Sunday 27 December 2020

2020 Hindsight: The 41st WACEM-ACAIM Special Global Weekly e-Summit Closing Ceremony of e-EMINDIA2020 on COVID-19 in India


Saturday (26.12.2020) marked the 41st consecutive week of ACAIM-WACEM meetings, with the last 12 weeks enjoying academics at its finest with faculty and student presentations for the e-EMIndia2020. Dr. Vimal Krishnan, Principal Secretary of EMA India, hosted the session with his usual wit, charm and leadership. Dr. Sagar Galwankar recapped the history of INDUSEM, ACEE, WACEM, ACAIM, and the EMA, reminding us of that the current crop of emergency medicine was borne off the foundations laid by stalwarts at a time when there was much resistance to the specialty and much work to be done. 
Many others were part of the conversations this week, all focused towards further improvements in academics and education, research and development, raising the flag of emergency medicine even higher. 

After a certificate presentation ceremony, recognizing the efforts and contributions of various EMA members, the annual general meeting addressed its agenda for the day. The overwhelming vote was for the sitting committee to continue in their roles, with a few zonal changes adding newer members to the ranks. This week marked the end of the EMA agenda, however, not the end of the Saturday meetings. From 2021, the Saturday meetings will transition into the latest in point of care ultrasound in emergency medicine. Stick around for more innovation and academics.

Sunday 20 December 2020

The 40th WACEM-ACAIM Weekly Summit: Week 12 of e-EMINDIA2020


The risk of SARS-CoV-2 reinfection in an intense re-exposure setting

Dr. Hassan Al-Thani
Head of Trauma and Vascular Surgery
Hamad General Hospital, Doha, Qatar

Dr. Al-Thani started his talk by introducing CDC's guidelines on investigating the possibility of reinfection with COVID-19. He presented his review of the paper "Assessment of the risk of SARS-CoV-2 reinfection in an intense re-exposure setting". The study aims to assess the risk and incidence rate of documented reinfection in a cohort of 133,266 SARS-CoV-2 laboratory confirmed infected persons. Viral genome sequencing was conducted on retrieved samples of the first positive swab, and reinfection swab of patients with strong or good evidence for reinfection as confirmatory analysis. Results suggested conclusive evidence of reinfection, however, the risk of documented reinfection was rare, at about 1-2 reinfections per 10,000 infected persons. A significant proportion of the population has been repeatedly exposed to the infection but such re-exposures hardly led to any documentable reinfections. Nearly two-third cases were discovered accidentally, either through random testing campaigns or surveys or through contact tracing, of which none were severe, critical or fatal infections. These findings suggest that most infected persons do develop immunity against reinfection that lasts for at least few months, and reinfections (if they occur) are well tolerated and no more symptomatic than the primary infections. Dr. Al-Thani concluded his talk by suggesting that SARS-COV-2 reinfection appears to be a rare phenomenon, and that immunity develops after the primary infection and lasts for at least a few months, and that immunity protects against reinfection.

Biothreat and COVID-19 experience in Malaysia

Prof. Dr. Mohamed Alwi Abdul Rahman
HOD Emergency and Trauma,
Selayang Hospital, Malaysia
Fellowship coordinator in EM, Malaysia
General secretary WACEM 2021, Malaysia

Malaysia has experienced several types of disasters including natural and man-made ones. In order to prevent global outbreaks, it is critical for high-risk countries such as Malaysia to be prepared and have appropriate biothreat preparedness. Among some of the statistics provided by Dr. Alwi, 78 deaths from the H1N1 pandemic in 2009, and 5 suspected cases during the SARS pandemic of 2003, compared to 265 cases and 105 deaths during the 1999 Nipah virus outbreak, stood out. A study of biothreat preparedness of hospitals in Klang Valley, Malaysia published in 2019, revealed that there is room for improvement in terms of hospital preparedness to biothreats, namely regular staff education and training, space designated for airborne biothreats i.e. negative pressure rooms/isolation rooms, and plans addressing stockpiling of antibiotics and supplies, and adequate laboratory diagnostic capabilities. In order to improve biothreat preparedness, hospitals should update their emergency plans consistently, have frequent training for staff including disaster exercises, store appropriate antibiotics, improve laboratory diagnostic capability, and ensure adequate supplies of PPE and related equipment. In this COVID pandemic, Malaysia fought its own fair share of challenges, just as the rest of the world did, for instance surge capacity, adherence to PPE, dynamic guidelines and SOPs. They made sure to focus and communicate with their healthcare workers regarding coping with stress during the outbreak, and regular reiteration of safety measures. He concluded his talk with a few key messages, highlighting the need to consolidate and enhance existing pandemic plan strategies, prioritize biosafety and security of healthcare workers, need for continuous risk communication and community engagement, and developing sustainable business continuity plans. 

National Residency Programs

Government Medical College, 

Kozhikode, Kerala

Post-COVID Syndromes

Dr. R. Chandni
Professor and head,
EM member, State Expert Committee and
State Medical Board for COVID, Kerala

Dr. Chandni presented an overview of the outbreak, presentations, management concerns and long term sequelae of COVID-19. After a quick review of cytokine storm in COVID-19, Dr. Chandni reminded us that COVID-19 is unlike MERS and SARS outbreaks in having a high prevalence of VTE and its potential complications. The recovery process itself is a spectrum from short disease to longer term illness or syndromes. People continuing to experience symptoms after their initial recovery, the so-called "long-haulers" are said to have the post-COVID syndrome or "long COVID-19". For some people, some symptoms may linger or recur for weeks to months following initial recovery, while others develop medical complications that may have lasting health effects. There may be mood disorders, such as PTSD, depression, anxiety, and sleep disturbances; neurological effects such as anosmia, cognitive impairment - memory and concentration; thromboembolic disease such as DVT, PE, MI, Stroke. There is plenty still unknown with COVID-19. We have seen that it can result in prolonged illness and persistent symptoms. It can happen even in the young, the mildly symptomatic or asymptomatic. She briefly touched upon the diagnosis of MIS-C, a Kawasaki-like illness with features of toxic shock syndrome, reported in children and adolescents. She concluded her presentation by emphasizing the need to recognize red-flag features of serious disease or complications in the post-COVID syndrome, recognizing psychological impacts, as well as the need for long term rehabilitation. 

Zydus Hospital and Healthcare Research,

Ahmedabad, Gujarat

Administrative Modifications for COVID-19

Dr. Ketan Patel,
Consultant and Head, EM

Dr. Patel had an excellent presentation, short and sweet, and loaded with photographs as he described the administrative modifications by his department during the pandemic. Their focus was on creating safe and clear areas, and allowing the best safety standards for both patients and staff. He particularly highlighted the use of the lightweight abrasive blasting helmet - among their modification to a PAPR (powered air purifying respirator). The PAPR allowed for circulation of cool purified air within the PPE suit, while the blasting helmet, in his experience, reduced the unfortunate problem of fogging. With the need to use full PPE for aerosol generating procedures, having a device and get-up that provides both safety and clarity of vision is a boon for the clinician. 

Aftershocks of sweet COVID

Dr. Rignesh Patel
Consultant, EM

Dr. Rignesh opened with his case of a male patient in his 60s, with a background of diabetes, who attended with acute unilateral visual loss following three days of decreased vision and redness in the ipsilateral eye, and five days of reduced ipsilateral facial sensation. His vitals on arrival were significant for a mild fever, hypertension, tachypnea and moderately elevated random blood glucose reading. Review of systems demonstrated a normal systemic examination, while his facial examination was grossly abnormal. He had a swollen, red, right eye with non-reactive pupils, ophthalmoplegia and periorbital edema extending to the cheek area. His labs were significant for elevated white cell count, and D-dimer. His COVID IgG was reactive, though RT-PCR was negative, explained by a recent history of COVID-19 infection just 10 days prior to this attendance. He had been treated with remdesivir and steroids. After further tests, including CTs of his brain and paranasal sinuses which revealed significant soft tissue swelling, eye involvement, mastoiditis, and importantly, bony erosion of the maxillary sinus, he received his diagnosis of mucormycosis. Mucormycosis is a highly invasive and often fatal disease, in this case infecting the susceptible patient who was immunocompromised by his diabetes, recent COVID infection and steroid treatment. 

EDAC in the ED

Dr. Arjun J V

Dr. Arjun presented his case of a female patient in her 30s who attended with acute respiratory distress and reduced consciousness, who had pink frothy secretions requiring frequent suctioning. After promptly recognizing the need for a definitive airway, she was intubated. She had bi-basal crepitations, and type 1 respiratory failure, tachycardia with feeble peripheral pulses, and so she was duly resuscitated. The team provisionally diagnosed respiratory failure due to COVID, but also considered other differentials such as a major cardiac event, aortic catastrophe, cerebrovascular accident, sepsis, shock, endocrine emergency, and poisoning. A collateral history revealed that she had been experiencing an expectorating cough for two days, and that she had a background history of hypothyroidism for which she was not medicated. Initial investigations were conducted, including POCUS and CT brain which were reassuring, CT Thorax which revealed bilateral congestive changes, a negative urine toxicology report, and labs significant only for raised white cell count and mildly elevated CRP. In the midst of this, the patient developed a gross swelling of her neck. It was initially thought to be due to iatrogenic injury caused during intubation. Specialty consultations were sought, and further investigations conducted. A USG of the neck revealed the clinically detected mass to be a diffuse enlargement of the thyroid gland suggestive of nodular goiter, and a CT neck further revealed retro-clavicular extension of the left thyroid lobe, and tracheal compression (further increased by neck flexion). The patient thus had a further diagnosis of large multinodular goiter with dynamic obstruction of the upper airway, and type 2 respiratory failure. This initiated Dr. Arjun's discussion of his interesting topic, EDAC (excessive dynamic airway collapse) i.e. a pathological collapse and narrowing of the airway lumen by 50% or more (some suggest 70% or more) of the sagittal diameter. The emergency clinician must be quick to recognize the signs of airway obstruction, and anticipate difficult bag-mask ventilation and intubation, thus getting ready for direct laryngoscopy, using a supraglottic airway device, and potentially even front of neck access, due to distortion of anatomy and obscuring of landmarks. Notably, stridor is a late sign of airway compromise, thus we should recognize other signs, such as subtle voice change, hoarseness, dyspnea, agitation.  Because of the unpredictability of a partial obstruction transforming into complete obstruction, one must be prepared at all times. 

Sunday 13 December 2020

The 39th WACEM-ACAIM Weekly Summit: Week 11 of e-EMINDIA2020


Goals of Care During COVID-19

Nidhi Garg, 

We were joined this week by Dr. Nidhi Garg, director of emergency medicine research at Southside Hospital/Northwell health, and assistant professor at Donald and Barbara Zucker school of medicine Hofstra/Northwell. She led her talk discussing the policy developed by their hospital to outline processes promoting transparent, fair and ethical clinical decision-making regarding allocation of life-sustaining resources if crisis conditions prevail. The policy also defines advanced illness - patients with chronic illness, including frailty or dementia, and two or more further criteria out of a preset list. The pandemic revealed the need for guidelines such as this one, regarding life sustaining treatment decisions for all patients in time of public health emergency. An important step in these treatment decisions is understanding the goals of care. The purpose of these discussions is to ensure that patients are aware of their prognosis and expected treatment outcomes or effects, while also allowing the physician to understand the patient's desires and values. The policy encourages shared decision-making choices so that patients continue to receive comprehensive care aligned with their values, including questions about resuscitation and intubation. These discussions and decisions should be documented clearly. Northwell Health provided an easy to follow, algorithmized approach to the goals of care program. The pandemic brought stress to everyone - including families of patients. Advanced directives such as living wills, physician orders for life-sustaining treatment, and DNR orders, are legal documents which were designed to understand the values and wishes if a person undergoing medical care no longer had the ability to make decisions for themselves. 

MOSC Medical College, Kolencherry, Ernakulum

Moving COVID

Dr. Ajith Venugopalan, head of department
Dr. Mervin Christo C, senior resident

Moving COVID dealt with the question of patient transport between hospitals (inter-hospital) and within hospitals (intra-hospital). The MOSC emergency medicine faculty recognized the challenges of a poorly understood disease with high risk of transmission, risk of clinical deterioration in transit, issues of disinfection and decontamination, and maintaining a closed environment. It is important to first answer the question of why a patient is being transported, in determining how to do so safely. Key in this determination is the clinical status of the patient being transported - e.g. the need for mechanical ventilation, inotropic support, critical care intervention or admission, and continuous monitoring. MOSC uses a communication proforma that allows for a smooth handover of patient care. They made interesting changes to their ambulances - equipment had transparent covers, a logbook was meticulously maintained, an oxygen reserve was ensured, drugs appropriately stocked, and the ambulance divided into three zones with dual-exhaust air conditioning to avoid cross contamination. Staff were trained to deal with complications, and the receiving unit kept notified about patient status and estimated time of arrival. 

Intra-hospital transport also needed careful planning. Theirs being a 50 year old hospital, a separate block or COVID was impossible. They developed isolation zones within the hospitals, identified transit routes, and worked on restricting contamination. The first floor of the emergency department was converted to receiving suspected or confirmed COVID cases. Even for transport within the hospital there is a need to stabilize the patient. There should be dedicated trollies, equipment, and crash carts. There should be an adequate supply of PPE for the transporting staff. Procedures should be planned, and conducted by the bedside whenever possible, with limited personnel. Meticulous documentation including consent and charting should be diligently maintained. Preplanning of transit routes, for instance, choosing the shortest route, with minimum exposure to others, dedicated elevators, security coordination, and separate line of communication help to prevent cross-infection. MOSC also identified areas of development - complete online and e-reporting, ambulance tracking, telemonitoring, and uniform guidelines and protocols. Transportation medicine is still in its developing phase, but indeed an area allowing for growth and innovation.

Post-COVID Era

Dr. Aravind V,
DNB resident

Dr. Aravind shared his case of a patient attending with persistent cough after a recent COVID infection. Their cough worsened and they developed a breathing difficulty leading to an admission. Imagining revealed bi-basal atelectasis and bronchiectasis, along with patchy ground glass opacities. Dr. Aravind shared an interesting poster of non-respiratory manifestations of COVID-19. He therefore highlighted the need for an emergency department plan including screening for post-COVID symptoms and red flag signs, and prioritizing treatment of post-COVID complications. He also suggested telemedicine for follow-up and centralized communication within the hospital. 

Mass Casualty during COVID Pandemic

Dr. Tigi C Varghese,
Junior resident

In the middle of challenging pandemic, MOSC received news of a mass casualty incident - they were to receive 50 patients coming to the emergency department following a landslide at Munnar. Their institute was one of the nearest tertiary centers, so they put into practice the PRE-DISASTER paradigm. A helpful mnemonic to prepare - Planning and practice, Resilience, Education and training, Detection, Incident management, Safety and security, Assessment of Hazards, Support, Triage and treatment, Evacuation and Recovery. Disaster planning entails a vicious cycle of mitigation, preparedness, response and recovery. In this instance, MOSC secured a separate ward, with assigned ICU beds and isolation beds. They enacted aggressive resuscitation and stabilization measures, all whilst maintaining staff safety measures. A post-event briefing was conducted whilst maintaining adequate distancing and PPE measure. They made an amazing job of integrating the disaster protocol with the COVID protocol.   

Sri Ramchandra Institute of Higher Education and Research, Chennai


Dr. S Jagadeesan,

Dr. Jagadeesan presented the latest guidelines of advanced resuscitation by American Heart Association and Resuscitation Council UK. Emphasis is placed on carrying out resuscitation whilst maintaining safety of all personnel involved. Guidelines allow for outlining standards of care for the emergency medical services pre-hospital, during transport, and in-hospital care. Planning for closed room resuscitation, limiting personnel, mitigating risk by reducing exposure during aerosol generating procedures. Dr. Jagadeesan talked us through each step of the COVID resuscitation guidance, is beyond the scope of this blog, so I will encourage all readers to update your resuscitation practice with the latest guidance.

Double Trouble: An atypical presentation of COVID-19

Dr. Amritnandan Pillai
PGY2 Resident

Dr. Pillai shared some interesting cases from his department. One amongst them was a patient in his 40s attending with diffuse acute abdominal pain, and left upper extremity weakness and numbness. The patient had no comorbidities. His examination revealed a tachycardia, and was significant for 3/5 power in the left upper limb, distended and generally tender abdomen, with absent bowel sounds. He was aggressively resuscitated, and imaging conducted. The CTA revealed SMA filling defects, and labs were significant for lactic acidosis. He was also COVID positive. The case highlighted the prothrombogenic nature of COVID-19. Proinflammatory cytokines, lupus antigen, antiphospholipid antigen have been implicated. 

Tune in for more next week...

Monday 7 December 2020

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


Simulation Education during COVID-19

Dr. Shruti Chandra
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.... 

Sunday 29 November 2020

The 37th WACEM-ACAIM Weekly Summit: Week 9 of e-EMINDIA2020


Oxygenation Protocols

This week began with a review of two of WACEM-ACAIM team's publications - "Optimizing respiratory care in coronavirus disease - 2019: A comprehensive, protocolized, evidence-based, algorithmic approach" and "Short Term Home Oxygen Therapy for COVID-19 patients: The COVID-HOT algorithm". When we began to understand the impact COVID-19 was already beginning to have back in March, the WACEM-ACAIM team put together a clinical task force to address some of problems we foresaw. There was much new about the disease, and in fact, our understanding is still evolving. But we recognized fairly early that there may be disparities in care based on resources available to individual healthcare settings. We developed algorithms that are easy to follow and applicable to various settings. The first algorithm provides a step-wise escalation of care that follows the patient from the time they have their initial assessment. The latter paper classifies COVID-19 by severity, and provides a protocol for home oxygenation, aiming to reduce hospital burden.

Israel in the Corona Era: From the beginning and hoping for the end

Dr. Eran Tal-Or
Director of Emergency Department, 
Pade-Poria Medical Center,
Secretary of the Association for Emergency Medicine

We are grateful for Dr. Tal-Or sharing his Israeli experience and wisdom with us. Politics and medicine become intertwined something as impactful as this pandemic. In Israel, various experts present their assessments before the corona cabinet, who then weigh up the medical and political decisions. In mid April, there was a slow release of restrictive measures that were installed to curb infection rates, but as the restrictions were relaxed, the numbers inflated, bringing about their second lockdown. Some of this was a contribution from religious communities, local culture, sports. 
Interestingly, Israel has been tracking SARS-CoV-2 RNA through the wastewater treatment process, providing preliminary evidence for the importance of tertiary treatment and chlorination in reducing dissemination of the virus. They have developed a novel test, that provides results within seconds, which showed great accuracy in trials. All it takes is gargling a specially developed mouthwash and spitting it into a tube which then goes into the analyzer. They also have a big data analysis system allowing for healthcare systems to screen mass population. They ran a study assessing the outcome of treatment with convalescent plasma in patients with moderate to severe COVID-19. They are developing a promising vaccine as well. 
There is much to be learnt from clinicians and scientists from different aspects of the world, and with these weekly conferences, we get access so some of the most brilliant minds and best practices which we can amalgamate within our own systems towards global clinical betterment.

The national residency program this week featured the Medical Trust Hospital, Kochi, moderated by Dr. Murtuza Ghiya.

Medical Trust Hospital, Kochi

The Mask: Superhero in COVID-19

Dr. Mohammad Haneef 
Consultant and HOD,
Department of Emergency Medicine,

Among the advice for prevention of transmission of COVID-19, encouragement to use masks features prominently. Dr. Haneef brought some science to the debate. First describing virus transmission via drop infection, contact and inhalation, with a short deep dive into fluid flow behavior, he explained the concept of droplet transmission via facemasks. There are two key aspects to choosing a mask - it's thermal comfort - particularly important in tropical countries, and flow resistance. He shared with us these facts - 70% mask use could eradicate the pandemic, N95 masks are more effective than surgical masks which are more effective than cotton masks, and faceshields are effective.

Role of CXR in COVID-19

Dr. Muhammed Jezin, 
DNB Emergency Medicine

CT chest is considered the gold standard for imaging of the thorax in COVID-19. Dr. Jezin reviewed a study conducted to assess chest x-rays of COVID positive patients using the modified RALE score in correlation with clinical spectrum of disease. They collected data of 108 patients over 2 months, of patients with COVID-19. The imagining findings were correlated with predefined clinical severity of disease. Among the positive patients in their study, 35% showed chest X-ray abnormalities. Of these the predominant finding was ground glass opacities involving mainly the peripheral areas. When correlating to severity, most patients fell into the mild category. 

CRP as a screening tool for COVID suspects

Dr. Rohini J W,
Junior resident, Emergency Medicine

In this study presented by Dr. Rohini, 67 patients were isolated for a month, of whom 10 were RT-PCR positive. Chest X-ray was abnormal 40% of these patients, and CRP values were noted for all. Their study concluded that CRP has limited value as a standalone investigation, but may be used for prognostication, and as an early marker for severe disease. It appears earlier than CT changes. However she ended her presentation with the message to hold a high index of suspicion for the disease, and to consider more than any one screening tool to minimize risks.

Sunday 22 November 2020

The 36th WACEM-ACAIM Weekly Summit: Week 8 of e-EMINDIA2020


History In The Making

We opened this week with a reminder of the history of INDUSEM, WACEM, and its connections to AAEM. As a young resident and member of AAEM, Dr. Galwankar worked to amalgamate the best principles of AAEM, as well as best practices from American and European EM while establishing INDUSEM. The crux of his mission was to start an organization for emergency medicine from the ground up within India. The urgency of placing due importance on board certified residency programs and inculcating the culture of regular reading and assessments led to the establishment of ACEE. The new residents of a fairly new specialty saw the need for networking, soon leading to the formation of the free membership organization, the EMA. Several other leadership initiatives such as FLAME (Female leadership academy for medicine and entrepreneurship) and EMCORD-India (Emergency Medicine Council of Residency Departments in India); research initiatives like INCIITE (INDUS Network of Critical Illness and Injury Translational Trial Experts) and INDUS-ARC (INDO-US Academic Research Cooperative); and journals such as JETS (The Journal of Emergencies, Trauma and Shock), JGID (The Journal of Global Infectious Diseases), etc., and many other initiatives all fall under  the umbrella of INDUSEM. In 2014, INDUSEM along with several global academic partners and associates, transformed to the global congress and council, WACEM. With much to its credit already, WACEM is still hard at work with a clear vision for 2025. (More information can be found in the links included within this write-up.)

Saturday 14 November 2020

The 35th WACEM-ACAIM Weekly Summit: Week 7 of e-EMINDIA2020


🎇 Happy Diwali! 🎇

Toxicological issues that have emerged during the pandemic

Dr. Ziad Kazzi, MD
Associate Professor of Emergency Medicine,
Director, International Postdoctoral Fellowship in Medical Toxicology, Emory University,
Assistant medical director, The Georgia Poison Center, 
President MENATOX, Board member, ACMT, MTF

    Dr. Kazzi started off this week's talks with a bang. He started with sharing a valuable resource, a web-series by ACMT (response to COVID-19). His talk focused on the increased exposure to poisoning from cleaning agents and disinfectants such as bleach and the more dangerous chlorine dioxide which produces severe adverse effects and death. Unfortunately there were cases of ingestion of these substances. Toxicologists play an important role in public education of correct use of equipment, procedures, types of agents, and their medical consequences. Relevant at present, was his mention of alcohol-based hand-sanitizers. Due to the pandemic, a lot of alcohol distilleries participated in production of these hand-sanitizers. These should contain a minimum of 94.9% ethanol by volume, or isopropyl alcohol, along with bittering agents such as hydrogen peroxide to dissuade ingestion. In some instances, methanol was used erroneously. Methanol, as we know, is highly toxic substance. 
    He also spoke about hydroxychloroquine/chloroquine. These become an important topic of discussion due to the initial touting for the "treatment and prevention" of COVID-19, by both clinicians who did not wait for an evidence base as well as non-medical people, particularly those in the public eye. These drugs produce sodium channel blockade, potassium channel blockade, and an intracellular shift of potassium. The trouble is unpredictable toxicity, sometimes even in therapeutic doses, potentially with multisystem adverse effects. Treatment is aggressive supportive care, high dose epinephrine, diazepam, careful use of sodium bicarbonate typically with replacement of potassium. There were also cases of oleander (a cardiac glycoside) poisoning. Interestingly, this can be treated with digoxin binding fragments, though likely to require higher doses than digoxin toxicity, and supportive care. Serum digoxin levels may also be helpful - though not targeting the exact substance, and thus likely to be inaccurate if considering quantitatively, any level at all is still suggestive of toxicity. 
    Dr. Kazzi spoke passionately about the fact that we must follow an evidence base. We must be patient in our therapeutic ventures. Undue use of any and every medicine we might think of is not the right way to practice medicine, and in fact is quite dangerous. His talk highlighted the role toxicology has and continues to play during this pandemic. 

Surviving COVID

Dr. Digambar Naik, MD
DOIH, DHA, FIAE, FAIMP (Cardiology)
Senior Cardio-metabolic physician, 
Senior Echocardiography Trainer, Goa

    Dr. Digambar spoke not only as a clinician, but as a recovered COVID-19 patient. Despite taking precautions and following the rules, Dr. Digambar found himself a victim of this terrible virus. He had been taking prophylactic medications at the time already, including hydroxychloroquine. As a patient in hospital, he was on a medication list so long it did not fit on just one page. This polypharmacy continued even upon discharge. What made a significant impact, as you could tell from the heaviness when he spoke about it, was being alone in his time of need. Due to typical institutional rules, he had no attendant, family support, contact. He learnt from this the importance of managing one's own wellbeing. He had a few thoughts that stuck with him, which he shared with us, the first of which was that COVID is not a simple flu. Accidents happen despite precautions. This is a virus that is killing the healers. Our knowledge of COVID is still incomplete. In a lot of cases, drugs are used irrationally. He also took drugs for lung fibrosis (glutathione in his case), on his own initiative and suggested that this warrants some attention. His structural ECHO was normal, but after he was discharged, he arrange a functional ECHO which revealed strain patterns. So he highlighted the importance of functional echocardiography. He closed by saying that a lot of hospital burden can be prevented by better post-COVID management. The patients have persisting symptoms which understandably cause a lot of worry, but often resolve without intervention. Follow up of these patients would reduce hospital attendance. 
    There are so many clinicians, nurses, paramedical staff who have experienced the disease themselves. It would be prudent to use their clinical experience and patient experience to improve clinical care for all.

Monday 9 November 2020

The 34th WACEM-ACAIM Weekly Summit: Week 6 of e-EMINDIA2020


Becoming EPIC

Dr. Indrani Sardesai, MBBS, MRCEM
SpR Emergency Medicine
QE Hospital, Gateshead, UK

I was had the honor and pleasure to host this the 34th weekly summit, and was one of two international speakers. Out of many topic choices, by request, I settled on sharing the story of my journey in emergency medicine as well as my proclivity towards art and education. EPIC is an acronym for 'emergency physician in charge'. You can read more about this through RCEM Workforce documents . As a specialty registrar, play the role of the senior decision maker. Years of sincere hard work and dedication to the field along with the blessing of support from amazing personalities has seen me through. Reaching this stage has been a personal achievement, and I still have a ways to go before I become EPIC (in both senses). But what I'm known for, quite happily, is my combination of artistic skills with delivery of education. Just as we are eternal learners, we are also eternal educators. I found a way to step into my comfort zone in order to step away from the crowd, and encourage everyone to find their own signature or niche. To quote Dr. Seuss, 'why fit in when you were born to stand out?'

The Evolution of SARS-CoV-2 and COVID-19

Dr. Sean Downing, MD
Department of Internal medicine
Department of Pediatrics
Sarasota Memorial Hospital, 
Sarasota, Florida, USA

Dr. Sean Downing, yet again, engaged us in his fascinating take and talk about the evolution of SARS-CoV-2. He reminded us of the patterns of SARS-CoV-1, and the similarities shared with the CoV-2. He used a graph to show us the present numbers of the virus in various countries, and interestingly while UK is peaking again with a sharp rise in numbers and USA still on the rise, India seemed to be plateauing. Along with this came the observation that though it seems like the virus is infecting more people, the mortality from the virus have slowed down, though by no means stopped, in comparison to March. There are a number of theories about why this might be, but Dr. Downing subscribes to the theory that the virus is evolving and so is our understanding of it. 

Thursday 5 November 2020

The 33rd WACEM-ACAIM Weekly Summit: Week 5 of e-EMINDIA2020 31st October

The meeting began with the WACEM chief Dr.Sagar Galwankar's brief introduction to The international speaker Dr. Pushpa Sharma from the Department of Anaesthesiology, Uniformed Services University of the Health Sciences, Bethesda, USA.

COVID-19 AND SEPSIS: Partners in crime to kill innocent mitochondria 

Dr. Pushpa Sharma Ph.D

The International speaker started off her talk with a question for the audience that was to get them hooked for the rest of her talk - why does covid target innocent mitochondria? She quoted the Global Sepsis Alliance, 2020 to explore the expanse of covid's relationship with sepsis and multi organ failure that itself was of pandemic proportions. Covid, according to her was smart in selecting mitochondria as their target for attack. By hijacking the powerhouse itself, it triggers a cascade of DNA depletion syndrome that aggravates hypoxemia or leads to a cellular shutdown phase! A transit recovery phase after this shut down was a crucial therapeutic window where anti-covid agents could act to improve survival. She concluded that we should look forward and look around to get over covid! The session had interesting questions at the end by Dr. Irshad Chaudhry and Dr. Sagar which were keenly answered by Dr.Pushpa. Expery comments by Prof. Sarman Singh, Director of AIIMS, Bhopal and Dr. Sagar concluded the session by emphasizing on the need for more collaboration for researches at molecular levels. This was followed by presentations from EM Residency Programs, moderated by Dr. Roshan Mathew, AIIMS, New Delhi.


Dr. Naman Agrawal MD

The faculty presentation was kick started by Dr. Naman Agrawal, Assistant Professor of Emergency Medicine at All India Institute of Medical Sciences, Rishikesh. He briefly outlined the realignment of working patterns, processes, and procedures amidst covid chaos at his centre in Uttarakhand in his inimitable style. Parallel emergency departments for covid and non-covid cases were initiated and run round the clock with the help of other department residents who were quickly trained and oriented by Emergency Medicine department.Unidirectional flow of patients were maintained with the help of innovative ideas to bridge gaps like "zero consultation zones". He navigated through issues like "Plastic Man syndrome" being PPE clad, socially isolated, with broken communication that were identified and steadied by appropriate coordination of team leaders, covid floor managers alongwith social media communications and automated checklists. 


Dr Himanshi Baid

Dr. Himanshi, MD Resident from AIIMS, Rishikesh presented a case series of Diabetic Ketoacidosis in covid as experienced from her center. She outlined a typical case initially and then presented insights from a case series audit among 13 patients with DKA and 2 patients with diabetic ketosis. She stressed on the importance of assesment of anion gap and balancing fluid resuscitation in DKA vis-a-vis fluid restriction in ARDS. 


Dr Hannah Chawang

Dr. Hannah, MD resident from AIIMS, Rishikesh spoke on the cardiovascular manifestations among covid patients at her centre. Take home message was having a third eye open for identification of thrombotic manifestations like pulmonary embolism and deep vein thrombosis necessitating thrombolysis during initial evaluation itself. She also outlined cases of arrhythmias arising out of MI, drug interactions, fluid and electrolyte issues. Rhe take home message was early bedside anticoagulation in covid patients.


Dr. Takshak Shankar

Dr. Takshak, MD Resident from AIIMS, Rishikesh presented a short research done by his department under guidance of Dr. Poonam. The findings of his cross sectional research were insightful and specific to healthcare workers working in the Emergency Department. He also compared their findings to the ones from recent studies from around the globe.


Dr. Manu Ayyan, MD, FACEE

The other faculty presentation was by Dr. Manu, 
Assistant Professor of Emergency Medicine,
JIPMER, Pondicherry. He shared the lessons learnt during covid from experiences at his centre which provides free medical care, food and shelter to patients. His talk enlightened us about the hierarchy of needs in ED and balancing individual needs from the shoes of an administrator, floor manager and clinician. He outlined the infrastructural changes, 'jugads', medical education remodelling, resource acquisition and disaster management skills pivoting ED to the centre of Covid care in their hospital. Covid was an opportunity to foster research among residents, being a team player with a delicate balance of being there for patients, families and friends.


Dr KNJ Prakash Raju, MD

Dr. Prakash, Senior Resident from JIPMER, Pondicherry spoke about the frugal innovation "Resuscitation coverall" modelled on saving the patient and saving the resuscitators. Highlight of the presentation was a pilot simulation test for contact and aerosol transmission done the Indian way by innovatively using paint and local detergents!


Dr. Rose Mary Joseph & Dr. Amaravathi

The final presentation for the day was a case presentation from JIPMER. It was a curious case of mesenteric ischemia arising as a result of simultaneous arterial and venous clot formation in a covid patient and was co-presented by Dr. Rose Mary and Dr.Amaravathi, MD residents from JIPMER, Pondicherry. They emphasized on the need for high clinical index of suspicion, fluids, D-dimer, analgesia, broad spectrum antibiotics and ED-lap for such patients presenting with covid and abdominal pain. Dr. Roshan was instrumental in maintaing the enthusiasm among listeners while maintaining the time limits.

The 5th week of academic extravaganza ended with Dr. Sagar concluding the session with an of inspiration calling upon fellow Emergency Physicians to work hard towards realizing Emergency Medicine as a surgical specialty in India.

Tune in for more next week.

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Sunday 18 October 2020

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:


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.