Is it just a viral disease?

June 29, 2020June 28, 2020 ~ Rebeca Rios, Brasil ~ Leave a comment

The world is scared of COVID19. Brazilian health professionals too. But today I bring something else that has haunted Brazil for years. It’s dengue. Even with the COVID19 pandemic, the mosquito Aedes aegipty doesn’t give us a break.

Dengue is an arbovirus of the flavivirus genus, which is transmitted by the Aedes aegypti mosquito, and has 4 well-established serotypes: DENV-1, DENV-2, DENV-3, and DENV-4.

Dengue is an infectious viral disease which causes a feverish syndrome. Only in January, February and March, there are 94,149 probable cases of dengue in Brazil. In 2019, there were 1,527,119 cases. The intense summer, high temperatures, and rain helped with the proliferation of the vector last year. And, there was also a change in the serotype. Dengue has 4 circulating serotypes. Here in Brazil, the most common had been 1 and 4; however, the circulation of serotype 2 increased – linked to greater severity and hemorrhage. We cannot concentrate all efforts on COVID19 and forget about some diseases that continue to attack our population.

Deaths from dengue are preventable, except for fulminating cases. Many deaths from dengue are consequences of an error, it may be the delay in seeking health care, the lack of access to the network, and the difficulty in identifying the seriousness of the cases.

The fight to stop the transmission of dengue requires a collective effort because it is transmitted by insects, and that is where exactly the Aedes aegypti mosquito, the great star of dengue, comes into play. The Aedes aegypti mosquito thrives in standing water. The female is responsible for carrying the dengue virus. In addition to dengue, this mosquito can transmit urban yellow fever, Zika, and Chikungunya.

Then, a patient with a high fever, retro-orbital pain, myalgia, prostration, headache, and maculopapular rash arrives and a recent trip to tropical regions (like Brazil!) … think, it could be dengue!

“As per WHO guideline 2009, dengue patients can be further categorized on the severity basis that includes severe dengue patients, dengue patients with few warning signs, and dengue patients with no warning signs. Dengue hemorrhagic fever which is most severe out of these three categories mainly occurs in 5% of total dengue patients”.(2)

Although there is a test called NS1 (viral antigen research) widely used in Brazil for the diagnosis of dengue, with a sensitivity of 70% and specificity of 95%, it is not a good test to rule out the suspicion of Dengue even if it comes negative – and this pattern is repeated in all the other methods like Viral Antigen Research (NS1), Genetic Amplification Test (RRT-PCR) and Tissue immunohistochemistry. It must be done until the 3rd day; after that, its accuracy drops a lot. Moreover, if the patient has had dengue before, its diagnostic value drops. (4)

Regardless of this issue of time, some tests valid for patients are blood count (presence of atypical lymphocytes and thrombocytopenia) and those that demonstrate organ dysfunction, such as TGO and TGP, urea and creatinine) to monitor the severity of the case and guide your treatment. Hemoconcentration, evidenced by the progressive increase in hematocrit (Ht) is the main laboratory finding in the identification of capillary leakage so it can show the severity of the patient.

Do not freak out! If your patient has no alarm signs and no special conditions, treatment can be done on an outpatient basis, advising the patient on the warning signs and the importance of hydration. There is no specific antiviral treatment available in the market yet. Generally, treatment includes the mechanism of controlling fever and pain with paracetamol rather than aspirin (aspirin may promote bleeding), and increasing fluid intake ³. (Look for the specific protocol of your country for the treatment of dengue). And avoid using medications that affect the coagulation cascade, such as non-steroidal anti-inflammatory and acetylsalicylic acid.

Staging and start hydrating!

You may be asking yourself, why do some people develop dengue more seriously and others don’t?

Halstead’s theory states that the disease is becoming more and more severe as the patient becomes infected with different serotypes of the causative virus.
The idea is that in the first infection, the organism can defend itself by producing a series of antibodies that are specific to that invading serotype. But if reinfection with another type of virus occurs, these antibodies may even bind to the pathogen, but they are not effective in stopping them. And this connection also favors the entry of viruses into cells, which enhances their multiplication and, consequently, the patient’s clinical condition.

This is the most accepted theory. There are others, such as the theory of multicausality, which claims the severity of the disease is associated with the interaction between several factors, ranging from the pathogen’s virulence to environmental conditions and also from the disease itself and patient being infected (such as previous comorbidities, age, among others).

Here in Brazil, we have a popular saying “It’s just a bug!”. We use it as a joke when we go to the doctor and he tells us: “it’s just a viral disease, go home, get hydrated and rest!” Yes, dengue is a viral disease. But it deserves special attention, as it can turn into a serious organ dysfunction if not treated properly !!

Cite this article as: Rebeca Rios, Brasil, "Is it just a viral disease?," in International Emergency Medicine Education Project, June 29, 2020, https://iem-student.org/2020/06/29/is-it-just-a-viral-disease/, date accessed: October 1, 2023

References

https://www1.folha.uol.com.br/cotidiano/2020/01/brasil-registra-em-2019-segundo-maior-numero-de-mortes-por-dengue-em-21-anos.shtml
Giang HT, Banno K, Minh LH, Trinh LT, Loc LT, Eltobgy A, et al. Dengue hemophagocytic syndrome: A systematic review and meta-analysis on epidemiology, clinical signs, outcomes, and risk factors. Rev Med Virol 2018; 28(6): e2005.
Rinku Rozera1, Surajpal Verma1, Ravi Kumar1, Anzarul Haque2, Anshul Attri1 Herbal remedies, vaccines and drugs for dengue fever: Emerging prevention and treatment strategies. Asian Pacific Journal of Tropical Medicine. 2019
CRUZ, Jaqueline. Avaliação de Testes Diagnósticos para a Identificação da Infecção pelo Vírus da Dengue em Pacientes com Síndrome Febril Aguda. Dissertação (Mestrado em Biotecnologia em Saúde e Medicina Investigativa) – Fundação Oswaldo Cruz, Salvador, 2014.
Ministério da Saúde. Dengue: Diagnóstico e Manejo Clínico. 5a ed. Brasília: Ministério da Saúde, 2016.

The Medical Emergency Simulation Olympics – G.SEM

the emergency medical simulation olympics

October 30, 2019October 25, 2019 ~ Rebeca Rios, Brasil ~ Leave a comment

The use of realistic simulation on medical teaching is increasingly being used in the universities of Brasilia. The controlled environment training brings important benefits and develops the non-technical skills of participants. Therefore, the Congress of Medical Emergencies of the Federal District that took place this month in Brasilia, Brazil, promoted a realistic MEDICAL EMERGENCY SIMULATION OLYMPICS (literal translation: Gincana de Simulação em Emergências Médicas – G.SEM) with medical and nursing students. The participants felt tremendous satisfaction and acknowledgment of their own flaws that must be improved before they graduate.

However, what does realistic simulation mean? By definition, “it is the technique, not technology, for reproducing or amplifying real experiences by guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive way.” That is, we set up environments of low, medium or high complexities that mimic reality. This way, the participant can emerge in practice without putting the patient at risk.

Through Kolb’s experiential learning cycle, we can understand how learning occurs during simulation.

During the simulation, the participant takes part in concrete experience, being able to identify knowledge gaps in which he can work. At the debriefing, the instructor helps the gamer to contemplate his performance.

When the participant gives meaning to what has happened, he becomes able to abstract and modify his mental model, which will be tested with active experimentation, generating a concrete reaction.

When simulating, not only theoretical knowledge is required, but also practical knowledge, such as how to do and how to act when facing the proposed situation. Doing this kind of exercise, we can better assimilate the content in a playful and effective way. Through error, and the reframing of debriefing, the participant can retain the content with the experience that will come across in the real environment.

The simulation was first used in the aerospace industry, where one mistake could cost many lives. Therefore, the practice of simulation in medicine is indispensable since we work directly with human lives. Train, train and train! This is the emergency mantra! Because by the time you are in the Emergency Department, acting, you already need to know what to do. The time to make mistakes is in the simulation. Moreover, it’s important to keep in mind that an error-free simulation is not a simulation, it is just a theater.

It is possible to divide this learning method into some levels. Through Miller Pyramid, we can analyze the clinical capacity in four levels: know, know-how, show-how, and does. Simulation is increasingly used to teach the first three levels, as it enables the programming of specific environments and conditions to the needs of each participant, promoting a favorable outcome.

Is it like playing pretend? Yes. The simulation can be compared to a pretend play. We can’t reproduce the exact reality, so we set up a fiction contract, where the instructor admits that the simulation is not real but tries to reproduce it as faithfully as possible, and the participants agree to act as they would in real situations.

Therefore, if during a high complexity simulation, a patient with low oxygen saturation needs intubation, for example, the participant must act by observing vital signs on the monitor, asking for drugs, infusing, ventilating, and intubating the doll and not just saying what he would do.

The Chiniara et al Simulation Zone Matrix, commonly used to demonstrate the teaching of simulation in pediatric emergencies, can be extended to emergencies in general. Simulation becomes advantageous over other teaching methods in low-opportunity, high-severity situations, quadrants where emergency is, due to low student exposure and increased concern for patient safety.

With simulation, it is possible to practice technical and non-technical skills, for example, interaction with the multidisciplinary team, leadership, communication and crisis management, which is almost impossible in a classroom.

When we promoted the G.SEM – Emergency Simulation Gymkhana – held by the EMIGs in Brasilia, we had many positive feedbacks from participants, and proved to be effective in exposing to participants points that they needed to improve to raise the level of their clinical practice.

Participating in G.SEM was a very exciting experience for me, as I was able to review important concepts and behaviors in various pathologies, including the approach to cardiopulmonary arrest. It was also a very interesting emotional experience, as we had a short time to make decisions since all patients had life-threatening pathologies that needed fast decisions and actions. In this context, an adrenaline over-discharge and, consequently, tachycardia were generated, generating significant stress that leads us to the real process of approaching a critically ill patient. In addition, one of the most important positive points was the team performance, as the team consisted of 2 medical and one nursing student, so we needed to work together, respect each other and make our communication were efficient and clear. Through the scenarios, it was possible to see how much we improve as a team, and in the final scenario, we were already much more intertwined and acting in a much more organized way compared to the first one. I also emphasize the importance of the evaluator’s feedback at the end of each season, as this allowed us to identify the errors and to correct them in the following simulations and, of course, to future. Finally, it was a unique opportunity that certainly made me grow very intellectually and also allowed me to improve the relationship with the team, which is indispensable in a multidisciplinary context.

says Lucas, a medical student who participated in the simulation scenarios.

There were six simultaneous scenarios, including two pre-hospital scenarios that were assembled by firefighters. G.SEM took place at the Uniceplac Realistic Simulation Center, with the support of the DF Fire Department, and the International Student Association of Emergency Medicine (ISAEM).

Content and Details

4 multidisciplinary teams, each consists of 3 medical students and 1 senior nursing student.
6 simultaneous scenarios. All teams exposed to all scenarios. 1) Diabetic ketoacidosis in children, 2) Intra-hospital care for multiple trauma patients, 3) Acute myocardial infarction, 4) Sepsis, 5) Pre-hospital care for multiple trauma patients (car x bicycle accident), 6) Pre-hospital care for cardiopulmonary arrest and the patient suffering from penetrating trauma.
Each scenario had a total duration of 20 minutes
Each scenario had a checklist of actions and knowledge that was expected from the team in that situation.
In the end of each simulation, the team went through a quick debriefing, for about 8 minutes, with the station instructors.
After all scenarios, there was a debriefing with the residents of emergency medicine, in order to demonstrate to participants the reality of those situations in the emergency department
The winning team was the one with the most checklist points.
The teams were awarded according to their classification.

The simulation itself already causes some anxiety in the participant, since it demonstrates its flaws and puts in check all its theoretical knowledge that should be applied in a practical way. During our emergency simulation game, we noticed an increased level of anxiety and stress from participants. It is believed that the necessity of quick decision making that the emergency requires and the short time of the season were determining factors. However, participants reported that the multidisciplinary team made the simulation environment different, that’s because nursing students do not have realistic simulations as a requirement in their course, and it’s not common the integration between the courses in a simulation scenario.

As a lesson of this event, we conclude that it is extremely important to integrate the programs in the undergraduate years, and we can use the simulations as a convergence point. It’s important to remember that the Emergency Department only works with a cohesive multidisciplinary team. One of the goals of G.SEM was to demonstrate to students this reality and break the barrier between programs by showing that the work in the Emergency Department is teamwork and that always needs team training!

References and Further Reading

Gaba DM. The future vision of simulation in healthcare. Simul healthc 2007; 2(2): 126-35
Cheng A, Duff J, Grant E, Kisson N, Grant VJ, Simulation in paediatrics: An educational revolution. Paediatri Child Health. 2007; 12(6): 465-8
Kolb DA. Experiential learning: Experience as the souce of leatning and development. Englewood Cliffs, NJ: Prentice-Hall; 1984
Zigmont JJ, Kappus LJ, Sudikoff SN. Theoretical foundations of learning through simulation. Semin Perinatol. 2011; 35 (2): 47-51
Paizin Filho A, Scarpelini S. Simulação: Definição: Medicina (ribeirao Preto). 2007; 40(2): 162-6
Miller GE. The assessment of clinical skillscompetence/performance. Acad Med. 1990; 65 (9 Suppl): S63-7
Couto TB. SImulação realistica no ensino de emergências pediátricas na graduação. São Paulo. 2014.

Reviewed by: Bruna Martins, Jule Santos and Henrique Herpich

Cite this article as: Rebeca Rios, Brasil, "The Medical Emergency Simulation Olympics – G.SEM," in International Emergency Medicine Education Project, October 30, 2019, https://iem-student.org/2019/10/30/the-medical-emergency-simulation-olympics-g-sem/, date accessed: October 1, 2023

Why Emergency Medicine?

July 22, 2019September 4, 2019 ~ Rebeca Rios, Brasil ~ Leave a comment

Emergency Medicine in Brazil is still a small baby. In some states, it’s crawling, like here in Brasília. But even so, it already made my eyes shine. In Brasilia, we are moving to graduate the first group of emergency physicians. Several people were struggling for this to happen. And today, I’m going to talk a little about them, and why I decided to do emergency medicine, even though I’m still in the fourth year.

It is quite common for many medical students to have doubts about which residency to choose as if this decision were unique and definitive, and that weighs heavily. During the fellowship of an Airway course, I overheard one student from the last year say, “I have not yet found the specialty that makes my eyes shine.” And that made me think about how lucky I am because I’ve already found it. My intention here is not to make you choose Emergency Medicine as your only option, but to show you that the most serious patient needs the best doctor and the best treatment. It is to show you that the emergency department has to be ready for all the patients who can open through emergency doors, from the child to the elderly. And if you’re like me, who did not settle for a specialty that focused on only one part of the human body, you’re going to fall in love with the Emergency Medicine as well.

I arrived at the emergency department of a hospital in the capital as a confused student, who still had no idea of my rotation. And whoever accepted me was the most fantastic doctor I could meet, no less than the boss of the state’s Emergency Medicine residency program. Well, I did not know that great detail of the time. But watching her play that “red room” was like watching an orchestra. Each bed is an instrument, which she commanded with mastery. I had never seen anything like it. She knew what she was doing. She was young and a strong woman. That by the standards of Brazil, borders the absurd, but there she was. In a public hospital, she was treating each patient as royalty. She maintained a firm posture, taught the students, and knew how to lead the team. It was beautiful to see. I knew that’s where I wanted to be; I knew I wanted to be at least 20% of the doctor she was. Despite the initial fear I had of her, little by little, she became my mentor. It was a big milestone in my life. She showed me what Emergency Medicine is and what is still going to be here in Brazil. And so, I was diving more and more into Emergency Medicine.

She taught me that the emergency department is not the messy garage entrance of a hospital. At least it should not. Here in Brazil, we face the overcrowding of emergency department and lack of resources. So an emergency physician here needs to be more than good, needs to be creative and resilient. However, generally in the country, the doctor who takes care of these patients is the most inexperienced. It’s usually the one who just got out of college and needs to work to earn money. And this needs to be changed. Some doctors saw this inconvenient situation and fought for it to be changed. But every change hurts, and it takes a lot of strength. Gradually, the movement grew. After several battles, Emergency Medicine managed to have an association of its own that finally took on the role of creating it. That’s why students with interest in the area are so valued, after all, it’s us who will keep this legacy.

I also learned from her the importance of being humble and training whenever possible. After all, the best professionals in each area spend more hours training than acting. Perfecting your technique, strengthening your mindset, is a must in medicine. Train, study, and be humble to recognize that you don’t know everything. Being an emergency physician is having to deal with every situation. You don’t have to deliver a diagnosis now, but the patient has to be stabilized until someone else can take over. And to reach this level of saying to death “not today,” you need to study and train!

If you are a Brazilian medical student and interested in the area, here are some tips. Be part of an EMIG (Emergency Medicine Interest Group). Thus, you will have contact with residents and preceptors of the area. Engage in the different opportunities within the Emergency Medicine field that arise, such as events and courses. Look for the associations in Brazil, and also outside the country. Accompany shifts with an emergency physician, so you can feel a little of the specialty and understand what your day to day life will be like. After graduating from college, you must take the test for the Emergency Medicine Residency. The residency lasts three years and already exists in several Brazilian states. After three years of residency, you must take the specialty exam (title test), to become an Emergency Medicine specialist. And if you can find your Emergency Medicine mentor in college, know that your path will become clearer, know that you will enter a world where you can hardly get out, because that’s the Emergency Medicine. A world far beyond only the doors of the emergency department.

Dedicated to Jule Santos.