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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, November 28, 2016

Spinal Epidural Abscess


Close to 90% of back pain related complaints in the ED are due to benign aetiologies. Only a limited number of patients have catastrophic diseases demanding immediate intervention. The process of ascertaining patients with grave diseases from the vast majority of patients with uncomplicated back pain can be tough. Therefore, a good history which identifies risk factors, a focussed back examination are paramount to pick any serious pathology.


Things that we should not be missing:
  • AAA, Retroperitoneal Bleed, Epidural Hematoma
  • Pyelonephritis, Psoas Abscess
  • Cord Compression (due to a Central Massive Disc Herniation, Spinal Epidural Abscess or Bony Metastasis)
  • Vertebral Fractures, Osteomyelitis
  • Cauda Equina Syndrome (CES)
Note - Cord Compression is a UMN lesion (Hyperreflexia) and CES is an LMN lesion (Hypo/Areflexia). 

I am going to mention specifically about Spinal Epidural Abscess in this post.

Risk Factors for Spinal Epidural Abscess (SEA) 
Document these in the patients medical record.
  • DM, HIV, Steroids, Renal Failure/ Hemodialysis, IVDU
  • Trauma, Sx, Instrumentation of spine
  • Recent Infections with bacteremia such as UTI, Respiratory infections, Bone, Skin or soft tissue infection

ED Presentation of Spinal Epidural Abscess

Classic triad of SEA is rare - Triad of Fever (seen only in < 50%), Pain, Neuro deficits  is seen only in 10-15% of patients. Insidious onset pain which gets worse at night and on recumbent position should ring the bells and should make us think about Infectious or cancer related pain. About 1/5th of the patients have no risk factors at all. 


Critical Exam Findings:
  • Midline Spine Tenderness on percussion (Infection, Fracture)
  • Saddle Anesthesia, Poor Rectal tone and peri-anal sensations (likely Cauda Equina)
  • Fever (Spinal Infection)
  • B/L multiple neurological deficits (likely Cauda Equina)
  • Hyperreflexia (Suggests UMN lesion - Cord Compression)
  • Hyporeflexia (Makes CES likely)
Caudal Equina Syndrome - Anything that compresses the lumbar spinal nerves at the lower end of the spinal cord can progress to cauda equine syndrome, leading to severe back pain, bowel/bladder dysfunction, sexual dysfunction, progression of neuro deficits, saddle anaesthesia and loss of rectal tone. Caudal equina can also present as gradual onset long standing pain. 

Document the findings of a focussed sensory-motor examination and gait, rectal exam findings. 

Myotomes 


Dermatomes

Diagnostic Pearls for Spinal Epidural Abscess
  • Some consider multiple ED visits (without a diagnosis) as a red flag for Epidural Abscess and also new thoracic location pain. Patients may not always have midline tenderness but paraspinal tenderness. 
  • Neuro dysfunction is rare in the beginning. It usually starts as motor —> sensory—> bowel and bladder dysfunction. We often get a false sense of reassurance in the absence of neurological deficits. 
  • Inflammatory markers such as CRP is 90% sensitive but it is much better than WCC. (A negative CRP makes SEA unlikely but it can be non-specific). A normal WCC cannot rule out SEA. Anti-inflammatory medications such as steroids may also falsely lower the CRP. But still, always order a WCC (because high WCC is concerning), CRP and ESR for concerning back pain.
  • X rays and CTs of spine do not reveal infectious etiologies. Use MRI to scan the entire spine with contrast because lesions often occur at multiple levels. When inflammatory markers are raised and the patient looks sick, administer broad spectrum Abx with MRSA and Gram negative cover.
  • CT can be negative as well - it will again not show infectious causes of back pain, MRI is the test of choice. CT shows only bony lesions.

Who needs emergency MRI?

When evaluating back pain, order an emergency MRI if:
  • Suspected spinal infection (fever, raised ESR or other risk factors for SEA) 
  • Cord compression (progressive neuro deficits, hyperreflexia, h/o cancer, bony lesions on X-Ray). 
  • Suspected Cauda Equine Syndrome (severe back pain, hyporeflexia, bowel/bladder/sexual dysfunction, saddle anaesthesia, paralysis)
Note: Isolated sensory findings or areflexia are not considered to be a progressive neurologic deficits.


Take Home: 
  • Document the risk factors in patient's chart.
  • Do a focused History and physical exam, rectal exam and gait assessment.
  • When discharging these patients as MSK back pain,  give them verbal and written advice explaining the red flags and when to return back. 


Author:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic

Monday, November 21, 2016

Amalgamating Emergency Medicine in India


Many still consider Emergency Medicine a nascent specialty in India and hold pessimistic thoughts about choosing EM as a full time career. However, EM continues to gain reputation among medical students. A major portion of candidates still pick EM only as an afterthought for reasons such as not matching in their desired field of interest, no standardized exams for entry into EM, quick money and speedy promotion to a Department Chief position almost immediately after the completion of training. Undoubtedly, EM is getting popular but despondently, apex medical bodies in India have been exceedingly sluggish towards the development of EM as an individual specialty and it was only in July 2009, when EM was recognized as a standalone specialty in India.



 


History of EM in India

EM started drawing attention among the young physicians in 1990s when private hospitals began to develop ED’s. At that time, there were only a few physicians who were passionate about this exciting field and were trying hard to fight the existing systems. As expected, there was quite a bit of resistance from other specialties that still continues to exist. A number of short courses, fellowships and diplomas emerged in 1990s to cater the need of the budding Emergency Departments. The issue that remained was a palpable lack of recognition for these credentials both nationally and internationally.

For those of you who are not familiar with this concept of private versus government sector healthcare in India, let me put it like this:
Private = Early access to care but you need to pay for that, extremely low threshold of admission
Government = Lengthy waiting hours but care provided is free of cost, very high threshold of admission

Medical Council of India alone cannot be blamed for our slow progress but there are a multitude of issues that interfere with the development of EM in India. For instance, most of the Emergency Departments (Private and Government) strive hard to meet the set standards to run a residency program especially when it comes to possessing experienced teaching faculty. Our colleagues from Anesthesia, Critical Care, Internal Medicine are often dragged to the Emergency Departments to book them as teaching faculty during the Medical Council inspection. While these physicians are exceptional in their particular fields of practice, they have undergone minimal or no prior training in EM!!

Emergency Departments have traditionally been referred as “Casualty” which is historically manned by Casualty Medical Officers (C.M.O.) who are considered as traffic policemen guiding patients to various specialties and keeping things relatively simple.

Abdominal Pain = Surgery
Fever = Internal Medicine
Fracture = Orthopedics
Isolated Head Trauma = Neurosurgery

The mindset was not focused on evaluation and treatment but just the final disposition. With such a system, the brunt used to fall on polytrauma victims who stayed in the “Casualty” for prolonged hours without any definite disposition plan. Due to a sense of lack of liability, patients used to get shunted through various departments with a complete lack of communication among the consultants leading to frequent mishaps.


Current Status of Emergency Medicine

     1.    Government EDs – These departments are always packed with innumerable patients with wide spectrum of illnesses with an average daily footfall of 200-500 patients/day. The treatment offered here is free (or at minimal costs) but waiting times cannot be estimated, as the concept of triage rarely exists. These EDs are manned by physicians, surgeons, orthopods with Casualty Medical Officers who work as messengers among the specialists. There is no accountability or requirement for any sort of prior training to work in a Casualty. The junior physicians working here simultaneously prepare for Post-Graduate Medical Entrance Examinations in the hope of securing a postgraduate position in established fields that are already well recognized by the MCI. The situation in these departments is no less than an everyday disaster! Only a few government hospital EDs have a consultant available with some prior training in EM. Unfortunately, nothing much has changed in the last two decades. The elite and influential classes prefer to stay away from government institutes and the underprivileged people have no other choice. 

This is the current scenario that prevails in a majority of the government run hospitals. Some of these government centers also run the recognised EM Residency programs.

2. Private EDs – In this sector, public needs to pay a fee for any sort of treatment (Yes, even for an EMERGENCY). Payment for laboratory tests and procedures is required before services are rendered and you are evaluated with minutes or seconds of arrival. In critical circumstances, a private hospital may perform initial stabilization in terms of ABC at a nominal fee, but then families must decide whether to pay for further services or transport a critically ill patient to a government hospital.

Private sector recognized the need to provide Emergency Care 24X7 in early 2000s and they began to provide protocol based Emergency Care. They now prefer to employ physicians who are trained in life support courses in addition to having some sort of basic EM training (1-3 years) but might expect them to seek expert consultation for almost every patient and handover ill patients to the qualified and more reliable ICU physicians at the earliest. The hospital management and physicians from other specialties find it hard to trust the clinical acumen of partially trained Emergency Physicians manning the EDs with credentials not recognised by national bodies. However, this perception changes dramatically with time if satisfactory teaching is delivered to the residents. Many private hospitals also run unaccredited (unaccredited program does not equal to incompetent trainees) training programs to employ a bunch of residents and provide minimal or no academic training. Most of the private centers have a consultant available 24X7 to liaise with in-patient specialties and maintain the flow in the ED. These centers are able to manage minor and major injuries well, but they rely profoundly on specialists-on-call from other departments for decision-making. Only a few of these private centers are truly academically oriented.
3. Also, in the past several years small hospitals and clinics have rapidly developed across India. These sites lack multidisciplinary support and trained Emergency Physicians and end up shunning patients to private hospitals (sometimes miles away) due to concerns about medico-legal issues and violence by the families in case of a mishap. 

It has now been more than 7 years since the recognition of EM as an individual specialty and we are certainly drifting in the right direction. Joint efforts are required to make giant strides rather than slow and steady development without meeting the needs of over 1.25 billion people. EM still needs to go a long way and conquer rural sectors to make 24X7 standardized emergency care to everyone and also minimize the unnecessary burden on specialists for trivial issues.



EM credentials in India

At the time of this writing, Medical Council of India (MCI) and National Board of Examinations (NBE) are two major bodies that oversee post-graduate training in India. Only these two credentials i.e. MD by MCI and DNB by NBE are nationally recognised in India.
·      MCI is the body that awards M.D. but offers a limited number of post-graduate positions in University based teaching programs. Of the total about 23,000 seats offered for Post Graduate Medical Courses, MD-EM comprises only 73 seats.
·      On the other hand, NBE awards DNB (Diplomate of National Board) and again offers a limited number of seats in hospital-based training programs. The National Board of Examinations at present offers 66 seats in DNB-EM at 20 institutions across India (November 2014).

EM is still counted as one of the least recognised specialties in India (others being Family Medicine, Palliative Care etc.) but there are more than half a dozen diploma, fellowships and residency programs which are offered to medical students. Here is a list of these programs:
  •  MD Emergency Medicine – 3 years (Nationally Recognized)
  •  DNB Emergency Medicine – 3 years (Nationally Recognized)
  •  MRCEM (by Royal College of EM, UK) – Eligible to enter FRCEM training
  • Masters in Emergency Medicine (i.e. MEM by Society of Emergency Medicine in India) – 3 years
  • Masters in Emergency Medicine (MEM affiliated with various North American    Universities) – 3 years
  • Fellowship in Accident and Emergency Medicine (setup in 1994, first Academic EM Department at Christian Medical College, Vellore) – 2 years
  • Diploma in Emergency Medicine (St. John’s Medical College, Bangalore) –   1 year
  • Royal College of General Practitioners Diploma in EM – 1 year


        Note- This may not be a complete list of EM programs currently run in India

The matter that stems out with these credentials is approval by the medical council. The training methods are diverse with minimal focus on Academics (in majority of them) and completely different methods to assess the candidates. While some programs strive hard and modify their curricula based on residencies in the United States others utilize residents only as a work force with self-directed learning through textbooks and social media.



EM organizations in India

1.   SEMI (Society of Emergency Medicine in India)
SEMI is the first Indian organization created for the development of Emergency Medicine in India. It was founded in 1999 with its first meeting conducted at EMCON 1999, the first Indian National Conference in Emergency Medicine. The 18th EMCON was recently conducted at Madurai in November 2016. SEMI has been making constant efforts to promote and uplift EM. SEMI also runs a 3 year Masters in Emergency Medicine (MEM) Program at various private hospitals in India.



          2.    AAEMI (American Academy of EM in India)
A group dedicated to promoting Emergency Medicine in India, formed by physicians of Indian background since 2001.



3.     INDUS-EM (INDUS EMERGENCY & TRAUMA COLLABORATIVE)
All India Institute of Medical Sciences, New Delhi and University of South Florida Emergency Medicine in USA founded INDUSEM in 2005. INDUSEM gets the support of the State University of New York, Downstate Medical Center and Baroda Medical College. INDUS EM group had published several white papers pertaining to training and EM Academics.


In an attempt to produce EM faculty, INDUS-EM encourages specialists from various medical backgrounds (anesthesia, internal medicine, OBGYN) to take 12 online monthly tests based on Tintinalli’s textbook of EM followed by a board review course to assess procedural competencies and check credentials (life support courses, ECG courses and USG skills, ortho skills). This gives them a taste of Emergency Medicine and puts them in place to teach Emergency Medicine. Read more here.

Even with a similar goal in their minds i.e. to nurture Emergency Medicine, there are obvious elements of friction and blatant lack of interaction among these organizations. This completely baffles the young EM advocates but more importantly hinders the development of Emergency Medicine as a specialty.



Sub-Speciality Training – Is this the right time?

I believe it is a bit early to develop sub-specialty training. First and foremost, we need to validate the existing credentials and reach a final end point to ensure that we all stay on the same page. Do you see a point specializing in EM Neurology if your General EM credentials are questioned at the first place?

It is time to familiarize us with Core EM topics and General Emergency Medicine first rather than getting into the depths of EM Neurology or EM Cardiology. One of the major challenges ahead would be to start working towards a “Rural EM” fellowship, which would be immensely beneficial for the villages and small towns in India where a single doctor is expected to manage every possible pathology.



Another hitch - Brain Drain

EM is already entangled with several internal regional and political issues and “brain drain” complicates it further. A majority of Indian trainees in EM take the Royal College of EM exams (Membership of RCEM Part A, B and C), which are entry-level exams in the UK to pursue higher specialty training in EM. But in India, you will come across several physicians employed as the Heads of the Emergency Departments (HOD/Chief) with MRCEM qualification and a mere 3 years of training in EM. These posts offer alluring salaries and are primarily offered by the private hospitals to flaunt their Emergency Departments.




At the same time, an enormous number of candidates migrate to Middle East, Singapore and the UK for various reasons like understanding a global perspective of EM Healthcare systems, much higher income and an opportunity to pursue higher training in Emergency Medicine. This puts India at the back foot again by extracting a significant number of trainees out of the system.

The route to United States still remains unexplored as USMLE comes as a major barrier in addition to the requirement of Standard Letters Of Recommendation, US Clinical experience and issues with Visa. However, there are plenty of trainees who took up initially USMLE but later changed their avenues and joined various local EM Programs. 


Potential Solutions

By no means, I am an expert or a policy maker and most of the material presented here is based solely on my past experiences and strong opinions. Every trainee considers his program as the best and belittles other programs. I believe that nobody is perfect at this point of time and we all have a long way to go. These are a few things that might help us to ensure better Emergency Care in India:


            1.    Standardizing a robust criteria to pursue EM

To pursue MD or DNB (the two nationally recognized credentials), candidates need to struggle and slog to crack the All India Post Graduate Exams but despite of that “most of the students get EM by fate, not by choice”. Unlike the US, there are no interviews, LORs, Clinical Experience and contribution to the specialty type questions asked. It is just based on the scores and ranks, which seems pretty unfair. Candidates choose EM because they think “having something is better than nothing” and it is certainly better than preparing for entrance exams for another 12 months!!

To accomplish a change at the national level, there needs to be a total reform in the existing systems but to begin with, at least the private hospitals must start scrutinizing candidates before enrolling them for a EM course. Surprisingly, some programs enroll candidates without any sort of screening or examinations. It is solely based on a candidate's ability to pay the annual fees. 


       2.  Incorporating FOAMed

Emergency Medicine has been leading the FOAMed movement and this can be a great learning resource. This is a boon for developing nations where EM is still in the cradle. Since there is a sheer lack of local educators in Emergency Medicine, FOAMed can take this responsibility off us until we have enough faculty. FOAMed fills the gaps in our knowledge and keeps us up to date by levelling all the differences. Understanding a core EM textbook still needs to be the skeleton around which FOAMed can revolve. Through FOAMed, we can interact with the world-class educators from all over the world and listen to their thoughts, ask questions and learn from their experiences. Existing EM programs must make weekly CME attained through podcasts mandatory for all the residents.



     3. Setting a Common standard of training

With plenty of EM training programs around, we need to lay minimum standards to call someone a qualified Emergency Physician in India. 

Who is a qualified Emergency Physician? 
  • Is it the MD/DNB candidates who are frequently taught by Hospitalists, Surgeons, Orthopods, Anaesthetists and Critical Care fellows lacking the EM Mindset? 
  • MRCEM qualified physicians who take three exams (MRCEM Part A,B,C) with no fixed rotations in other specialties and MRCEM is an entry level exam to pursue further training in the UK?
  • MEM by SEMI or MEM affiliated with US Universities – Only a few of these programs have managed to get trained faculty from countries with stronger EM Healthcare systems countries to fulfill their training requirements while others are struggling to run their academic schedules. Questions have also been raised about the enrolling criteria for these candidates.
  • Others with 1 or 2 year of diplomas and fellowships with similar issues pertaining to enrollment, academic and assessment of trainees.



      4. By default but what we nationally recognize is MD and DNB but what about the other programs? Is it okay to call all MD/DNB possessing candidates recognized despite knowing the fact that plenty of them have serious issues in their training?

In the end, it all depends on an individual - if he/she is keen to learn, progress and strive hard to bring a change. We all know a few exceptionally sound Emergency Medicine practitioners trained from the so called unaccredited programs and at the same time, we also happen to know “EM Physicians” from recognised training programs who struggle when it comes to providing the basic Emergency Care although they have robust theoretical background. We cannot paint everyone with the same brush. 

As EM Practitioners, we all have also dealt with MD/DNB possessing from every other specialty and time and again we have realized that all of them are not the same. Furthermore, many MD/DNB providing institutes have serious flaws in terms of having the appropriate teaching faculty, equipment and infrastructure to train the residents. Additionally, many candidates possessing recognised credentials never took any entrance exams because MD residency spots are also available as management positions (paid seats). 

Everyone possessing MD- Emergency Medicine cannot be considered as competent and all those with unrecognised credentials are not incompetent. 


    5. Is it justifiable to sweep thousands of diploma and fellowship candidates in a go and overlook their credentials and experience?

We need to be mindful of people who are practicing EM since 15-20 years now. Can three years of deficient training beat two decades of work experience (with a non-recognised EM qualification) in an Emergency Department?

If any candidate meets the training duration laid down by a “National Emergency Medicine Board” and also possesses the procedural skills, then he/she should be allowed to take a board certification exam  (theory + practical) set by MCI/DNB (if you consider that as the gold standard) to certify them as qualified Emergency Physicians. To many, this might sound like an unorthodox way of obtaining a qualification but this is the only feasible temporary solution that I can think of to generate enough EM faculties.  

If the first world nations such as United States, United Kingdom and Australia can accept Primary Medical Credentials of an Indian Graduate after USMLE, PLAB and AMC respectively, then why are not we ready to accept post graduate credentials which are acquired from our own country (after unaccredited graduates take a National EM board certification exam). 

However, India does recognize the Primary Medical Qualifications attained at a foreign university (such as Russia or China) after a candidate gets through an exam conducted by the National Board of Examinations. Why can’t we do the same with the so-called unaccredited EM programs in India to make them nationally acceptable and level all the differences between MD/DNB/MEM/MCEM/FEM…..? 


       6.    Joining hands with developed EM systems

Many programs are on board with this idea, which are constantly inviting US/UK based faculty in India to ensure Academics are taken care off. This keeps the residents engaged and motivated in addition to finding the right mentors.


       7.    Sponsoring exceptional candidates to train in developed systems

Apex government institutes can sponsor outstanding candidates to get further training in developed EM systems and pursue super-specialization with an agreement that they serve the home country for a fixed period of time after returning back from the sabbatical.


      8.    Incorporating EM in undergraduate curriculum

EM should be instilled in the minds of budding physicians at the outset not as an afterthought. As a specialty that emphasizes basic clinical skills, Emergency Medicine must incorporated in the undergraduate medical curriculum. A core curriculum that provides learning objectives, subject content list and structured learning environment, needs to be planned.




This was just a collation of my thoughts on EM in India and my objective was not to degrade  or support any specific program (recognized and unrecognized). I also acknowledge that some of my opinions would seem biased and unfair to each one of you. I would love to hear your thoughts and better solutions to combat this. Reaching a common ground is paramount to expedite our progress as a speciality. I cannot help but notice a clear sense of animosity among various programs, which is not helping us in anyway but hampering our movement. Our current situation looks similar to what happened in the US in early 1990s - The Rape of Emergency Medicine.




References:
  • Arora P, Bhavnani A, Kole T, Curry C. Academic emergency medicine in India and international collaboration. Emergency Medicine Australasia. 2013 Aug 1;25(4):294-6.
  • David SS, Selvaranjini S, Thomas M. Incorporation of emergency medicine in the undergraduate curriculum. Natl Med J India 1997;10:80-1.
  • Jain M, Batra B, Clark EG, Kole T. Development of post graduate program in emergency medicine in India: Current status, scope and career pathways. Astrocyte. 2014 Oct 1;1(3):218.
  • Alagappan K, Cherukuri K, Narang V, Kwiatkowski T, Rajagopalan A. Early development of emergency medicine in Chennai (Madras), India. Annals of emergency medicine. 1998 Nov 30;32(5):604-8
  • http://www.mciindia.org/InformationDesk/CollegesCoursesSearch.aspx
  • Pal, Ranabir, et al. "The 2014 Academic College of Emergency Experts in India's INDO-US Joint Working Group (JWG) White Paper on" Developing Trauma Sciences and Injury Care in India"." International journal of critical illness and injury science 4.2 (2014): 114.
  • Das, A. K., et al. "White paper on academic emergency medicine in India: INDO-US Joint Working Group (JWG)." Japi 56 (2008): 789-797.
  • Subhan, Imron, and Anunaya Jain. "Emergency care in India: the building blocks." International journal of emergency medicine 3.4 (2010): 207-211.


Author:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic