INJURED FIRST !!! : Road Traffic Trauma and the Complexities of being a Good Samaritan or a Responsible Driver in Developing India

Prevention is better than being a Patient

From the Desk of Sagar Galwankar, MD, FACEE, Diplomat. ABEM (USA)

 

Amongst all the media discussion about the court verdict in a recent celebrity hit and run road traffic case I found myself thinking about the complexities of this whole issue of road traffic injuries in India.

India is changing and it’s happening fast. International Cars are now being driven on Indian roads. These are high speed cars. India has now gotten expressways which are four lane to six lane. Heavy Motor Vehicle Travel has also increased with economic growth and manufacturing industries making India their home.

People can now own vehicles with ease, thanks to loans by prospering banks.

In all this frenzy one thing hasn’t changed and that is the behavior of the Indian Road Traveler.

The Road Safety Education and the Road Travel Skills still continue to lag behind.

Drivers love to have cars which can easily speed 120 km/Hrs. without realizing that if the tires burst then death is instantaneous.

I often wondered why there are speed limits on roads and after much research found out that the speed limit is calculated based on the probability whether an accident at that speed can enhance least damage and survival. It also takes into account pedestrian traffic and volume of traffic. So in all abusing the speed limit is high risk by itself.

Drinking alcohol and driving is a big No and the highest risk because in a crash the first to die could be the driver itself.

Now in case of two wheelers the concept that the rider should only need a helmet and the back seat rider doesn’t need one is something which is very difficult to comprehend by me. In a crash both the riders will be equally exposed so without a helmet the rider is at high risk of death.

 I was travelling in India recently and in a city I saw a crash happen in front of my eyes. A driver was driving his imported car and it crashed into a motor cycle being driven by a Non Helmeted rider. It was an accident because the motor cycle skid and came in front of the car and the rider got head injury. The rider was awake and bleeding but what happened next ?

People gathered and started beating up the driver who had stopped, gotten out of the car and picked the rider and put him in his car and was taking him to the hospital. The first response of the by standers was the Driver in Car must have made the mistake …… Hammer the driver.

This is a wrong behavior which needs to be changed. The thought that Car Drivers have more money so they can afford cars and if they are in a crash it’s their fault so take justice into their hands and forget the patient is absolutely wrong. Forgetting the patient is just wrong.

This leads to the phenomenon of drivers running away after hitting other pedestrians / vehicles. If anyone wants to take the crash victims to the hospital they will not and just run away because they don’t want to face the mob mentality.

On the other hand drivers should be responsible whether on bikes or in car to maintain slow speed and make sure they don’t hit anyone.

 Wearing helmets, driving with car seats for children when with children , driving within speed limits, wearing seat belts, checking their eyes, not driving if they have high diabetes or seizures or pacemakers are some of the responsibilities Citizens have to exercise on their own.

In many of my public events where I was called to inaugurate Road Safety and Basic Emergency Care Training programs I ask one question: What do you do when you see a crash on the road?

The truthful answer I get is: we don’t stop because we don’t want to get involved with the Mob or the Police.

Why are we as citizens afraid of doing the right thing?

Police will not bother you if you helped a bleeding victim. There is no use of learning Basic Life support courses if you don’t have the intent to help someone in need. We still are far from having EMS within minutes so the cars and bystanders are the first responders and hence going to a hospital which has 24/7 Emergency Care with Radiology and Laboratory Back up is the first important step after stabilizing the airway c spine and stopping the bleeding.

Focusing on the Injured is very important and that’s a First.

We have crowded cities and vast rural corridors.

We have lack of space for pedestrians to walk that’s why they walk on roads.

We have high speed corridors going through rural area without crossings, overhead bridges or barricades.

This is all there because development and infrastructure are in a mismatch.

What we can match is our behavior.

The vehicle industry and the road traffic license departments have to take a lead role in education and regulation of behavior of travelers. Just selling vehicles and issuing licenses is not the only responsibility.

Changing our behavior and educating the masses that a crash is a crash and INJURED FIRST should be the focus is the responsibility of the Social Media, Marketing and Medical Community.

Avoiding a Crash is better than being in one….still crashes will happen.

We should be responsible and always remember the INJURED IS ALWAYS FIRST !

INDUSEM has launched the Jan Suraksha Abhiyan on Injury Prevention which compliments the Prime Ministers Jan Suraksha Bima Yojana on Insurance of Accidents and Injured victim. www.indusem.org

Thanks to Web Images for the open source Picture !
 

Come April - Rules For Fools: Do they help ?

From the Desk of Sagar Galwankar, MD

I realized its April when the Social Media was buzzing with Jokes ridiculing Fools and Celebrating Happy Fools Day.

As celebrations and rediculations continued across the world needy patients continued to visit Emergency Departments and continued to be cared for as I sat wondering “When we come to Things like “Standard Orders”, “Protocols” Can we make Rules for Fools?

There is a lot of discussion that Emergency Medicine is all protocol based, its overkill of investigations, it’s all to the point, etc. etc. Additionally when it comes to Education, I come across many strategies in EM Teaching where educators want to shorten lectures and topics making the lectures “To the Point” without going into the deep logic.

Yes, Emergency Medicine is based on Fundamentals of Unknown and Vital Signs govern the paths to diagnosis and care, but I  vehemently maintain that Emergency Medicine is a science, it does have an immense content of basic medical sciences and the algorithms are based on scientific evidence with a deep understanding of the way the nature of pathology works.

Emergency Medicine evolved from a Traffic Police System of Symptom based stratification and stat disposition to different departments & physicians to its current day where one Expert called as THE EMERGENCY PHYSICIAN mans the Emergency Department with his knowledge, skills, Diligence, and intelligence. This EP makes the lives of his colleagues from all disciplines who work on the floors and wards easier thus providing Urgent Clinical Care by a Specialist to the Emergency Patient immediately on arrival to the hospital.

This transition has brought immense value to health care.

I remember the time when single handedly I started the mission to develop Emergency Medicine in India and was ridiculed by the all physicians from different specialties and hospitals.
Today the same hospitals are selling Emergency Medicine as their strong points and advertise claiming the best emergency care just to attract more patients.

Coming back to the point:

Standard Orders, Protocols and Clinical Pathways are basically a set of rules which have to mandatorily be followed. 

The creation of such templates comes after a lot of discussion, debate and consensus both at a scientific level and then at an operational level in an individual facility.
The philosophy behind such Pathways is to make sure that every patient is cared for matching the clinical evidence available. These pathways also envision ensuring that the slightest risk is negated and every patient is safely cared for.

Well the most common and the most famous clinical pathways are for Chest Pain / Acute Coronary Syndromes/ Stroke / Sepsis while the Resuscitation Pathways are standardized for Cardiac Arrest and Trauma for both adults and children. 

Clinical Protocols is a different league wherein every facility has its own Standard Set of orders to overcome the Challenge of Overcrowding and underdiagnoses / misdiagnosis of life threatening conditions. Not Missing AMI / Stroke / Sepsis or any life threatening condition, and hastening diagnosis by kick starting investigations and administering fluids, pain meds, antibiotics, antiemetics and antiallergic medications etc is the intent of such orders.

The complete spectrum of this approach is to make sure patients are cared for safely and are offered the highest quality of evidence based care.

Well the most important part of this whole story is the Physician who has to examine the patient and make the judgement whether the protocol is correct or needs to be modified in terms of medications, investigations or final disposition.

It’s not that simple and it’s wrong to assume that a protocol covers all. In a chest pain protocol the physician still has to rule out a Pneumothorax or Aortic Dissection. In sepsis the physician still has to decide the gravity and clinical condition of the patient and locate the source.

What if there is a Nausea Vomiting Protocol and the patient comes as DKA , I can remember multiple times that patient has come with nausea vomiting sugars of 1000 and his EKG shows an Acute MI but patient was being worked up on lines of Nausea and Vomiting.

I can tell you multiple incidents when patient came with symptoms saying that they had facial weakness and hemiplegia which resolved and was started on TIA protocol and I walk in and do a stroke scale and find the patient to have visual deficits and then change it to Stroke Alert Stat CT and TPA. Not every TIA goes for Stat CT with radiologist read in 10 minutes.

The point I am making is that Doctors are the ones whose knowledge will help the protocols to function optimality. 

Protocols have their downside too.

Developing protocols is cumbersome and time consuming and involves multiple departments, individual specialty guidelines, and operational rules and by-laws of the hospitals. There are times when the protocols finally see the light of the day and scientific evidence changes and again the protocols have to be modified.

These standardized rules have a downside at academic emergency departments. Post Graduate Students tend to just implement protocols without knowing each and every step in the protocol. They need to learn and understand the logic.

I am cautious to support these new era of “Short to the Point Lecture Format” which is immensely misleading and disastrous if one does not know the logic behind every point.

That is the very reason Boards in Emergency Medicine across the  world have a written as well as an oral component and only a handful of specialties in have both exams with majority only conducting and certifying based on MCQ Written Tests.

Emergency Medicine is a branch of Challenge and Opportunity.  

Emergency Physicians will never have patients to be followed as Primary Physician, They may not be great surgeons but they are surely doctors whose difference is visible and that too immediately.
The actions we take and the reactions to the actions is what saves the patients or doesn’t.

With responsibilities of MAKE OR BREAK on our shoulders, surrounded by an Era of Accountability to self and your patients and trenched in systems with egos, protocols, patient safety and quality, having the up to date knowledge becomes more crucial than ever.

On the other hand Teaching correct knowledge and practicing as per current algorithms is very important in our specialty.

We may have the best tools, we may have the most up to date rules but in hands of a fool there is no value to any tool or any rule because a fool is a fool regardless…..

Solution is .......cure the foolishness…read, learn, practice and improvise with a deep understanding of the scientific subject matter. 

We are dealing with lives and not some product manufacturing industry!

Do we need a Honor System in the Worlds Largest English Speaking Democracy ?

The Education System is Shaped by the Ones Educated in it !

From the Heart of Sagar Galwankar, MD

The whole western world went berserk when they viewed pictures of the mass cheating at a high school in a state of India.

It does not matter which state of India did the school belong to. The fact is the School was from India.

We are at a very vibrant stage in India wherein our National Leadership is advocating India and Indians to be the largest supplier of English speaking, technology savvy, knowledge rich and high skilled human resource in the world. Complimentarily the government is pitching the case to the world to come and Make in India.

At moments like these where our Nation is making such an honest case to the world, instances like these have left a big question mark across the western world.

It is very easy to use the famous Indian terms “It’s OK, It’s one school”…Well let me tell you it’s not OK, it’s not one school, it’s A School in India.

Being an ardent Indian working in the United States I was sad when one of my colleagues from USA came and showed me this news. I was shocked and embarrassed and I said nothing except, “Don’t Judge the Nation and its Citizens by what you hear and what you are shown. I understand that this happened but that does not reflect on the nation”

Why should we bring ourselves to a stage where we have to defend ourselves?

The whole education system in India needs a Second Look and a thoughtful solution.

The whole Education Systems revolves around three important  points

1.   Marks

2.   Caste

3.   Financial Capabilities

We should be reminded that a country is made by those who are aware and educated and not by those who are ignorant. The world is now connecting in seconds and India has reached Mars.

Our Education system is facing the biggest challenge it has ever faced. Competition has been limited to only 10 % of the whole education system because commercial education dominates the rest of 90%.

Students of today believe that if they pay they deserve to get the Degree. They believe education can be bought. There are only a few who believe that real talent will always win and there are those who give up all hope when they fall on the border and get eliminated by the Caste Line of Scores where a student with lower grades can make it to top institution but a student with high grade can’t get in because his quota is filled up.

 This gives rise to what I called “Fractured Progress”. We sow the seeds of dissent in the system which is created to cure dissent.

We speak about BRAIN DRAIN but we forget that the very reason for brain drain is the loss of faith in the future.

If the affording believe that they can buy any degree at any cost and the struggling believe that marks are the only way they can be educated then be it any caste there will always be a race to win and win at any cost and that cost could amount to cheating and academic dishonesty too.

What happened at one school is a small indicator of what can happen.

The world has many achievers who are Indian. Let us not stigmatize them.

The government has to fortify its vigilance and regulatory framework in Education by partnering and learning from Successful Education Systems across the world.

It’s not that difficult.

I will give the Example of Allopathic Medicine in India:

1.   Make Common Entrance Test applicable to getting admission in any medical school which comes under the Medical Council of India be it Private or be it Government Funded

2.   Offer Student Loans to students to fund their own education

3.   Keep Points for the resource limited students but don’t divide merit on caste

4.   Let One Apex Agency be responsible for Accreditation of the Medical Institutions of Under Graduate, Post Graduate and Sub Specialty Education

5.   Let another independent agency be responsible to conduct nationwide examinations of every field, discipline with complete freedom.

6.   Create a National Medical License Tracking system

7.   Empower a regulatory authority to accredit the healthcare facilities to provide quality healthcare.

8.   Penalize those who default at any level

9.   Encourage Physicians to become teachers by offering training initiatives and incentives and set up benchmarks for career advancement.

10. Integrate the vibrant corporate healthcare system into the academic medicine system by cross sectorial collaboration

These are 10 Points which by itself will reform Health Education and HealthCare in India.

With current existing scenario where Caste, Marks and Finance dominate the future of smart citizens,  it is reforms like these which will change the face of India.

There should be no student who should feel helpless because he could not avail the education he desired, there should be no student who should be compelled to compromise in order to win at any costs, there should be no student who believes that money can buy the degree they demand, there should be no student who should be left behind.

I believe in Bharat where Universities like Benares Hindu University and Nalanda University made history, I believe in my country which has institutes like All India Institute of Medical Sciences, I believe in my country where the largest skill population of the world lives, I believe in my country which placed me where I am today !

 I believe in my country which has the potential to bounce back when challenged.

Let’s bring the honor code into education, let’s create an environment to implement the honor code, let us value that an Educated Nation is an Empowered Nation, An Educated Nation is an Economically Progressive Nation.

 I have a dream and I dream to make it true !

 

 

The story of Merging HealthCare, Insurance Industry and Quality in Emerging Economies: When…… it’s OK ….IS NOT OK!

From the Desk of Sagar Galwankar, MD

I often look at Economies in Transition, where healthcare is considered an emerging market and wonder whether the speed at which consumer demand grows for materials ever aligns with the demand for more healthcare.

When we say …we need something…that means we don’t have the thing and we need it…..or we have something but we want it more or we want better.

When we put healthcare into the same perspective …….an increased demand or what the capitalist calls “Emerging Market” means the market is so ill that it is extremely thirsty for health care solutions.

To the world an Emerging HealthCare Market definitely gives a different picture when you say Health of the Nation is Wealth of the Nation.

 When speaking of nations some nations have universal healthcare while some emerging nations have a two forked system of health care…one funded by the government and one funded by private money.

The Government Funded is considered or utilized maximum by the “Less Affording/ resource limited patients” as well as mandated government employees and the Private Funded is utilized by insured and self-paying patients.

I don’t deny that there is a miniscule overlap and cross over.

Now we come to a scenario where there is rising economy and employers are mandated to insure their employees as well as people realizing that they need insurance …thanks to advertising, sensitization, and mass realization, we now have a rising number of insured citizens.

Based on the few facts namely:  1. Rising Population 2. Rising number of insured 3. Increase burden of illness and 4. Growing economy .....the phenomenon “Emerging HealthCare Market” is born.

This phenomenon leads to a radical tsunami of investor enthusiasm and promotor confidence.  Everyone dreams of becoming a Billionaire, this is again based on the fundamental that there are many affording ill people to support the industry of patient care.

These investors who have names like Venture Capitalist, Equity Players, Private Funders etc. now start pouring money into healthcare.

How do they pour this money into healthcare?

They do this via four mechanisms:

1.    Support Big Players in the HealthCare like big chain of hospitals to diversify and create day care centers, lab networks etc. and grow further

2.    Support Small hospitals to become big by opening more branches

3.    Buy stocks in health sector in the stock exchange

4.    Buy shares and invest via funds who again invest directly or indirectly into health care markets, hospitals etc.

When Investors put their money they want their money back.

They want margins and profits.

Hospitals start looking like hotels and healthcare equates to hospitality.

The difference is that ….in Hotels clients come with happiness and to hospitals patients come with pain.

It’s a different set of situations but for investors it is the same when it comes to ….money in and money out.

So now the Invested HealthCare system has to generate revenue instantly to prove growth and reinforce investor confidence.

What do the promotors do: Hire Marketing Teams, Get Advertising to the door of every primary care doctor, reach out to every potential patient, Offer different products like Health Check Ups, Create inquisitiveness to hunt out some disease so that some cure can be offered at their hospital. Skin, Anxiety, Breast Exam etc.  Run Banners and hoardings showing a patient holding his chest with a tag line # “Chest Pain….it could be a heart attack…call ……”

E-Marketing….That’s another gateway to publicize.

Marketing more than Medicine is a reality.

Advertising Firms, Door to Door Agents…you name it and the strategies exist. Facebook, Twitter, Social Media, Events …..There is no end.

Revenue is the Key …..Patient Flow which Pays is the answer.

Health of the patients becomes the business of the promotors.

The maximum importance is giving to marketing and advertising in order to increase paying patient flow….this is the truth about new as well as established hospitals and healthcare facilities.

The administrator/ CEO/ Managing Director is rarely a Physician, this is because Supply Chain, Maintenance, Instrumentations, Security, Food and Beverage, Billing, Human Resource, Finances, Strategies are major areas in a heavily invested healthcare system.

The Physician and the patient on whose shoulder the system is fundamentally existing suddenly becoming a miniscule part of the whole picture.

It’s definitely an Oxymoron from my perspective.

Now comes the aspect of QUALITY: Where does this aspect exist in this whole story of GROWTH

Imagine…..You have borrowed Millions, Set up a big hospital which looks like a Hotel, spent tons on marketing and advertising …..What is left for Human Resource and Quality ?

Instruments, Equipment, Approvals, Staff all cost money. Administrators, Advertisers, Managers, Marketers all cost money. So does Maintaining Quality….but is there enough left after so much consumed by the earlier?

Quality HealthCare in the real sense means practice of Evidence Based Medicine.

Example: When a Patient of Chest Pain Comes: The Emergency Physician rules out all causes of Chest Pain from Myocardial Infarction to Pulmonary Embolism to an Aortic Dissection and many more.

In nations where Troponin Test is the most expensive test and is priced 100 times the Retail Price, it’s impossible to practice Quality Care. Where EKG continues to be used to triage chest pain then Quality is always a Question. Where CT Scan is a medium to extrapolate profit, quality is always a challenge.

In Emerging Markets Insurance Companies mandate that a 24 Hour Admission is required at the least to claim for healthcare benefits from the policy. Well that results in increase rates of admission.

When a simple fever costs thousands then insurance cost goes up. The hospital wants to recover the cost it has invested in the system so it bills thousands.

 Just Talking about Quality is of no use when there is demonstration of lack of practice of Evidence Based Medicine.

In any HealthCare system the Emergency Department Care reflects the overall quality of care given by a HealthCare System.

Until every physician in the Emergency Department is duly qualified by a Single Accredited National Agency governing a Uniform Set Training Model, it’s impossible to establish quality care.

Till the time every physician practices the same evidence based guidelines and does not use his own guidelines based on the science of “In My Experience” things will always be the same.

The perception that Insurance Companies will continue to insure people and people will continue to feel that they have access to health care......will break very soon.

Insurers will crack down on healthcare facilities, charges/payments will be questioned, quality will be accessed and care decisions will be challenged. They too like others have to make money...they also have investors to answer to !

Insurers will question: Admission Criteria to High Billing Critical Units, Criteria for keeping patient longer in hospital, payments for hospital acquired infections, payments for patients who come back to the hospital within few days, justification for multiple consultations, number of outpatient visits, number of investigations….it’s just a matter of time.

It took a decade in the developed world for this Insurance Industry crack down, it will happen faster in Emerging Markets.

Where the mantra is “If you have a fever and the malaria parasite test is negative still don’t do blood cultures but treat for malaria, typhoid and admit in ICU for observation” “It’s OK to do that…”

It will soon be “Not OK”

Investors are banking on paying patients who will either pay from their pocket or insurance will pay for them.

In the times to come it will be the Insurer who will decide the fate of investors.

Quality will become the leading question very soon.

“It’s OK ……..will soon be ……it’s not OK!”

“Patient Satisfaction”- A Biomarker for Quality HealthCare !

From the Desk of Sagar Galwankar, MD

 As the world continues to invest in HealthCare and as Administrators are born to rise continuously, “Patient Satisfaction” has emerged as a Crucial Biomarker in the Diagnosis & Prognosis of Quality of HealthCare.

#PS as I call it … is indeed the Indicator which is now being used with greater intensity to grade the quality of healthcare delivery.

Across the so called “Developed” World which is “Enveloped” in its own existence #PS continues to exist and grow with scores, patterns and algorithms being built to access the end point i.e. Quality Health Care.

What is the #PS, How does it affect us, what are the things that matter the most, how do you get the maximum score, what does that relate to, how do scores translate …….

In simple terms #PS means when a patient is asked how did you like the care provided to you ….he/she should say Great/Good/Satisfactory/Not Good/Bad.

Now this end point is broken into several questions with scoring sheets, numerical grades and with complex calculations and that emerges a score which is compared to averages across the industry.

#PS can refer to a whole system Example: “Care in the ED” or “Care by an Individual physician/ Nurse”.

Administrative Leaders stress a lot on #PS. This is because of the influence of the materials and service industry where it’s the rule “customer is always right”.

I am intrigued “Is the Customer-The patient – Always Right”

Well that’s an answer which by itself can institutionalize the debate generated around it.

The world of Litigation, Regulation, Accreditation, and Consumer Rights revolves around Customer Dissatisfaction and Enforcement of Patient Rights –which by the way I support totally.

But again ………How is #PS is a crucial biomarker?

I recently read somewhere about comparison of patient attitudes in USA and South America featured around an ED visit where two patient attitudes were compared: One in USA who is upset because his ED visit took 2 hours from entry to medication filling and discharge versus a patient in South America who walked miles to get seen after waiting for hours outside a busy ED and was happy with simple pain meds and thanked the physician and walked back home.

When I review all the writing and think simply I feel it is all about relationships. In Emergency Departments there is very little time to build a relationship and establish confidence.

No matter what we do , If corporate culture has entered healthcare, if investors are reaping returns in healthcare, if there are administrators who are accountable and if patient is considered a customer and physician/nurse a service provider like Fast Food Chain or Cell Industry ……. Then #PS will not only live, but thrive, survive, advance and expand.

The Developed World is full focused on #PS but this phenomenal has yet to oblige the economies in transition.

Countries where HealthCare is considered an Emerging Market like India #PS is sparingly used and restricted to patient complaints and compliance to satisfy these unsatisfied/ dissatisfied customers.

The Investor Industry which drives accountability from administrators will soon introduce and foster the #PS Phenomenon and institutionalize it in India in a BIG WAY.

It will not be long before Administrators who are already singing the Phrases of Quality and Safety will start speaking and proctoring #PS and making their operating systems, health care, executives and physicians accountable.

It is just a matter of time!

I will say few points which affect me and my care:

1.    Patient is First, his/her welfare is first

2.    Addressing the primary concern is my focus – Pain, Fever, Bleeding , Rash are things will I address stat

3.    Humble Approach, apologize if patient had a long wait, be considerate about the complaints, privacy while examining and regular discussion with patient, relatives through the stay of patient are crucial skills

4.    Keeping patient comfortable and pleased is the key

5.    Good manners and giving full attention to the anxiety of the patient is important.

Don’t answer Phone calls when patient is with you. Apologize that phone rang and switch the call off. If you get called for a serious patient, ask patients permission and then apologize and leave and affirm that you will be back as soon as the task is over etc etc.

There are times when you perceive that patient’s complaints are exaggerated. Even if the complaint seems Exaggerated – that by itself is a symptom which has to be addressed by you.  

Pain Control is a big player in #PS. Many times in Developed World patients are prescribed strong pain control medications which can get the patient into habitual use.

Use, Overuse and Abuse are very closely related. In all these processes the healthcare provider is involved as the patient evolves.

Controlling Pain is crucial like all of many complaints.

No matter you made a correct diagnosis, no matter you gave the best treatment, if you did not satisfy the patient, then #PS suffers so do you and your future!

As the payments, performance and progress gets tied to #PS , physicians have to revisit their past training. Bedside Manners were taught to us in Medical School… #PS now continuously grades those skills.

Knowledge is Key but Strategic Techniques to customer service are crucial.

Do we need Coaching Classes for that…….better than remediation after faulting! Prevention is better than cure…….we all agree to that!

We should not forget that we the physicians call our HealthCare Lifestyle as “My Practice”. It means in true sense you as a Physician continuously Practice your way to Perfection and Progress. This is a continuous process.

The New “P” is Patient Satisfaction which if good will improve your practice, perfect you and will definitely progress you.

“It’s the little things that matter the most”!

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

From the Desk of Sagar Galwankar, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

From the Desk of Sagar Galwankar, MD

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

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

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

Why did I become an emergency physician?

Many reasons:

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

This was 17 Years ago.

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

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

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

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

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

I began my journey to be a Student.

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

 Once a student always a student:

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

Be a Dedicated Learner:

Dedication to learning is the Step to Caring.

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

Learning a Self-Activity:

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

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

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

The Textbook is your best Teacher:

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

Use Different Sources:

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

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

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

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

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

Environments are always conducive to Change:

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

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

I will give you an Example:

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

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

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

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

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

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

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

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

I said OK.

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

I said then what about other diagnosis.

Can you discharge the patient as safe?

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

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

Every Protocol is still a protocol.

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

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

Getting their buy in will ensure the existence of EM.

 
Environments in Transition where EM is new, continue to face the maximum challenges to change.

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

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

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

Knowledge and Confidence are key to effective Leadership:

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

Thus concluding:

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

Don’t blame others for you not learning.

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

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

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

“God helps those who help themselves”

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

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