My latest presentation. Three parts ; Part A - defining EM ,Part B delineate inception and Part C deals real ground realities

1. Emergency Medicine:
A most wanted specialty in India
Dr.Venugopalan.P.P
DA,DNB,MNAMS,MEM[GWU-US]
Director ,Emergency Medicine
Aster-DM Healthcare –India
Site Director ,MEM program GWU
Deputy Director –MIMS Academy
PG –Teacher Emergency Medicine –
NBE
Founder &Executive Director –
ANGELS

2. Part A
•What is
emergency
Medicine ?
•How it is
different ?
•What is its
uniqueness

3. Emergency Medicine
The medical specialty with the principal
mission of evaluating, managing and
preventing unexpected illness and
injury.

4. Emergency
Medicine
Encompasses
a unique body
of knowledge
reflected in the
“Model of the
clinical practice
of Emergency
Medicine”

5. Clinical E M
Initial evaluation,
treatment and disposition
of any person at any time
for any symptom, event or
disorder deemed by the
person or someone acting
on his or her behalf to
require expeditious
medical, surgical or
psychiatric attention.
ACEM

6. Emergency
.
Any condition perceived by the
prudent layperson or some one on
his or her behalf as requiring
immediate medical or surgical
evaluation and treatment

7. Emergency
It is a situation or condition having a
high probability of disabling or
immediate life threatening
consequences requiring urgent
intervention including first aid
ACEM

8. ER physician
A specialist who
has been trained to
engage in the
immediate initial
recognition,
evaluation and
disposition of patient
with acute illness
and injury..

9. ER Physicians
•Not provide long
term or continuous
care
•They diagnose a
wide range of
diseases and
perform
interventions to
stabilize the patient

10. ER Physicians • See a large number of
patients, treat their
illness and arrange for
disposition either
admitting them to the
hospital or releasing
them after treatment as
necessary

11. ER physician
Broad field of
knowledge and
advanced procedure
skills including
surgical procedures,
trauma
resuscitation,
advance cardiac life
support advanced
airway management
etc

12. • Good ER physicians
know every single
details of
resuscitation and
treatment methods
of sick and injured
relating to almost
every specialty.

13. Emergency
Medicine
• Demands excellent
communication skills and
knowledge of human
psychology.
• The ED physician has to
deal with as well as
establish rapport with
patient and their
bystanders who are in an
extremely stressful
situation of unexpected
emergencies.

14. Challenges..
•Deal with crying children,
•Child abuse,
•Violent patient attendants
who more often than not think
that the problem is not worth
admitting the patient

15. Challenges..
• Patient who do not trust
doctors,
• Anxious and depressed
patient
• Over worked staff.

16. Other Responsibilities [ACEM]
• Administration, research and teaching of
all aspects of Emergency care.
• Follow up care (observation medicine)
• Provision for emergency care to hospital
patient on request.
• EMS and pre hospital care

17. Other Responsibilities [ACEM]
• Disaster planning and management (both
natural and man made events)
• Toxicology and poisons center development
• Education of Healthcare providers and the
common public
• Preventive care medicine
• Basic and clinical research especially in
resuscitation and acute care.

18. o ED Administrator
o EMS Directors
o EMS and Paramedic
Trainers
• Disaster Planning
Consultants
Opportunities

19. o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR, Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities

20. EM team
•EM Physician
•Physician Assistant
•Nurses
•EMT Paramedics
•Radiology team
•Ambulance Assistants
•Medico-socio worker

21. ER APPROACH
• EM has unique aspects, such as
approach to patient care and decision-
making
Hidden life
threatening issues ..

22. APPROACH
• Comprehensive history,
examinations, routine lab
test, specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology, which is
not appropriate in ER.

23. APPROACH
Most important
question that must
be answered is
“WHAT IS THE
LIFE THREAT?”

24. A General rule
“Only 10-20
percent of
people who
present to an
ER truly have
Emergent
problems”

25. Three components are
necessary to quickly identify life-
threatening patient.
Chief complaints
Vitals
V-A-T

26. • Symptoms
• Allergy/anaphylaxis
• Medical history
• Past medical /Surgical history
• Last meal
• Event
• Social History

27. V
I
T
A
L
S
PULSE
BLOOD PRESSURE
RESPIRATION
TEMPERATURE

28. V A T
ASCULTATE TOUCH
VISULAISE
LOOK-
LISTEN -
FEEL

29. • Vital sign and Chief
complaints, when
used as Triage Tools,
will identify majority of
life threatened
patients.
• Familiarity with
normal vital signs for
all age groups is
essential.

30. Beware of the special
groups
Extremes of Ages
Athletes
Pregnancy
Pacemakers
Beta blockers

31. Approach
The idea of
performing a
'complete'
examination in the
ED is misleading,
because most
frequently a
'complete'
examination is
neither required nor
appropriate.

32. “Do an 'adequate' examination!”
&
“Decide - The patient is stable or unstable”.

33. Once a life threat has
identified
Interven
e to
reverse
the life
threat

34. FOCUS
OXYGEN

35. Stabilize
As fast as possible.

36. • The DD must begin with the most serious
condition possible to explain the patient's
presentation
• Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS

37. • It is unreasonable to expect that every patient
evaluated in ED should or must have a
diagnosis made in ED
• Even in specialties sometimes it will take days,
weeks, or months for the final diagnosis to be
made
DIFFERENTIAL DIAGNOSIS

38. DIFFERENTIAL
DIAGNOSIS
“The role of ED
physician is to rule out
serious or life
threatening cause of a
patients presentation.
Not to arrive at the
definitive diagnosis”

39. Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And

40. Focused Tests
•12 lead ECG should
be taken and read
within 10 minutes of
ED arrival – Chest pain
•FAST - Trauma
•CT and MRI – Stroke
/Spinal Cord Injury
•Blood tests and C&S
immediately in sepsis
and septic shock
•Toxicological survey

41. .
No role for X-Ray Chest
to rule out Tension
pneumothorax

42. CHRONIC PATIENTS AND ED
APPROACHES

43. A patient with recurrent migraine head ache, on
this presentation ERP should rule out the
possibility of Acute subarachnoid bleed .
“What is different
now?”

44. HOSPITAL ADMISSION -
DECISIONS
•Is there a medical
need that can be
fulfilled only by
hospitalization?
•Does the patient
need intravenous
therapy?

45. DECISIONS
•Does the patient
need oxygen
therapy or cardiac
monitoring?
•Whether the
patient can be
safely observed in
outpatient setting?

46. ED DISPOSAL
•Admission to
hospital Wards, I C
U, OT etc
•Observation
•Referral to
specialists
•ED discharge –
with advice or
against medical
advice.

47. ED discharge
• The ED discharge should be with specific
follow up instruction, which include specific
mention of most serious potential
complication of the patient condition.

48. Before discharging the patient from ED
Two Questions should be answered
1.Why did the patient come to the ED?
2.Have I made the patient feel better?
Relieve the Physical,
Physiological and Psychological
Pain before ED disposal

49. MEDICAL
RECORDS
•One should be
able to ascertain
from reading the
chart that the
more serious
diagnosis were
indeed considered.
• Must contain
appropriate follow
up instructions.

50. MEDICO LEGAL RECORDS
Writing proper
Medico legal
Case records,
Intimating
Police, Issuing
wound
certificates are
the primary job
of EPs

51. EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors, nurse,
assistants, etc) who are specifically trained in
these respective specialties.

52. EMERGENCY MEDICINE
CRITICAL CARE
 EM personnel are not adequately trained for
ICU work and ICU personnel are not skilled to
function in an emergency department
 Procedural skills are the same for both
specialties.
 Resuscitations and deaths are common in
both specialties.

53. EM versus CCM

54. EM versus CCM
EMERGENCY MEDICINE
 Emergency room
 Emergency
Physicians
 Pre hospital care
 Disaster management
CRITICAL CARE
 Intensive care units
 Intensivists
 Not much role
 Limited role

55. EM versus CCM
Patients are
unlimited
Short-term
management
 Spectrum of
patients and
Problem is vast
 Patients limited
by number of
beds
 Long-term
management
 Spectrum
limited to the
specialty of
Intensive care
Unit

56. EM versus CCM
Diagnosis is
not required
Diagnosis
necessary and
required for
continuation of
treatment

57. New Branch!
New Challenges?

58. Part B
EM inception
and growth

59. Academics ..Research..Protocols..

60. When looking back …
Sept. 21, 1979, that
the American Board
of Emergency
Medicine was
recognized as a
conjoint specialty

61. Emergency medicine had
its beginnings as early
as 1961, when four
physicians in Alexandria,
VA, formed the first
group dedicated to
providing care in an
emergency department
setting, which became
known as the Alexandria
Plan.

62. September 21, 1979,
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership,
recognizing emergency
medicine as the 23rd
medical specialty

63. • Fellowships
• Certificate Courses
• Degree Courses
• MCI
• NBE
• Government
•Government
EM
India…

64. INDIA
• MCI recognized EM as
the 30th Primary
specialty in INDIA
• Another important
Milestone

65. Part C
EM Indian
Scenarios
Few issues
from day to
day practice

66. Scenario
• Dr.Eqbal is fresh graduate scored excellent
rank in NEET exam and he is very much
interested to join MD EM . He seeks a second
opinion with his role model professors.
• Medicine professor advised him “Don’t take
such dirty specialty”.
• Microbiology professor “ What is it…I am not
aware of such specialty “

67. 1# Concept
• What is emergency medicine
• Where exactly the boundaries
• Know your strength and weakness
• Name of the specialty
Casualty
E
M
E
R
G
E
C
Y
M
E
D
I
C
I
N
E

68. Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology

69. Take
opinions
from those
persons
who know
about it ..

70. Scenario
• Dr.Vineetha knows about the speciality of
Emergency medicine . She also knows some
courses are available.
• She was so much worried about the
placement , job responsibilities payments
,recognition etc…

71. 2# Emergency Physician
• Qualification
• Academics and visibility
• Faculty from other specialties
Involve as much as

72. Emergency Physician
• A specialist who has
been trained to
engage in the
immediate initial
recognition,
evaluation and
disposition of patient
with acute illness and
injury..

73. Emergency Physician
• ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient

74. Emergency Physician
• Attitude
• Aptitude
• Alertness
• Aggressiveness
• Adaptability
• Awareness
• Accomplishment
7 A

76. Qualifications
• MD
• MCI recognized other specialists like surgery
anesthesia ; Medicine ; Pulmonologist
• DNB
• MEM
• MCEM;FCEM
• Fellowships
• PGDEM
M
o
R
e
D
E
m
a
N
d
Less people

77. Scenario
• 55years gentle man presented to emergency
department with giddiness and tachypnea at
2 AM. Known case of CAD and APD, had stent
and on anticoagulant
• P A to state transport minister and he was not
even willing to do initial evaluation.
• He want to see his cardiologist .
• Cardiologist is not taking phone
• More than 10 bystanders around

78. 3# People
• They are not much bothered about who you
are !
• 1000 people… more than 10,000 ideas
• Competency and care up to their expectations
• Quality and professionalism
• Ethics , Transparency and Truthfulness
Passionate always

80. Scenario
• 23yr old female brought to ED following RTA.
Had suspected C-spine injury , # Humerus and
# Femur
• Attending did Primary survey and Secondary
survey as per ATLS protocols
• Later new bystanders started agitation and
abusive language for tearing dresses for
exposure in Primary survey

82. #4 Patients
• Have a problem and sometimes many ….
• Distress
• Rewards are …how fast you make them
comfortable
• Need physical , physiological and psychological
resuscitation
• Culture ,Race and Religion
Bystanders are the
real problem ….

84. Scenario
• 25 year old lady present abnormal behavior
and hyperventilation . Case was referred from
rural Kerala. Vitals normal. 12 bystander
crowding around patient. Few of the shouting.
Some are on mobile phone . Chaotic casualty.

86. #5Premise
• ER is the front office
• Good reception lead good care lead to
comfort and confidence
• Plan ,Performance and Perfection
• Implement what exactly you want
Be live …save lives …

90. Pediatric Emergency Medicine

91. Family system
Joint family
Nuclear
family
Ultra
Nuclear

93. Scenario
• 5 bedded rural casualty, 1 OT, No CT facility 3
doctors, 6 Nurses ,One ambulance and 2
ambulance assistants
• 8 patients brought to casualty following a
collision of Jeep versus Autorickshaw
• 5 Walking patients , 1 case with fracture femur
of Hypotension, 1 case with facio-maxillary
injury with obstructed airway and one case
fracture dislocation of shoulder

94. #6 Team
• Doctors, Nurses,
Paramedics ,
Ambulance assistants
,Security ….
• Training, modulation
and empowerment
Team work is the success

95. You can win…..

96. When resources are exhausted …

97. Scenario
• 78 year old lady ,Known case of DM, CKD,CAD
and COPD presented to ED with SOB and Signs
of Sepsis
• Attending EP initiated early stabilization and
contacted different consultants
• Medical ICU beds are full except crash bed
• Consultants are not very keen to take case

98. #7 Destination
• When destination is not clear …
• Overcrowding
• Dumping
• No man area
• Multisystem cases and Poly trauma
Protocol based practice

101. Scenario
• 37 year old gentleman brought to Ed with
shortness of breath , palpitation and dizziness
• Vital Pulse 210 /mt reg. BP 110 ,SpO2 94 RA
• ECG – supra ventricular Tachy
• Not responding to Vagal maneuver and
responds to one dose of adenosine and called
cardiologist for expert opinion
• He shouted to EP like anything and asked to
do the rest of the management as well

103. #8 Consultants
• Supportive
• Incompatible
• Lazy
• Egoistic
• Money
• Over work /Burn out
Evidence based Medicine
Do for the best interest of patient

105. Scenario
• 25 year old male presented with Tachypnea
and pleuritic chest pain. He was just travelled
from Washington yesterday.
• PGY2 order D-Dimer .
• PGY 3 objected and they are in Arguments

106. #9 Academics
• Regular academics
• Multiple levels
• Different modalities
Teaching is the best way to learn

111. Scenario
• A corporate Emergency department claimed
to do good works . They reported the they
treated 65,000 cases per year. Resuscitated
many cases.
• NABH auditors visited in the department
declared that department is not meet the
standards

112. #10 Quality assurance
• Regular follow up
• Documentation
• Know about the errors and its chances
• Fix measurable Parameters , process and
protocol
• Errors
• Audit
Only way to get into next level

114. Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient
Presentation
ED Design
Triage
Cueing
Over crowding
Information Gap
Lab errors
Report
Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
Resource
Constrain
Sense
Making
Affective state
Radiology
Error
Fatigue &
Shift work
Cognitive properties of
the mind
Violation producing
factors
Procedural
factors
Medication errors
Inadequate
Discharge
Plan
Long waiting time
For Bed
Follow up
failures
Sources of Failures and Errors in ED

115. Acad Emerg Med. 2000 Nov;7(11):1204-22.
Promoting patient safety and preventing medical error in emergency departments.
Schenkel S.
Author information
Abstract
An estimated 108,000 people die each year from potentially preventable iatrogenic injury. One in 50 hospitalized patients experiences a preventable adverse event. Up to 3% of these injuries and
events take place in emergency departments. With long and detailed training, morbidity and mortality conferences, and an emphasis on practitioner responsibility, medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners. Yet no matter how well trained and how careful health care providers are,
individuals will make mistakes because they are human. In general medicine, the study of adverse drug events has led the way to new methods of error detection and error prevention. A combination
of chart reviews, incident logs, observation, and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review. In emergency medicine (EM), error detection has focused on subjects of high liability: missed myocardial infarctions, missed appendicitis, and misreading of radiographs. Some system-level
efforts in error prevention have focused on teamwork, on strengthening communication between pharmacists and emergency physicians, on automating drug dosing and distribution, and on
rationalizing shifts. This article reviews the definitions, detection, and presentation of error in medicine and EM. Based on review of the current literature, recommendations are offered to enhance the
likelihood of reduction of error in EM practice.
PMID:
11073469
[PubMed - indexed for MEDLINE]
•108000 preventable deaths from iatrogenic injuries per year
•1 in 50 hospitalized patients experiences preventable adverse events
•3% from ER

118. Finally …..
The most important Tool of ER

119. Communication
Communication
Communication
Communication

124. Summarizing….
….Look at the picture

128. Look and relook

129. E
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MEDICINE
Thank you so much
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