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....