Friday 20 February 2015

International Involvement in the National Agenda to develop Academic Emergency Medicine: Defining “Involvement” – Capitalism and Colonialism Versus Creativity and Collaboration !

From the Desk of Sagar Galwankar, MD

Today a lot of stress is laid on Global Health as we continue to hear words like “One World”, “Global Citizen”, “Care Beyond Borders” etc. It is now accepted that health of one nation as can affect the health of other nations with travel and movement becoming easier than ever.

The Glooming threat of EBOLA continues to haunt the world. In this era of Global Stress to contain health within the borders of nations, it is but natural that keeping other nations healthy is of paramount importance.

Such a transition in culture attracts immense opportunities for partnerships and cohesive creativity. Emergency Medicine is an important part of this compendium of “Global Health”.

I like to use the word “Emergency Health” as it signifies the core fundamental of sustaining systems to provide Contingency Care not only to patients but to the population at large. EBOLA is the biggest challenge to any Nation as it continues to test the Emergency Preparedness and response of every country across the world.

Speaking of Nations where Emergency Medicine Continues to advance at its pace, I want to discuss specifically the Aspect of International Involvement in Countries where Emergency Medicine is a new specialty.

International Involvement brings the technical inputs needed to advance the specialty in a country where EM is in a nascent stage.

It is important to not let personal interests surpass the larger vision because then the mission is compromised. This is the biggest challenge to developing Emergency Medicine with International Partnerships.

To bring Government Recognized Residency Training Programs in Emergency Medicine and getting the specialty recognized should be the First Focus of any International Partner who is working towards the goal of supporting a partner country to establish EM.

In the developing nation there will always be a surge of Enthusiasts who will see the opportunity of being big in a new career option. It is important that these Enthusiast recognize their role and capabilities. There are times when these enthusiasts misinterpret their leadership skills to be teaching skills and this is the most harmful step to the process of developing Emergency Medicine.

“Educators and Education” is a concept which takes bilateral continuous repetitive and persistent efforts to sustain and grow and advocacy leaders are not a correct choice for that role. I don’t rule it out completely but it is challenging to be an Advocacy Leader as well as a good teacher all the time.

International Partnerships should recognize the above fact and be distinct in defining the cadre of leaders and the crew of educators so as to foster both Advocacy and Education successfully.

International Partnerships should bring opportunities for collaboration in Research, Education and Patient Care. I do understand that Financial Stability is paramount for any partnership to grow, but the path to financial stability should not stem from the philosophy of making financial profits out of a nation in transition who is being supported to develop emergency medicine. Advancing Local efforts to establish government recognized Training programs should be the most important step.

Starting new unrecognized training and certification programs and charging hefty fees for unrecognized training certificates by luring local partners and forging partnerships for profit under the umbrella of “INTERNATIONAL COLLBORATION FOR DEVELOPMENT” is one fact which can harm the growth of International Emergency Medicine. When there is no EM there is a need for training, but when it gets commercialized then there will definitely be personal be short term gain but there will be greater long term harm to the whole population and country at large. This is because when Government Programs start certifying Emergency Physicians these unrecognized certified physicians will always be in a conflict over authority in hospitals and in the academic and clinical arena of the country.

When there is no EM or any Training there is always a need for Expertise Development and Skills Training. As an International Academic Partner Ethically one is expected to partner to train and grow. When Capitalism sets in and Education becomes an Expressway to enhancing profits by creating commercially viable training programs, the death of the larger vision occurs.

Encouraging Local Leadership is very important, but it is more important to not create a “COLONIAL ENVIORNMENT”. International Partners bring expertise which is more valuable than ever but when the partners want to be rulers “Divide and Rule” sets in and this is what I call “The Colonial Model”.  Deviating from the larger mission and focusing on personal gains is the worst thing an International Partnership can bring to any developmental platform as it reflects poorly on the individuals, institution and the nation from where they originate.

Uniting with other partners who are working for the same cause, uniting leaders in the country where the mission is similar should be the role of International Partners.

International Partners should refrain from speaking negatively at International Meetings and Global Forums about Nations where they are working to bring change. This reflects poorly on their individual ethos.

Cross Nation Collaboration, Organized Development, Personal Growth and Integrated Innovation are important aspects of Internationalization. Bringing the world near and the citizens closer not only by information but also by emotions should be the philosophy of any partnership.

“Partnerships should focus on Peace and Progress of Populations with Strong Prevention against Personal Gains” – This is my Mantra for Growth !

 In the race between Capitalism + Colonialism versus Creativity + Collaboration I hope the later wins because then it is then that the patients will win !

Thursday 12 February 2015

From a Learner to a LifeSaver: The Journey of a Responsible Emergency Physician !

From the Desk of Sagar Galwankar, MD

 “Life is a journey and we are always evolving” – I have always been aware of this reality.

There has been never a time that I have felt that “This is the final frontier, I have gotten all I wanted”. I feel no one feels that way. The day a normal human feels that way, humanity has Transcendented reality.

Today being a qualified emergency physician I often have to fight death for my patients. Sometimes I fail sometimes I don’t, I never felt I won. This is because like birth, death is also real.

Why did I become an emergency physician?

Many reasons:

I came from a family of two generations of physicians and I saw my teacher die on the road from the lack of emergency care. I got enamored when I saw the TV Show “ER” and I could not come to terms that my country India did not have emergency services.

This was 17 Years ago.

My tryst with destiny began and I faced many challenges in this journey.

When I started working to bring EM to India way back in 1998 the interested stake holders were the Corporate Hospitals. Corporate hospitals were interested in developing Ambulance Based Emergency Care so they could get emergency patients to their hospitals. There were private hospitals who wanted to start their own courses so they could have a stable supply of “Casualty Department” Doctors. By the way “Causality Department” was the old name for Emergency Department in India. Leaders assumed themselves to be Emergency Experts recognizing the opportunity to fame.

Emergency Medicine started with fragmented personal interests coming together. My vision was different. It was to develop Emergency Medicine in its whole sense which included Academics, HealthCare, Policy and Public Health. I was more bothered about my patients. I cared more for them and their right to correct care at the correct time.

I decided to come to America and get trained as an Emergency Physician. I decided to take the hard pathway of Learning the skill and implementing the change because Mahatma Gandhi always said “Be the Change you want to be”. I could not see myself being in a position to advocate myself as an Emergency Physician when I did not train to be one. India had no qualified EM Physicians who were formally trained hence I looked to the United States Education System to support my endeavor.

I was lucky to have the eye of Dr. Kelly P O’Keefe the Director of University of South Florida Emergency Medicine program who decided to take me as his student of Emergency Medicine.

I began my journey to be a Student.

Today I share with you what I have believe are the responsibilities of being a student and going on to be a quality patient care provider.

 Once a student always a student:

This is a fact a Physician should never forget. We are always learning. Science Changes, Times Changes, People change. We should be aware and adaptive to change. This is in the best interest of our patients.

Be a Dedicated Learner:

Dedication to learning is the Step to Caring.

When we learn we practice what we learnt. If we learn correctly we will practice correctly. If we are dedicated to learn that will translate to our patients. Better Care impacts how our patients fare.

Learning a Self-Activity:

In environments where EM is developing the expectations from teachers cannot exceed the knowledge they have about the new field. This is a challenge to the Pioneers of Emergency Medicine which are the new students in a new specialty like EM. Extra efforts to learn have to be taken. The onus of learning in such a situation now falls on the young shoulders of the new students.

Maximum Utilization of the Student Training period which is 1000 Days (3 Years) should be made by these students.

Every teacher teaches something. Listen, Watch, Verify, Discuss, Self Satisfy and Learn are steps which I say are crucial to being an expert.

The Textbook is your best Teacher:

Mastering the theory is very important to perform. Getting your Fundamentals Right is most important. Challenging the Fundamentals and changing them by Innovating Research comes much later. As a student master the textbook and then try to practice what you learnt.

Use Different Sources:

Journals, Internet, You Tube, Videos, and International Conference Proceedings are important resources to learn and help you groom yourself.

Believe in what you have chosen and give it your 100 %

Taking up the challenge of EM which has no teachers or Novo Teachers is the biggest challenge which as a student you have picked up. Now Win In It. The best way is to study, study and study. Use the 1000 Days to learn correctly.

EM is not Procedures, EM is not the number of patients you see:

EM is not about the above. The above are a part of EM Care but that’s not complete EM. EM like every specialty has pathways, protocols, and principles. Those don’t come by reading, those come by practicing.

Environments are always conducive to Change:

There are times when students may feel that the environment which is being offered to them is not conducive and does not allow them to practice what they read in the textbook.

Try to use your knowledge to first care for every patient you see and then try to bring the change.

I will give you an Example:

I returned to India after getting Residency Trained and Board Certified in America in Emergency Medicine. I started working at a Private Hospital in Mumbai to develop Emergency Medicine.

I had my protocols for ordering Labs and Investigations for sets of patients with chest pain.

Well guess what: The Cardiologist did not agree. Every Cardiologist had a different view point.

What did I do, I Said lets come up with a Unified Protocol?

The cardiologist said “We should be called for every chest Pain”.

I said Give me in writing what you want the ED to do and all Cardiologist Sign off.

They gave me a protocol which said do the Trop and EKG and call them.

I said ok and asked them in how much time can you come. They said 10 Minutes.

I said OK.

Well this where we get all the data. They were always delayed. When asked what about Pulmonary Embolism or Pneumothorax or Thoracic Aortic Aneurysm Rule out, they said well there is no ACS.

I said then what about other diagnosis.

Can you discharge the patient as safe?

In 48 hours I had the control of the Chest Pain Program.

There is no need to argue, there is no need to have discontent.

Every Protocol is still a protocol.

Get it established and then modify it “For the Benefit of the patient”

Emergency Medicine secures the patient and starts the care for the patient. Hospitals have realized that. It’s time that the other specialties realize the same.

Getting their buy in will ensure the existence of EM.
Environments in Transition where EM is new, continue to face the maximum challenges to change.

The ego of the career specialists from other fields is higher than Mount Everest. They are used to being called for every small thing and the fact that the Physician in ED is a traffic officer and not a Real Doctor.

Well things change when hospitals and administrators commit to establishing Emergency Departments lead by Leaders who believe in EM.

Getting their buy in of other specialties will ensure the existence of EM.

Knowledge and Confidence are key to effective Leadership:

Strong Knowledge and Confidence to Care in the ED are biggest showcases for leading the change in Challenging Environments where EM is in Transition. Knowledge comes from learning and that too learning continuously.

Thus concluding:

Don’t depend on others to teach you, Each One Teach One

Don’t blame others for you not learning.

Keep your eyes, ears and senses always open to learning. Knowledge is everywhere just try harder.

A good student is one who is well studied hence can debate and verify. Blind Adaptation of what is taught is also wrong.

Be committed, be dedicated, be loyal – You will always be Royal.

“God helps those who help themselves”

It comes down to being a student of science, a sustainer of solutions, and a sculptor of semantics.

I have always believed in the above hence continue to learn …………


Saturday 7 February 2015

A Comparison of Practices

Hello from UK!

Just as a quick introduction, I'm Indy, and I'm a young doctor fairly new to the world of Emergency Medicine. Definitely new to the world of Emergency Medicine in the UK. I've been in the field since late 2013, and had the opportunity to work under some wonderful mentor-ship in Mumbai, India, and now in good ole UK.

I contemplated a fair bit about the title of this post. You see, I've only been here for a month as of today. The points mentioned in this post are basically a few of my observations so far. In fact, I'm sure I've noticed more, but it's difficult to pen down the smallest of differences. These are the ones that stood out to me.


Now, personally I was fortunate enough to be under the guidance of Emergency Physicians from the get go. But, not all of India has them. What I mean, is that though there are physicians from various faculties coming together to comprehensively train the future Indian EP of tomorrow, there aren't many places with trained EPs to begin with. The reason for this is that Emergency Medicine has only been recognized as a separate branch of Medicine in India recently, and so it is a growing field, still in its infant stages. In the UK, there are already a bunch of Emergency Medicine Consultants, and sometimes that makes things a little easier by not going in-depth into the various associated specialties, and instead staying focused on the Emergent aspect of the cases.

Teaching Environment

Our training is based largely, like any other medical practice, on the shop floor - learning as we go with each patient, each case. But we do also have scheduled lectures. So the junior doctors get a chance to assemble, and focus together on a certain topic presented by the consultants, and with a good deal of interaction going on. Though the lectures are in themselves very useful, I find the system useful in helping us develop and maintain a discipline. Each week at the same time, we have a lecture. We're expected to show up, and we always do. You end up making a habit of it. And a habit of learning is always a good one.

Work-based Assessments

Exams are important. Passing exams - even more important. But studying with the intent to just pass the exam, isn't very good. The system here is good in that way because they take two components into review. One is of course, exams. But those alone don't get you very far if you're lacking in the other element. Work-based Assessments. There are different ways of doing these - Mini system based exams focused on any particular system, Procedures, Communication skills, Case-based discussions, Feedback, CMEs, Workshops. All these help to build a strong portfolio. More importantly, they ensure a systematic learning process.

No one is expected to be an expert at every aspect on their first attempt - or even second. What they do expect is growth from every experience - and that's made much easier when you know your strengths and weaknesses. This sort of stratified, systematic, and guided learning is one of the highlights for me here. You aren't passing to the next level because you've finished a requisite amount of time - you're passing because you've spent a requisite amount of effort. Personally, I think that's brilliant.


At any given point, there is always a registrar on duty. When the consultant is not around, a registrar is capable enough of handling the department (with some exceptions obviously). That means the more junior doctors such as myself, have someone to turn to when we get stuck or when we need some good advice. Now this doesn't mean that you go and talk about every single case with them, but should the time come when you're overwhelmed, or feel like something is out of scope, there is someone who has more experience, more knowledge and practical wisdom to turn to for aid.

Another thing I like about the system here, is that they are happy to help, happy to teach. From the overall department point of view, the top priority is the patient. But from the training point of view, the priority is that the growing doctors learn. Whenever we seek advice from seniors, whether it be a case review, or knowing local hospital protocols, they are happy to help. They want you to learn. It benefits you, them, the system and the patient. When reviewing cases related issues, they don't tell you the answers. On my first day working here, I showed one of my consultants an ECG, and asked him what it is. His eyebrows shot up, and he said to me, 'It matters what you think it is.' So he asked me first to give my interpretation and then he would tell me his. It's a good thought-provoking way of learning.

The System

How it works here is that the GP is the main point of contact for patients. Unless it's an emergency, they don't show up to the A&E very often - they do, just not every patient ends up at the A&E as their first point of contact. The patients go to their GPs who assess them, treat them and arrange for referrals. It's unusual that absolute emergencies would go to the GP first; those do come to us.

Now in India, we have the system of the patient contacting the hospital or doctor directly and taking available appointments of their choice with whatever relevant (sometimes even irrelevant) specialties. Here, it is the GP who determines if a specialist consult is required, if so, which, when and so forth. Hence I said, they are the patient's primary contact. The record keeping here is quite tremendous and meticulous, so the GPs have all their patients' records.

And after a patient has been to the A&E it is a practice for us to let the GPs know the important and relevant parts about the visits. I won't go into the details of how - it's an elaborate internalized, computerized system. Wonderful how useful technology can be, eh?

It may not be a fully closed loop, but it is certainly useful.

Record Keeping

Segueing into record-keeping, as I said, it is meticulous. Again, I was fortunate to have worked at a hospital under an experienced EP who knew how important records are/can be. And so I haven't been having too bad a time adjusting to that aspect. They are even more important in cases which can/may go to court - but since you can't always predict which cases those will be, good record keeping is a key practice for every case.
With the general population developing more awareness of their rights, I would say it is important world-over. Those who till now, have not paid much attention to their patient notes, I'd say now is a good time to start. It helps the patients, it helps the doctors involved, the institution. Good records are a reflection of good practice.

Continuous learning

When you're in a (healthy) competitive environment, you end up really motivated. That is the case here. I feel in awe of a lot of my peers. They are so knowledgeable and up-to-date. It makes you want to be like that too. Since coming here, I have been reading articles on medical forums like medscape and similar, doing online CMEs, reading Journal articles. And of course, there are always books.
It's invigorating to progress - not for progress sake - but to actually be able to improve your knowledge and practice.

Basic Skills

I've certainly been revising a lot of skills that I haven't much practiced since internship - cannulations, ABGs, blood collections etc etc. It's not that I've forgotten how, but when you're out of practice, it shows. It is an art - especially the difficult lines - let me tell you, relearning all of it seemed daunting for the first couple of weeks. But I feel a lot more confident now that I've gotten back into the groove. Besides, there is always someone to help should help be needed. That in itself lends you the confidence to begin a job.


Something that everyone from overseas takes a bit of time and effort to adapt to over here is the communication aspect of good medical practice. Bed side manners are important here. You always ask for permission. You always maintain a calm, even tone. It is important for everyone concerned to not be judgmental. And this has to be done for every patient, every time. Sometimes it can get a bit hard, but with enough practice it becomes habit. Communication is important anywhere in the world, but it is different in different places. It is important to conform yourself to local practices. You cannot be rigid in your way. It's all about a achieving a good balance, with the ultimate goal of helping the patient, and the patient being made aware of that in the proper manner.

That is pretty much all I can think for now. I'm sure there are more things, but they seem to have gone to a secluded part of my conscious thoughts. If I can think of more, I'll be sure to let you know. It is interesting to know the various practices from different parts of the globe. For me it is a great opportunity and a wonderful learning experience. If and when you get the opportunity to work abroad, don't pass it by without due consideration. And with that preachy bit, I bid you goodbye until next time!

Wednesday 4 February 2015

Emergency Nurses: The Real Force of Quality Care in Transitional Academic Departments !

From the Desk of Sagar Galwankar, MD

I was working the 1 pm shift in my emergency department. The nurses generally work from 7 am to 7 pm and Emergency Physicians work 8 hour shifts at different times and slots. It was 8 pm and I glanced around as my 8 hour shift was ending in another one hour. I saw one of my nursing colleagues from the day shift who was in a somber mood and standing in one corner.

I looked to her and asked her whether all was ok. She came close to me and whispered in my ear “Is she going to make it?”

I saw the eyes of my nurse and the tone of the voice and also realized that it was one hour post her shift. I was touched and overwhelmed. She was referring to one of our patients who was not doing well.

This made me realize the emotional aspect of what we the Emergency Health Providers do day in and day out. It made me visit the corridor of the perspectives as regards my nurses and what they go through every day every shift.

It made me realize yet again that Emergency Nurses are valuable and the most important part of the Emergency Health Care System.

Patients flow through the emergency department. As physicians we go from one bed to another so at any time we could be caring for more than 10 patients. The nurses are the closest to the patient and are the real eyes of the physician.

In the United States and across the Developed world, tremendous emphasis is placed on training emergency nurses. This training is above and beyond general nursing training.

Competency on Running Resuscitations, Getting Intra-Venous Access, Administering Life Saving Medications in minutes, Starting emergency medicine infusions, assisting in life saving procedures are some of many additional skills which need continuous education.

In Transitional Academic Departments where Physician Talent is new, developing Emergency Nursing Talent needs additional fostering. I believe that more emphasis should be placed on Emergency Nursing.

In my experience of setting up Academic Emergency Departments where Emergency Medicine was new I have successfully nurtured growth based on Good Emergency Nursing Care. Once the nurses are confident and well trained they take care of many of the processes in Emergency Care namely starting of investigation protocols, getting IV lines , managing patient flow and triage etc. New physicians get support and learn a lot of working culture and practices from Nurses. This is an established fact. In Transitional Emergency Departments there will be a lot of attrition but the nurses are the more constant part of the environment across the world.

Patient comes to emergency department in a lot of stress, and pain. Nurses are the interphase where compassion meets concern and solidifies the competency to comfort the patient. This makes a huge difference in the way the patient gets comforted and feels like he/she is being treated.

As Physicians it is our job to make sure that our immediate colleagues the Emergency Nurses are in synchrony of what we think and what we are doing and what we expect of them.

There should be a Bond of Confidence between the nurses and the doctors and this bond should be tested and fortified with every patient encounter.

It is bonds like these which stand the test of difficult times which in Emergency Medicine is All the Time!

Nurses are inherently caring and very diligent. They are trained that way. They do things which we may not be aware off. They clean the patients, they get IV lines, and they are more prone to infectious exposures, blood splashes, needle sticks because of their line of duty.

Additionally they keeping watching the patient in the ED continuously. When the ED is busy they can go up to managing 4 serious patients at the same time.

We as physicians are very swift in examining the patient and putting our orders in. We see one patient at a time and on an average put 5-10 orders. When one nurse is overseeing 3 patients and has 10 orders per patient she has 30 orders to chart, perform and accomplish.

Every job has its flip side and diverse points but challenges are far more for Emergency Nurses. They work longer hours, they work continuously and they are always in a mode in which they have to deliver.

Over the years I have come to value their contributions more and more. There are times when you feel that a nurse has been rude to you, there are times when you feel that a particular nurse does not listen to your orders, and there are times when you become judgmental about the acumen of the nurse.

Well this is a self-learning point that never be rude to anyone, listen and discuss when there is lack of clarity and never be judgmental.  Life is much bigger than the Job and Job is not the whole life.

Our success as Emergency Physicians depends on our Emergency Nurses which in turn depends on the way they operate which in the end depends on how We Cooperate.

The magic word is cooperation, which is in our hands at least 50 percent of all the time. Our success includes winning the other Nursing 50 % repeatedly and consistently. When the above is 100% the patient naturally wins.

Compassion, Competency, Confidence and, Cooperation are Crucial to Care.

When Nurses become Emergency Nurses that Extra equals Quality Care !