Macro-lensing the Emergency Department

Macro-lensing the Emergency Department

How do you remember the emergency department (ED) that trained you? Could it be that you have learned a lot more than just medicine there? Between worrying about the delayed laboratory report and explaining the need to rule out a myocardial injury to a visitor of a patient with peptic ulcer disease, you might have picked up other attributes. Subtle traits that have nudged your personality. Remembering the ED where I did my internship sparks nostalgia and makes me want to speed up my typing. As if I need to attend to something else right after this. Hopefully, I’ll give you a glimpse of what putting on different lenses can show even when we look at the same object.

Peeling yellow paint, some old cracks in the wall, and an acute sense of urgency lingering in the air are what I remember of the department. Patan Academy of Health Sciences has an ED where confused students scratching their heads to the witty professors’ question takes you to your own golden days. A subtle grin on the wise face of a grey-haired professor eagerly waiting for the next wrong answer makes you want to reach out to your old mentor. A know it all student on the verge of blurting out the answer physically holding himself behind makes you wonder what that one classmate of yours is doing these days. It is a place where teaching, helping people, running against time and having fun while at it, blends into an experience of a lifetime. Stories of eased pain, dodged suffering and narrow escapes from grave aliments enrich the history of the department.

One fine evening in the department as an intern I found myself seated in the doctor’s station, a rare but insightful experience. I found myself pondering about the lessons I can take from this part of the hospital: not just medical knowledge but lessons I can share with people from different facets of life. Below I list the common situations or sayings used in a typical ED and try to translate it for use in day to day life.

Think horses before zebras but watch out for zebras that can fly

A patient with mild fever, chest pain, and some respiratory distress probably has some sort of URTI. But the very fact that he/she landed up in the ED makes the doctor order an ECG because of the chest pain. The doctor will, of course, be leaning towards a more common diagnosis. Ruling out a diagnosis with grave prognosis, however, will be among the top priorities. 

searching zebra

This can translate into studying common exam materials while also being aware of the zebras. Zebras show up rarely, but when they do, they tend to be stubborn. Be aware of the topics that don’t usually show up in your exam but impact the outcome when they do. We can also borrow this idea while thinking about anything in general. We tend to assume the worst, but when your date is late to dinner, it probably is just the busy traffic.

Communication is the key

A medical officer reads the patient’s history to the professor using as few words as possible, pertinent negatives and a precise format. The information and condition of the patient are conveyed very accurately. When reporting history, we aim for effective communication at its best. 

communication

I wonder how many day-to-day problems can be solved if only we communicated that efficiently outside of history taking and reporting. Using clear words, very few fillers and addressing what we don’t mean beforehand can help in getting the intended message across.

Prioritizing

The most critical patients that visit Patan Hospital head for the ED. Recognizing them and treating the ones who need immediate attention is the second nature of a good emergency physician. Likewise, being able to focus on the most critical aspects of one’s life can be an attribute worth borrowing from the department. 

prioritising

How many times do we complain that we just do not have enough time to do things that are important to us? It’s mostly about deciding what comes first.

Resource allocation

This sort of ties into the previous one. Most experienced physician attends the most critical patient. More nurses are allocated to and the best USG machine is used in the red triage area. Time, money, physical or mental effort all are resources we use to get tasks done. Sometimes success differs from failure, not in how much effort is put but where it is used. Determining which task is most resource-intensive or most productive can be a worthwhile idea to learn from the ED.

resource allocation

Did you check your tools?

Monitor connected to a gradually stabilizing patient beeps rapidly, indicating a sudden collapse. As you run towards the patient with your ACLS neurons firing at a rate more rapid than the patient’s declining pulse, do take a look if the pulse oximeter is connected correctly. Translated in the world where things go south more frequently than not, decide if it is a perceived problem or a real one. How many times have you let yourself go into flight or fight mode only to realize that the threat wasn’t even there?

Give thiamine before glucose

Hypoglycemia kills. Glucose save lives. Even then, giving thiamine before glucose is the norm in most EDs. The biochemistry behind is simple; thiamine is a cofactor used by many enzymes in glucose metabolism and depleting more thiamine can cause Wernicke Korsakoff disease. Look at it with the lens of a student who needs to start preparing for an exam. Determine your thiamine (proper sleep, good food, exercise, enough water and probably mindfulness). Only then glucose supplementation (studying) will yield results.

The loudest screamer isn’t always suffering the most

“How do you triage when there are more people than you can attend to?” asked a professor. The answer was funny but made a point firmly. “You should ask the most critical patients to come forward. Then you attend those that are left behind!”. The idea being; sickest of them all won’t even be able to advocate for themselves. Similarly, we can be tactful when overwhelmed by problems. Try to come up with ideas to segregate the screamers (problems that seem to be the biggest) from the sickest (actual problems).

triage

Know your limits and ask for help

We manage acute exacerbation of COPD in the ED. Not all patients that feel relieved are discharged from there. Some patients require medical consultation and transfer. This, in no way, means that the ER physicians are incompetent in managing the disease throughout. Rather it is the evidence of understanding the job description and trust in the system as a whole. Asking for help when need be is critical to our wellbeing. Being able to ask for help shows courage and humility above all.

knowing limits
Cite this article as: Sajan Acharya, "Macro-lensing the Emergency Department," in International Emergency Medicine Education Project, October 28, 2019, https://iem-student.org/2019/10/28/macro-lensing-the-emergency-department/, date accessed: November 20, 2019

A Medical Student’s Encounter with Disaster

a medical student's encounter with disaster

25th April 2015

A 7.8 magnitude earthquake struck Nepal on 25th April 2015, affecting 35 of the 77 districts of Nepal and causing a death toll of over 8000 lives with 22,309 people reported as injured and an estimated 2.8 million displaced. The following article is based on the first-hand experience of a then fourth-year medical student from Patan Academy of Health Sciences, a tertiary care center in Lalitpur District, one of the worst-hit districts in Nepal.

Rescue work following 7.8 Richter scale earthquake. Image by Omar Havana via https://www.theatlantic.com/photo/2015/04/nepal-after-the-earthquake/391481/
Rescue work following 7.8 Richter scale earthquake. Image by Omar Havana via https://www.theatlantic.com/photo/2015/04/nepal-after-the-earthquake/391481/

Reflection

25th April 2015, started off as a casual Saturday morning. At the boy’s hostel, everyone was preparing for the inter-medical college football tournament which was to start off that day, until the first jolt changed plans for the whole day and many more days to come. Our first response was to rush out of the hostel and make sure our family members and friends were okay. Just as all of us were frantically, unsuccessfully so, trying to contact our families, a friend of mine came running and informed that all medical students were to go to the hospital with their aprons. We had not even considered going to the hospital until my friend arrived; maybe because none of us had faced such a situation before or because we were yet to come back to our right state of mind.

Students ready to receive disaster victims. Image by Online Khabar via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Students ready to receive disaster victims. Image by Online Khabar via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/

As we reached the hospital, it was already flooded with injured patients from the disaster. Everyone started doing what they could. Some started giving analgesics to people who were agonized by the pain, some started talking and trying to calm down people who were on the verge of hyperventilation, some took gauge pieces and pressed it against the bleed on people’s head and some helped in patient transportation. There were a lot of people doing a lot of things, but neither was I in very observant state of mine nor could I recall enough now to mention the minute details. One thing I remember with absolute clarity is that me and my friends (as I found out in the after talks) forgot that we were trying to contact our families when we were called.

Students providing wound care. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Students providing wound care. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Medical students providing Tetanus Toxoid injection to victims. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Medical students providing Tetanus Toxoid injection to victims. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/

A lady was lying on the floor, covered with mud, she wasn’t moving at all. My friend and I suspected she was seriously injured but didn’t see any obvious wound from where we were standing. We went near and tried to feel the carotid pulse. Never in my life had I even remotely imagined that one day I will confuse whether or not the carotid pulse is present. But there I was. I didn’t feel the pulse, but I was reluctant to admit that she didn’t have one; so we decided to ask one of our teachers. We did and got the obvious answer. Now we were to put the black tag on her and take her to the black area. She was the first to be taken to the black triage. Before putting her down from the stretcher, we took the pulse again. It was one of my first encounters with death declaration.

I came out of the front door and was among a lot of injured patients; nerve wrecked students and doctors trying to help people in the best possible way. It was then that most of us remembered that we hadn’t contacted out families yet; maybe sadness had taken over our survival instinct or maybe we were learning to keep our professional duties up ahead. This continued for the day and the next day was nearly the same; only a little more organized. Basically, the name of the game for the couple of days that followed was help in all that you are capable of.

Apart from being the most traumatizing experience of our life until now, this earthquake also taught us some lessons and profoundly so. I knew that survival instinct takes over everything at first when you perceive a threat to our life; however, once you are just out of the instinct and see before you, the circumstance that you are trained to deal with, you prioritize things and work in the line of your training.

Survival instinct takes over everything at first when you perceive a threat to our life...

Students raising awareness to prevent possible outbreaks. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Students raising awareness to prevent possible outbreaks. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/

a need for disaster curriculum to be rigorously taught to every medical student.

One thing that I realized while trying to help the casualties that will help me every time I sit to study is: no matter how much you memorize stuff until you really understand something well, you won’t be able to use the knowledge when it is most needed. The disaster drill that we performed a few months before the disaster helped us make sense of triage, proper transportation and of what was happening. I realized the importance of training and keeping myself updated on skills that we need at times when we are less likely to think rationally. Also, I felt a need for disaster curriculum to be rigorously taught to every medical student. Medical students formed an important workforce during this disaster. Having occurred on the weekend, medical students were the most readily and adequately available resource. However, with limited knowledge and skill, medical students left to work unsupervised are prone to cause harm to themselves and patients; hence proper training and work delegation are required so that they can become a better-skilled workforce.

This was yet another example for me to ponder and reinforce upon myself that not everything will go on as planned; hence, I need to keep myself updated and work on my improvising skills. This event as devastating as it was also made me feel proud of what I am training to become and instilled in me more passion towards my profession.

Further Reading

  • World Health Organization, Regional Office for South-East Asia. Nepal earthquake 2015: an insight into risks: a vision for resilience. New Delhi, India: World Health Organization, SEARO; 2016. Available from: https://apps.who.int/iris/handle/10665/255623
  • Sheppard PS, Landry MD. Lessons from the 2015 earthquake (s) in Nepal: implication for rehabilitation. Disability and Rehabilitation. 2016 Apr 23;38(9):910-3.
  • Nepal earthquake of 2015 – link
Cite this article as: Sajan Acharya, "A Medical Student’s Encounter with Disaster," in International Emergency Medicine Education Project, August 5, 2019, https://iem-student.org/2019/08/05/a-medical-students-encounter-with-disaster/, date accessed: November 20, 2019