ISAEM COVID-19 Social Media Initiative

In this post, we are sharing an announcement with you. One of our collaborators, ISAEM, is starting a new social media initiative. Here is their message.

Dear Emergency Physicians, First Responders and Front-Line Health Care Staff:

We are emailing you on behalf of the International Student Association of Emergency Medicine (ISAEM). We hope that you are staying healthy during these difficult times.

Our team is organizing a new social media initiative to share experiences from the frontline across the world during the COVID-19 pandemic in a similar style to the Humans of New York page (https://www.humansofnewyork.com/).

We are looking for short reflections about your experience working in the emergency department and in other health care settings as well as any other thoughts you would like to share. We would also ask for a photo of yourself and/or of your current healthcare environment currently. You may submit multiple photos, but please ensure you have the permission of anyone in the photos before sending it to us. A photo consent form is provided here: https://drive.google.com/file/d/1yERDeZOKKKJTajUJmhsZg9HJ6iX957qR/view?usp=sharing 

You will be featured on the ISAEM Facebook/ Twitter accounts as well as the instagram account @humansofemerg administered by the Canadian Association of Emergency Physicians (CAEP).

You may consider responding to one of these questions, or share a different comment altogether.

  • How are things going in your ED right now (positives, challenges)?
  • How are you and your colleagues coping?
  • Do you have any advice for the general public?
  • Are there any encouraging or uplifting experiences you can share during your time working on the frontlines during the COVID-19 crisis?
  • How are you staying connected with others?

All submissions can be sent to isaem.info@gmail.com 

We hope that this project will allow us to share candid experiences and perspectives with members of the healthcare community across the world. Thank you for considering to participate and thank you for all the work you are doing every day.

Sincerely,

ISAEM Team

Cite this article as: iEM Education Project Team, "ISAEM COVID-19 Social Media Initiative," in International Emergency Medicine Education Project, March 30, 2020, https://iem-student.org/2020/03/30/isaem-covid-19-social-media-initiative/, date accessed: April 3, 2020

19 Questions and Answers on the COVID-19 Pandemic from a Emergency Medicine-based Perspective

covid 19 - from a Emergency Medicine-based Perspective

1) What is COVID-19?

Corona Virus Disease 2019 (COVID-19) is the disease caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

2) What is SARS-CoV-2?

SARS-CoV-2 is a virus belonging to the Coronaviridae family. Spike proteins (S proteins) on the outer surface of SARS-CoV-2 are arranged in a way that resembles the appearance of a crown when viewed under an electron microscope (see Figure 1). S proteins facilitate viral entry into host cells by binding to the angiotensin-converting enzyme 2 (ACE2) host receptor. Several cell types express the ACE2 receptor, including lung alveoli cells. [1].

Morphology of the SARS-CoV-2
Figure 1 - Morphology of the SARS-CoV-2 viewed under an electron microscope.Note the spikes that adorn the outer surface of the virus, which impart the look of a corona surrounding the virion. (https://phil.cdc.gov/Details.aspx?pid=23312)

3) How is SARS-CoV-2 transmitted?

Viral particles can spread from person-to-person through airborne transmission (e.g., large droplets) or direct contact(e.g., touching, shaking hands). We have to remember that large droplets are particles with a diameter > 5 microns and that they can be spread by coughing, sneezing, talking, etc., so do not forget to wear full PPE in the Emergency Department (ED). Other potential routes of transmission are still being investigated.

4) What is the incubation time?

In humans, the incubation period of the SARS-CoV-2 varies from 4 days to 14 days, with a median of about 4 days [2].

5) Can we say the COVID-19 is like the seasonal flu?

No, we can’t say that. COVID-19 differs from the flu in several ways:

  • First of all, SARS-CoV-2 replicates in the lower respiratory tract at the level of the pulmonary alveoli (terminal alveoli). In contrast, Influenza viruses, the causative agents of the flu, replicate in the mucosa of the upper respiratory tract.
  • Secondly, SARS-CoV-2 is a new virus that has never met our adaptive immune system.
  • Thirdly, we do not currently have an approved vaccine to prevent infection by SARS-CoV-2.
  • Lastly, we do not currently have drugs of proven efficacy for the treatment of disease caused by SARS-CoV-2.

6) Who is at risk of contracting the COVID-19?

We are all susceptible to contracting the COVID-19, so it is essential that everyone respects the biohazard prevention rules developed by national and international health committees. Elderly persons, patients with comorbidities (e.g., diabetics, cancer, COPD, and CVD), and smokers appear to exhibit poor clinical outcome and greater mortality from COVID-19 [3]

7) What are the symptoms of the COVID-19?

There are four primary symptoms of COVID-19: feverdry coughfatigue; and shortness of breath (SOB).

Other symptoms are loss of appetite, muscle and joint pain, sore throat, nasal congestion and runny nose, headache, nausea and vomiting, diarrhea, anosmia, and dysgeusia.

8) What is the severity of symptoms from COVID-19?

In most cases, COVID-19 mild or moderate symptoms, so much so it can resolve after two weeks of rest at home. However, onset of severe viral pneumonia requires hospital admission.

9) Which COVID-19 patients we should admit to the hospital?

The onset of severe viral pneumonia requires hospital admission. COVID-19-associated pneumonia can quickly evolve into respiratory failure, resulting in decreased gas exchange and the onset of hypoxia (we can already detect this deterioration in gas exchange with a pulse oximeter at the patient’s home). This clinical picture can rapidly further evolve into ARDS and severe multi-organ failure.

The use of the PSI/PORT score (or even the MuLBSTA score, although this score needs to be validated) can help us in the hospital admission decision-making process.

10) Do patients with COVID-19 exhibit laboratory abnormalities?

Most patients exhibit lymphocytopenia [11], an increase in prothrombin time, procalcitonin (> 0.5 ng/mL), and/or LDH (> 250 U/L).

11) Are there specific tests that allow us to diagnose COVID-19?

RT-PCR is a specific test that currently appears to have high specificity but not very high sensitivity [12]. We can obtain material for this test from nasopharyngeal swabs, tracheal aspirates of intubated patients, sputum, and bronchoalveolar lavages (BAL). However, the latter two procedures increase the risk of contagion.

However, since rapid tests are not yet available, RT-PCR results may take days to obtain, since laboratory activity can quickly saturate during epidemics. Furthermore, poor pharyngeal swabbing technique or sampling that occurs during the early stage of COVID-19 can lead to further decreased testing sensitivity.

Consequently, for the best patient care, we must rely on clinical symptoms, labs, and diagnostic imaging (US, CXR, CT). The use of a diagnostic flowchart can be useful (see Figure 2).

diagnostic flow chart
Figure 2 - A possible diagnostic flow chart for an ill patient admitted to hospital with suspected COVID-19 (from EMCrit Blog)

12) Can lung ultrasound help diagnose COVID-19?

Yes, it can help! The use of POCUS lung ultrasound is a useful method both in diagnosis and in real-time monitoring of the COVID-19 patient.

In addition, we could monitor the patient not only in the emergency department (ED) or intensive care unit (ICU), but also in a pre-hospital setting, such as in the home of a patient who is in quarantine.

In fact, POCUS lung ultrasounds not only allows one to anticipate further complications such as lung consolidation from bacterial superinfection or pneumothorax, but it also allows detection of viral pneumonia at the early stages. Furthermore, the use of a high-frequency ultrasound probe, which is an adoption of the 12-lung areas method [4] and the portable ultrasound (they are easily decontaminated), allow this method to be repeatable, inexpensive, easy to transport, and radiation-free.

There are no known pathognomonic patterns of COVID-19.

The early stages COVID-19 pneumonia results in peripheral alveolar damage including alveolar edema and a proteinaceous exudate [5]. This interstitial syndrome can be observed via ultrasound by the presence of scattered B lines in a single intercostal space (see videos below).

Subsequently, COVID-19 pneumonia progression leads to what’s called “white lung”, which ultrasound represents as converging B lines that cover the entire area of the intercostal space; they start from the pleura to end at the bottom of the screen.

Finally, the later stages of this viral pneumonia lead to “dry lung”, which consists of a pattern of small consolidations (< 1 cm) and subpleural nodules. Unlike bacterial foci of infection, these consolidations do not create a Doppler signal within the lesions. We should consider the development from “white lung” to “dry lung” as an unfavorable evolution of the disease.[6]

(the 5 videos above come from the COVID-19 gallery on the Butterflynetwork website)

13) Can CXR/CT help us in the diagnosis of COVID-19?

Yes, it can help! There are essentially three patterns we observed in COVID-19.

In the early stages, the main pattern is ground-glass opacity (GGO)[7]. Ground glass opacity is represented at the lung bases with a peripheral distribution (see videos below) .

The second pattern is constituted by consolidations, which unlike ground-glass opacity, determine a complete “opacification” of the lung parenchyma. The greater the extent of consolidations, the greater the severity and the possibility of admission in ICU.

The third pattern is called crazy paving[8]. It is caused by the thickening of the pulmonary lobular interstitium.

However, we should consider four things when we do a CXR/CT exam. First, many patients, especially in the elderly, exhibit multiple, simultaneously occurring pathologies, so it is possible to clinically observe nodular effusions, lymph node enlargements, and pleural effusions that are not typical of COVID-19 pneumonia. Secondly, we have to be aware that other types of viral pneumonia can also cause GGO, so they cannot be excluded during the diagnostic process. Thirdly, imaging can help evaluate the extent of the disease and alternative diagnoses, but we cannot use it exclusively for diagnosis. Lastly, we should carefully assess the risk of contagion from transporting these patients to the CT room.

14) What is the treatment for this type of patient?

COVID-19 patients quickly become hypoxic without many symptoms (apparently due to “silent” atelectasis). Therapy for these clinical manifestations is resuscitation and support therapy. In patients with mild respiratory insufficiency, oxygen therapy is adopted. In severe patients in which respiratory mechanics are compromised, non-invasive ventilation (NIV) or invasive ventilation should be adopted.

15) How can we non-invasively manage the airways of patients with COVID-19?

In the presence of a virus epidemic, we should remember that all the procedures that generate aerosolization (e.g., NIV, HFNC, BMV, intubation, nebulizers) are high-risk procedures.

Among the non-invasive oxygenation methods, the best-recommended solution is to have patients wear both a high-flow nasal cannula (HFNC) and a surgical mask[9]. Still, we should also consider using CPAP with a helmet interface. Furthermore, we should avoid the administration of medications through nebulization or utilize metered-dose inhalers with spacer (Figure 3).

Figure 3 – General schema for Respiratory Support in Patients with COVID-19 (from PulmCrit Blog)

16) How can we invasively manage the airways of patients with COVID-19?

We should intubate as soon as possible, even in non-critical conditions (Figure 3). Intubation is a high contagion risk procedure. As a result, we should adopt the highest levels of precaution[10]. To be more precise:

  • As healthcare operator, we should wear full PPE. Only the most skilled person at intubation in the staff should intubate. Furthermore we should consider using a video laryngoscope. Last but not least, we should ensure the correct positioning of the endotracheal tube without a stethoscope (link HERE).
  • The room where intubation occurs should be a negative pressure room. When that is not feasible, the room should have doors closed during the intubation procedure.
  • The suction device  should have a closed-circuit so as not to generate aerosolization outside.
  • Preoxygenation should be done using means that do not generate aerosols. Let us remember that HFNC and BVM both can generate aerosolization. So, it is important to remember to turn off the flow of the HFNC before removing it from the patient face to minimize the risk and to use a two-handed grip when using BVM, interposing an antiviral filter between the BVM and resuscitation bag and ventilating gently.
  • Intubation drugs that do not cause coughing should be used. In addition, we should evaluate the use of Rocuronium in the Rapid Sequence Intubation (RSI) since it has a longer half-life compared to succinylcholine and thus prevents the onset of coughing or vomiting.

In conclusion, let us remember that intubation, extubation, bronchoscopy, NIV, CPR prior to intubation, manual ventilation etc. produce aerosolization of the virus, therefore, it is necessary that we wear full PPE.

17) What is the drug therapy for COVID-19?

Currently, there is no validated drug therapy for COVID-19. Some drugs are currently under study. They include Remdesivir (blocks RNA-dependent RNA polymerase), Chloroquine and Hydroxychloroquine (both block the entry of the virus into the endosome), Tocilizumab and Siltuximab (both block IL-6).

18) Is there a vaccine available for COVID-19?

No, there is still no vaccine currently available to the public.

19) What precautions should we take with COVID-19 infected patients?

As healthcare professionals, we should wear full personal protective equipment (PPE) and know how to wear them (“DONning”) and how to remove them properly (“DOFFing”) (see video below). Furthermore, we should wear full PPE for the entire shift and when in contact with patients with respiratory problems.

Resources on COVID-19

Cite this article as: Francesco Adami, Italy, "19 Questions and Answers on the COVID-19 Pandemic from a Emergency Medicine-based Perspective," in International Emergency Medicine Education Project, March 27, 2020, https://iem-student.org/2020/03/27/19-questions-and-answers-on-the-covid-19/, date accessed: April 3, 2020

References

[1] Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. NatRev Cardiol. 2020 Mar 5.

[2] del Rio C, Malani PN. COVID-19—New Insights on a Rapidly Changing Epidemic. JAMA. Published online February 28, 2020. doi:10.1001/jama.2020.3072

[3] Yee J et al. Novel coronavirus 2019 (COVID-19): Emergence and Implications for Emergency Care. Infectious Disease 2020. https://doi.org/10.1002/emp2.12034

[4] Belaïd Bouhemad, Silvia Mongodi, Gabriele Via, Isabelle Rouquette; Ultrasound for “Lung Monitoring” of Ventilated Patients. Anesthesiology 2015;122(2):437-447. doi: https://doi.org/10.1097/ALN.0000000000000558.

[5] Qian-Yi Peng, Xiao-Ting Wang, Li-Na Zhang & Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. 12 March 2020 Intensive Care Medicine.

[6]  Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet 2020.

[7] Chest CT Findings in Cases from the Cruise Ship “Diamond Princess” with Coronavirus Disease 2019 (COVID-19)

[8] Radiographic and CT Features of Viral Pneumonia Hyun Jung Koo, Soyeoun Lim, Jooae Choe, Sang-Ho Choi, Heungsup Sung, and Kyung-Hyun Do RadioGraphics 2018 38:3, 719-739 doi: https://doi.org/10.1148/rg.2018170048

[9]  WHO – Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected.

[10] Safe Airway Society. Consensus Statement: Safe Airway Society Principles of Airway management and Tracheal Intubation Specific to the COVID-19 Adult Patient Group. MJA 2020.

[11] GUAN WJ, Ni ZY, Hu Y, Liang WH, et al  Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032

[12] Tao Ai et al. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology, published online February 26, 2020; doi: 10.1148/radiol.2020200642

COVID-19 vs Influenza: A Diagnostic Dilemma

covid 19 vs influenza

During the last two months, the world experienced an outbreak of what was known to be an unknown yet contagious virus, The Coronavirus, namely COVID-19. News circulated about the virus being spread in China, and the number of people affected increased daily. While there was panic in China, other parts of the world were alert and anticipating a few occurrences, but definitely not as much as the situation is today.

Eventually, as the numbers increased, number of hospital staff who started wearing masks and taking necessary precautions increased, anticipating the arrival of the disease into their regions, until a few days later, there was news of the virus being spread to different countries, new cases emerging from different parts of the world, the case fatality rate rising, infection control rules became stricter and this was the start of what has lead the COVID-19 to be announced as a pandemic by the World Health Organization.

While researches are being conducted, treatments are being tested, one of the biggest dilemmas physicians are facing, is to differentiate between Coronavirus and Flu caused by Influenza virus. The latter being a more known and common cause of flu during the winter months.

When news of the coronavirus created alarm in the general public, there was an influx of patients in the Emergency Departments all around the world, most of them being travelers with flu symptoms and airport staff. Since little was known about the virus then, standard infection control protocols were applied as a general rule until a diagnosis and the severity of illness was sought.This created another issue, could this be seasonal flu, or was it Corona? The decision was harder amongst people in extremes of age. When the disease had just been discovered, testing and results took time and little was known, unlike what the situation is today where countries such as South Korea are offering drive-through tests, with results within 24 hours.

This added to the importance of knowing the differences and similarities between the two to provide adequate management and treatment.

Similarities

  1. Transmitted by contact, droplets and fomites.
  2. Both require precautions such as good hand and respiratory hygiene
  3. Both cause mild to severe respiratory illness
  4. People are commonly affected in winter

Differences

  1. Influenza virus has additional symptoms such as muscle aches and fatigue whereas COVID-19 can present with diarrhea
  2. Influenza has a shorter incubation period as compared to COVID-19 (2-14 days)
  3. According to current data, children, women and elderly are more affected by influenza, whereas COVID-19 causes more severe illness in the elderly and those who are immunocompromised and those suffering from underlying medical conditions
  4. COVID-19 is being known to have a higher mortality rate as compared to influenza
  5. Annual vaccines and antiviral agents are effective against influenza, and there is currently no proven treatment for COVID-19
  6. People who have flu caused by influenza are most contagious in the first 3-4 days after contacting the illness

Overview of the COVID- 19

It belongs to the family of Coronaviruses, which may cause illness in animals or humans. In humans, several coronaviruses are known to cause respiratory infections ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). COVID-19 is the newest type discovered in Wuhan, China, in December 2019.

Method of transmission: is respiratory droplets from the nose or mouth of a person who is infected by the virus (coughs/sneezes within 1 meter).
Incubation period: 1-14 days

Symptoms, Diagnosis and Treatment

The most common symptoms of COVID-19 are fever, tiredness, and dry cough. Some patients may have aches and pains, nasal congestion, runny nose, sore throat, or diarrhea. Around 1 out of every six people who get COVID-19 becomes seriously ill and develops difficulty breathing.

Diagnosis: Nasopharyngeal swab, sputum culture
Chest Xray and CT: Bilateral chest infiltrates, consolidation (pneumonia)
Treatment: Symptomatic until a proven treatment is discovered.

Prevention

The four essential steps:
W – wash hands
A – avoid physical contact and public places
S – sterilize and sanitize regularly
H – hygiene is essential.

Cover your nose or mouth with your bent elbow or tissue while sneezing and dispose of the used tissue immediately.

Wear a mask when you have symptoms of flu to prevent spreading the illness.

Cite this article as: Sumaiya Hafiz, UAE, "COVID-19 vs Influenza: A Diagnostic Dilemma," in International Emergency Medicine Education Project, March 25, 2020, https://iem-student.org/2020/03/25/covid-19-vs-influenza/, date accessed: April 3, 2020

References

Interview: Stephanie Kayden (Part 2)

stephanie kayden md

Are you ready to meet the genuine people behind the professional?

iEM team proudly presents the ICON360 interviews. In this series, world-renowned experts will share their habits, give advice on life, wellness and the profession.

Stephanie Kayden

Stephanie Kayden, MD, MPH, is Vice Chair of the Department of Emergency Medicine at Brigham and Women’s Hospital and Harvard University. She has a focus on international humanitarian response and leadership. She serves on the faculty of the Humanitarian Studies, Ethics, and Human Rights cluster in the Department of Global Health and Population. As Director of the Lavine Family Humanitarian Studies Initiative at the Humanitarian Academy at Harvard, Dr. Kayden trains students and professionals in global health and humanitarian work.

More info.

Part 2

This interview recorded and produced by Arif Alper Cevik, Elif Dilek Cakal, Ali Kaan Ataman during the ESEM18 conference, Dubai, UAE.

Special thanks to Emirates Society of Emergency Medicine.

Cite this article as: iEM Education Project Team, "Interview: Stephanie Kayden (Part 2)," in International Emergency Medicine Education Project, March 20, 2020, https://iem-student.org/2020/03/20/interview-stephanie-kayden-part-2/, date accessed: April 3, 2020

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Interview: Stephanie Kayden (Part 1)

stephanie kayden icon360 interview

Are you ready to meet the genuine people behind the professional?

iEM team proudly presents the ICON360 interviews. In this series, world-renowned experts will share their habits, give advice on life, wellness and the profession.

Stephanie Kayden

Stephanie Kayden, MD, MPH, is Vice Chair of the Department of Emergency Medicine at Brigham and Women’s Hospital and Harvard University. She has a focus on international humanitarian response and leadership. She serves on the faculty of the Humanitarian Studies, Ethics, and Human Rights cluster in the Department of Global Health and Population. As Director of the Lavine Family Humanitarian Studies Initiative at the Humanitarian Academy at Harvard, Dr. Kayden trains students and professionals in global health and humanitarian work.

Part 1

This interview recorded and produced by Arif Alper Cevik, Elif Dilek Cakal, Ali Kaan Ataman during the ESEM18 conference, Dubai, UAE.

Special thanks to Emirates Society of Emergency Medicine.

Cite this article as: iEM Education Project Team, "Interview: Stephanie Kayden (Part 1)," in International Emergency Medicine Education Project, March 13, 2020, https://iem-student.org/2020/03/13/interview-stephanie-kayden-part-1/, date accessed: April 3, 2020

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Passion about “Airway Management”

passion about airway management

I have been passionate about learning and teaching airway management since I started practicing in the Emergency Department. As I learned more about the airway, I started to see a whole new world of knowledge to be explored. In fact, I felt a little indignant, because my college training had failed to teach me so much information necessary to manage the airway safely and responsibly in the emergency department. To fill the gap I perceived, I went to many national and international courses, and here are a few:

Meanwhile, Dr. George Kovacs has been one of the biggest inspirations in my mission to learn and teach airway management, especially after I watched his spectacular lecture “The Psychologically Dangerous Airway.” 

I learned he ran a course as a part of his “Airway Interventions & Management in Emergencies (AIME)” Project (http://aimeairway.ca). Learning from him became a big dream. And finally, in February, I managed to go to Halifax, Canada, to take the AIME Advanced coursehttp://aimeairway.ca

passion about airway management 6

What to expect

The course offers some theoretical classes and plenty of space to practice with various devices. Each instructor supervises 5 or 6 trainees. All trainees rotate the stations to practice each skill on varying airway difficulties.

The highlights of the course include:

  • Real-like Practice: “Nothing is closer to the human body than the human body itself.” Even the best mannequins fail to mimic human anatomy and conditions required to practice airway microskills, in terms of space, weight, and pressure. Therefore, participants of the AIME advanced course practice skills on cadavers donated to the Human Body Donation Program at Dalhousie. Learning with cadavers makes all the difference!
  • Awake Intubation: This is one of the greatest works of Dr. Kovacs, who makes a live demonstration -on himself- of his technique and the materials he uses. Awake intubation is a simple technique, but it requires advanced knowledge. The main indication is anticipated anatomically and/or physiologically difficult airway in cooperative patients.
  • Various devices: The course offers training with a spectrum of devices. In addition to hands-on training, instructors discuss the limitations of the devices and how to overcome them. For example, intubation with a fiberscope assisted by a video laryngoscope in the sedated patient.
  • High-quality teaching materials: Case discussions in the course parallel real-life challenges and present viable solutions. The videos are excellent. All facilitate information exchange and learning.

Also, I must mention that all instructors are very receptive and fun, and interactions between students are excellent. 

The only shortcoming of this course is that it lasts only one day.

So you may ask, “But is awake intubation worth learning even if I work in the Emergencies Departments in Brazil (or other resource-limited contexts for that matter)?” Well, reviewing the advanced airway anatomy and indications for interventions always help to improve practice. If where you work has a video device or fiberscope, you will benefit most from the course. If not (Most EDs in Brazil today don’t), taking the course is a good reason to ask your manager for buying affordable alternatives like VividTrac®, King Vision® or Airtraq®. Also, awake intubation may be performed with Direct Laryngoscopy; however, it does not make much sense to me considering the main indication: an anatomically difficult airway.

Finally, I recommend the AIME advanced course to everyone who wants to improve their skills and learn how to manage the airway in the awake patient. 

If you are interested in airway management, here is another course I can recommend: PRACTICAL EMERGENCY AIRWAY MANAGEMENT https://www.ceme.org/content/practical-emergency-airway-management-november-2020

Cite this article as: Jule Santos, Brasil, "Passion about “Airway Management”," in International Emergency Medicine Education Project, March 9, 2020, https://iem-student.org/2020/03/09/passion-about-airway-management/, date accessed: April 3, 2020

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iEM Monthly: March 2020

iEM Monthly March 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.

Recent News

Recent Posts

Top Countries

An Interview

News

  • iEM education project is interviewing with world-renowned leaders of Emergency Medicine. Simon Carley, Rob Rogers, Ian Stiell, Tracy Sanson, Neil Cunningham, Selim Suner, Judith Tintinalli, Melanie Stander, Taj Hassan, Stephanie Kayden, Nicki Noble are some of the experts in our lists who shared their thoughts, wisdom about life, profession, wellness and more. iEM team is now ready to share these interviews. Stay tuned!

In this series, world-renowned experts will share their habits, give advice on life, wellness and the profession.

  • iEM student is preparing to be in ICEM2020 Buenos Aires / Argentina in June. This is the biggest international conference hosted by IFEM and EM Society fo Argentina. We are looking forward to meeting our contributors, authors, and student followers at the conference.

Recent Posts

Top Countries

These countries viewed iEM content the most in February 2020. 

Top 3 Post Reads in February 2020

a case decreasing resistance in er
Carmina Shrestha, Nepal
BEC WHO
J. Austin Lee, USA
a simple cellulitis of the foot?
Anthony Rodigin, USA

Interview with Melanie Stander

The list of useful scores and rules for ED

useful rules for ed

Pursuing clinical research as a medical student

Pursuing clinical research as a medical student

It all started as an undergraduate medical student.

I am an Assistant Professor of Emergency Medicine and Critical Care at Addis Ababa University, College of Health Sciences. As an Emergency Medicine physician, I am committed not only to develop my clinical skills in the Emergency Department but also to improving my skills in clinical research, which all started as a final year medical student during my undergraduate studies.

temesgen beyene

Emergency Medicine (EM) is a completely new specialty in Ethiopia by the time when I have started to pursue my specialty training, with not much research base exists to support our practice. Clinical research done elsewhere is rarely relevant here and many of the research questions asked elsewhere do not apply in our setting. As the practice of EM develops in Ethiopia, research to support that practice must develop also. I wanted to become an expert in the field of clinical research, so I can lead that development.

While I was having my three poster presentations at the International Conference on Emergency Medicine (ICEM 2016) in Cape Town South Africa and also participating in a two-day pre-conference workshop in Research Methodology, I heard news of my acceptance for a one year Harvard Medical School Global Clinical Scholars Research Training Program 2016/17.

temesgen beyene

This was after my own web-based search and application for clinical research training in addition to my residency training.

Global Clinical Scholars Research Training Program (GCSRTP) offered by Harvard University Medical School Office of Global Education is highly competitive clinical research training for clinical research scientists from all over the country. I am one of 113 advanced trainees from around the world selected for their ability and interest in pursuing clinical or epidemiological research. Students are drawn from hospitals, clinics, and academic communities globally and bring the unique perspective of their home country and institution to address research issues in a clinical or population-based setting.

temesgen beyene

This is a year-long intensive program is designed for clinicians and clinician-scientists aimed to achieve three goals: 

  1. To build skills in clinical research, 
  2. To provide knowledge to address issues critical for success in contemporary clinical research, and 
  3. To develop a global network. 

The GCSRTP consists of three on-site workshops (two in London, UK, and one in Boston) as well as 85 online lectures, 5 team assignments, 20 quizzes covering lecture content, a midterm and a final exam, as well as 2 or 3 interactive webinars per month in biostatistics, epidemiology, biostatistical computing, ethics and regulatory approaches, leadership, applied regression, longitudinal analysis and correlated outcomes, survey design, causal diagrams, and advanced quantitative methods. Additionally, I have selected an elective and a concentration and completed my own course work related to those tracks. The program requires an original research proposal as a Capstone Project. Graduation from the program relies on successful completion of this project. And thus, I had successfully completed my capstone project titled Diuretics Options in Acute Coronary Syndrome as a requirement for my successful graduation.

Through the Harvard Medical School Tuition Reduction Program, I was able to negotiate a 50% reduction in the usual tuition of $11,900 for the program. Additional expenses for travel and accommodation and supplies were my responsibility.

How all of the above came into fruition as a start base from my undergraduate study in Medicine?

There was a medical student mentorship research program of the Medical Education Partnership Initiative as a part of the NIH funded grant in 2013. For the same, I have assessed an undergraduate medical student’s clerkship rotation in Emergency Medicine as an Ethiopian experience. This paper, which was also published in the African Journal of Emergency Medicine, was a gateway for all of my clinical research experiences to date. There is a blog post about my clinical research experience in the same journal as well as I was a speaker on the most recent African Conference on Emergency Medicine in Kigali Rwanda, 2018.

My subsequent future as a clinical researcher:

I completed my residency in January 2018. With the skills developed in the GCSRT and my clinical qualification, I was well-positioned to apply for further clinical research fellowship at Addis Ababa University and got accepted for a Junior Faculty Research Fellowship under an NIH funded grant of Medical Education Partnership Initiative 2019-2020. I hope to begin developing research projects, possibly multi-site within Ethiopia that will address the many questions that are relevant to Emergency Medicine as it is practiced in our low-resource setting.

Cite this article as: Temesgen Beyene, Ethiopia, "Pursuing clinical research as a medical student," in International Emergency Medicine Education Project, February 28, 2020, https://iem-student.org/2020/02/28/pursuing-clinical-research-as-a-medical-student/, date accessed: April 3, 2020

A case of decreasing resistance in ER

a case decreasing resistance in er

I keep games on the 4th home screen of my cell phone. The third screen is blank. A minuscule of energy required to swipe my thumb has prevented me one too many times from mindlessly launching an RPG. Only to realize 2 hours later I had other plans for those 2 hours. An American comedian, the late Mitch Hedberg famously joked once,

Mitch Hedberg (1968-2005)
Mitch Hedberg (1968-2005)

I have always believed that the subtle truths kneaded so artfully in seemingly light, small-talk-worthy jokes are what makes a comedian a genius. How many times have you thought that you need to pick up that particular grocery or fill up that one conference form only to instead get consumed by what was easily available?

Our mind is built so that it follows the path of least resistance no matter how insignificant the resistance is. Although smudged all over the canvas of self-help, non-fiction genre, medicine somehow isn’t used frequently to exemplify the path of least resistance.

Today, I present to you a case that inspired us at Beltar, to remove one such small resistance from our workflow. The implications as you will see were no less than life-saving.

Rural Health System : Oversimplified

Before I present to you the case, a small preamble: Health care in rural Nepal is still run mostly by paramedics. No matter what spectrum you fall in terms of appreciating their work, the fact remains that they are the major workforce we have at the rural. It suffices to say that they are the portal of entry to the health system of our country for many. All emergency cases, once screened and declared complicated, the medical officer (usually a MBBS doctor) at the PHC sees the patient. Majority of cases are seen only by paramedics – considering 3 to 5 paramedics, usually and barely one medical officer in most PHCs.

A mobile game I wouldn't play

Now that the characters are in place, let’s dive right into the no less than a fairy tale land of the rural health system. Lamenting about the obvious lack of resources has been so old school that I don’t even make a typo while typing about it these days. We had one ECG machine at Beltar. The old ECG machine with its squeaky sound and myriad varieties of artifacts stood with all its mighty bulk inside a locked door of a room. The key protected from no one in particular by the office assistant who would open the door, drag the machine out, bring it to the bedside. The paramedic who decided to do the ECG would then untangle the wire glazed with what little of gel we had applied to the previous patient. He would then connect the limb leads and the pre-cordial leads with the trusty suction knobs which hopefully has some gel left from the previous use and then comes the biggest connection to be made: connecting the machine to the power grid. “Don’t you keep your machine charged!?”, you ask. We do. But the Li-ion battery probably has undergone autophagy, or whatever fancy name the process is given. That is a lot of steps and by extension, a lot of resistance. If this were a mobile game, I don’t think I would be addicted to it.

A Race Against Time

A patient with diabetes who had visited our ER a couple of times before was being monitored for chest pain at around 7 AM on a Saturday morning. I was washing my clothes on the first floor unaware that my Saturday is not going to be about laundry and daily chores. When I was called to check the patient, she was already deteriorating at a rate far greater than our PHC could ever catch up. We tried to borrow the speed of an ambulance and refer the patient to a higher center. An ST elevation in any two contiguous lead is an MI. Our paramedics knew that. To everybody’s surprise, ECG was not done! Given the fact that we did not have cardiac enzymes available at the PHC and Aspirin was all we could have prescribed before discharge anyway: we gave the patient 2 Aspirin tablets to chew and referred her as fast as we could. My paramedic colleagues have demonstrated utmost clinical competence and professionalism too many times to doubt any of that. The work environment was still error-prone and the circumstance demanded a change. Could we have changed the outcome given the same resources and clinical scenario? Maybe we need to decrease the resistance I thought. Changing how we store ECG (shown in the picture below), making it more accessible not only increased the frequency with which it was being used but also served as a reminder. A physical question hanging down the IV stand asking anyone who is attending a case, “Do you need to use me?”

ECG machine in plain sight with IV stand holding the limb and pre-cordial leads for accessibility

Workarounds: Because Solutions are Late to the Party.

If you have been following my writings, you’d have noticed this as another small tweak, a workaround, a nudge to the existing system so to speak that isn’t the substitute for the actual sustainable solution. Robust training that helps hard-working paramedics conceptualize and understand the protocols related to the use of basic yet life-saving diagnostics like ECG can be a start. We tried printing and pasting some protocols on the walls; another workaround we hope would help make patient care better until it actually sustainably improves. Another workaround that a friend suggested was: everyone who aches above the waist, gets an ECG. Such simplification works well to decrease the resistance in learning complex protocols. I am sure there are plenty of workarounds used worldwide, a necessity, after all, is the mother of invention. I leave you with a thought: What effect do you think will a systematic sharing of such workarounds among the rural healthcare workers will produce?

Guides to ECG electrode placement and protocols
Cite this article as: Carmina Shrestha, Nepal, "A case of decreasing resistance in ER," in International Emergency Medicine Education Project, February 21, 2020, https://iem-student.org/2020/02/21/a-case-of-decreasing-resistance-in-er/, date accessed: April 3, 2020

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Basic Emergency Care (BEC): A New Global Health Framework

BEC WHO

Experienced emergency medicine providers know the ins and outs of how to approach and assess any patient of any age with a critical illness. As has been discussed previously on this blog, the need to rapidly identify and manage sick and dying patients requires a systematic approach. When a new patient arrives for care, or alternatively when a patient decompensates and gets acutely sicker, the emergency medicine provider is tasked with systematically identifying and treating such conditions.

Because most trauma and critical care approaches and training modules were developed and implemented in high-income, resource-rich contexts, there has long been a need for a systematic approach to critically ill patients in lower-income settings.

Over the past several years, the World Health Organization, the International Committee of the Red Cross/Red Crescent, and the International Federation for Emergency Medicine have been working together to develop and create a training course to aid frontline providers in managing acute illness and acute injury in resource-limited contexts.

BEC in Uganda 2
Zambian BEC course facilitators Hassan, Alex, Chipoya (doctors), and Irene (nurse) demonstrate how to safely move an injured patient.

Since 2018, the World Health Organization’s Basic Emergency Care course has been developed and refined as a way to teach a systematic, high-yield approach to urgent and emergent health problems. Using both triage and interventional strategies, the course trains participants to be prepared to deal with a variety of critical illnesses, with a focus on trauma, breathing, shock, and altered mental status.

The BEC course is generally given as a 4 to 6-day course to individuals working in healthcare systems around the world. The BEC course is intended for individuals who might be able to or expected to provide emergent patient care, including students, trainees, nurses, physicians, and even pre-hospital or inpatient care providers, among others. This course is not only intended for emergency medicine physicians, but for all types of locally appropriate providers.

The BEC course participants first learn about the ABCDE approach to ill patients, with a recurring emphasis on obtaining a focused patient history using the SAMPLE mnemonic. These skills are crucial and can be applied to almost any patient in any context.

BEC in Uganda
Tanzanian BEC course facilitators, Suzie (nurse) and Juma (doctor) demonstrate infant resuscitation.

The knowledge gained around ABCDEs and the SAMPLE histories are then applied across the four main care modules in the course, which are: trauma, breathing, shock, and altered mental status. As has been pointed out by others, before any patient goes from alive to dead, they usually pass through the framework of one of these four critical care modules. The hypoglycemic patient develops altered mentation, or the patient with pneumonia develops respiratory distress. As such, lifesaving interventions at these crucial action points can truly save lives.

Each day of the 5-day training course generally has a mix of lectures, group discussions, case scenarios, and hands-on skills stations. The freely available WHO BEC Handbook can help one to better understand the course structure and content.

It should be noted that the BEC course does presume the participant has a very basic but pre-existing knowledge of some of the following: basic human anatomy, basic history taking, basic physical examination skills including vital signs auscultation and abdominal exam, use of a glucometer, and the use of intravenous and intramuscular medications.

In several locations around the world, after the completion of the 5-day course, a Training of the Trainers course has been given, where top course participants and other health system leaders come together to learn how to teach the BEC course. As such, there is a goal for developing and cultivating both local leadership regarding the skills and knowledge around care during critical illness. Subsequently, a locally perpetual training around BEC can take root and become the new standard of emergency care.

Early research by Tenner et al., among others, into the efficacy and impact of the BEC course is showing that indeed, the WHO BEC course is both effective and helpful. For those who are interested in either taking the course, or in becoming a certified trainer, you can contact your national or local emergency medicine leaders and ask for times and locations near you where there may be the opportunity to take this incredibly valuable and impactful course. One such BEC and follow-on training of the trainer course will be taking place in Rwanda in March of 2020; to contribute financially to this Rwandan effort, consider a small donation: here.

References

  • Tenner AG, Sawe HR, Amato S, et al. Results from a World Health Organization pilot of the Basic Emergency Care Course in Sub Saharan Africa. PLoS One. 2019;14(11):e0224257. Published 2019 Nov 13. doi:10.1371/journal.pone.0224257 – pdf link
Cite this article as: J. Austin Lee, USA, "Basic Emergency Care (BEC): A New Global Health Framework," in International Emergency Medicine Education Project, February 17, 2020, https://iem-student.org/2020/02/17/basic-emergency-care/, date accessed: April 3, 2020

Lower Extremity Deep Venous US Imaging – Illustrations

lower extremity us illustrations

Ultrasound evaluation for deep venous thrombosis (DVT) is one of the 11 core ultrasound applications for emergency physicians as listed in the 2008 American College of Emergency Physicians guidelines (1). Because ultrasound applications started to be implemented into medical school curriculum in many countries, learning basic ultrasound applications as early as possible will benefit medical students and junior residents. In this post, I will share lower extremity venous ultrasound illustrations with you. 

Indications

The clinical indications for performing a lower venous ultrasound examination is the suspicion of a lower extremity DVT in a swollen or discoloured leg. 

Transducer

Select a high-frequency linear transducer, (5-10) MHz transducer since it provides optimal venous copmression and image resolution.

lower extremity venous ultrasound - linear transducer

Remember Risk Factors of DVT

  • Age > 60
  • Cancer
  • Central venous catheter/insertion
  • Genetic causes of hypercoagulopaty
  • History of DVT
  • Immobilization
  • Obesity
  • Pregnancy
  • Smoking
  • Trauma or recent surgery
  • Use of birth control pills or hormone replacement therapy

Wells Score for Deep Vein Thrombosis

CriteriaScore
Active cancer(treatment ongoing or within previous 6 months or palliative treatment)
1
Paralysis, paresis, or recent plaster immobilization or of the lower extremities1
Recently bedridden for 3 days or more or major surgery within the previous 12 weeks requiring general or regional anesthesia1
Localized tenderness along the distribution of the deep venous system1
Entire leg swollen1
Calf swelling > 3cm compared to asymptomatic leg (measuring 10 cm below tibial tuberosity)1
Pitting edema confined to the symptomatic leg1
Non varicose collateral superficial veins1
Previously documented DVT1
Alternative diagnosis at least as likely as DVT1
DVT evaluation algorithm
Select a high-frequency linear transducer, (5-10) MHz transducer since it provides optimal venous copmression and image resolution.
sectional anatomy of lower extremity veins

Normal DVT Ultrasound Findings

normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings

Reference and Further Reading

  1. American College of Emergency Physicians. Emergency ultrasound guidelines 2008. http://www.acep.org/WorkArea/DownloadAsset.aspx?ID=32878. February 2012.

Note: Visual drawings are inspired by the Point-of-Care ULTRASOUND Book.

Cite this article as: Murat Yazici, Turkey, "Lower Extremity Deep Venous US Imaging – Illustrations," in International Emergency Medicine Education Project, February 14, 2020, https://iem-student.org/2020/02/14/lower-extremity-deep-venous-us-imaging-illustrations/, date accessed: April 3, 2020

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