Sorting out Gabrahat (Anxiety) ~ The Common Complaint in the ED

 Gabrahat (Anxiety) is often a common complaint with many implications.

While working in Emergency Departments in India I have been surprised with what the ultimate diagnosis was when I investigated Gabrahat.

For me Gabrahat is as vague as the Horizon and I take this complaint very seriously. It is very easy for any Nurse or Emergency Physician to get framed and just label Gabrahat as Anxiety or Hysteria.

This can be the Epic Blunder of Large Proportions. 

Many times relatives who accompany the patient will Frame the Emergency Physician by saying words like “There is Tension”. What they mean to imply is Gabarahat is Stress Related.

I often relate Gabrahat to a “SENSE OF IMPENDING DOOM”. When you grade GABRAHAT in that perspective, it guides the Emergency Physician to be very Proactive and diligent.

Let me share a few blasts from the past which I have modified for the sake of Education.

Case One:

Middle Age Female comes to the ED saying that she is feeling SOB. She is hyperventilating and Diaphoretic. She says that she has been having pain all over the body and fells GABRAHAT as if something is going to happen to her.

Her vitals are stable but she continues to breathe hard and breath fast. The relatives were doing a Fine job of Framing her as hysteria.

Rapid Fire Questionnaire Labs EKG Trop and a X-ray Beta HCG UA and a BNP are ordered.

On examining the patient the only Finding is the breathing. Lorazepam given IV and Oxygen started and ABG Ordered which is showing alkalosis. Aspirin given and a bedside Glucose is Normal. She settles down but continues to breathe hard. A CTA Chest is ordered. 

There are massive shower Pulmonary Emboli. Pt gets thrombolyzed and goes to ICU.

Case Two:

A 55-year-old women comes with GABRAHAT. She says that she is afraid something is going to happen. She has no other symptom. She has no Past Psyc Issues.

Labs EKG Trop and an X-ray UA ordered. She has had a prior hysterectomy.

She had an ST Elevation MI. Went to the Cath Lab. No Symptoms at all. No Past History at all.

Case Three:

30-Year-old man came saying He had Gabrahat and felt that there was Irritation in the Chest. NO PAIN BUT ONLY IRRITATION. Exam Past History negative.

Cardiac labs CBC RFT LFT was negative so was his EKG and Xray. Against the will of the Internal Medicine Colleagues Pt admitted. 4 hour repeat EKG and Trop was placed from the ED. His EKG was normal but his Trop had become positive.

Cardiology who scheduled the patient for a cath after admitting him to CCU found a Tight Lcx Lesion which needed a Stent.

Case Four:

48 Female with Gabrahat. Second visit after discharge from the hospital. Come back saying she is afraid. No Pain, No Focus of Infection. 

CBC RFT LFT Cardiac Labs X-ray Beta HCG and UA Negative.

Says her Mind tell her Something is wrong. She has GABRAHAT.

Was admitted in a nursing home. CBC Electrolytes creatinine and SGPT was done and after overnight IV Fluids patients sent home. A CT Head done and the patient had SAH. No Neck stiffness no Eye signs. Admitted to Neurosciences ICU

The only thing that prompted a CT Head was “My Mind is telling Me. This was perceived as Hallucinations hence CT Head Ordered.

Case Five:

18 Year Old Male comes with Gabrahat with Hallucinations. He was at friends party and says “ I have gabrahat as I see a ghost”.

Tox Work up was done and it was positive for multiple substances.

Routine CBC RFT LFT EKG Trop UA and Xray with a CT Head and Tox Screen were done.

Case Six:

40 year old male comes saying that he has Gabrahat and he feels like a huge Log of wood just fell on his head and nailed his whole body vertically into the ground. Clinical Exam and Vitals were normal.

CBC LFT RFT Trop EKG Xray negative

No Neck stiffness Neuro exam normal. He kept saying I am afraid I am sinking into the ground.

CTA Aortagram ordered: He had a dissection from Thorax to iliac bifurcation.

Admitted to CVTS Sx.

Summary:

• Basic Approach should be T/P/R/BP/Pulse Ox
• I always order a CBC LFT RFT EKG Trop CXR. Looking for Rhythm abnormalities is also important. Fever can also cause Gabrahat.
• In Females in the Pregnancy Age group a HCG-UA is ordered
• If Patient has SOB I will R/O Thoracic Causes like Dissection/Pneumothorax and PE.
• If Patient has a presentation of Altered Mental Status I always order a CT Head.
• If Toxicology screen is available, I will order one.
• Co-Symptoms should guide further investigations.
• Discussing with the Relatives in key to educate them- that this is not Hysteria / Tension / Stress. Those are the diagnosis to be considered once Major Life threatening causes are ruled out.
• I have often Seen Marital Discord / Intimate Partner Abuse to be causes of GABRAHAT. So Going deeper into the history. Sitting with the patient with Privacy is the key.
• Anxiety / Panic attack also can be on the differential once Major causes are ruled out.
• Being a Compassionate Emergency Physician is the key. Communication is the answer and Competency to Care is crucial.
• GABRAHAT CAN KILL !

I want to Share a Web Review of what Non EM Experts say about GABRAHAT.

I feel a Well Trained Emergency Physician leaves no stone unturned to do the best for his/her patient

Web Review:

• http://bhj.org.in/journal/special_issue_tb/DPII_11.HTM
• http://hrelate.com/natural-remedies-for-anxiety/
• http://www.njhonline.com/1993/july_aug_93_vol_11_no_4/spider/ghabrahat.shtml

Author:

Dr. Sagar Galwankar

CEO of INDUSEM & Faculty of Emergency Medicine at University of Florida Jacksonville, Florida

@SagarGalwankar

Sagar completed his med school from the University of Pune (India). He attained Board Certified in Internal Medicine from the National Board of Examinations in India. Following this, he went on to train at the University of South Florida, USA in areas of International Health Diplomacy, Infectious Diseases and Emergency Medicine. He also holds a MPH from the University of South Florida and is a Board Certified Emergency Physician with the American Board of Emergency Medicine.

Sagar's academic and clinical career spans over a decade with experience in Education, Care and Research both in India and the USA. He has extensively published, cited and honoured for his works in International Medicine, Public Health, Infectious Diseases, Emergency Medicine and Injury Sciences. Sagar is the Founder and CEO of the INDO-US Academic Initiative for Emergency and Trauma and continue to play a defining role in establishing Emergency Medicine as a separate specialty in India.

He has had previous appointments at the University of South Florida and University of Florida in Departments of Emergency Medicine, Internal Medicine, Global Health and Mental Health. His areas of Interest include Emergency Medical Intelligence, Health Policy, Injury Medicine, International Health, Humanitarian Assistance, Quality Health Care Delivery in Emerging Economies and Global Health Diplomacy.  Sagar believes that "The role of the World's Largest and the Oldest Democracies namely India and United States is crucial for the future progress of transitional Economies and Peace across the Globe". Health is Definately an important part of this growth Story.

Originally published at beepers365.blogspot  on 11 December, 2016. Reposted with permission.

Patient Confidentiality and Social Media

In the last decade, social media has changed the face of medicine. There are physicians who live their lives on social media and update their social media status q4h.  In the midst of a physician’s personal photographs, we often come across a patient’s clinical encounter with detailed description, ECG/Radiology Imaging displaying the name of the patient. We need to remember that any information posted on social media could end up on the front page of a newspaper. Posting patient photographs, meticulous description of hospital encounters can certainly put us at risk of litigation.

Breach of patient confidentiality on social media is a legitimate concern and as Health Care Professionals, it is our responsibility to ensure patient privacy. These issues can be extremely sensitive as patients share vital bits of information with physicians (sexual, psych, recreational drug use etc.). Violations in these regards expose us to liability under various privacy laws. 

On one hand, the western countries are extremely cautious about "patient confidentiality" issues whereas in developing nations, the concept of patient confidentiality remains unknown to many medical students, residents, practitioners and as well as the patients. It is not uncommon in third-world countries to find residents and even physicians openly discussing patient details, prognostication in elevators and hospital cafeterias. Conversely, personal information is not released to a patient's spouse without prior patient consent. 

Social media potentially improves health outcomes, facilitates developing a professional network, increases personal awareness of news and discoveries and also aids in providing health information to the community. And the intent behind information sharing on social media is knowledge dissemination and having discussion for the overall betterment of patient care. Nevertheless, this should not be done at the cost of breaching patient confidentiality. Here are a few suggestions that can provide a useful framework before posting any patient related information on Social Media:

• Avoid writing about specific patients: It is reasonable to generalize things when discussing about a patient rather then referring to someone in particular. This shields identification to some extent without loosing the point of discussion.
• Obtain patient consent when required: If you are going to post a photograph on a social media platform such as patient’s ECG or Radiological imaging, make sure you crop the image or take explicit patient consent before posting such information online. If done in the right manner, it is rare to find a patient who will refuse to share his details.
• De-identification: De-identification is the process used to prevent a person’s identity from being connected with information. Common strategies for de-identification include deleting or masking name and DOB, Age, ZIP code. Adding hypothetical points to a patient’s story is another way to de-identify but without loosing the crux of the matter. The Health Insurance Portability and Accountability Act defines data as de-identified if it “does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual is not individually identifiable health information.”
• Use a respectful tone when discussing patients: Social Media is accessible by everyone. Many patients do not appreciate the fact that majority of medical decisions are based on a physician's past experiences, opinions, local practices and comfort level rather than mandated rigid protocols. Beware of this whenever you are involved in an online discussion accessible by patients  Also, be courteous and demonstrate utmost respect towards a patient. Even when the outcome is going to be dismal, be sensitive while expressing your opinion.
• Have a separate personal and professional account
• Know your local/national laws and policies: If you medical licensing body or hospital has a social media policy, then give it a thorough read. 

Further Reading:

Ventola CL. Social media and health care professionals: benefits, risks, and best practices. Pharmacy and Therapeutics. 2014 Jul;39(7):491.

Coaching Residents to use FOAMed in developing EM systems

FOAMed is a revolutionary movement that has spread across the globe in last 5 years. A bulk of online content producers belong to highly developed EM systems who create material that is more pertinent to their own settings. Replicating the exact guidelines, thought processes and protocols in developing systems is not always a feasible option. Therefore, as local educators we need to step ahead and coach EM trainees in the developing world about utilising FOAMed to the acquire the maximum out of it. Also, we need to focus on creating our own resources that fits our needs better. Here are a few suggestions for beginners:

1. Be active on twitter/facebook (preferably twitter)

Social Media plays a key role whenever we discuss about FOAMed. Majority of educators prefer twitter as it imposes a limit (140 characters) on your messages. There are plenty of discussion groups on Facebook and google plus as well. You can converse directly with the experts in a field/topic and get their perspective of looking at things. 

2. Upload a photo and a short bio on twitter
Upload a brief bio about yourself and add your career interests as well to let people know who you are. Nobody likes to connect with a profile devoid of a photograph and personal details.

3. Be inquisitive, participate and ask questions BUT be a professional 

This might be a cultural issue. I reckon that there is a deal of hesitation among physicians  from developing nations especially residents in utilising open access medical educational material. We need to be more open for discussions and sharing our knowledge/tricks. I presume the reason for this reluctance is partly due to pressure from preceptors who are not ready to embrace FOAMed. Residents in developing nations do use online education to enhance their knowledge but there is sheer apprehension when it comes to an open discussion and commenting. Some prefer to be "Anonymous" while commenting on blogposts. Another reason for this behaviour could be fear on being wrong/criticised on a public platform.  

Professionalism: When you come across a anecdotal/baseless information, do not jump to any conclusions but try to understand the other persons's perspective. If you don't get that or disagree with that, state your opinions without being unprofessional in anyway. Remember that people are watching you on social media. Don't be abusive or mean and avoid making any sarcastic remarks, rather try and have an educated and fruitful discussion. It is also recommended to use a different account for your personal and professional use. Try and keep Politics/Celebrities away from your professional account. 

4. Make a list of your favourite podcasts/blogs  (you can't follow everything)

There is a ton of material available on internet. You cannot consume and retain everything. Be selective, use a RSS feeder to get you the desired stuff, subscribe to your favourite resources or use a website like lifteinthefastlane which distributes a weekly summary recommended by the experts. It is very similar to using textbooks. You cannot read every EM textbook and thus end up choosing Tintinalli's or Rosen's. Likewise, pick a few blogs and make the most out of them. 

5. Take everything with a grain of salt

Big Point - Do not trust everything that you read on the internet. It is recommended to go through the references by yourself and also with your consultants prior to changing your practise. Occasionally, a given opinion might be based on an anecdote or something which is done only at a well equipped tertiary care hospital. Read the evidence yourself and think what are the possible issues that can possibly arise at your shop with use of novel therapy. 

For instance, if you perform a resuscitative thoracotomy then you must have the ability to quickly mobilise the resources and arrange for definitive care. When you plan a Peri-Mortem LSCS, you must have OBGYN and Neonatology support ready within minutes. 

Educators on FOAMed world do appreciate this issue and explicitly mention this as on their website disclaimer as well. It is important to stick to local protocols and go by the clinical acumen of a physician when making life-changing decisions. 

6. Discuss with local mentors/senior physicians about their opinions

You may not able to practise what you hear on every single podcast. What is practised at a particular centre in the United States or England, may not be completely applicable in developing EM nation like India, for reasons such as lack of such high standards of EM training, infrastructure and equipment related issues or simply due to lack of expertise and poor allied speciality support. It is crucial to discuss with a consultant beforehand if you intend to use information gathered through FOAMed for patient care. 

My advice - Before you start using some sort of intervention that you recently heard on a podcast, have a discussion with your consultants outside the clinical shifts. In the midst of a busy shift, it can be hard to convince people for obvious reasons. It is extremely rare to find a mentor who trusts your acumen as a junior physician and is open to an immediate change. However, I have been fortunate to work with physicians who were always open for a conversation. 

Here I recall when I first used ketamine as an induction agent for a septic hypotensive patient, despite my consultant being unfamiliar with it. He was brave enough to say "I have never used ketamine before for RSI" and allowed me to use my choice of RSI drugs. More importantly stood at the bedside and said - go ahead and I am going to stay around to handle any mishaps. To my surprise, the very next day I noticed ketamine employed in our choice of RSI meds. He could have easily ridiculed me and moved on with traditional Midazolam and Sux. 

7. Get filtered FOAMed resources 

If your faculty is not on board with FOAMed, then it is a good idea to introduce them to the FOAMed world. Once they are accustomed with this concept, they can filter information and give you selected high quality weekly podcasts/ blogs which can then be directly applied to patient care. 

8. Don't forget the textbook

You won't find everything on FOAMed. Your EM textbook is still your best bet. Use FOAMed to enhance your knowledge and understanding as FOAMed often talks only about the controversial and hot topics. Read a topic from a textbook and then use FOAMed as a supplement. 

FOAMed questions our current practise and dissects the evidence behind a treatment/ intervention which is what makes many of us uncomfortable. As medical students and residents, the importance of having a solid foundation cannot be emphasised enough. 

Before doing a Delayed Sequence Intubation, familiaze yourself with a Rapid Sequence Intubation. 

9. Find virtual mentors

FOAMed gives us an opportunity to find virtual mentors. Trainees from developing EM systems can obtain invaluable  guidance. Weekly meetings, teaching sessions can be arranged to disseminate knowledge. 

Take Home: FOAMed appears to be paramount for developing EM systems. It is here to stay and we need to get comfortable with it. In this era of technology, it is hard to escape FOAMed and teaching residents about how to incorporate this into their curriculum seems to be the way out rather than going into a completely aversive mode towards it.

A list of my favourite FOAMed resources:

• lifeinthefastlane.com
• www.aliem.com
• www.rebelem.com 
• coreem.net 
• embasic.org
• emlyceum.com
• ecgweekly.com
• emcrit.org

References:

• Nickson, Christopher P., and Michael D. Cadogan. "Free Open Access Medical education (FOAM) for the emergency physician." Emergency Medicine Australasia 26.1 (2014): 76-83.
• Cadogan M, Thoma B, Chan TM, et al. Free open access meducation (FOAM): the rise of emergency medicine and critical care blogs and podcasts (2002-2013). Emerg Med J. 2014
• Thoma, Brent, et al. "Five strategies to effectively use online resources in emergency medicine." Annals of emergency medicine 64.4 (2014). 

Author:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

Arguments against Free Open Access Medical Education

I have always been an avid supporter of FOAMed as much of whatever I have learned (besides textbook), came through the use of social media. I recently participated in a panel discussion at the Developing EM Conference on the Pros and Cons of FOAMed. In this whole process I also realised that there are certain critical issues with FOAMed that need to be tackled to streamline things and make these resources more credible. 


Argument 1 - FOAMed Lacks Peer Review

Many are of the opinion that Peer Review itself is a flawed process. Some the the editors who review the articles are self-declared experts. This raises questions on this whole process of peer review. I would argue in favour of FOAMed here as you get an instantaneous post-post peer review by readers across the world (some of those are really the experts). A recent example is PESIT study published in NEJM. This paper grossly overestimated the prevalence of PE in patients presenting with syncope. 

Moreover, material is far more easily accessible to readers via social media rather than paper published journals. Peer reviewed is often nothing but an expert stating that `The paper looks all right to me'. A peer review that asks for raw data, repeated analyses, checks all the references, and making detailed suggestions for improvement is rare. To understand more about the drawbacks of peer review - click here



Argument 2 - Violation of Patient Rights

When using internet for online education, patient privacy comes under threat. There have been cases when Physicians were dismissed following a privacy violation on social media. There are two ways to sort this out - either take a written consent or change the personal details of the patient. Also, we need to sensitise students regarding this.

Argument 3 - Professionalism and your digital foot print

There have been a few altercations on FOAMed in the recent past due to highly polarised opinions. We need to remember that social cues are completely lost when we interact through social media. In addition, as educators we must lay strong principles on professionalism right from the beginning of the medical school from a social media standpoint. Medical Schools and Residency programs now have people assigned to handle this particular task. 

By the time, a student enters the medical school, he/she may already have a digital footprint that may not suit a physician's persona. Whatever we post on social media (Facebook, twitter, google plus and even whatsapp) should be considered accessible to everyone (including your patients and employer as well). Residency programs may google the name of an applicant to look at his/her digital footprint before a formal interview is conducted. 

Argument 4 - Information Overload

Read about how to manage information overload here. I personally use the weekly life in the fast lane review and read whatever interests me. 


Argument 5 - Confuses Learners (esp Medical Students)

This issue deserves serious attention as junior trainees and medical students often find themselves lost between two strikingly different opinions between their core content textbook and a recently FOAMed article published by an expert. For instance, some texts still mention Loop Diuretics as the first drug of choice for a crashing pulmonary edema while in practise many Emergency Physicians use high dose boluses of NTG for these patients. 

A possible solution is having a discussion with the trainee and probing for the evidence behind the use of diuretics and NTG. Educators need to spare a few minutes to explain about the best available evidence and rationale behind a particular treatment. However, some treatments are just based on a clinician's past experiences and anecdotes. It would be appropriate to let the trainee know whenever a treatment is based on a clinician's personal opinion rather than EBM, There are often many ways to treat a disease with none of them being absolutely right or wrong. 


Argument 6 -  FOAMed = Partial or Swiss Cheese Knowledge

FOAMed is not meant to replace a textbook or get rid of bedside teaching. Medicine is best learned by role modelling and observing our mentors while on shift. None of the FOAMed supporters say that students need not read the textbooks. A textbook is still the foundation and FOAMed is a SUPPLEMENT to solidify the foundation. 

Author:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic