Endorsed by WACEM & The World Health Organization Collaborating Center for Emergency and Trauma, AIIMS, New Delhi, India in Partnership with The Emergency Medicine Association and The Academic College of Emergency Experts as well as The American College of Academic International Medicine
Ethics in COVID Research
Dr. Siddharth Dubhashi, MS
Professor, General Surgery
Dr. Dubashi kicked off e-EMINDIA 2020 with his relevant discussion of the concept of ethics, as a general research principle, and particularly important with the rise in research in this COVID era. Four main principles govern ethics in research - Non-maleficence, beneficence, autonomy, and justice. Non-maleficence refers to the concept of "do no harm" which is one of the fundamentals of medicine. Beneficence is the concept of "do good", where-in the clinician acts in the best interests of the patient. Non-maleficence and beneficence act in tandem. Autonomy allows the patient their right to choose or refuse a medical treatment. Justice in the context of research, means impartial treatment of patients, with removal of bias to gender, race, sexuality, financial status, etc. In his talk, Dr. Dubhashi regaled us with the history of development of research and therein the evolution of and need for an ethical approach. Considering the ethical implications of any research or study is a reflection of the respect for participants and respect for the process.
USG in COVID
Dr. Edgar Miranda, MD
Oak Hill Hospital, Florida
Dr. Miranda shared his expertise in the use of bedside ultrasound in patients with respiratory involvement due to COVID. With many examples of recorded clips, he described the "normal" expected A lines (horizontal lines in an ultrasound exam), and abnormal B lines (vertical lines in an ultrasound exam), in using the BLUE (Basic Lung Ultrasound Examination) Protocol. It is difficult to translate his excellent visual presentation into a concise summary. The first stage of the BLUE protocol involves looking for lung sliding. The next step is looking for A or B lines. Thus, in a gist:
Lung sliding present + B lines = suggestive of pulmonary edema.
Lung sliding present + A lines = scan for DVT (positive suggests PE in lungs, negative triggers a further PLAPS* examination).
Lung sliding absent + B lines = suggestive of pneumonia.
Lung sliding absent + A lines = look for lung point (with lung point = suggestive of pneumothorax, without lung point = consider other diagnoses)
*PLAPS = Posterior-lateral alveolar fluid and/or Pleural Fluid.
Of course a good ultrasound diagnosis and reliability is operator dependent. However, in the hands of experienced and certified users, there are several studies showing impressive predictive value of using ultrasound in diagnosis of COVID or prognostication in combination with other imaging modalities. However, in the hands of the untrained confident users, there is scope for significant errors and misinterpretation. In the words of Dr. Sagar Galwankar, a fool with a tool is still a fool.
Logistics Aspects at Ground Zero
Dr. Sagar Sinha, MD, DNB,
Assistant Professor, EM,
MGM Hospital, Mumbai
Dr. Sinha, in charge of the COVID response in his department drew us a picture of the hard-hitting pandemic in a hot-zone. Due to the sheer volume of population as well as its density, COVID spread swiftly in Mumbai and Navi-Mumbai, quickly making it a major contributor to India's number of infected individuals. There were anticipatory responses, such as generating surge capacity, creating safe corridors, and carefully regulating staffing levels. Several logistical aspects came into play. While managing panicking public, the hospital had also to manage its worried staff. While creating "safe zones", they had to make physical temporary/permanent changes (generation of air-borne illness isolation rooms, increasing capacity of intensive care and high dependence units, etc.). Being designated as one of the few "COVID hospitals" in their catchment area meant that they saw an exponential rise in their hospital attendance from their immediate vicinity, expanding into further areas whose COVID or suspected COVID patients could not use non-COVID hospitals or clinics. They had to deal with supply chain issues, such as adequate oxygen supply which of course is the most important part in dealing with a primarily respiratory disease. Dr. Sinha has been an important member of these WACEM-ACAIM joint group meetings from the beginning, and as such, we know his level of involvement in his departmental response and the incredible amount of work and sacrifices required of him. His hospital, department, and team members led by his formidable spirit, braved the storm and continue their impressive efforts at managing this COVID crisis.
Adventures of an Oxyphile
Dr. Ramakrishnan and Dr. Suraj Horakeri,
Emergency Medicine Residents,
MGM Hospital, Mumbai
Transitioning into the highlight of e-EMINDIA, EM resident speakers shared their talk on "adventures of an oxyphile," describing the journey of their patient with who was diagnosed with COVID-19 pneumonia. They chronicled the course of illness of their patient who initially presented with shortness of breath, developed a need for oxygen which escalated quickly, and fluctuated through the illness. They described their use of protocols (once of our WACEM-ACAIM publications available at: https://www.ijciis.org/article.asp?issn=2229-5151;year=2020;volume=10;issue=2;spage=56;epage=63;aulast=Sinha , of which, Dr. Ramakrishnan is a co-author). Using the various risk stratification tools developed, they charted the illness and recovery which was case-based evidence of the success in following a systematic approach to basic medical therapy and escalation and optimization of care as triggered by the algorithm. Although we cannot share the point by point journey of their patient, we congratulate Drs Ramakrishnan and Horakeri on their confident and knowledgeable presentation, which will hopefully inspire their co-residents and colleagues to bring their best to e-EMINDIA 2020.
More to come next week (Saturday, October 10th).....