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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