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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, February 29, 2016

HELLP Syndrome - Podcast


HELLP syndrome - Another great masquerader that requires a high suspicion for diagnosis. Check out the show notes and listen to the podcast.


Hellp

Monday, February 22, 2016

Patients, Physicians and Google - What are we up to?

In this era of technology, all of us have dealt with patients who first "google" their symptoms, try and figure out what is possibly happening with them, reach a self diagnosis and try some remedies to see if their symptoms get better. And if things don't settle down, then they visit a physician. From whatever I have observed so far, most physicians tend to get upset with these patients (some physicians call them semi-literate patients or an e-patient) but only a handful of them actually try and talk to them, dig deep and understand their concerns, do shared decision making and reach a treatment plan that is acceptable to both, the physician as well as the patient. 
It is not uncommon to come across this demanding subgroup of patients in the ED but in the outpatient setting where there are no time constraints, every other patient is an e-patient. Let us understand why do patients do this:


Why ask google when physicians are available? 

In a physician - patient relationship, historically the physicians have dominated the conversation (ideally it should be the other way around) and patients have always been submissive. But things are changing and many find it hard to accept when a patient questions on a diagnosis or treatment plan. Also in modern day scenario, I think the key issue that we are dealing with is lack of trust on physicians . If we look back at the last decade, the way media and television has projected physicians, things have really gone away too far and it has changed a lot. Now, patients do not see physicians as someone they can readily rely on, so they want some baseline information to start with. And when they visit a doctor, their chief concern is that they do not want to be mislead with unwanted investigations and sometimes unnecessary medications. What remains the best way to get unbiased help is the always available "GOOGLE". 

And this may not be the only reason for googling symptoms, people have also become more aware and they want to know what is happening with them and much more about the medications, side effects. Fortunately (for some physicians), this wave of technology has spread only to the metropolitans and a majority of patients in India are still clingy and depend completely on doctors to make decisions for them.






How do physicians react when they deal with an e-patient?

All of us would agree on this that doctors have big egos and as physicians do get offended thinking that they are confusing our medical degree with google or we might think that 

How can he come with a self-diagnosis? 
Then why the hell did I go to medical school?

Due to this passive aggression, poor rapport and cold relationship these patients get shunted among various specialists (which is bad medicine) consuming time and wasting resources.

We as health care providers, need to understand that medicine is much more than just making the correct diagnosis and treatment. Empathising and emotional support to a patient often can do wonders to patient's compliance and symptom relief. Social media, technology and google cannot give them the healing touch, but you can. It just needs some patience and a few extra minutes.


What can we possibly do about e-patients?

Short answer: Shed your ego and do shared decision making

If a patient is enlisting his/her symptoms and also what they read about it on internet, be upfront and ask them what do they think is happening with them and be willing to listen to their self-diagnosis (which might be the correct diagnosis!). Listen to them carefully without the prejudice that they are wrong. Ask them where did they read about it and what do you think about what they have read. Also give them some more reliable resources to refer to a t then end of your consultation.

Most of them don't want to offend you and neither they are testing your knowledge but they are just concerned about their health and want to participate in understanding their illness, more importantly they want to have a feeling of security and reassurance that they are not being mislead. Unfortunately this is what we have come down to. Our job is still to help them out, take a few minutes and do shared decision making. These e-patients are only going to increase in future, so rather than creating being insecure and making a hue and cry about this, we need to accept this and be amazed if they are not googling their symptoms!

Googling symptoms is absolutely normal.


And guess what do physicians do when they want information on something?
Google


What if you have no idea about what they are talking about?

If you have no clue about a treatment that they are referring to, before you tell them that it makes no sense. Check on that and don't be surprised if they tell you something about medicine that you don't already know. (Something like non-surgical treatment for appendicitis). Medicine is making advancements everyday and it is hard to stay up to date. So hold on, tell them that you have not heard of something like this but you will find out more on this and revert back. Many times, patients with chronic diseases know more about their disease and treatment than an emergency physician!

I think sooner or later we are going to have a computer that can give a reliable list of differentials. We already have systems in place that alert us about various drug reactions, doses etc. then why not a list of possible differentials. But again, medicine is not about only the diagnosis and treatment. A physician has much more to offer..


Bottom Line:
  • Shed your egos and just listen to them.
  • Look at e-patients as a possible help. Most of them are just concerned and want to make sure they are on the right track. 
  • Set the right rapport and build that trust to drive things smooth. 

Monday, February 15, 2016

In flight emergencies

It was back in 2005, when I was flying from New Delhi to Chennai (about 2:30 min flying time) to start my medical school. Everything was all good until I heard this:

Is there a doctor on board? We have an emergency..
Is there a doctor on board? We have an emergency..

I (was going to become a medical student but..) could do nothing to help a man who was breathless. He was placed on an oxygen mask and fortunately he got better. As a layperson I had no clue about what was wrong with him. 

It was then when I realised how important it is to have some sort of basic understanding about common ailments, not only for all the physicians (regardless of their field of specialisation) but for everyone esp when we are flying 30,000 feet above the ground. And now, it is not uncommon for physicians to fly across the continents to attend various conferences and meetings. For those of us who have been into this, would know that even as emergency health care providers, it can be really challenging to manage an "in flight emergency".






First thing, we need to be familiar with the equipment available, at least have some idea about what would be available to you. You would be left with no excuse if you screw up this and if you happen to be an emergency physician. 


Contents of in flight Emergency Medical Kits (you may not have all of this available)

Assessment Supplies
Sphygmomanometer 
Stethoscope
Gloves


Airway and Breathing 

Oropharyngeal airways 
Bag-valve masks (3 sizes)
CPR masks (3 sizes) 


Intravenous Access 
Intravenous administration set 
Saline solution, 500 ml 
Needles, Syringes

Medications
Analgesic tablets
Nonnarcotic 
Antihistamine 
Aspirin
Atropine
Bronchodilator inhaler 

Dextrose, 50%
Epinephrine

Intravenous lidocaine 
Nitroglycerin tablets



How to go about in flight emergencies:
  • Introduce yourself and state your medical qualifications.
  • Ask the passenger for permission to treat, if feasible.
  • Request access to the medical kit.
  • Use a language interpreter, if necessary, but be aware of patient privacy.
  • Focused history and physical examination, obtain vital signs.
  • Administer treatments within the scope of your qualifications.
  • Recommend diversion of the flight if the patient’s medical condition is critical.
  • Communicate and coordinate with ground-based medical resources.
  • Continue to provide care until the emergency medical condition is stabilized or care is transferred to other qualified medical personnel.
  • Document the patient encounter. 


Specific Problems
For the most of them, you would be providing only the basic and common sense care. If it is really getting out of control, get diverted and land ASAP to the nearest airport where reasonable medical care would be available. They key is to stick to the basics and don't forget that there are major restrictions in terms of the kind of stuff that you can do in a hospital.

  • Syncope (rule out hypoglycaemia, lay flat and elevate the legs, fluids if needed)
  • ACS (O2, Aspirin, Nitrates, Reassure)
  • Cardiac Arrest (Chest Compressions, Shock, Ice)
  • Dyspnea (O2, beta 2 agonists, needle decompression)
  • Stroke (No Aspirin in a suspected stroke, rule out hypoglycaemia)
  • Seizures (Left lateral position, O2, rule out hypoglycaemia)
  • Psych (Calm them and Restrain them)
  • Minor trauma (Immobilze, cold compresses, Analgesics)

And it was once again, I came across a similar situation but by this time I was an EM Trainee and it was a flight that got diverted and landed on emergent basis. I was rotating at Airport Medical Centre. It was around 7PM, when we received a call that asked for a physician saying 


"This flight has been diverted because a passenger was complaining of chest discomfort and breathlessness". 

We (a physician and two nurses) got braced up for this and literally rushed to the aircraft with the resuscitation kit. And as we reached there, I entered the aircraft, it was packed with 180 passengers and they all were staring at me hoping that I would fix this man's problem. I heard people mumbling, Oh..the doctor is here... (sigh of relief for them and it was horrifying for me, imagine 180 strangers who are going to observe/film the scenario). 

Well, I guess this was not enough, there I saw a 70 year old gentleman who was on oxygen, drowsy, breathless, sweaty. His wife, held my hand and said, doctor please do something and narrated his past history. I asked him if he was fine? He opened his eyes for a second, nodded and pointed towards his chest. And I got a sigh of relief, because he was at least responding (So probably he is not going to get intubated on board). My nurses quickly got an IV, checked vitals. He was put on the monitor and then...It was Ventricular Tachycardia (with pulse) with pressures of 80/60!

Medical centre was 4-5 minutes from the Aircraft. And I was left with these three options:
1) Push Amiodarone, though he was unstable and then shift to the medical centre
2) Do the heroic act of Sync Cardioversion in the Aircraft 
3) Do nothing, Just rush to the medical centre and then do Sync Cardioversion

I somehow stood away from the urge of pushing amiodarone and shocking was out of question in the aircraft.  We rushed to the medical centre in less than 5 minutes and he was reverted with the third sync shock and it was all good after that. Everyone was happy (patient, family and most importantly the cardiologist).


Take Home: In flight emergencies, 
  • Introduce yourself, ask for their permission to treat
  • Know what is the usual equipment available
  • Stick to the basics and know your limitations


References:

Nable, Jose V., et al. "In-Flight Medical Emergencies during Commercial Travel." New England Journal of Medicine 373.10 (2015): 939-945.

Monday, February 8, 2016

Zika virus disease: A brief description



History and Introduction: 


The Zika virus disease is an emerging disease that was first identified in 1947 in rhesus monkeys in Uganda. In 1952 it was identified in humans in Uganda and the United Republic of Tanzania. Outbreaks of Zika virus disease have been recorded in Africa, the Americas, Asia and the Pacific.
There are many gaps in our knowledge of the virus- for instance, we do not know the reservoir of infection, and the incubation period.
However, what we do know is that the virus
  • belongs to the genus Flaviviridae (it is a flavivirus)
  • is transmitted by infected aedes aegypti mosquitoes (these bite during the day time; and are the same mosquitoes that transmit yellow fever, dengue fever, dengue haemorrhagic fever, chikungunya fever and chikungunya haemorrhagic fever)
 Signs and Symptoms:
The symptoms are similar to other arbovirus infections such as dengue, and include
  • fever,
  • skin rashes,
  • conjunctivitis,
  • muscle and joint pain,
  • malaise, and
  • headache
These symptoms are usually mild and last for 2-7 days.
Recently in Brazil, local health authorities have observed an increase in Zika virus infections in the general public as well as an increase in babies born with microcephaly in northeast Brazil. However, further investigation is needed before we understand the relationship between microcephaly in babies and the Zika virus. Other potential causes are also being investigated.

Transmission:

In the tropics, Zika virus is mainly transmitted via the bite of an infected aedes aegypti mosquito.

Diagnosis:

Zika virus is diagnosed through PCR (polymerase chain reaction) and virus isolation from blood samples.
Diagnosis by serology can be difficult as the virus can cross-react with other flaviviruses such as dengue, West Nile and yellow fever.

Treatment:

There is no specific treatment for zika virus disease.
People sick with Zika virus should get plenty of rest, drink enough fluids, and treat pain and fever with common medicines.
If symptoms worsen, they should seek medical care and advice.

Prevention:

Prevention and control depends upon
  • reducing breeding of mosquitoes (source reduction through environmental modification)
  • personal protection from mosquito bites (use of mosquito repellents, wearing clothes that cover the entire body, using mosquito screens and sleeping under mosquito bed nets)
  • spraying of insecticides during outbreaks
There is no vaccine available at present.


Useful Links:

Link to the WHO fact sheet on Zika virus:
Link to the WHO zika virus Question & Answer page:

Author


Dr. Liaquat Roopesh MBBS, MD (Community Medicine) 
Alumnus of Christian Medical College, Vellore. 
Interests: teaching and medical education


Originally published at communitymedicineforasses on Feb 1, 2016. Reposted with permission.



Monday, February 1, 2016

Improving patient satisfaction

Emergency Departments represent the face of a hospital and it is based on the kind of care delivered in the ED, patients judge the institute overall. So it becomes extremely important for us, as emergency physicians to focus on this "customer care" part of our practise. I often equate a busy ED with a busy restaurant, where if someone treats you well, you always tend to remember that particular service provider. The only difference is that in a restaurant, you are less likely to get sued if your customer is unhappy! They might just swear at you and move to another one. On the other hand if they leave satisfied, they are more likely to use the same service again.




Most patients do not understand about the practical details of the processes and the treatments they go through in the hospitals. And for them an up to date evidence based care is not essentially equal to satisfactory care or a satisfactory experience. They don't care about sepsis goals or whether you are sticking to the guidelines or not. Here are a few things that we can do to improve patient experience in the ED:

1. See them as quickly as possible
Nobody likes to wait and that is human nature. Everyone wants to be attended ASAP. So one way to do this is physician assisted triage that demands extra staffing OR set up a fast track unit where minor ailments are handled quickly without interrupting the flow. The key is keeping the fast track close to the normally functioning ED, otherwise patients may perceive this as lack of attention on the physician's part. 


2. The way you Communicate and your body language matters: Once again, undoubtedly the most important component. Click here to read more on communication. 


3. If you made them wait, Apologise - Patients can get really annoyed if they are made to wait for too long. If this happens for whatever reason, just apologise without giving any sort of explanations because the one who is waiting does not really care. 

Physician: I am sorry to keep you waiting for so long, there was a really sick patient in the ED
Patient: Okay doctor, so you want us to land up in that critical state and only then you will attend me.


Engage them with something (brochures, television) while they are waiting and keep them posted about what is happening. Don't leave anyone unattended for more than 10-15 minutes. Make sure someone talks to them and resets their clock (it can be a physician, nurse, intern or a med student). This make a huge difference between the actual and perceived waiting times. Also remember that even minimal delay can seem long to an anxious patient, while longer delays may be well tolerated by patients at ease with events and confident that they are being looked after seriously. 

Everyone who speaks with the patient—including nurses, physicians, lab technicians, and radiologists—must inform the patient about what will happen next and roughly how long it will be until it happens. This information once again resets the patient’s clock. 

4. See things from their perspective: All subsequent caregivers must describe what they are going to do and what it will feel like. Giving them more information is key to reducing stress. 

Telling them how they will feel before inserting the IV can itself reduce the pain.
When a Gastroenterologist scopes a patients, he always keeps talking and explaining the patient about how he/she is going to feel with each and every step. 

5. Learn how to empathise: The physician's interaction with the patient is a major part of the ED experience. Few words of empathy can do wonders to your interaction.

I am sorry to hear that
That must be really hard to cope up with
Now you are at the right place, we will take care of that


6. Stop being judgemental: Most of us fall for this and start judging patients based on the acuity/ chronicity of their complaint and tend to get casual with the diagnosis. I think it takes a lot of time and courage to decide when to go to the ED because of the environment in which we work. Self treatment is always the rule and when nothing works or things get really out of control, only then we go to the ED.

If they land up early, we say "All right, it is just a day of fever. Did you try some paracetamol?" 
and 
When they come too late we ask "Why did not you come sooner?"


7. Tell them how the ED functions 
EM is still evolving in India and don't be surprised if patients are not familiar with your work process. Be upfront about the systems, if required take a minute to explain them triage and let them know we don't attend people on first come first serve basis, but the sickest is dealt with first.


8. Maintain Privacy
Patients gets to decide who is going to stay with him/her. We need to make sure that we maintain  privacy while asking personal bits of history and doing the examination. If you draw the curtains before starting the interview, it makes them feel safe and secure. Do not set your own arbitrary rules for them.

9. Educate everyone on how they can contribute
It is not only the physicians who should work towards improving the patient satisfaction, but everyone involved in the patient care. Educate each of one of them, right from the housekeeping staff to your nurses, interns, medical students. Working towards patient satisfaction is not optional, but this should be mandatory.  


10. Follow up phone call (My favourite)
This might sound a bit too much, but you will absolutely nail it if you can do this. Regardless of whatever happened during the ED visit (good or bad), if you can follow up your patients with a phone call then I guarantee you that all of them will turn back to you next time. This really goes a long way in terms of branding your ED and also building relationships.


For patients "care" of course includes not only the treatment but also the manner and social/emotional context in which treatment is given. Lower patient satisfaction means lower-quality care, regardless of the technical appropriateness of treatment and regardless of how well you do on the core measures. 


It is not how much you do, but how you do it


These were a few things that we can all try and do and make our patients feel better and more satisfied. Always make high patient satisfaction a rule and whey they are satisfied, you will be automatically satisfied.