PokeMon Emergencies : A Call for Public Health Safety

From the Desk Of:
Sagar Galwankar, MBBBS, DNB, FACEE (INDIA), MPH, Dip. ABEM (USA), FRCP (UK)

As I went to work I saw few of my colleagues discussing about this new app called PokeMon GO.

This is a Freely available Video Game played via a downloadable app. 

This allows players to capture digital creatures at real locations synchronized with GPS. The GPS Activated locations are called POKESPOTS and the players can capture and gain points called XP. 

There are various awards and rewards by playing this game. 

This has a lot of implications. 

There is massive Public Frenzy and craze and as I had guessed People are trespassing and many accidents and injuries are anticipated when driving walking as people continue to play  and not pay attention.

A New Era of Public Safety Threat has emerged and reached a whole new level !

I recently read this article: http://www.foxnews.com/tech/2016/07/14/death-by-pokemon-public-safety-fears-mount-as-pokemon-go-craze-continues.html

Were we not glued on enough to the Smart Phone on Social Media and video games ?

Were we not disconnected enough that Messaging became the New means of Communication ?

Were we not lonely enough that animated characters are the new friends ?

Technology can with advances but also came with Public Health Threats.

Smarts Phone created a new platform and era of STAT COMMUNICATIONS and UPTODATE INFORMATION.

That brought the Public Health Threat of Civil Safety as Social Media played an Open Access Platform with information about who is doing what and when.

It also brought to light the Road Safety issues where crashes happened while Texting.

It brought to light the violation of privacy of people in the world.

I believe that Mass Frenzy is a phenomenon which has often been the single most important factor to heightened ignorance and accidents.

Travel on Roads as a Driver/ Rider or Pedestrian, Walking at Home or at work and not focusing on what you do will cause a fall/crash and injuries are more severe than ever.

I have seen patients who have got insomnia as a result of sounds and rings of social media and their addiction to see the phone asap.....like a Pavlov Rat.

This Digital Plantation of Revolutions have brought a new age of humans who have isolated themselves to find solace in their single trusted friend.....their smart phone.

Video Games are the new friends introduced by this trusted friend.

There have been many news which have already started reporting injuries and accidents and I soon think we will have to ask for every car crash / and fall .....Were you playing on the SmartPhone ?

The answer may just be YES.

I think its time that Public Health Social Marketing Strategies highlight the urgency to design initiatives to break this addictive unsafe habits of SmartPhone Mania....so Public Health can be safer than before !

When people's mind is fixated on one thing then that is what drives their lives. 

Texting, trespassing and all the crashes falls and accidents with the above apps proves that these are sane people who are conditioned to commit themselves to this public safety risk and hazards..... this is much bigger than just a Habit.... this is addiction and the single biggest Mental Health Challenge to Public Health.

"For The Patients" ~ Lets talk about Headache in Adults !

From the Desk of Sagar Galwankar, MBBS, DNB, FACEE, MPH, Diplomat. ABEM, FRCP

The Patients who come seeking Emergency Care...."My Emergency Patients in My ED" is all that has mattered since years as it is because of them that I am a EM Doc and this specialty called EM exists.

I see lots of Social media Posts trying to be to become Education Materials. I see EKGs being discussed on social media. Nowadays they are the new classrooms.

So lets talk about symptoms which need lots of thinking and are High Risk.

This series will be called "For the Patients"

Today I will discuss HEADACHE.

Headache is one of the common symptoms when patients come to the ED.

Headache can be a Presenting Complaint when the patient arrives. "I got a Headache" and sometimes when patients are being evaluated at bedside for some other symptoms they can add the complaint "..and I also have an Headache"

History takes paramount importance when a patient complains of Headache as a Primary Symptoms or a Co-Symptom as a part of a Series of Complaints.

Always evaluate Headache keeping a 360 Degree approach.

Always address Headache. via your Thought process, History taking and Clinical Exam.


Vital Signs take a Lot of Importance and ask for them as you immediately prescribe pain medications to treat the PAIN.

Temperature, Pulse, Blood Pressure, Respiration, Pulse Ox, and Bedside Glucose are key stat Bedside Parameters which guide you to a story. Order an EKG Stat and read it.

Remember:  Gender does matter ! Pregnant Females & Females who do not know they are pregnant can come to the ED. Being Pregnant Changes the way you will evaluate these patients. Having abdominal pain, Hyperemesis gravidarum vaginal bleed can come with an headache and evaluating for abdominal emergencies and Ruling out Ectopic Pregnancy at the same time deciding about CT Head and Headache work up is a complex issue. They can also have HELP Syndrome or Eclampsia also can start with Headache.

Age is crucial before Young Female with Headache and Cold and Cough is different from a 50 Year old with Headache and Blurry Vision.

History taking should include: When did it start, how severe is it from a scale of 1-10, any other symptoms of Dizziness, Focal weakness, Gen weakness, Vision changes, neck pain, Syncope Seizures, Nausea, V omitting Diarrhea, Chest Pain, SOB, Neck Pain/Stiffness, Dizziness, Vertigo have to be ruled in or ruled out.

Past History of DM HTN CAD CVA Cancer HIV Hep B Hep C are important.
Is patient on anticoagulants also is key history point.

Some Cluster approaches are:
Fever, Tachycardia, Headache, Neck Pain: Here Headache can be as simple as a Viral Fever or as severe as early meningitis or even a URI if Cold Cough Sinus Tenderness are present.

Headache could be a early Bleed (Subarachanoid) or even a CVA when patients have vasculitis, Bleeding disorders, Hypertension , DM.

Headache can be due to Glaucoma or due to Otitis Media or even early Temporal arteritis.
Headache can be segmental along a nerve for a early developing Zoster.

Syncope, Fall, Seizure, Loss of Sensorium, Altered Mental Status with Headache all can be indicating a worse diagnosis  than how the Headache presented.

Post Ictal Phase can present as Headache.

Another con-founder: MI/ACS can also present as an Headache so can arrhythmia or PE. So EKG Trop are Important.

There have been cases who have presented as an Headache and when you do labs there has been Low Hemoglobin and patient has a GI Bleed and the Immediate anemia has caused an headache.

Be very particular and alert when Patients says "Headache is what brought me to the ED"
On the other hand there is tons of Literature of approach to Migraine in ED.

Its very important that you read the literature as there are various combinations of medications used to break the migraine.

When a patient says "I have a Migraine attack" you still have to approach it as an HEADACHE.

Sometimes patients present with Neck Pain and Stiffness and we disregard it as "Slept on wrong side or Neck sprain". Evaluating for Cord Compression and keeping Dissection and SAH as a differential is equally important as much as ACS/MI or even a Retro pharyngeal abscess in a URI patient.

What it comes down to is:

Vitals, Past History, Med List, Clinical Co-Symptoms, History of Complaint, Detail Clinical Exam to include total undressing of patient Neuro Vascular HFN HEENT Exam and Lab Results is crucial.

Overdose and Drug abuse are important historical points which can indicate Cocaine abuse or even overdose unintentionally on paracetamol ibuprofen trying to self medicate with Over Counter Medications.

CBC, LFT RFT Trop EKG UA Tox Screen and CT / MRI ESR are a part of the work up in ED.
In a patients with Hypoglycemia or Hyperglycemia Ketoacidosis versus Toxicity v/s sepsis or infection has to be kept at back of mind.

In HTN emergency headache can be because of raised BP and Raised BP can cause headache. Treating both is important but also is important ruling out cardiac pathologies a CT Head and look for Posterior Reversible Encephalopathy Syndrome.

I have also read reports where patients were on anticoagulants and had neck pain and when MRI was done it has Hemomyelia into the spinal cord.

There have been cases alcoholism where patients wake up with headache in ED but they dont know that Methanol or Toxic alcohols were also drunk and they have an Headache.

Being very aggressive to rule out meningitis and SAH and using Spinal Taps with Clinical Co relation is important in the ED.

Patients often return post spinal tap with headache and at this time Blood Patch becomes a choice after you have ruled out any other cause or pathology.

Patients also have headache after Nitro given for Chest Pain.

Fever can exacerbate Headache and Hunger can do that too.

A TIA can be presenting as Headache being one of the Co-Symptoms.

Documentation:

Always Document in detail the history the clinical exam and the plan for ordering tests and meds and chart your thought process and notes as you reevaluate the patient.

That helps and maintains the continuum of care at the same time maintaining standards of care.
Discharge is a crucial part. Here too Educating the patient and giving return instructions is key.

Do not Disregard or Less regard HEADACHE. Its a Part of the PAIN PATHOLOGIES which can cause PAIN if ignored.

Patients have Pain , treat it first but work it up and decipher the cause then treat the cause....  FOR THE PATIENTS !

EM or Critical Care, EM & Critical Care, EM-Critical Care, Critical Emergency Care or Emergency Critical Care- What’s the Right Choice for a Real World Emergency Physician in India ?

From the Desk of Sagar Galwankar, MBBS, DNB, FACEE (INDIA), MPH, Diplomat. ABEM (USA), FRCP (UK)

In my recent conversations with young residents who have graduated with an MD in Emergency Medicine and others who hold various kinds of Non Accredited MD in EM, Certificates, Rogue Masters in Emergency Medicine or Pseudo Diploma’s in Emergency Medicine I have come to realize the harsh truth about what these young trained physicians visualize themselves or rather where they are in today’s era.

We must accept the fact, that in India the majority of jobs for physicians lie in the private sector. When it comes to Emergency Medicine, Hospital Based Practice is the natural course for the career of an Emergency Physician.

Keeping this economic opportunity alive is the best a system can do to keep a specialty alive.

There was a time that Dermatology was the last choice for majority of graduating young physicians and today thanks to the economic growth of cosmetology and aesthetic medicine, Dermatology has suddenly become the top field of choice for new graduates.

There was a time Emergency Medicine departments were called Casualty Departments. This was in 1996 when I first saw the vision for Emergency Medicine and sowed the seeds for its development in India. Today Emergency Medicine boats of having many Father’s but these fathers were nowhere when I started my journey to bring EM to India. “Success has many fathers failure has none”

Anyways, when I started to convince the hospitals to start EM back in 1996, I was mocked and called the “Messiah of Worthless CMOs (Casualty Medical officers).”  It has been a long journey and today every private hospital tries to canvas and market its Emergency Services. The rise of healthcare and the demand and the brand of EM has gone up.

I question whether the economics has become equally lucrative or not for the job market. I will defend the later. Rogue Certifications and Diploma’s and the modus operandi run by many organizations to conduct non accredited courses across private hospital emergency departments led by one or two pseudo leaders (who don’t have any experience at education) has defeated the theory of categorical evolution of a specialty. Today these Non-accredited Programs are run by a Head of EM (who is also mostly having a non-accredited degree) and this head recruits up to 15 students per year by misguiding them that “One Day Their Certificate/ Masters will be recognized”. The students who join these courses haven’t made it to conventional MD/DNB programs nor have they decided to take the International Pathways to USA/UK. They pursue these Non-accredited programs as an option which will add a Few Letters after their MBBS. It would be nice if these letters had UK or USA with them. Whether these Letters really are recognized oversees or not is another story…because what do the patients realize anyways?

So here we are …..We have started these mass training programs across the network of biggest employer for EM … the corporate hospitals. These students generate high fees and income from an erstwhile Casualty now called an ED and also cost way less because it is now operated by a Ring Master called a “Head”. The “Head” Safe Guards his existence by showing this Operandi as a way of productivity for the hospitals.

I have previously discussed how holding conferences or awarding oneself also helps preserve this “Mirage of Image” for these leaders towards the employers and the young physicians who they want to mislead.

What Happens to these graduates once they gets their Diplomas, Masters Etc. The job market is congested with leaders/ Heads or will soon get congested with these pseudo courses. This is because the so called EM Leaders have fed an easier money making option to the employers.  There are no jobs and if there are any, they are low paying like even less than 1,00,000 per month with an expectation that in return for the title of the “Head” you are expected to run the the Operandi of Training which is become a Norm across the Private Hospitals in India.

It’s a vicious Cycle.

You do what you are taught and what you learn, you learn wrong, you do wrong. The people who do wrong believe that they are right and that’s why they do it !

The Premise “INDIA NEEDS EMERGENCY PHYSICIANS” is correct!

Well India needs Nephrologists, Cardiologists too. Why don’t we pick up all MD Medicine Doctors who know how to do Dialysis and give them a DM/DNB in Nephrology and so also all those who practice Diabetology a DM/DNB in Endocrinology. This cannot happen as every specialty has to evolve and that too with the evolution of healthcare services. By giving a viable option of cheap labor money generating non accredited training program to the largest employer of the specialty of EM, the growth of EM and the academic advantage to Emergency Physicians is gone with the wind.

So what are the options?

Critical Care is the only one which is viable.

Today Critical Care has been able to safe guard the job & Salary economics for its constituents, thanks to the structured growth of this specialty in India. CCM and its structured growth is in a way one of the deterrents to growth of EM because all that is expected from the EP is wheel the patient to critical care. The hospital makes more money if patient lies critical in the critical care unit rather than be stabilized in the ED.

This has given rise to idea that Emergency Physicians can handle critical care or rather emergency physicians are critical care physicians anyways. These students are made to believe that they are getting an Post Graduation in Critical Care with a Title of  EM.

Critical Care is a vast, labor intensive, high knowledge specialty which needs intense training. When you go to a CCM Meeting you realize the different sub specialties in CCM from Neuro to post-surgical critical care, trauma critical care, toxicology critical care  etc.

In India Specialties like anesthesia, chest medicine and internal medicine have made inroads into CCM. Physicians who have training in CCM even today work hard to gain knowledge and very few boast that they know all the sub specialties in CCM well.  

I have heard EM Leaders make callous statements like “what do critical care guys do ?” “Just give inotropes, antibiotics and monitor outputs from GI GU and feed via NG Tube/Peg Tube”

This is wrong and a total disregard for a specialty which is so crucial to healthcare.  CCM Experts do much more and definitely know tons more than emergency physicians. EM Physicians are expected to be trained in handling all emergencies. In India they are definitely not trained in Peads EM.  They can arrogantly boast and lie to themselves and others but fact is they are not trained…that’s the truth. When these misguiding leaders continue to misguide these young physicians that CCM is  EM and EM & CCM are one specialty….. I would call upon CCM Specialist to be cautious. There may be chance that Rogue Mafia will now invade CCM Centers with a Cheap Labor Hiring Operandi like they have done in EM.

 There is a big myth being floated to start EICU (Emergency ICU) so that money can be generated by labelling an area in ED and calling it an ICU. I have confirmed news that these model has started.

I would call upon CCM to safe guard its specialty by cracking down on these rogues. There are many failed Intensivists who have found home in Emergency Medicine. Their hospitals have given them leadership positions to head their Casualties where they too run the Training Operandi.

They need industry support to run these marketing campaigns like Conferences and Award Syndicate. The money is in Critical Care, so guess what……start floating the idea that EM and CCM is one…start training programs to match this myth and encourage graduates to work in CC Units and make CCM their future. Even conferences on EM in India now have partnerships and sessions on Critical Care…. A step to infiltrate a Structured Specialty.

In all these mess……We forgot why we were here…, we were here to provide EM Care to our patients, we started this specialty when CCM was already in existence and now we are coming a full circle to say EM is same as CCM. Yes Emergency Physicians can undergo more training (up to 3 Years) to gain adequate knowledge to staff a CCM Unit but to lead a CCM Unit it will be years. CCM is vast and a lot needs to be learnt. It is the same way Now days Heads of EM are appointed as soon as they confirm that they can operate the modus operandi ….and they always know CCM is there to back them up…

I urge my fellow interested youngsters to question all those who offer to guide them, check their credentials, ask around, talk to different people, explore whether you will have a good job career, don’t get emotional, you have worked too hard to be misguided by a few who are there because their job Is to generate cheap labor and safe guard their positions……

I want all who read my blog to understand that speaking the truth, hearing the truth and accepting the truth is better than to live in a False Reality....there will always be an explanation and a perspective.... the fact is ... is that perspective REAL ?

I believe in the truth and if its the truth.... its Real...I do not deter but I just speak it out !

The future is better when the present is good….and when it involves many then a few cannot reap its fruits…and if few are reaping its fruits …… many are not getting and will not be getting what they deserve……..That’s oppression by false motivation….

Till then the patient continues to seek Emergency Care……..expecting the best,  trusting what is being handed out…..well there is always Critical Care to back the ED anyways !

The Prime Focus on Health: Questioning Actions, Charting Challenges and Demanding an Answer ~ Is the answer - Voice, Visibility or Ability?

From the Desk of Bipin Batra, MBBS, DNB ~CEO & Executive Director NBE & Sagar Galwankar, MBBS, DNB~CEO of INDUSEM

Introduction:

The Social Media and Print Media are all buzzing with some Editorial Article in a Journal questioning the Governance in India as regards the health care policy.

India is being subjected to a Media Trial with serious questions being raised about its Health Policy actions and alarming deductions predicting India’s Health Care doom as against the predicted Health Care Boom by the whole investment world.

Let’s look at some of the actions in the Health Policy, Public Health and Global Diplomacy arena with respect to India.

I answer because India is in Question:

India is openly committed to a People Centered Health Model with simultaneous and equal investments in Research, Education, Treatment, Public Health and Global Health with a progressive vision.

Research:

The massive expansion of the Translational Research Program lead by Department of Biotechnology (DBT) with focus on finding solutions to diseases at a Nano-Molecular level will make India as a Biotech Leader in Asia.

The installation of Progressive and Aggressive Leadership at the Helm of Indian Council of Medical Research (ICMR) and DBT reinforces the commitment of the Government to solve the TB / Communicable and Non Communicable Disease Crisis.

The Directors and Secretaries at both above departments bring years of successful program development and implementation at their earlier positions. Their experience and capabilities can now be escalated at National and International Level.

ICMR and DBT are developing Live Surveillance and Study Systems at Molecular, Genetic and Patient Care Levels at multiple locations to gather data and act on the findings to derive fast track solutions.
Increasing funding and encouraging research at Medical Students, Teaching Faculty and Private Hospital Level is a Major area of Expansion for ICMR and DBT.

Education:

Increasing the number of seats across Medical Colleges, Spear Heading the creation of AYUSH Ministry and focusing on the growth of Traditional Medicine as well as increasing number of Allopathic Graduates is a major game changing strategy by the government.

Reformatting the Medical Council of India (MCI) and bringing in intense coordination between the National Board of Examinations and MCI to bridge the difference in number of Under Graduate Medicine Seats and Post Graduate Medicine Seats will be a major accomplishment whose results will be robustly visible in coming years.

The biggest feather in the cap is the National Roll out of the Specialty Training Programs in Emergency Medicine across NBE Recognized and MCI Recognized Hospitals across India. The First Programs started in the Home State of PMO when he was CM of Gujarat and today they are across the Nation.
Until 72 Hours ago commitments were made to develop More AIIIMS and Similar Institutions across States in India with a vision that every state will have an Apex Institution for Super Specialty and Complex Health Problems.

Building on the earlier vision to develop Trauma Centers in India there was no Training on Trauma Surgery in India and now the Government with the help of the Academic Community has rolled out Subspecialty training in Trauma Surgery and Critical Care.

Additionally Post Graduate Training in Family Medicine has been a Prime Focus to create Specialist Primary Care Doctors across India.

Treatment:

We must admit that India is the Epicenter of Economical Generic Medication Manufacturing and Global Supply of the same.

Development of National Treatment Algorithms for DM, HTN and HIV, TB and Malaria as well as Faster Diagnostic Technologies and infrastructure development for rare and common diseases are the prime agenda of Indian’s Health Security.

As a part of India’s Commitment to the Global Health Security Mission, India in partnership with WHO, UN and USA Governments is implementing various multi-level strategy to address Prevention, Diagnosis, Response and Policy of Major Infectious Disease Threats and Challenges.

As a part of the Quality and Patient Safety Mission the NABH and NBE have formalized a Maiden Partnership to augment dual certification for Quality and Educational Accreditation. This has started with Accreditation EM Departments for PG Training as well as for Patient Safety and Quality Care. This will be expanded to the whole facilities and soon all the Educations Institutions will follow.

 

Rural Health Care:

Efforts are on and strategies are being made to use the Rural Health System as a training and education gateway by creating Post Graduate Training Programs at Rural Health Centers with National Procedural Skill Training Centers for Specialty and Sub Specialty HealthCare at Major Institutes in Every State of the Country.

Private-Public Sector partnerships to Operate Primary Health Care Centers and incorporating Ambulatory / Mobile Health Care Delivery Models are also being developed across major States.

Multi-Level-Multi-Fork Strategy:

Involving Private Hospitals, Governmental Hospitals, and Hospitals under NABH, NBE, MCI and Health Facilities under the purview of Directorate of Health Services of States, Interacting with National and International Health Agencies, Working closely with Bio-Pharma Industry and Commercialization of Innovation with a focus on India’s Health Security is the Interlaced Model the Government is working on.

Various Acts/ Policies and Laws are being Modified, Amended and being worked on as India moves ahead with its Progressive Health Agenda.

The Existing PNDCT act is being fortified to crack down on Female Feticide with greater vigilance being instituted. Additionally experts group are working on amendments to validate the use of Ultrasound in Emergency and Trauma under the purview of the PNDCT Act.

Experts are working on putting together the Bhartiya Emergency Medicine for All Act (BHEMAA) which will be a Historical Move to ensure Emergency Care to every citizen of India.

The Clinical Establishment Act is being implemented with great care and will show results in coming years.

Funds are bring allotted and States are being encouraged to ensure Ambulance Services for all Emergency patients. This is a step towards having an EMS Service for the whole nation.

A universal Emergency Number is also being issued.

International Investments are flowing into states with Uttar Pradesh Being the First State to have Massive Foreign Direct Investment in HealthCare in year 2014. This is called the SVADESH Program lead by Investors from Silicon Valley, USA.

The government is not basking on its success of a Healthy Kumbh Mela at Nashik or the eradication or polio or its Disaster Response system which not only is successful in India but also helped neighbors during environmental crisis, instead it is moving ahead with changes which are progressive.

The Health Care Models in Gujarat are complimented by similar models in Rajasthan Chhattisgarh and Many States.

Flagship Projects:

The Swach Bharat Abhiyan is a massive SEffort for Public Health &Cultural Transformation where efforts are being made to establish civil sense and responsibility.

The same applies to organ donation, and various other programs where massive media marketing is being used to instill Championed Cause for various initiatives.

Summary:

There are endless such initiatives which can be listed.

The Government is focused on building relations with Nations to speed the Economy. Health is a Silent but Vibrant Part of this Wealth Story which will not only progress India but also Position it as a Stable Player in Peace and Security.

India has a population of 125 Crores and hence problems are many. Governmental Health Care is available for all but Utilized more than 70 %. Rest use Fee Based Corporate Care.

Just because Health has not been in the news does not mean India's Health Story is doomed.
The results of Health Interventions in the Populations take time to be visible.

I still am open to specifics as we continue to be critical of the definition of Visibility, Voice and Viability as well as question the sheer existence of Ability.

I think Remembering Sustainability is equally important!

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 !