I recently posted a question to the Twitterverse:
“Imagine that an Emergency Medicine intern asked you for advice before his/her FIRST SHIFT. What would be your FIRST ADVICE?”
I also raised the same question in Turkish. In a couple of days, I received nearly 100 answers from reputable names of Emergency Medicine working worldwide. I highly benefited from these advice, and I think that our site’s valuable readers can also benefit. I tried to select the most inspiring ones and divided them into main categories. Under each advice, you can find the name of the tweet owner and the link to the original tweet. Let’s start.
Imagine that a new Emergency Medicine resident asked you for advice before the FIRST SHIFT. What would be your FIRST ADVICE? (The answers will be used for a blog post- Pls RT to spread) @EBMgoneWILD @EM_Educator @EM_RESUS @emcrit @Damian_Roland @FOAMpodcast @ssuner @FOAMedinburgh— İbrahim Sarbay (@ibrahimsarbay) July 3, 2020
That’s all for now. By the way, what would your advice be?
Laryngoscopy can be described as endoscopy of the larynx, which used to facilitate tracheal intubation during general anesthesia or cardiopulmonary resuscitation. For decades, direct laryngoscopy has been the standard technique for tracheal intubation. But today, there are two main types of laryngoscopy: direct and indirect. Indirect laryngoscopy means the provider visualizes the patient’s vocal cords without having a direct line of sight. Indirect Laryngoscopy includes video laryngoscopes, fiberoptic bronchoscopes, and optically-enhanced laryngoscopes. Video laryngoscopy introduced in recent years and it aims to overcome the limitations of direct laryngoscopy by using a camera attached to the laryngoscope. While it has clear advantages over direct laryngoscopy, video laryngoscopy still has a high cost of investment. It remains a rare commodity for Emergency Medicine clinics, especially in resource-limited settings.
While the COVID-19 pandemic was affecting the world, the people who were under the most significant risk were healthcare workers. We know that the risk of transmission of the disease is quite high, especially when performing high-risk medical procedures such as endotracheal intubation. It is a known fact that personal protective equipment such as masks or face shields are very important in protection. But it is even more important to stay physically away from the patient whenever possible. When intubating a patient, video laryngoscopy has a clear advantage in terms of eliminating the need to approach the patient’s head and trying to have a direct line of sight.
Video laryngoscopy devices are expensive. But, if you think about the essential components of it, you can easily realize that it doesn’t have to be this way. You need a blade, a camera system, a display, and a way to attach the blade and the camera system. While laryngoscopy blades are essential for Emergency clinics anyway, I can safely assume every Emergency clinic has them. A camera system and a display are also both fairly cheap and easy to obtain for most of the places on earth. Find those three and voila! You have a cheap video laryngoscope (In this post, I will not elaborate on the technique of combining a normal blade with a video camera).
For those who want to go to the next level, there are some ways of making your very own prettier video laryngoscopy devices. You just need a 3D printer, but luckily it is possible to find 3D printers in many cities these days.
So here we go.
The pandemic paved the way for innovation in many ways. Numerous doctors from all over the world rolled up their sleeves to develop new medical devices. Yasemin Özdamar, an Emergency Medicine specialist from Turkey, designed 3D-printable video laryngoscope blades named “Umay” (possibly an allusion to Orkhon inscriptions) in pediatric and adult forms based on normal laryngoscope blades.
AirAngel is a not-for-profit tutorial center dedicated to making video laryngoscopes accessible in under-resourced nations. You can purchase the blade or video laryngoscopy devices from their website with a fairly low price of US$100-180. You can also get the file of the blade for free and 3D print it yourself. Its design is really similar to a D blade. You can head to AirAngel’s website and grab the printing file now.
Here is an example tutorial for AirAngel:
In our tests (in Turkey), the cost of printing one blade approximately 50 Turkish Liras (roughly equal to US$7 with today’s exchange rates). We also bought a “Borescope USB Camera” with a camera head outer diameter of 5.5mm from our local internet store for approximately US$13 (A similar product from Amazon). So, the cost was US$20 in total, which is cheaper than AirAngel’s offer, and a lot cheaper than a conventional video laryngoscope. We have attached the camera to the blade using special parts on them and connected the camera to a phone. And under a minute, a video laryngoscope was born.
Please note: The intended purpose of these designs is to be used as a training tool. They do not replace any medical-grade video laryngoscope systems. They are not in any way approved medical device designs, nor have they been reviewed by the FDA or any other organization. Be aware that many plastics vary in strength, heat resistance, and chemical resistance. The strength and durability of the blade will vary depending on what you print it with. Harmful and life-threatening complications may occur if pieces break in the airway.
Recently, I published a Turkish article about my predictions on how emergency medicine will be in 2040 in the well-known Turkish FOAMed blog Acilci.net. In this article, we had the opportunity to brainstorm through a futuristic story about a typical Emergency Department in 2040. We have also conducted an online survey to collect the future projections of more than 40 scientists working on medicine, genetics and engineering fields; and included these predictions in the said article.
As this article was praised, I want to write about 5 ways technology will change Emergency Medicine in the coming years.
Virtual reality is an immersive, three-dimensional, computer-generated environment. While it may seem like technology for gaming and entertainment, it is exceptionally suitable to be used in medicine. One of the most prominent applications of it is in teaching Anatomy, allowing manipulations and dissections on the human body, more precisely than classical cadaveric dissections. Any medical student can access these materials from anywhere in the world. It is also cost-effective and requires less expertise, making it a dream come true for medical faculties(1). Surgical teams started to use 3D printing to build amazingly lifelike reproductions of real patients, and VR will only make it easier and better.
Sağlıkta Yapay Zeka Kongresi 2020'de "Sağlıkta Mobil AI ve AR Teknolojileri" sunumumu gerçekleştirdim. Geliştirdiğimiz AI destekli uygulamaları anlatarak, AR tabanlı uygulamalarımızdan birkaçını canlı olarak dinleyicilere sundum. pic.twitter.com/V1feFPZFTp— Dr.Yusuf Yeşil 🚀 (@dryusufyesil) 17 January 2020
Artificial Intelligence (AI) is a popular term these days. It means “a system’s ability to correctly interpret external data, to learn from such data, and to use those learnings to achieve specific goals and tasks through flexible adaptation.”(2) Scientists all over the world are working determinedly to gain maximum benefit from this technology. AI outperforms a conventional algorithm for emergency department electrocardiogram interpretation. Apparently, it can even diagnose heart arrhythmias with cardiologist-level accuracy. An AI-enabled ECG can detect if a patient has atrial fibrillation even if the patient has a normal sinus rhythm during the test(3). Can we determine the ejection fraction using ECG? For sure. Is it possible to determine age and gender? Of course. If you are tired about ECG, let’s try another one: Can atrial fibrillation be detected just by looking at a patient’s face? Well it turns out deep-learning and a smartphone camera are all you need to do so. AI is capable of surpassing human experts in breast cancer prediction, and it can read X-Rays better than humans. It can diagnose pneumonia better than radiologists. An Israeli company announced that its algorithms were successful in helping to detect the presence of coronary artery disease. Another initiative, Sonde Health Inc., develops a voice-based technology platform for monitoring and diagnosing mental and physical medical conditions. AI will also help to solve doctor shortages: According to MIT Technology Review, Chinese doctors and tech companies are developing tools to automate routine medical tasks and alleviate China’s doctor shortage.
And these are just the baby steps of AI!
When we say «Health wearables,» the first thing that comes into mind might be a smartwatch capable of health features, but it covers an area much broader than that (Can we count pocket-sized ultrasound devices as Health Wearables? Probably.) A tech company Kymira works on a heart monitoring t-shirt that uses a single-lead ECG and movement reducing hardware to offer an accurate reading of heart rate during exercise. Just like Apple Watch, AliveCor’s Kardia measures ECGs and can detect atrial fibrillation with high sensitivity. With the slogan of «Personal ECG for the whole family», Wiwe can detect arrhythmias, help making risk assessment for stroke and sudden cardiac arrest, and also determine blood oxygen levels. The Clinicloud, the EKO Core, the eKuore Pro measure heart and lung sounds as digital stethoscopes. Omron Blood Pressure Smartwatch and the MOCAcare pocket sensor, can monitor blood pressure.
Traditionally EEGs are tests that require hospital settings, but a new device lets you record EEGs in your home. With a noninvasive neural interface that sits on the back of the head, it is possible to control compatible software. Do you want to send a text message with a thought? Say no more!
Great new apps and devices let visually impaired people engage with their environments in ways that were a dream once.
The 3D printing process builds a three-dimensional object from a computer-aided design model. Due to the increasing technological developments, there have been significant improvements in the field of 3D printing in recent years. For example, US-based CELLINK develops bioprinters and bioprinting materials for providing models to enable 3D cell culture, personalized medicine, and enhanced therapeutics. United Therapeutics, managed to bioprint lung tissues. Scientists from Spain have presented a prototype for a 3D bioprinter that can make functional human skin. 3D printed orthopedic casts became an alternative to conventional casting to treating bone fractures.
CRISPR and genomics
CRISPR is the abbreviation of «clustered regularly interspaced short palindromic repeats,» and it is a family of DNA sequences found within the genomes of prokaryotic organisms. Since the description of it in 1987 by Yoshizumi Ishino and his colleagues’, CRISPR have attracted researchers’ attention due to its great potential. By the end of 2014 more than 1000 research papers had been published that mentioned CRISPR (4). CRISPR associated nucleases have shown to be useful as a tool for molecular testing. Scientists used CRISPR to successfully delete one of the defective genes responsible for hypertrophic cardiomyopathy in human embryos. In 2017, a team of Chinese researchers successfully increased resistance to HIV in mice by replicating a mutation. Researchers managed to treat mice infected with antibiotic-resistant infections using CRISPR-engineered bacteriophages. CRISPR may help grow new and healthier food. It also helps fighting with the disease in Ways we couldn’t even imagine in the past: By targeting female reproduction in the malaria mosquito vector Anopheles gambiae, scientists try to eradicate malaria.
We still have a long way to go. It is not difficult to predict that some of the «magnificent» innovations promoted today will turn up to be phony. Although technology advances; problems such as anti-vaccination, global warming, poverty will open up new fronts. Still, the future will absolutely bring great potentials. We are eagerly looking forward to see.
References and Further Reading
- Al-Jibury O. Use of Virtual Reality in Medical Education – Reality or Deception? Med Case Rep. 2017, 3:1. doi: 10.21767/2471-8041.1000039
- Kaplan, Andreas; Haenlein, Michael (1 January 2019). “Siri, Siri, in my hand: Who’s the fairest in the land? On the interpretations, illustrations, and implications of artificial intelligence”. Business Horizons. 62 (1): 15–25. doi:10.1016/j.bushor.2018.08.004
- Attia ZI, Noseworthy PA, Lopez-Jiminez F, et al. An Artificial Intelligence-Enabled ECG Algorithm for the Identification of Patients With Atrial Fibrillation During Sinus Rhythm: A Retrospective Analysis of Outcome Prediction. Lancet 2019;394:861-867.
- Doudna JA, Charpentier E. Genome editing. The new frontier of genome engineering with CRISPR-Cas9. Science 2014. 346 (6213): 1258096. doi:10.1126/science.1258096
Save the date: 17th November 2019!
Why? Because road victims will be remembered that day. Starting from 2005, The World Day of Remembrance for Road Traffic Victims is held on the third Sunday of November each year to remember those who died or were injured from road crashes (1).
Road traffic injuries kill more than 1.35 million people every year and they are the number one cause of death among 15–29-year-olds. There are also over 50 million people who are injured in non-fatal crashes every year. These also cause a real economic burden. Total cost of injuries is as high as 5% of GDP in some low- and middle-income countries and cost 3% of gross domestic product (2). It is also important to note that there has been no reduction in the number of road traffic deaths in any low-income country since 2013.
Emergency care for injury has pivotal importance in improving the post-crash response. “Effective care of the injured requires a series of time-sensitive actions, beginning with the activation of the emergency care system, and continuing with care at the scene, transport, and facility-based emergency care” as outlined in detail in World Health Organization’s (WHO) Post-Crash Response Booklet.
As we know, the majority of deaths after road traffic injuries occur in the first hours following the accident. Interventions performed during these “golden hours” are considered to have the most significant impact on mortality and morbidity. Therefore, having an advanced emergency medical response system in order to make emergency care effective is highly essential for countries.
Various health components are used to assess the development of health systems by country. Where a country is placed in these parameters also shows the level of overall development of that country. WHO states that 93% of the world’s fatalities related to road injuries occur in low-income and middle-income countries, even though these countries have approximately 60% of the world’s vehicles. This statistic shows that road traffic injuries may be considered as one of the “barometer”s to assess the development of a country’s health system. If a country has a high rate of road traffic injuries, that may clearly demonstrate the country has deficiencies of health management as well as infrastructure, education and legal deficiencies.
WHO is monitoring progress on road safety through global status reports. Its’ global status report on road safety 2018 presents information on road safety from 175 countries (3).
We have studied the statistics presented in the report and made two maps (All countries and High-income countries) illustrating the road accident death rate by country (per 100,000 population). You can view these works below (click on images to view full size).
References and Further Reading
- Official website of The World Day of Remembrance, https://worlddayofremembrance.org
- WHO. Road traffic injuries – https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries
- WHO. Global status report on road safety 2018 – https://www.who.int/violence_injury_prevention/road_safety_status/2018/en/
The phone was ringing incessantly. I barely woke up. In my pitch dark bedroom, the ringing phone was the only light source. I slowly grabbed my phone while involuntarily rubbing my eyes. I looked at the caller I.D. It was my father. And what time was it? 1:30 am! In a typical day, this might be an early hour for me, but I was attending a local Emergency Medicine conference that day; so I went to bed early.
While I was preparing in a hurry, my heart started to beat faster and my mind swelled with CPR guidelines, syncope algorithms and my past experiences.
My home is down the block from my parents. I ran there and saw a crowd gathered around a man who was lying on the street. When I passed through I realized someone was doing CPR. I have spotted my parents standing in the crowd and my eyes met with my father. He pointed my younger brother, a trainee surgeon also lives in the same area and was taking his turn on the CPR and checking his pulse. I rushed near them and he filled me in with all they know about the citizen at that point.
The first responder to the cries of the patient’s wife was an ambulance driver with ten years of experience. He said he pulled the patient out of his vehicle. He laid down the man in his 50s suffered from heartburn for the last couple of hours and was about to go to the hospital but lost his consciousness as soon as he started the engine. Since the man wasn’t responding, the former driver started the CPR. About 3 minutes later, my brother showed up along with my father and he took the turn while they kept checking for any response. He said that the rhythm never lasted longer than 10 seconds. So I asked them to keep it up and I took my turn till the ambulance shows up.
It was clear that the patient endured a heart-related condition, probably a myocardial infarction. And I knew by experience that with a proper CPR and early defibrillation, these patients have a high chance of returning of spontaneous circulation, and survival.
We have arrived at the hospital. After 10 minutes of additional CPR and proper mediations, spontaneous circulation of the patient returned spontaneous circulation. And a control ECG was consistent with Inferior MI. In a couple of minutes, we were in a different ambulance, headed to the nearest hospital with a coronary angiography unit and ICU.
I took a deep breath after we have delivered the patient to the ICU safe and sound. It was over, for now. One week later, he returned to his home with full recovery, without any neurological sequelae. They were very thankful.
Later on, I’ve heard many funny words people were chattering about this incident. One has particularly given me the giggle. It was coming from an ENT specialist. He said, “So that was no big deal, they probably overreacted and caused him a couple of broken ribs.”
Yeah, there were just some broken ribs… and a life saved.
“A podcast, is an episodic series of digital audio or video files which a user can download in order to listen to.” by Wikipedia’s definition. Listening to podcasts is a useful way of consuming FOAMed materials.
iEM Student audio podcast is one of the components of the project to increase accessibility to the content provided by international contributors. If you like to subscribe and listen to this podcast through your favourite podcast player, here is how:
1. Just click to your favourite podcast player (We use Overcast app as an example).
2.Click to the plus sign located on the top right.
3. Click to Add URL link.
4. Add below link
to the box located below "Podcast URL" text.
5. iEM Student Podcast is now available on the app's main page.
6. Click to the podcast to see the list of available recordings.
That's all! Enjoy!
As health care professionals working on Emergency medicine, our history is still being written. Let’s say you would like to learn which countries officially recognize Emergency Medicine (EM) as a specialty, and want to make a beautiful interactive infographic depicting these countries with their official EM recognition years (Because, why not?). It should be an easy task, right? WRONG.
What is your guess?
How many countries recognize Emergency Medicine as a specialty?
Even though it seems like a simple question which should have a clear answer, the answer is somewhat of a conundrum. There are a few difficulties for the answer. First of all, what is the definition of “recognition”? Could it be possible to consider having an EM residency program or the presence of EM specialists in a country as recognition? Probably not. Secondly, some of the countries recognize EM as a specialty but the exact year of recognition is unclear. Also, the answer may vary between articles and makes it hard to choose one. To make things clear, we have accepted the definition of “recognition” as a country’s official approvement of Emergency Medicine as a primary specialty. Countries recognizing EM as a supra-specialty (such as Switzerland) were also considered as a recognizing country in our list.
Anyway, we have rolled our sleeves up and dug deep. Many articles and tweets later, we had all the data available on this topic. To the best of our knowledge, this is the first time an article or blog post lists EM’s official dates of recognition for the entire world. We have also taken one step further and showed them on a neat interactive map.
So here we go: As of 05/2019, there are 82 countries in the world which recognize EM as a specialty. 13 countries from Africa, 27 countries from Asia, 13 countries from the America, 27 countries from Europe, and two countries from Oceania recognize EM.
As a well-known fact, the first two countries to recognize EM as a specialty are the United States and the U.K. Which are the latest? Germany and Denmark are the most recent of these countries, as both of them recognized EM in 2018. Perhaps, one year later, there will be new countries which welcome EM specialty. Who knows?
Shall we take a look at the current situation in an eye-pleasing way? Of course! You can view our interactive map right here. You can view maps with colors corresponding to the years of EM recognition for each country in the world (darker the color, earlier the date) in Figure 1. You can also view continental maps for Africa, Asia, Americas, Europe and Oceania in Figures 2, 3, 4, 5, 6, respectively.
Figure 1. Countries Recognize Emergency Medicine as a Specialty
Figure 2. Countries Recognize Emergency Medicine as a Specialty
Figure 3. Countries Recognize Emergency Medicine as a Specialty
Figure 4. Countries Recognize Emergency Medicine as a Specialty
Figure 5. Countries Recognize Emergency Medicine as a Specialty
Figure 6. Countries Recognize Emergency Medicine as a Specialty
For the ones who believe nothing is better than a list, all countries are listed in alphabetical order in Table 1. Table 1. List of counties which recognize EM as a specialty (alphabetical order).
|Country Name||Year of Recognition|
|United Arab Emirates||2004|
* Exact year of EM recognition in Bahrain is unknown and establishing of The Bahrain Emergentologist Association (BEMASSO) in 2004 accepted as the recognition year for this infographic.
§ Cuba has an EM/intensive care unit (ICU) training program which was begun in 2000.
# EM is considered as a supra-specialty in Germany, Greece, and Switzerland.
That is all for now! Please feel free to share it and comment on this list. Also, please tell us if we had any countries left behind or if there were any mistakes. EM family grows every day!
Together we are stronger!
References and Further Reading
- Swanson RC, Soto NR, Villafuerte AG, Emergency medicine in Peru, J Emerg Med. 2005 Oct;29(3):353-6, DOI:10.1016/j.jemermed.2005.
- Garcia-Rosas C, Iserson KV, Emergency medicine in México, J Emerg Med. 2006 Nov;31(4):441-5, DOI:10.1016/j.jemermed.2006.
- Al-Azri NH, Emergency medicine in Oman: current status and future challenges,Int J Emerg Med. 2009 Dec 11;2(4):199-203. doi: 10.1007/s12245-009-0143-6.
- Sakr M, Wardrope J, Casualty, accident and emergency, or emergency medicine, the evolution, J Accid Emerg Med. 2000 Sep;17(5):314-9.
- Pek J.H., Lim S.H., Ho H.F., Emergency medicine as a specialty in Asia, Acute Med Surg. 2016 Apr; 3(2): 65–73, doi: 10.1002/ams2.154
- Fleischmann T, Fulde G.,Emergency medicine in modern Europe, Emerg Med Australas. 2007 Aug;19(4):300-2.
- Partridge R., Emergency medicine in Cuba: an update, Am J Emerg Med. 2005 Sep;23(5):705-6, DOI: 10.1016/j.ajem.2005.03.006.
- MacFarlane C, van Loggerenberg C, Kloeck W.,International EMS systems in South Africa–past, present, and future,Resuscitation. 2005 Feb;64(2):145-8,DOI:10.1016/j.