasvi presents is an important one. Not all patients who have COVID, have COVID alone. There are several patients with underlying conditions, which we know pose a threat even without the added disease burden of COVID. We must not be blinded to other diseases, to comorbidities, and to diseases that can exacerbate other conditions. 

The 29th WACEM-ACAIM Weekly Summit Presents: e-EMINDIA2020

 

Endorsed by WACEM & The World Health Organization Collaborating Center for Emergency and Trauma, AIIMS, New Delhi, India in Partnership with The Emergency Medicine Association and The Academic College of Emergency Experts as well as The American College of Academic International Medicine