Mental Practice: A tool for skill training during COVID pandemic

June 8, 2020June 12, 2020 ~ Elif Dilek Cakal, Turkey ~ Leave a comment

COVID-19 pandemic has caused drastic changes in personal and educational lives of medical students, who hold a unique position between being a student and a part of the health care workforce (1). The role of senior medical students who are on the brink of becoming licenced physicians, in particular, have been discussed thoroughly by experts from the perspective of safety, education and the need for skilled workforce. As the discussions continue, medical students got to stay home – as it should be, in my opinion – at least in most countries. Remote learning became the primary training modality all in a sudden.

Remote learning, even though the safest option, is not free of problems. Studying from home and continuing daily routine require a strong determination, especially when people have a lot on their minds. But most of all, clinical and procedural skills are hard, if not impossible, to translate into online learning. Medical students need alternative methods to physical practice of clinical and procedural skills, other than reading instructions and watching procedural videos. Mental practice may offer a solution for medical students who want to sharpen or at least retain procedural skills at home.

What is Mental Practice?

Mental practice refers to the introspective rehearsal or visualisation of psychomotor skills (2). It has been called many names including ‘‘imaginary practice,’’ ‘‘covert rehearsal,’’ ‘‘conceptualization,’’ or ‘‘mental imagery rehearsal’.’ It has been researched extensively in sports literature and is shown to provide both cognitive and motivational benefits (3). Can it do the same trick for medical training, though? At this point, being sceptical is perfectly normal. Let’s look into the literature.

The History of Mental Practice

Surprisingly, even as early as the 1900s, the scientists were discussing the effect of ideational elements in motor learning (4). In the 1930s, pioneer researchers had already experimented on rats that were deprived of kinesthetic impulses by sectioning of the cervical cord and discovered that even they could not run the maze as perfectly as normal rats in terms of motor skills, they still learned it (5, 6, 7). They asserted that kinesthetic impulses were neither sufficient nor necessary in learning of the motor skill. A few years later in 1940, researchers observed ideational clues helped human subjects to learn basic motor skills making fewer attempts, committing fewer errors, and spending less time (8). Subsequent studies tested mental practice against the physical in basketball free throws, dart games, and ring toss (9, 10). All reached the same conclusion: Mental practice was effective, even about as effective as physical practice in learning of motor skills.

What About Medical Training?

Experiments on the use of mental practice in the area of medical training started a few decades later. One of the first studies examined the use of mental practice in the pelvic examination. The students who did 5-minute audio-guided mental practices before and after the physical practice on a model performed significantly better at skill examination (11). Research in this area has gained momentum recently. Mental practice was shown to facilitate medical students’ learning of suturing, venipuncture, cricothyroidotomy, and lumbar puncture (12-15). In some studies, it performed as effective as physical practice, and superior to studying text (12, 16).

The evidence shows that mental practice can be a strong and free learning tool. It can serve as a satisfactory substitute for physical practice in the days of the pandemic, which forces medical students to stay at home. But, let’s not get ahead of ourselves. Mental practice does not provide all of the answers. Remember the rats: They still needed motor practice to run perfectly and as fast as normal rats (7). In other words, you still need the train your muscles to operate smoothly what you have learned. Even after years of mental practice, one could never score a free throw if he or she is lacking the muscle strength to make the ball reach the basket. Admittedly, most medical procedures do not require large motor skills or much strength, but they still demand well-trained small muscles. However, until the world figures out how to put a medical student and a simulator together in the same room safely, the mental practice seems like a solid way of learning new procedures.

References

Miller, D. G., Pierson, L., & Doernberg, S. (2020). The role of medical students during the COVID-19 pandemic. Annals of Internal Medicine.
Oxendine, J.B. (1968). Psychology of motor learning. Englewood Cliffs, New York: Prentice-Hall.
Rogers, R. G. (2006). Mental practice and acquisition of motor skills: examples from sports training and surgical education. Obstetrics and Gynecology Clinics, 33(2), 297-304.
Watson, J. B. (1907). Kinæsthetic and organic sensations: Their role in the reactions of the white rat to the maze. The Psychological Review: Monograph Supplements, 8(2), i.
Lashley, K. S., & Ball, J. (1929). Spinal conduction and kinesthetic sensitivity in the maze habit. Journal of Comparative Psychology, 9(1), 71.
Ingebritsen, O. C. (1932). Maze learning after lesion in the cervical cord. Journal of Comparative Psychology, 14(2), 279.
Honzik, C. H. (1936). The role of kinesthesis in maze learning. Science, 84(2182), 373-373.
Buegel, H. F. (1940). The effects of introducing ideational elements in perceptual-motor learning. Journal of Experimental Psychology, 27(2), 111.
Vandell, R. A., Davis, R. A., & Clugston, H. A. (1943). The function of mental practice in the acquisition of motor skills. The Journal of General Psychology, 29(2), 243-250.
Twining, W. E. (1949). Mental practice and physical practice in learning a motor skill. Research Quarterly. American Association for Health, Physical Education and Recreation, 20(4), 432-435.
Rakestraw, P. G., Irby, D. M., & Vontver, L. A. (1983). The use of mental practice in pelvic examination instruction. Journal of Medical Education, 58(4), 335.
Sanders, C. W., Sadoski, M., Bramson, R., Wiprud, R., & Van Walsum, K. (2004). Comparing the effects of physical practice and mental imagery rehearsal on learning basic surgical skills by medical students. American journal of obstetrics and gynecology, 191(5), 1811-1814.
Sanders, C. W., Sadoski, M., Wasserman, R. M., Wiprud, R., English, M., & Bramson, R. (2007). Comparing the effects of physical practice and mental imagery rehearsal on learning basic venipuncture by medical students. Imagination, Cognition and Personality, 27(2), 117-127.
Bathalon, S., Martin, M., & Dorion, D. (2004). Cognitive task analysis, kinesiology and mental imagery: Challenging surgical attrition. Journal of the American College of Surgeons, 199(3), 73.
Bramson, R., Sanders, C. W., Sadoski, M., West, C., Wiprud, R., English, M., … & Xenakis, A. (2011). Comparing the effects of mental imagery rehearsal and physical practice on learning lumbar puncture by medical students. Annals of Behavioral Science and Medical Education, 17(2), 3-6.
Sanders, C. W., Sadoski, M., van Walsum, K., Bramson, R., Wiprud, R., & Fossum, T. W. (2008). Learning basic surgical skills with mental imagery: using the simulation centre in the mind. Medical Education, 42(6), 607-612.

Cite this article as: Elif Dilek Cakal, Turkey, "Mental Practice: A tool for skill training during COVID pandemic," in International Emergency Medicine Education Project, June 8, 2020, https://iem-student.org/2020/06/08/mental-practice-a-tool-for-skill-training-during-covid-pandemic/, date accessed: April 26, 2024

COVID-19 Pandemic: Rural Preparations

May 25, 2020June 7, 2020 ~ Carmina Shrestha, Nepal ~ Leave a comment

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]

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:

Expand, train and deploy your health care and public health workforce;
Implement a system to find every suspected case at the community level;
Ramp up the production, capacity, and availability of testing;
Identify, adapt and equip facilities you will use to treat and isolate patients;
Develop a clear plan and process to quarantine contacts;
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

Cite this article as: Carmina Shrestha, Nepal, "COVID-19 Pandemic: Rural Preparations," in International Emergency Medicine Education Project, May 25, 2020, https://iem-student.org/2020/05/25/covid-19-pandemic-rural-preparations/, date accessed: April 26, 2024

A place for covoptimism?

May 8, 2020June 7, 2020 ~ Anthony Rodigin, USA ~ Leave a comment

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.

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.

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.

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.”

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.

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.

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.

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.

Cite this article as: Anthony Rodigin, USA, "A place for covoptimism?," in International Emergency Medicine Education Project, May 8, 2020, https://iem-student.org/2020/05/08/a-place-for-covoptimism/, date accessed: April 26, 2024

3D Video Laryngoscopes

May 4, 2020June 12, 2020 ~ Ibrahim Sarbay, Turkey ~ Leave a comment

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.

Cite this article as: Ibrahim Sarbay, Turkey, "3D Video Laryngoscopes," in International Emergency Medicine Education Project, May 4, 2020, https://iem-student.org/2020/05/04/3d-video-laryngoscopes/, date accessed: April 26, 2024

Free Open Online Emergency Medicine Course for Medical Students

May 1, 2020July 10, 2020 ~ Arif Alper Cevik ~ 2 Comments

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

Cite this article as: Arif Alper Cevik, "Free Open Online Emergency Medicine Course for Medical Students," in International Emergency Medicine Education Project, May 1, 2020, https://iem-student.org/2020/05/01/free-open-online-emergency-medicine-course-for-medical-students/, date accessed: April 26, 2024

What has COVID-19 taught us thus far.

April 13, 2020April 13, 2020 ~ Sajan Acharya, Nepal ~ Leave a comment

On a brighter note, more than 150 countries have less than 100 cases as of April 5, 2020. That being said, there probably isn’t an unaffected country on our planet. I am from Nepal, and we have identified 9 cases with one local transmission as of April 5, 2020. One recovered, and 8 in isolation with no death reported to date.[1] It may be hard to comprehend the effect 9 cases have on a country where the probability of dying between the age of 15 and 60 years is 171 per thousand, but total expenditure on health is only 5.8% of GDP. The effect is fairly straightforward but too subtle to get the spotlight amidst this crisis. I contemplated if this is the right time to document these subtleties, but reflections are most useful for future reference only if made accurate. And a major component of accurate reflection is the “time since the event.”

I will take you to the time during my USMLE step 3 preparation and try to tie that in with my point here. One typical day during my preparation, I was doing my 2nd Uworld block and stumbled upon a deceivingly simple question. The gist of the question was: why do patients ask for euthanasia or physician-assisted suicide? I, in the hope of breezing through the question, answered physical pain. To my surprise, that was the most common wrong answer—the right answer: the anticipation of a lack of control and loss of autonomy.
If we are to understand the fear my country is going through, we need to let that information sink. The anticipation of a lack of control makes people ask for help in ending their life.

Nepal ranks 150 in terms of the overall health system in the world. I have been a doctor in one of the most academic tertiary care hospitals here, and I won’t hesitate a second to tell you that our health system will break the moment a fraction of the so-called tsunami of COVID-19 hits us. The country has been on lock-down for nearly two weeks now and plans to stay that way for some more days [Meetings is ongoing, and the final decision hasn’t been reached]. Of course, that will mean people will not have enough money to sustain. Patients of chronic illness will not have enough medicine. The country’s already crippled economy will be damaged beyond repair, and whatever first steps the country was attempting to make towards development will not only be held but legs fractured and eyes blinded. If God forbid, the pandemic hits us hard, no one in Nepal will have outrage that we did not increase the number of ventilators. That just isn’t a variable worth considering [to the general public], given our economy. We are talking about a country where when a village gets a USG machine; it is not used until inaugurated by someone at a position and the inauguration is celebrated like a festival. Everyone who understands the stake knows that we are praying to avoid a war we will invariably lose.

Having said that, I am impressed by the steps taken by the country. Lock-down was a gutsy move. Right when the director-general told people of WHO that lock-down is just a second window of opportunity for countries to prepare for what is to come, I was interested in what our preparedness looks like. Makeshift quarantine rooms are being constructed, test kits being brought in [Update: test kits were of too poor quality to use and hence were returned to China].[2] Patan Academy of Health Sciences, where I studied, has taken the initiative to make their own PPE. Some municipalities are mobilizing locals to make sanitizers, and the government is subsidizing some of the public expenditure. Of course, proportional to the country’s economy, but all this is happening when the country has 9 cases. Remember that actual physical pain was a wrong answer, and the anticipation of future suffering was the right one?

With people staying inside comes a myriad of difficulties. We have already seen it happen, “lucky” us! Everyone will start hoarding on essential supplies, which will increase the price because, apparently, the market still runs on supply and demand. Fear, loneliness, and abundance of time to ruminate on every minuscule of a problem on earth will start showing their effect. Depression, anxiety, and many other psychiatric morbidities will use the time as a breeding season. Household violence increases, and quality of life will take a big toll. Less affluent portions of the population will take a bigger hit in all aspects because inequalities in health are a double injustice; most affected are the people who are already suffering. The graph we hope to flatten will lend its height to the one plotting many other problems.

But we are willing to take that trade and probably everyone should. By no means am I saying that Nepal is doing a great preparation because I know it isn’t. There is much more we can do if we had the resources and global political influence.

We have seen countries with abundance kneeling before this virus. I pay my deepest sympathies to the lost lives around the world and even deeper respect to the frontline warriors. My message here, I guess: When prevention is better than cure is wrong not only because there is no cure but also because you know you will fail to provide care, you better prevent it as your life depends on it. Because it probably does.

Cite this article as: Sajan Acharya, Nepal, "What has COVID-19 taught us thus far.," in International Emergency Medicine Education Project, April 13, 2020, https://iem-student.org/2020/04/13/what-has-covid-19-taught-us-thus-far/, date accessed: April 26, 2024

References

WHO. Coronavirus disease 2019 (COVID-19) Situation Report—76 [online], 06 apr 2020. [cited 2020 Apr 6]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200405-sitrep-76-covid-19.pdf?sfvrsn=6ecf0977_2.
Sapkota R. Nepal to test COVID-19 test kits from China. Nepali Times [Internet]. 2020 Apr 1 [cited 2020 Apr 6]. Available from: https://www.nepalitimes.com/latest/nepal-to-test-covid-19-test-kits-from-china/

COVID19 Info for Medical Students

April 3, 2020July 10, 2020 ~ iEM Education Project Team ~ Leave a comment

In our recent communication with Lecturio, we learned that they have a good set of free chapters and videos about COVID19. We would like to share with you.

Read from here – https://www.lecturio.com/covid-19-coronavirus-disease-2019/

List of videos here – https://www.lecturio.com/medical-courses/covid-19-overview-management.course#/

Free Videos From Lecturio

Coronavirus 2019

SARS and COVID19

Mortality Rate

Detection Bias

For more free COVID19 videos from Lecturio, please visit – https://www.youtube.com/playlist?list=PLVnjTkEwv-uOxdymJaccUdT3LapvnrL61

You may want to read these posts in iEM too

Cite this article as: iEM Education Project Team, "COVID19 Info for Medical Students," in International Emergency Medicine Education Project, April 3, 2020, https://iem-student.org/2020/04/03/covid19-info-for-medical-students/, date accessed: April 26, 2024

ISAEM COVID-19 Social Media Initiative

March 30, 2020July 10, 2020 ~ iEM Education Project Team ~ Leave a comment

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 26, 2024

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

covid 19 - from a Emergency Medicine-based Perspective

March 27, 2020June 12, 2020 ~ Francesco Adami, Italy ~ Leave a comment

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].

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: fever; dry cough; fatigue; 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).

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.

Quality CT/XR images on proven COVID-19 provided by Prof. Dr. Filippo Cademartiri, Chairman of Radiology , Marche – Italy. pic.twitter.com/MchsLQMf8z
— Martin Schranz (@martinpschranz) March 5, 2020

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 26, 2024

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

March 25, 2020June 12, 2020 ~ Sumaiya Hafiz, UAE ~ 1 Comment

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

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

Differences

Influenza virus has additional symptoms such as muscle aches and fatigue whereas COVID-19 can present with diarrhea
Influenza has a shorter incubation period as compared to COVID-19 (2-14 days)
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
COVID-19 is being known to have a higher mortality rate as compared to influenza
Annual vaccines and antiviral agents are effective against influenza, and there is currently no proven treatment for COVID-19
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.

For more info: https://www.who.int/news-room/q-a-detail/q-a-coronaviruses

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 26, 2024