Artificial Intelligence in Emergency Medicine

Artificial Intelligence in Emergency Medicine

Progressing through my medical training, I have witnessed the progression of paper-based medical records, all the way to different forms of electronic medical records, let alone intelligence infused medical records. It is safe to say that health informatics has evaded the way we practice medicine in all its disciplines and all across health care systems.

Artificial intelligence (AI) describes the capability of a machine to learn human cognitive functions and learning. AI applications in healthcare have brought in a paradigm shift powered by data mapping, data aggregation, analytics, and algorithmic techniques that can simulate our decision making as clinicians.

Furthermore, it can predict and suggest clinical pathways, data-based prognosis, and outcomes. AI has already been incorporated in major disciplines such as genetics, diagnostic imaging, neurology, and cancer. Yet, its path into emergency medicine (EM) is still paving its way for vast integration.

EM is a unique field of medicine, as its rich with varying paces of practice, the criticality of conditions, acuity of diagnostic decisions, and a highly stressful environment. It puts their providers consistently on a stretched active clinical decision making and interventions. Hence it is worth to foresee how AI can help enhance and complement the emergency department (ED) functions and add significant benefits to the EM physician’s daily tasks.

One of the main applications of AI is triage. Efficient triage can significantly enhance patients flow, lengths of stay, resource allocations, and risk stratifications. A study published by the American College of Emergency Physicians evaluated electronic triage (E-Triage) systems based on machine learning as opposed to the Emergency Severity Index (ESI). They found out that E-Triage can more accurately classify ESI level 3 patients and highlight opportunities to use predictive analytics to support triage and decision making. (1) A lot more studies established the use of different forms of electronic triage algorithms in improving patient distribution by clinical outcomes, and improved acuity predictions.

Another application of AI was significantly noted in diagnostic imaging departments. Offering remote clinics with restricted resources access to tools for reading imaging needed for active clinical interventions. Feeding into these AI systems is a wealth of comparative studies to predict and describe abnormal studies, and enhance its predictions. Let alone how efficient it would be in a fast-paced ED, getting approximate quick predictions that can be overseen by supervising radiologists.

Additionally, AI has been used in monitoring patient’s vitals, and predicting deteriorating clinical course, requiring early resource utilization and critical decision making in a timely manner. One significant example where AI and machine learning is heavily invested in is Sepsis, and mortality prediction scores, aiding at early detection, guiding clinical course and interventions by using simple data trajectories and analysis.

Another utilization of AI in an ED setting is predictions of Acute Coronary Syndromes, predicting the urgent need for revascularization from reading 12 Lead electrocardiographs (ECGs). A Study done in Keio University Hospital developed an AI model enabled to detect patients requiring urgent revascularization within 48 hours from only 12 leads electrocardiogram. (2) This significantly helps fast pace a lot of the grey cases we see and monitor in our ED’s, especially if validated with risk stratification scores we are already utilizing.

It is worth saying that there are still some barriers to the vast adoption of AI integration to EDs as it’s still a new evolving technology, with restrictive access, ethical discussions, safety, and needed regulations.

I personally have always had a utopian vision of how far health informatics can take our clinical practice, specifically EM. Injecting machine learning and AI into healthcare curates the perfect system that could decrease lengths of stay, intelligently and safely triage our patients, predict clinical course, suggest evidence-based treatment pathways, reduce medication errors and improve clinical outcomes. A more utopian version of my vision is how such a system can help remote and restricted regions requiring extensive resources to aid the reach of its care to underserved populations. It goes without saying that most of these do exist in one way or another, some are still being enhanced, and some are under the works for the next stage. We would foresee its progress nonetheless and slow infusion into our daily practice.

References and Further Reading

  1. Levin S, Toerper M, Hamrock E, et al. Machine-Learning-Based Electronic Triage More Accurately Differentiates Patients With Respect to Clinical Outcomes Compared With the Emergency Severity Index. Ann Emerg Med. 2018;71(5):565‐574.e2. doi:10.1016/j.annemergmed.2017.08.005
  2. Goto S, Kimura M, Katsumata Y, et al. Artificial intelligence to predict needs for urgent revascularization from 12-leads electrocardiography in emergency patients. PLoS One. 2019;14(1):e0210103. Published 2019 Jan 9. doi:10.1371/journal.pone.0210103
  3. McParland, Aidan. (2019). Applications of artificial intelligence in emergency medicine. University of Toronto medical journal. 96.
  4. Liu, Janny & Chen, Yongchun & Lan, Li & Lin, Boli & Chen, Weijian & Wang, Meihao & Li, Rui & Zhao, Bing & Hu, Zilong & Duan, Yuxia. (2018). Prediction of rupture risk in anterior communicating artery aneurysms with a feed-forward artificial neural network. European Radiology. 28. 10.1007/s00330-017-5300-3.
  5. Berlyand, Yosef & Raja, Ali & Dorner, Stephen & Prabhakar, Anand & Sonis, Jonathan & Gottumukkala, Ravi & Succi, Marc & Yun, Brian. (2018). How artificial intelligence could transform emergency department operations. The American Journal of Emergency Medicine. 36. 10.1016/j.ajem.2018.01.017.
  6. LIU, N., ZHANG, Z., WAH HO, A., HOCK ONG, M.. Artificial intelligence in emergency medicine. Journal of Emergency and Critical Care Medicine, North America, 2, oct. 2018. Available at: <http://jeccm.amegroups.com/article/view/4700&gt;. Date accessed: 22 May. 2020.
  7. Stewart J, Sprivulis P, Dwivedi G. Artificial intelligence and machine learning in emergency medicine. Emerg Med Australas. 2018;30(6):870‐874. doi:10.1111/1742-6723.13145
  8. Lee S, Mohr NM, Street WN, Nadkarni P. Machine Learning in Relation to Emergency Medicine Clinical and Operational Scenarios: An Overview. West J Emerg Med. 2019;20(2):219‐227. doi:10.5811/westjem.2019.1.41244

Management of Status Epilepticus in ER

References and Further Reading

  1. Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48–61. doi:10.5698/1535-7597-16.1.48
  2. Joshua G. Kornegay.  Chapter 171. Seizures. In: Tintinalli JE, ed. Tintinalli’s Emergency Medicine A Comprehensive Study Guide. 8th Edition. McGraw-Hill Education; 2016: 1176-1178
  3. Rabin E, Jagoda AS. Chapter 92. Seizures. In: Walls RM, Hockberger RS, Gausche-Hill  M, eds. Rosen’s Emergency Medicine Concepts and Clinical Practice. 9th Edition. Philadelphia: Elsevier Saunders; 2018: 1256-1264
  4. Sharma AN, Hoffman RJ. Toxin-related seizures. Emerg Med Clin North Am. 2011;29(1):125–139. doi:10.1016/j.emc.2010.08.011

 

Rapid Ultrasound for Shock and Hypotension (RUSH) Protocol US Imaging – Illustrations

Patients with hypotension or shock have high mortality rates, and traditional physical exam techniques can be misleading. Diagnosis and initial care must be accurate and prompt to optimize patient care. Ultrasound is ideal for evaluating critically ill patients in shock, and ACEP guidelines now delineate a new category of ultrasound (US)– “resuscitative.” Bedside US allows for direct visualization of pathology and differentiation of shock states (1). The RUSH is one of the most commonly used protocols for this purpose.

The RUSH exam involves a 3-part bedside physiologic assessment simplified as “the pump,” “the tank,” and “the pipes” (2).

Pump

Tank

Rush Tank

Pipes

References and Further Reading

  1. By Organ System or Specialty Archives | Page 84 of 123 | ALiEM. https://www.aliem.com/category/emergency-medicine-clinical/system/page/84/
  2. Seif D1, Perera PMailhot TRiley DMandavia D. “Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol” Crit Care Res Pract. 2012;2012:503254.
  3. https://iem-student.org/2020/02/14/lower-extremity-deep-venous-us-imaging-illustrations/
  4. https://iem-student.org/rush/
  5. https://iem-student.org/efast/

RUSH Course for Medical Students

Dear students,

We are pleased to open our third course for you; Rapid Ultrasound in Shock and Hypotension (RUSH).

As a part of our social responsibility initiative, iem-course.org will continue to provide free open online courses related to emergency medicine. We hope our courses help you to continue your education during these difficult times.

Please send us your feedback or requests about courses.

We are here to help you.

Best regards.

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

iEM Course is a social responsibility initiative of iEM Education Project

Hypotension is a high-risk sign which is associated with increased morbidity and mortality rate. The differential diagnosis for hypotension is broad and the treatment depends on the underlying etiology. In most cases of hypotension, patients present with limited history and physical examination may be inaccurate making the management of the condition a great challenge for emergency physicians.

The use of POCUS in undifferentiated hypotension has been shown to help correctly and rapidly identify the etiology and therefore initiate the appropriate management. Since 2001, there are many protocols published describing a systematic approach to the use of POCUS in undifferentiated hypotension. 

In this course, we will focus on the Rapid Ultrasound in Shock and Hypotension (RUSH) protocol.

This course aims to provide the necessary information on ultrasonography, its use in a hypotensive patient, and to prepare you for a RUSH practice session.

The course content is prepared and curated from iEM Education chapters, iEM image and video archives, and various FOAMed resources.

At the end of this course, you will be able to;

  • Describe the basics of ultrasound (terminology, knobology, image acquisition, artifacts, etc.)
  • Describe indications of RUSH protocol
  • Describe patient and machine preparations
  • Describe ultrasound examination views
  • Recognize normal anatomical structures
  • Recognize abnormal findings
  • Feel confident to take a practical session for RUSH protocol

Who can get benefit from this course?

  • Junior and senior medical students (course specifically designed for these groups)
  • Interns/Junior emergency medicine residents/registrars

Other Free Online Courses

COVID-19 Pandemic: Rural Preparations

Hoping for the best while preparing for the worst has been the theme of all medical institutes around the world, especially in counties that are yet to be hit by the dreaded tsunami of overwhelming COVID-19 cases. We have 191 positive cases 153 of which are in the hospital being treated and 33 have recovered. Fortunately, there have been no mortalities till date. [1] The current statistic may not look dreadful given the large numbers that we are exposed to daily these days. Before the cases reached 100, most Nepalese wondered, sometimes boastfully, why the cases are not spreading like wildfire. People went on record, crediting our culture of greeting with Namaste instead of a handshake, eating with hand instead of a spoon – which necessitates handwashing at least 4 times a day, the hygiene hypothesis, the fact that our country has only one international airport, and the universal coverage of BCG vaccination in Nepal. There are too many biases and heuristics at play here, but somewhere inside, I want to believe that at least some of them are true.

The Sukraraj Infectious and Tropical Disease Hospital (STIDH) in Teku, Kathmandu has been designated by the Government of Nepal (GoN) as the primary hospital along with Patan Hospital and the Armed Police Forces Hospital in the Kathmandu Valley. The Ministry of Health and Population (MoHP) has requested the 25 hubs and satellite hospital networks across the country – designated for managing mass casualty events – to be ready with infection prevention and control measures, and critical care beds where available. The Government is allocating spaces for quarantine purposes throughout the country and some sites have already been populated by migrants who recently returned from India. [2]

We have seen healthcare systems that are multi-fold advanced than that of our crumble when faced head-on with this illness. After working in the healthcare system of my country for 2 years, I am convinced that it will take a miracle for us to deal with this pandemic.

I have seen what preparations we are striving towards and what portion of it has been achieved. We are struggling to reach our preparation goals. That is not nearly as frustrating as the fact that many countries whose baseline was our goal have failed terribly. Today keeping the theme of workarounds rather than complaints about things outside of our circle of influence, I am presenting to you some preparatory works being done at Beltar PHC, a peripheral center located in one of the most affected districts, Udayapur, of Nepal. [1]

Credit, where credit is due: We have done 17878 RT-PCR, and 58546 RDT to find 191 positive cases till May 12, 2020. [1] We came up with a protocol and are also gradually updating it to meet the contemporary need. Funny word that contemporary is, especially now that no information gets to age before a new one replaces it. Speaking of temporary, a very recurring theme these days, there are temporary shelters made at every ward level in Beltar. People returning from abroad are kept in isolation for 14 days there. We run a temporary fever clinic at the PHC and refer suspected cases to higher centers for the COVID-19 test. We don’t have rapid diagnostic kits at the PHC yet. Our PHC with 26 staff has received 13 disposable PPEs that we have had the privilege of reusing. There is an Interim reporting form for suspected cases of COVID-19 (based on WHO Minimum Data Set Report Form) which can be downloaded and filled from the MOHP website. [3]

Available PPE at PHC level. Photo credit: Mr. Govinda Khadka
Fever clinic at Beltar PHC. Photo credit: Mr. Govinda Khadka
Quarantine setup at a ward in Chaudandigadi Municipality. Photo credit: Mr. Govinda Khadka

Lockdown was announced in Nepal on March 24, 2020. Excerpt from WHO Director-General’s opening remarks at the media briefing [4] on COVID-19, 25 March 2020 says this: “Asking people to stay at home and shutting down population movement is buying time and reducing the pressure on health systems. But on their own, these measures will not extinguish epidemics. The point of these actions is to enable the more precise and targeted measures that are needed to stop transmission and save lives. We call on all countries who have introduced so-called “lockdown” measures to use this time to attack the virus. You have created a second window of opportunity. The question is, how will you use it? There are six key actions that we recommend:

  1. Expand, train and deploy your health care and public health workforce;
  2. Implement a system to find every suspected case at the community level;
  3. Ramp up the production, capacity, and availability of testing;
  4. Identify, adapt and equip facilities you will use to treat and isolate patients;
  5. Develop a clear plan and process to quarantine contacts;
  6. Refocus the whole of government on suppressing and controlling COVID-19.”

In Nepal, there has been documentation of protocol for various aspects of the pandemic; PPE for each level of care has been decided, need to scale up the testing recognized, and even the support for Solidarity trials discussed. The protocol designed to tackle COVID-19 recognizes that different strategies for the rural and urban areas are necessary. The response to outbreaks in remote and rural areas where containment may be easier though assistance more difficult vs. outbreak in urban locations where containment is likely more difficult, but treatment and assistance likely to be easier.

The mist of immediate threat followed by the rubble of destruction it causes keeps us blind to the problems lurking in the background. As big and dangerous, if not bigger. Especially when you know nothing even vaguely similar to CARES-Act is being prepared for dampening the direct and indirect economic impact of the epidemic. Add to the fact that the American government’s CARES-Act already faces various criticism—that gives birth to anxiety for even the most seasoned economists. That is looking at just one domain of the post epidemic future. Healthcare might be crippled, social structure tossed over, politics somersaulted and people stripped off their faith. That may give rise to a jigsaw too complicated to attempt. It is high time we start thinking about solving some of those puzzles now.

References

1. Corona Info. Ministry of Health and Population. Accessed May 12, 2020. https://covid19.mohp.gov.np/#/
2. COVID-19 Nepal preparedness and response plan (NPRP) draft. April 9. Accessed May 10, 2020. https://www.who.int/docs/default-source/nepal-documents/novel-coronavirus/covid-19-nepal-preparedness-and-response-plan-(nprp)-draft-april-9.pdf?sfvrsn=808a970a_2
3. Reporting form for COVID. Accessed May 12, 2020. http://edcd.gov.np/resources/download/reporting-form-for-covid
4. Situation reports on COVID-19 outbreak, 25 March 2020. WHO | Regional Office for Africa. Accessed May 12, 2020. https://www.afro.who.int/publications/situation-reports-covid-19-outbreak-25-march-2020

FOAMed Resources for ECG Interpretation

You often hear that learning how to read an electrocardiogram (ECG or EKG) is like learning a new language. Interpreting ECGs is an essential skill for emergency physicians who frequently treat patients with acute cardiac conditions. As a medical student, it is crucial to practice as much as possible because it takes time to develop this skill and become comfortable with it. The International Federation of Emergency Medicine (IFEM) lists basic electrocardiographic analysis as an essential component of undergraduate education for medical students including recognition of acute myocardial infarction and life-threatening arrhythmias.

As I went through my emergency medicine rotation during my clerkship, I found that this skill took a lot of practice to learn. Along the way, I discovered some excellent resources that helped me get better at it. I wanted to share these Free Open Access to Medical Education (FOAMed) resources to help other medical students looking to strengthen their ECG skills and apply their knowledge on a shift in the emergency department.

Analysis and Interpretation of the Electrocardiogram from Queen’s University

This self-directed online module was where I started. Reading ECGs requires a systematic approach and I really liked how this module presents a step-by-step breakdown. It includes clearly labeled overview diagrams of the different intervals and segments as well as expected values for a normal ECG. The “Approach to the ECG” section is very helpful with examples provided to help you master each step. Check out the ECG index section for examples of different ECG rhythms including some details about each arrhythmia, ECG criteria and associated clinical presentations.

Practical Clinical Skills

This is a very comprehensive website that is useful for anyone from beginners to more advanced medical learners. The ECG basics was a great introduction to the different parts of tracing and how each part relates to cardiac physiology. There’s a concise reference guide of arrhythmias for quick review. What I liked most about this resource was the opportunity to check your knowledge with the ECG Quiz. There’s also an excellent ECG Tutor section, which allows you to customize the quiz and practice the types of rhythms you are having most difficulty with. This website also features ECG content in Spanish!

Life in the FAST Lane

Life in the Fast Lane is a great all-around resource for students interested in emergency medicine. Even beyond ECGs, they have excellent clinical cases for practicing chest x-ray and ultrasound interpretation as well as other common clinical presentations (see the Top 100 tab). They also have a toxicology section that features illustrated flashcards. Check it out!

For ECGs, I found Life in the Fast Lane to be a very comprehensive resource. From a review of the basics to a comprehensive library of examples by an arrhythmia – this FOAMed resource has a lot to offer anyone looking to brush up on their ECG skills. I used this resource later in my studies when I already had some basic knowledge. I found the Top 100 ECG Clinical Cases section very useful. This section allows you to practice ECG interpretation, check your answers, and many are contextualized with a clinical scenario. The clinical outcome section of these ECG cases was great in helping to link an arrhythmia to clinical management. It was a great review of what you are going to do for the patient once you interpret their ECG. There were also often additional commentary and resources provided for more in-depth reading about the arrhythmia if desired. I found it very useful in my EM rotation.

Free ECG Simulator

This is a well-designed, sleek resource that I discovered only after my EM rotation. Some of my colleagues have found it very helpful and highly recommend it. The “learn” mode is great for review, and you can check your knowledge afterward with the game mode. Pro tip: you can change the settings from ‘dynamic’ to ‘static’ mode when you are still learning. The ‘dynamic’ mode can be a little stressful, but it makes for a great added challenge when you are more comfortable with ECG interpretation!

These are some of the resources I found useful when learning how to read ECGs. Everyone has their own learning style. Hopefully, one of these resources works well for you too. I am sure there are many other excellent resources out there. If you have enjoyed any other great FOAMed resources on ECG interpretation, please share them with us in the comments.

eFAST Course for Medical Students

Dear students,

We are pleased to open our second course for you; Extended Focused Assessment with Sonography for Trauma (eFAST).

As a part of our social responsibility initiative, iem-course.org will continue to provide free open online courses related to emergency medicine. We hope our courses help you to continue your education during these difficult times.

Please send us your feedback or requests about courses.

We are here to help you.

Best regards.

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

iEM Course is a social responsibility initiative of iEM Education Project

Extended Focused Assessment With Sonography In Trauma (eFAST) is one of the most commonly used emergency ultrasound or Point-Of-Care Ultrasound protocols. It is a protocol that we use in trauma patients. However, the eFAST examination can also be a part of another protocol, such as RUSH protocol.

The early diagnosis of a bleeding trauma patient is essential for better patient care. Unfortunately, it is proven that our physical exam findings are not perfect in every case. Therefore, using a bedside tool in addition to the physical examination can improve patient management.

As a 21st-century medical student/young physician, you must learn how to use this tool to provide more comprehensive and accurate care to your patients.

This course aims to provide the necessary information on ultrasonography, its use in a multiply injured trauma patient, and to prepare you for an eFAST practice session.

iEM Monthly – May 2020

Welcome to the iEM Education Project Monthly Newsletter. We will share the achievements, information about top posts, chapters, activities and future plans of the project.

New Authors

Recent News

Recent Posts

Top Countries

Top Reads

New Blog Authors

Keerthi Gondy

Keerthi Gondy

I'm a fourth-year medical student at the University of Michigan applying to Emergency Medicine. I am passionate about medical education, especially end-of-life care in the ED, and resilience/wellness. Outside of medical school, I am an avid triathlete, nature-lover, and an advocate on sustainability and climate change.

Joey Ciano

Joey Ciano

My name is Joey Ciano, I am a born and raised New Yorker currently working and living in Queens, NY. I am finishing my first year of International Emergency Medicine Fellowship in the Northwell Health system. My main interest in International EM is promoting EM systems building. This focuses on promoting the development of the specialty of EM in countries that have not yet recognized EM as a field or are in the early stages of this process. My main interest is working on the post-graduate educational infrastructure. I have done EM educational work in Uganda and continue to work in West Bengal, India to help educate practitioners in EM to help specialty development. COVID-19 has changed the way we teach locally and internationally, so I thought this project would be a great opportunity to reach international students in EM during these challenging times.

Amita Sudhir

Amita Sudhir

Amita Sudhir, MD is the Emergency Medicine Residency Program Director at the University of Virginia, USA. She was also the third year emergency medicine clerkship director for 8 years. She has authored several textbook chapters, an ACEP clinical policy (on NTSEMI ACS), lectured both nationally and internationally and created multiple curricula and educational modules. She is also on the Scientific Advisory Council (First Aid subcommittee) for the American Red Cross.

David Wiercigroch

David Wiercigroch

David Wiercigroch is a senior medical student at the University of Toronto in Canada. His interests are in health policy, international EM and global health. He enjoys collaborating with medical students around the world to advance EM through free-open access to medical education (FOAMed) and student leadership as part of the International Student Association of Emergency Medicine (ISAEM). He is an avid writer, aspiring chef and camping enthusiast.

News

  • We announced iEM/Lecturio Emergency Medicine Core Content Course on May 1, 2020. We thank our contributors who provided amazing chapters and our course partner Lectruio for making emergency medicine lectures freely available. We also thank IFEM for sharing this social responsibility initiative with their followers.

Some highlights from social media

  • Our next course is Extended Focused Assessment with Sonography in Trauma. This course is prepared by using chapters and videos/images in iEM Education Project. We are so grateful for your contribution to iEM. The course includes orientation > entry formative quiz > US basics (physics, knobology, artifacts + formative quiz) > eFAST protocol (application, views, anatomical structures, etc. + formative quiz) > Normal and abnormal images > exit formative quiz... and finally summative assessment for course completion certification. It will be ready for students on May 18, 2020.

Blog Posts of April

Top Countries

These countries viewed iEM content the most in April 2020. 

Top Three Reads of March 2020

How to read chest x-raysby Ozlem Koksal

336.3 - normal PA chest x-ray AIRWAY STRUCTURES

How to read pelvic x-rays, by Sara Nikolić and Gregor Prosen

628.12 - femur neck fx

How to Read C-Spine X-Ray, by Dejvid Ahmetović and Gregor Prosen

626.4 - Figure 4 - c-spine lateral x-ray - alignement

Trauma and Public Health

Trauma is a leading cause of preventable morbidity and mortality. Each reader will have a different context regarding what causes traumatic injuries locally, from different types of motor vehicles, various weapons or security concerns, unique household and workplace injuries, among others. There are several generalizable public health level considerations that we can all benefit from.

Traumatic injuries occur “at the organic level, resulting from acute exposure to energy (mechanical, thermal, electrical, etc.) in amounts that exceed the threshold of physiologic tolerance” [1]. Historically, humans have viewed traumatic injuries as “accidents”; it’s even what we often call them. This view has made trauma a neglected subset of public health focus and funding, though more recently, there has been an increased recognition from public health entities that traumatic injuries are often preventable and treatable [1].

Every year, more than 5 million people die from injury, which is a mortality rate of more than 1.5 times that of HIV, tuberculosis, and malaria combined [2]. Beyond deaths, nearly one billion people sustain injuries that require health care each year from around the globe [3]. Notably, for every death from injury, there are 20–50 nonfatal injuries that result in some disability [4]. Further, the morbidity from trauma is often long-lasting and impacts the quality of life, productivity, and the financial security of individuals, families, and entire communities [5].

Of the 5 million annual trauma deaths, an estimated 1.3 million people are killed in road traffic crashes each year, and projections indicate these will likely increase by another 65% over the coming two decades [6]. Common throughout the world, pedestrians and two-wheel vehicle users are at greater risk of injury and death than vehicle occupants [7]. As vehicles like cars and trucks are owned and operated by more individuals around the world, such projections make logical sense.

After a traumatic injury occurs, the aim is the progress of a patient through a continuum of trauma care, as represented in the below figure:

Yet, such systems and continuums of care lack around the world. In one 2017 review of trauma systems from around the globe, Dijkink et al. found only 9 of 23 high incomes countries had well-defined and documented national trauma systems. Very few low and middle income (LMIC) countries had a formal trauma system or trauma registry [9]. Of note, most injuries occur in low-income and middle-income countries, and most trauma care research comes from high-income countries [10].

In their review of LMICs developing trauma care system, Reynolds et al. identified several common strengths, including training, prehospital systems, and organization, but also found weaknesses in LMICs’ lack of focus on performing quality-improvement, costing, rehabilitation, and policy around trauma care [10].

Each context, even within countries, has a unique set of advantages and barriers, ranging from well-developed to non-existent: EMS systems, in-hospital diagnosis and treatment, and rehabilitation care. Estimates derived from the Global Burden of Disease data suggest that nearly 2 million lives could be saved every year if case fatality rates among seriously injured persons in low- and middle-income countries were similar to those achieved in high-income countries [10,11].

Moving towards such improvements is a monumental task that requires stepwise action. One tool that can help is something I have written about previously: the World Health Organization’s Basic Emergency Care course. The multi-day course curriculum has been developed to teach a high-yield approach to emergent health problems systematically. The course focuses on triage interventions for treating trauma, breathing, shock, and altered mental status. This framework for knowledge and skills can help to improve the acute care of a traumatic injury in almost any location.

I strongly encourage every reader to take a few minutes to consider what are the local causes of traumatic injury, to think about how your current trauma care system is both doing well and where it needs help. I would ask that you think about what ways you could focus on this crucial public health issue and find ways either through education, advocacy, or otherwise, to improve the health of your local and global community.

References

  1. Krug et al. The global burden of injuries. Am J Public Health. 2000 Apr;90(4):523-6. DOI: 10.2105/ajph.90.4.523.
  2. World Health Organization, 2014. Injuries and Violence: The Facts. Geneva: WHO
  3. Haagsma et al. 2016. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj. Prev. 22(1): 3–18
  4. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. 2015. Essential Surgery: Disease Control Priorities, Vol. 1. Washington, DC: Int. Bank Reconstr. Dev./World Bank. 3rd ed.
  5. Wesson HKH, Boikhutso N, Bachani AM, Hofman KJ, Hyder AA. 2014. The cost of injury and trauma care in low- and middle-income countries: a review of economic evidence. Health Policy Plan. 29(6): 795–808.
  6. Global Road Safety Facility (2014) Transport for health: the global burden of disease from motorized road transport. Washington, DC, The World Bank.
  7. Jayanth Paniker, et al. Global trauma: the great divide. SICOT J. 2015; 1: 19. Published online 2015 Jul 21. doi: 10.1051/sicotj/2015019.
  8. National Academy of Sciences, Committee on Military Trauma Care’s Learning Health System; Health and Medicine Division. Berwick D, Downey A, Cornett E, editors. Washington (DC): National Academies Press (US); 2016 Sep. https://doi.org/10.17226/23511
  9. Dijkink S et al. Trauma systems around the world: A systematic overview. J Trauma Acute Care Surg. 2017 Nov;83(5):917-925. doi: 10.1097/TA.0000000000001633
  10. Reynolds TA et al. The Impact of Trauma Care Systems in Low- and Middle-Income Countries. Annu Rev Public Health. 2017 Mar 20;38:507-532. doi: 10.1146/annurev-publhealth-032315-021412. Epub 2017 Jan 11.
  11. Mock C, Joshipura M, Arreola-Risa C, Quansah R. 2012. An estimate of the number of lives that could be saved through improvements in trauma care globally. World J. Surg. 36(5): 959–63.

 

A place for covoptimism?

Whether you are an optimist, a pessimist, or a strict realist is likely to impact how you would project potential effects of COVID on the post-COVID world.

I would argue that from the medical-practical perspective, the three attitudes above are not mutually exclusive. As we often conclude when reading pro- and con- arguments for a new legislature, unrefined reality allows for enough mixed data and scattered observations upon which to base and justify either stance.

My approach here is more of realistic anticipation: what changes to our global emergency care practice environment may result from what we are experiencing today? Undoubtedly, such changes will affect trainees a lot more than seasoned EM providers.

Telemedicine

While by no means a new thing, Telemedicine has advanced exponentially over the last few months and has come to the forefront of medical care in terms of its scope, breadth, and practical applications.

I am what my spouse would call “technologically challenged” (if she were to put it kindly). Yet even a tech-doofus (me) has had to dabble in Telehealth over the last few weeks – both inside my ED and to reach patients thousands of miles away.

  • TAKE-HOME: The earlier and the more you get exposed to Telemedicine, the smoother your future tele-practice will be. Telemedicine to EM today is sort of like what Ultrasound was to EM twenty years ago. I see an EM Telemedicine fellowship coming your way.

Local Resource Preparedness

Everyone now realizes that you need to have tucked away but keep readily available roughly two N-95 masks per healthcare worker per day for three hundred and sixty-five days, amen.

Which changes in how entire healthcare systems are financed are necessary is a huge comprehensive topic. But point-preparedness, as in being ready at the actual place where you and I live and work locally, is a much easier thing to wrap our heads around and become directly involved in.

  • TAKE-HOME: Find others like you, cooperate, get involved, and make your voices and opinions heard and count. We do not know when the Penguin flu or SARS-5 will hit us, but surely they will and with a vengeance. There is a tacit hope we will be smarter and more prepared next time.

Provider Cross-Training

I do not know if golf practice makes you better at playing basketball or swimming at karate. But I do know that we have become so specialized, it is almost like there are hand specialists nowadays who will only deal with the left index finger.

COVID has shown all of us that it is not helpful to only possess knowledge and skills within the comfort zone of your specialty or sub-specialty.

As an EM doc, I have been okay with my ventilator and ARDS management skills. But the last few weeks have been extraordinary in reading up on anything from the forgotten basics of epidemiology and virology to palliative care. And that’s a good habit of keeping up for the future.

  • TAKE-HOME: Get out of your profession’s shell and encourage others to do the same. EM standing for Everything Medicine has never been more true. We are kind of lucky that way.

Sorting Out The Trash In Medical Literature

It is one thing to be able to verbally shred a New England or a Lancet paper at a leisurely journal club; it is quite another to be able to apply new (or old) reported research to clinical practice without harming anyone.

In the times of YouTube anxieties and misinformation, the latter task becomes even more crucial yet difficult. COVID controversies ranging from antimalarials to early intubation are a prime example.

But the good news with COVID is that I think we have just been handed the requirement for a free refresher course on how to appraise medical literature critically. We have to do this under pressure, without much time, and, arguably, fighting with our own natural inclination that “to do something is better than doing nothing.”

  • TAKE-HOME: Less YouTube, more journal clubs. Our relatively young standard of evidence-based medicine is being tested worldwide like never before. Let us wish for it to perform well and withstand all the temptations. And yes, you do need to become a pro with this one.

Patient Privacy and Empty EDs - As They Were Intended?

These points are controversial. But with medical information privacy requirements being loosened in many locations and with fewer non-COVID patients going to EDs, it is a valid question to ask: is right now how things should have always been?

Whether certain patients do not belong to an ED is a complex topic. Finding the golden middle between protecting confidential patient information and enabling providers to reach and treat patients most efficiently is likewise easier said than done.

For now, I am just inviting you to think about it.

  • TAKE-HOME: It may be that things will never go back to how they were. Perhaps we have all overdid it with patient privacy laws that, for a long time, had trumped basic common sense. It may also prove that no one will suffer a dire consequence because they chose to call a doctor via video rather than to drive to an ED. Keep a lookout for good data.

Viruses In Focus

After decades and billions poured into research, we finally have stuff against HIV. Hepatitis and the herpes families are the two runners up, plus we developed a few effective vaccines like the MMR – but that’s about it really.

So much time and focus have gone into killing bacteria, we have somewhat neglected the other big guy. Until now.

  • TAKE-HOME: Nobel price winner Joshua Lederberg once said that “The single biggest threat to man’s continued dominance on this planet is the virus.” You will likely be practicing during an era of unprecedented anti-viral efforts. Just like with bacteria, we may not succeed all the way. But as long as we do not all turn into zombies, it’s okay.

The Cure For The Common Burnout

Emotional exhaustion may indeed be the key factor in professional burnout for emergency care providers. But other factors contribute as well – including feeling unappreciated or not needed, and work seems routine and mundane.

We now have COVID, which has reignited the fire for many EM providers, no matter how deep are those post-N95 facial marks. Otherwise, why would one fly to New York or elsewhere right now “to help”?

Frontline medicine certainly takes its toll on you. But hardly anyone in our specialty should feel not needed or unappreciated anymore.

  • TAKE-HOME: Wake up and go to bed humbled, proud, and lucky to be able to do this work.

The few changes I have listed come from a very long list. Whether they will prove to be overwhelmingly positive remains to be seen. Of course, future benefits do not negate the tremendous harm and suffering the pandemic has already brought and will continue to bring in the months to come.

But one thing is for sure: COVID is not the last time we are dealing with something like this. What your attitude and knowledge will be then, is up to you.

3D Video Laryngoscopes

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.

Umay

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.

The printing files of these blades can be downloaded for free in formats suitable for printing with PLA material, which is frequently used in 3D printers, and PA12, which is preferred for more professional printing. You can download the files here: Pediatric – Adult.

AirAngel

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.

Free Open Online Emergency Medicine Course for Medical Students

Dear colleagues,

I hope this message finds you well in the busy and risky days of COVID-19. 

As known by most of you, the International Emergency Medicine Education Project has been providing free emergency medicine educational resources for medical students since June 2018. Currently, content produced by 175 contributors from 27 countries reached thousands of students from 197 countries around the globe. 

COVID-19 pandemic made many differences in our lives. Education is no exception to this. Because of the pandemic precautions, medical students miss their normal course of education. This may be a bigger issue in countries lacking e-learning options. Therefore, we have been thinking of ways to help students and educators who might be needing such a resource. 

As some of you might know, we were already planning to start a MOOC for medical students in upcoming years. However, COVID-19 forced us to fasten our plans. We have been working for a solution to help students and educators, who lack the means to continue their education activities. Finally, we managed to create a platform: iem-course.org. This platform is designed to provide free online emergency medicine courses for medical students. 

In this platform, we activated the first course, “Emergency Medicine Core Content Course.” It is a 4-week course, covering 11 core topics of emergency medicine. The course includes video and reading assignments, multiple formative quizzes. In addition, if students prefer to receive a course completion certificate, they can take the summative assessment at the end. The reading assignments are curated from freely available online resources (e.g., iEM Education Project 2018 eBook and Society for Academic Emergency Medicine’s CDEM Curriculum chapters). Videos are provided by Lecturio, and all emergency medicine videos (200 items) are freely available for students who join the “iEM/Lecturio Emergency Medicine Core Content Course.” All students around the world are free to register and use the resources provided in this course. 

We hope that this course may help students and educators to overcome educational challenges related to pandemic. We consider this initiative as our responsibility to our international community in these difficult days. We thank all emergency medicine societies, organizations and institutions that endorsed and supported us since the beginning. We are grateful to our contributors, who made creating a project like this possible by writing chapters, providing images and videos. If you are interested in contributing, please let us know by e-mail

iEM Course is a social responsibility initiative of iEM Education Project

Also, we would like to remind you of other iEM project resources below: 

iem-student.org is the main hub of the iEM Education project. Students can reach 2018 eBook chapters, blog posts, video, image, audio archives through this website. 

Flickr image archive is where we share images and short videos provided by our contributors. All photos and short videos are free to download. You can use these items in your presentations and exams. 

Youtube video archive is where we share clinical videos and interviews with world-renowned experts. 

SoundCloud audio archive is where we share iEM 2018 ebook chapters recorded in audio so students can download and listen anytime and anywhere.

All iEM resources are cost- and copyright-free for all medical students and educators. Please share these resources with your students and colleagues in need. If you are interested in sharing your available resources through our platforms, please contact us. We are stronger together.

Best regards.

Arif Alper Cevik, MD, FEMAT, FIFEM

On behalf of iEM Education Project Team

For more information, please visit iem-course.org