Monday, 7 December 2020

The 38th WACEM-ACAIM Weekly Summit: Week 10 of e-EMINDIA2020

 



Simulation Education during COVID-19

Dr. Shruti Chandra
MD, MEHP
Assistant Professor, Department of Emergency Medicine
Sydney Kimmel Medical College,
Thomas Jefferson University

Dr. Chandra brought her insight and expertise in simulation education and left us all in awe. She described the efforts undertaken by her team in adapting to the various restrictions brought around by the pandemic. It has been imperative to provide a protected environment, and so classroom teaching was stopped, number of rotations and residents on any given day reduced. Because there were more groups with fewer participants in each, they trained more faculty to meet the needs. 
They carried out in-situ simulation when possible. The education facility and staff cleaned and prepared equipment for the "grab and go" model, allowing for this. They provided and practiced various procedures like donning and doffing of PPE, including PAPR; personnel limitation in COVID-19 scenarios, resuscitation with box intubation and limited bagging etc. The coordinators and facilitators arranged for lending the correct equipment out to departments, and disinfection upon return so it would be ready for the next use. 
They adopted virtual curriculum delivery and assessment. Initially trying a hybrid model of virtual and in-person training which was challenging due to concerns with in-person exposure risks; they soon switched to full virtual teaching. The virtual teaching included socially distanced virtual standardized patients, physical exam on self, virtual OSCE, and virtual sims (including a nifty program called "full code". This allowed not just to train students and residents in classic teaching, but also in practicing telemedicine - the need of the hour which a lot of clinicians feel is here to stay at least to some degree even once this pandemic settles. 
With many changes to aid their goal of continuing to deliver education to the future generation of clinicians, including increased funding, the team at Jefferson University provides inspiration to us all. 


The national residency program was moderated this week by Dr. Rachana Bhat - senior resident from AIIMS, New Delhi.

St. Johns Medical College, Bangalore

COVID-19: A Department at War

Dr. Ashray V
Assistant Professor

Dr. Ashray talked us through St. Johns Medical College's journey through the pandemic so far. In true EM fashion, they first addressed preparedness. Their department held meetings and discussions on COVID-19 in Jan 2020, recognizing its potential to evolve into a pandemic. Members of the emergency department were appointed to the hospital task force committee. They converted their regular triage area into a SARI (severe acute respiratory illness) triage in February. They held training for COVID-19 sample collection, video laryngoscopy, PPE use and hand hygiene. They held daily task force meetings for planning and organization of resources, created a "Ready Reckoner" chart which worked as an effective tool for screening and testing, and held regular online CME (continued medical education) sessions. They dealt impressively with challenges: where they recognized manpower shortage, they deputized health care workers from other departments. Bed shortages led to capacity creation, including extending SARI holding areas in the ED. While there were nation wide PPE shortages, they tacked this with in-house PPE production; using the full PPE judiciously only for aerosol generation procedures. To aid patients facing financial constraints, empanelment with government schemes allowed for cashless admission of patients. They developed a departmental and hospital wide wellbeing and support group. They ensured access to N95 masks and face shields for all hospital staff. 
Dr. Ashray described something we are all familiar with - frequent surges and dips of infection rates, stating that the key to recovery will be in vaccine administration. 

COVID-19: Extended resuscitation and EICU perspective

Dr. Ashish Bosco,
PGY2 Resident

Dr. Bosco began by addressing the problem statement - grave shortage of ICU beds and long wait times in the ED. He highlighted that emergency departments are primarily resuscitation units, where extended critical care provision is limited. Patients receive suboptimal care in the interim waiting period. This has all been made worse by the COVID-19 pandemic. His department has an EICU (Emergency intensive care unit) which comprises of 6 ventilated beds, 2 step-down beds, dedicated staff including a named consultant and rotating residents - all being within controlled and coordinated by the ED. They attend to cases ranging from trauma to toxicology, patients requiring emergency interventions as well as acute medical cases. Their main focus is provision of high level intensive care when needed for short duration - e.g. cases of DKA, overdoses, acute pulmonary edema - then allowing for these to be stepped down. 
During COVID-19, they have designated the ED and EICU as respiratory emergency areas, with clinicians and allied staff in full PPE. They admitted only COVID positive patients, excluding patients with a dialysis requirement, but fitting the profile for extended resuscitation. Long-term cases or those requiring dialysis were transferred to the medical ICU. 
Some facts that Dr. Bosco highlighted - The EICU model, successfully implemented in various centers, did not show inferiority in terms of mortality. There was a significant improvement in wait times. It provided continuous intensive monitoring without breaks in care provision. It allowed flexibility and control for the ED. However, they also dealt with their own set of challenges during the pandemic - gaps in training, need for supervision, new disease pattern, staffing shortages, burnout. As well as patient related challenges - like counselling the relatives via telephone or video calls. Instances where admission was prolonged more than anticipated. 
He ended his talk by concluding that there is a need for innovation in resource constrained settings. EICU is one such innovation lending to more efficient management. 

AIIMS, Bhopal

Restructuring the ED at AIIMS Bhopal during COVID times

Dr. Manoj Nagar, 
Assistant Professor

Dr. Nagar described the restructuring efforts of his department during this pandemic. The medical emergency area was re-designated as the COVID emergency area. A triage area was set up in front of the emergency entrance. What was formerly their trauma emergency area is now for non-COVID emergencies. They normally have a red triage area in their trauma bay which is now upgraded to a 6 bedded ICU, while their yellow triage area saw expanded capacity. Following an evidence base, AIIMS Bhopal adopted the qSOFA tool into their triaging process. Dr. Nagar referred to an article concluding that the qSOFA was not inferior to SOFA or CURB-65 scores in predicting ICU admission, ARDS, and 28 day mortality of patients presenting to the ED with CAP. They ratified a COVID-19 triage and disposition system. COVID positive patients who had saturations greater than 94% were advised home isolation or referred to a COVID care center, while those with lower saturations were admitted to the COVID wards. Patients with a qSOFA score greater than 1 were transferred to the red triage area. Suspected cases with hypoxia were transferred to the yellow triage, where as suspected patients with a qSOFA score greater than 1 were transferred to a COVID suspect ICU. These were some among other measures undertaken by AIIMS, Bhopal.

Traumatic spine injury with whiteout right lung

Dr. Ravi Pratap Singh, 
Senior Resident

Ravi described an interesting case of a male patient in his 20s who attended the emergency department 5 days after having fallen from a height of 20 feet. He presented with bilateral lower limb weakness and breathing difficulties. They followed ATLS protocols to manage him. He had saturations of 85% and respiratory rate of 40/min while his neurological assessment was significant for a neurological level of injury at D11 with ASIA A (motor and sensory deficit below the level). High flow oxygen was administered quickly through reservoir bag mask, and adjuncts employed. His chest X-ray demonstrated a whiteout right hemithorax, while a contrast enhanced CT scan revealed further basal atelectasis. An MRI revealed a T12 fracture with disc retropulsion leading to cord compression. A pulmonary consult led to a bronchoscopy following intubation which lead to revealing and managing right lobe obstruction by debris and mucous plug. Following a second bronchoscopy, lung expansion was seen. The patient was found to be COVID positive in the midst of this, and after recovering from COVID, was referred to spinal surgeons to manage his cord compression syndrome. 

Pan-facial fracture with CSF rhinorrhea

Dr. Rohit Tiwari,
Senior Resident

Dr. Tiwari described a case of a male bike rider in his 40s who suffered significant facial injuries following a head-on collision with a stationary truck. He was brought to the emergency department with a reduced GCS, facial injuries including ongoing bleeding from the nose and ear, and peri-orbital edema. ATLS principles were applied in his management, and imagining revealed multiple facial fractures with clinically distorting anatomy. The decision was made to carry out an emergent tracheostomy to secure his airway, and mechanically ventilate. His C-spine immobilization was maintained, he received treatment of his wounds. He subsequently developed CSF rhinorrhea which was managed conservatively. He was also COVID positive, shifted to the COVID emergency area, managed per their COVID guidelines. Dr. Tiwari emphasized some take home points from this case - Threatened airway should be suspected with facial injuries. Significant pan facial injuries can result in anatomical distortion and difficulty with bag mask ventilation as well as intubation. Surgical airway should be an option in those cases. Nasogastric tube insertion in contraindicated in case of significant facial trauma due to potential of cribriform plate fracture. He ended with the message that standard trauma care does not change in COVID 19 patients.


More to follow next week.... 





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