Current state of affairs in India in emergency medicine and medicine in general

 I qualified in India in 1995 and did my post graduate studies in General surgery in India before moving to UK/NHS in 1999. I worked predominantly in Emergency Medicine in UK for 21 years before relocating to India. I have now been working in India for the last 5 months and these are some reflections based on my experiences in India so far. Some of the points I make might be controversial and might showcase emergency medicine in India in poor light. This is not a criticism from a position of 'look how great NHS is' but more of a regret that Indian healthcare in general and emergency medicine in particular could do better for the Indian population.

First of all, healthcare in India is great if you have the money or the insurance to pay for the hefty bills. In addition, because of increased funding for healthcare over the last two decades the quality and range of services provided in government hospitals is excellent. The number and quality of private hospitals in India has made a tremendous leap in the last two to three decades. India and its top-notch private hospitals are not only providing international quality health care for its citizens but also have become a hub for foreign nationals from a variety of countries who come to India as healthcare tourists. A significant number of excellent doctors from India are not just renowned in India but are widely respected in international circles and have become trainers and teachers for aspiring young doctors from all over the world. This is the truth about the penthouse suites of Indian healthcare. But the rest of the building in general and importantly its foundations are in a poor state.

The major problems I noticed in India over the last few months are.

1-Lack of standardization and quality control in medical services and medical education

This is by far the biggest problem in India. You could literally go to two different health care establishments with a few kms of each other and have vastly different experience as a patient. The simple reason is that medicine and healthcare is dependent too much on the individual brilliance of the doctors rather than the preferred reliance on better healthcare systems. The same is true of medical education at all levels from MBBS to post graduation to specialization in subspecialities (organ specific). There is no standardization of education and training. So, you could go to two different clinicians with identical qualifications with very huge variance in the quality of care they provide because one has trained in a better institution and the other has trained in a substandard institution.

2-Low percentage of individuals with some form of health insurance policy

Too frequently I see patients being denied appropriate emergency care because of lack of financial resources. This is in spite of various state and central government schemes to cover the emergency healthcare needs of people with low financial resources. The reasons for this are complicated. Most people are unaware of such government schemes, many private institutions have stopped supporting these schemes because the government was not reimbursing the expenses incurred as guaranteed by these schemes.

3-Lack of healthcare regulation

There is no governmental body which is overseeing the quality of healthcare provided by individual clinicians or by health care organizations. This means there is essentially a situation where the reliance is completely on self-regulation of individuals and organizations. There are certain bodies like NABH which are trying to play the role of a regulatory body. However, this is like school inspector visiting schools and hospitals simply play the game of appearing to have everything in place just during the NABH visits. 

4-Lack of quality and standardized primary care physicians

Universally this the one simple step which would provide the biggest improvements in overall healthcare provision in any country. Unfortunately, in India both the public and the medical professionals have very little respect for this area of medicine. Everybody wants treatment from a specialist even when the condition is simple and just needs a primary care physician. This leads to unwanted escalation of cost of treatment of simple conditions. Fortunately, there is a small but growing tribe of well-trained primary care physicians who are starting to make a difference in this field which has been overlooked by everyone including the medical community.

5-Lack of quality and standardized prehospital medicine

The number of lives lost in emergencies because of the deficiencies in this area of medicine is heart breaking. I frequently see patient who come in dead or almost dead to the emergency department simply because simple measures have not been initiated at home and enroute to hospital. This can only be achieved if we vastly increase the number and quality of trained prehospital health care professionals -doctors, nurses and paramedics who are working in prehospital medicine. If I had to choose only one of the above five deficiencies that needs to be corrected, I would choose this simply because the current situation in India is inhumane. However, all the above five deficiencies are somehow interlinked to each other and complement each other if appropriate corrective measures are taken.

Finally Indian citizens would benefit from better education on health-better diets, better lifestyles, training in BLS and first aid (which should be mandatory for all adults). The health minister and health administration of each state should be more proactive to rectify these huge deficiencies in India if India truly wants to become a 'developed nation'.

Thank you for your patience in reading this little write up. Please feel free to add your comments and opinions below.

Sudden collapse -causes, approach and international standards in management

 Hi Everyone

11 years back a professional footballer collapsed on field in UK. He was in cardiac arrest and successfully resuscitated, diagnosed with a dysrhythmia and treated definitively with an implantable cardiac defibrillator. He could no longer continue as a professional footballer but carried on living a near normal life being a son, brother, husband and father. It could easily have been a tragic end, but a lot of things happened on that day which helped him return back to his near normal life after this life changing event. A year back Karnataka and India were shocked to hear the news of the collapse and death of a film and public superstar. He was only in his forties and was known to be super fit. In recent times most of you might have come across the news of a young person (possibly in 30s/40s/50s) having a tragic early end of his life after suddenly collapsing. In this little reflective writing, I wanted to give junior doctors and allied health professionals some basics about common causes, initial approach and international standards in management of these patients. Please feel free to add comments and forward this to others who might benefit from this article.

A sudden collapse of an adult from standing or sitting position is a rapid event with very little forewarning in most cases. There are only two body organs which can do this to a human being- the brain and the heart. If the primary problem is the brain, they could have a preceding sudden onset of a headache, but this is not always the case. It is the more or less the same for pathologies of the heart. The commonest underlying pathology in both organs is related to the vascular supply. In the case of the heart, it could be due to the electrical wiring of the heart (a dysrhythmia). The most important link in the survival chain of such patients is the provision of appropriate immediate care immediately after a collapse. In the vast majority of situations such care needs to be provided by somebody who is not a health professional. The footballer in the previous paragraph was fortunate to collapse on a football field during a professional match where well-trained paramedics, doctors and nurses are available right next to the playing field. It is mandated by the English football association to have such a support facility at all such matches. There are other health and safety measures mandated in various public places in UK and other well-developed nations the chief among this being training of employees in BASIC LIFE SUPPORT and provision of AUTOMATIC EXTERNAL DEFIBRILLATORS(AED) in key public places like shopping malls and sports facilities like gyms and sports fields. Personally, I felt ecstatic when the UP Chief Minister made arrangements for all governmental offices to be provided with AED. Something which could be emulated by other chief ministers in India.

The person who collapses from a brain pathology is commonly suffering from either a sudden bleeding in the brain (subarachnoid or intraparenchymal) or a large blood clot (cerebrovascular event/Stroke). Other common cause is epilepsy, but this is usually characterized by typical involuntary jerky movements and in the vast majority of cases does not lead to a fatal outcome. Therefore, the key focus for healthcare professionals is to correctly identify the underlying pathology of either a large bleeding or a large clot. The gold standard investigation for this is a CT scan. However, the priority even before the CT scan is to ensure appropriate immediate care in the form of BLS and safe transportation to an appropriate healthcare facility (somewhere were a good quality CT scanner and radiologist is available immediately). Even better would be a place with a good quality emergency physician, anesthesiologist, intensive care specialist, neurologist, neurosurgeon and interventional radiologist. A lot of lives in India are lost because this chain of survival gets broken in multiple places. Only a small proportion of members of public are trained in provision of first aid/BLS, very few cities have access to good quality prehospital team(paramedics/doctors), many times they are taken to a healthcare facility which does not even have the basic facilities needed for immediate care of these patients etc.

The person who collapses from a heart pathology commonly is either having a heart attack (blood clot in the arteries which supply blood to the heart) or is having a fatal cardiac dysrhythmia. In these patients once again the key to survival is good quality immediate care in the form of BLS, however the one single factor which can significantly increase survival percentages is early access and use of a defibrillator. A heart which stops beating suddenly commonly is in ventricular fibrillation (VF). This is a potentially reversible rhythm if there is immediate provision of BLS and use of defibrillation(shock). The easiest and most effective way to achieve this would be train as many members of the public as possible on BLS and ensure that AED is available at strategic places in key crowd gathering venues around a city and in all emergency response vehicles(ambulances). This needs an impetus from a governmental level and will only happen if the regional health minister and chief minister takes an initiative. Doctors in general but emergency physicians and cardiologists in particular need to lobby these decision makers for such a move in every single state in India. 

Basic life support used to be complicated many years back. Maybe the thought of giving mouth to mouth breathing to a random stranger puts off most people. The good news is that this is no longer part of basic life support teaching and training. research over the years has shown that simply providing good quality chest compressions alone at the right rate and depth will save lives without the need for breathing support (mouth to mouth breathing). These days well qualified paramedics and doctors have other easier ways to deliver breathing support during advanced life support (ALS). Small pocket masks with a one-way valve, bag and mask ventilation and supraglottic airway devices(I-gel) have revolutionized ALS and emergency care. I am hoping for a day when India and other similar low/medium income countries make training in BLS mandatory for all school children, employees and citizens. I think it is as important as learning ABDEFGH...Z. In BLS you can stop with just ABCDE! And someday even a common man could get a chance to save somebody's life. As an emergency physician I can guarantee you there is no better feeling you can ever get compared to the ecstasy you feel when you have successfully resuscitated a collapsed person.

Automatic external defibrillators are nifty little gadgets no bigger than a small suitcase and can be securely mounted in strategic public places and be easily carried by emergency responders(paramedics/doctors) in the back of an ambulance or the boot of a car. The additional advantage is that you need no medical knowledge to use these gadgets. They are so beautifully designed that the machine talks you through the steps needed and in most developed countries there is a helpline number which is manned 24/7/365 by trained health care professionals who can talk you through this at the end of phone. My aim in the next few months is to have at least five of these installed in strategic places in my hometown in northwestern Tamil Nadu. If this is successful, I am hoping to lobby the government with the help of other like-minded doctors from IMA, SEMI and Cardiology societies to implement this plan across all towns and cities in Tamil Nadu and beyond.

If anybody reading this is enthused about providing BLS training or be involved in the project to place AED in public places, please email me on drgarun@gmail.com. Every little help will be useful. I have provided a link for some useful websites for further reading. Please have a look at them. 

Thank you for your patience in reading this article. Please feel free to add comments/feedback. Please forward it to others who will benefit from reading this.

Sudden Cardiac Arrest: Causes & Symptoms (clevelandclinic.org)

Sudden cardiac arrest - Symptoms and causes - Mayo Clinic

Sudden Cardiac Death - StatPearls - NCBI Bookshelf (nih.gov)

Learn CPR in 15 minutes | RevivR | BHF - BHF

Basic Life Support BLS Training | American Heart Association CPR & First Aid

3.BLS-Algorithms-STEP-BY-STEP.pdf (cprguidelines.eu)

Provider Course Manual for Paramedics.pdf (mohfw.gov.in)

Basic Life Support (BLS) Course in Delhi, Mohali, Mumbai & Pune (smart-academy.in)

Automated external defibrillators: Do you need an AED? - Mayo Clinic

What Is an Automated External Defibrillator? (heart.org)

Emergency Medicine in India and UK

 

I am an emergency medicine doctor based in NHS, UK. I qualified as a doctor from Madras Medical College in 1995 and MS General Surgery from Manipal in 1998. I have worked briefly in Plastic surgery and General surgery after my qualification in India. In UK, I have worked for a couple of years in Cardiothoracic surgery before entering the field of emergency medicine. I have a keen interest in India and its healthcare and have maintained a blog www.indiahealthwatch.blogspot.com for more than 15 years. This is my own personal reflection on the field of emergency medicine from an Indian perspective. I dedicate this blog to innumerable lives lost and maimed in Orissa from the recent train collision disaster.

Sometime few weeks back I boarded a train from Kochi to Salem. The train was a long-distance train from Kanyakumari to Pune via Salem and Tirupathi. I had not seen the news for almost 12 hours. I am a big fan of train travel in general and train travel in India in particular. I was mighty impressed with the level of service that Indian Railways provides at such an incredibly low cost. The stations, the rest rooms, the coaches, the TTE's and almost every experience of using the Indian railways was a pleasure and I was commenting as such to the kind TTE who managed to get a Tatkal Berth for my unreserved travel. It was at this point he mentioned that it was heartwarming to hear such compliments on a day like today when the entire Indian Railway family is in deep sadness because of a train crash in Orissa. It was another few hours before I actually saw the news and realized what a big disaster it has been.

Sometime in 2000 I was starting my new job in NHS as a junior doctor in Emergency Medicine. A few months earlier there had been a train crash just outside London and about 2 dozen lives were lost and less than a hundred people were injured. There was a detailed enquiry about this train crash which was able to conclude the probable reasons for the crash and how we prevent such disasters in the future. I was gob smacked. I came from a country where such accidents happened every now and then and I have never come across a detailed enquiry report into such accidents. Even if they were conducted, they were rarely published in the news media nor discussed by anybody. Everybody was busy reporting what is Rajinikanth's next movie, why Silk Smitha died, how much money a certain politician made in a scam etc etc. The India I left had very little regulation with regards to health and safety. I have over the years noticed that the risk-taking behavior of the average Indian is baffling. They are like little kittens when they see a water body and will rarely venture into it for a swim but yet they become dare devil tigers on the road zipping at high speed with no care or bother.

Sometime in 2020 I was working in a busy emergency department during the pandemic. I kept a close eye on the developments in India. I was thoroughly impressed with the overall level of planning and implementation of pandemic health response in India. I was however unimpressed with the ad hoc and arbitrary nature of treatment of covid patients in India. I felt that this was a missed opportunity for robust trials and data gathering for educational and training purposes. Overall, I have to say India and its health professionals, healthcare managers and the government did a fantastic job irrespective of their political colours.

Sometime in 2003 I started work in a busy central London University hospital emergency department. I was shocked by the level of activity and the cosmopolitan nature of the patients. I was reminded on my 'casualty days in MMC GGH' back in 1994). There was a medical section manned by house surgeons(interns) and headed by a man who neither had the training nor the inclination to do any actual 'casualty' work. There was next to nothing in teaching and training. In fact, we learnt all the wrong things. And this was then in what was the premier medical college and GGH in the entire state of Tamil Nadu. Today one of my classmates and very good friend is the head of the same 'Emergency department'. Now things are very different. For starters the head is a senior experienced decorated Anesthetist with a passion and commitment for delivering high quality care. Overall, the level of funding and training in MMC and GGH is completely different from 3 decades back. I am looking forward to meeting this friend and visiting her prestigious department soon.

Sometime in 2017 I was increasingly jaded with the work I do in an NHS emergency department. The work has a large component of non-emergency primary care because the local primary care (GP) services are struggling to keep up with the workload. There was large number of burnt-out nurses and doctors, and we had a huge turnover of healthcare professionals who were either leaving emergency medicine or shortly planning to do so. I was visiting India and as was the norm during my India visits, I visited the local medical college hospital emergency department and met the doctors and nurses working there. This was in a small city in Tamil Nadu. I was impressed with the level of activity in treating real emergencies. Although the funding, equipment, level of training was far superior to 1994, it was still inadequate for the amount of clinical work. I wanted to come and work with them. However due to my commitments in UK and because of the standard NRI fears of 'relocating to India' I put those thoughts and plans away.

Sometime in 2006 the NHS and UK health department decided to abolish permit free training and the visa available for this training. This overnight abrupt decision affected a large number of graduates. The common sense advice was to change to a HSMP visa(this is a special visa category for somebody wanting to emigrate to UK and become an UK citizen who is highly skilled). I was not interested in becoming an UK citizen because I am a sad romantic who prizes his Indian citizenship. I felt such a move would be like spitting on the graves of innumerable freedom fighters of India who gave me the freedom and independence from UK colonialism. Anyhow the effect of this forced exodus of non EU doctors from UK back to their home countries had an adverse impact on the provision of emergency care in NHS hospitals. Overnight non medically qualified clinicians (mainly senior nurses) were thrust into unfamiliar clinical roles amounting to a junior doctor. This issue is by itself a controversial topic and my own personal opinion on this has changed over the years from one of disgust to one of acceptance. I am fortunate to now work in a hospital and department which actively encourages high quality non medically qualified clinicians. I am fortunate to work closely with these enthusiastic clinicians who add a great service to NHS.

Sometime in 2014 an excellent emergency physician from India moved back to UK to further his training. This was one of the doctors who was forcibly chucked out of UK due to the abrupt closure of permit free training in UK in 2006/7. He went on to do a post graduate training in India and gain further experience before deciding to have another go at living and working in UK. As mentioned earlier UK emergency medicine was adversely suffering from the changes in 2007 and for the last few years have gone back to the usual hunting commonwealth countries) for health professionals who can come and prop up the huge gaps in the doctor's Rota in emergency medicine. Indian emergency medicine by now was gathering pace. Indian emergency physicians benefitted from a system where the major bulk of work was actual emergency medicine and with their extended roles into the hospital intensive care units. Overall the type of clinical work done by an emergency physician in India was far more interesting and challenging compared to their counterparts in UK who had a major component of 'urgent' primary care work.

Sometime in 2011, after 11 years in UK I was granted unlimited leave to remain/permanent residency in United Kingdom. I was no longer a bonded laborer to a trust based on work permit rules. The relief an immigrant doctor in NHS feels when he reaches this stage of his visa status is special and can only be understood and appreciated by other immigrants anywhere in the world. I could already see the gradual decaying of service in NHS which was reeling from a combination of poor resources both money and manpower, a country in recession, frozen pay scales and an expectation to deliver 5-star quality on 2-star funding. Unfortunately, NHS is a sacred thing in UK psyche and no political party was willing to be honest with the public that it was broken, decaying and in need of a complete overhaul. India on the other hand was embracing private healthcare and health insurance in an American style and marching ahead. An universal emergency number '108' for emergency services had been launched and there were ambulance services up and down the country being upgraded. 

Now in 2023 this is the situation I see in India in comparison to UK. In Uk the emergency medical services are overwhelmed with the increased levels of activity which is not adequately supported by funding. There is overcrowding in every single emergency department leading to increased morbidity and mortality of patients. More importantly the human cost in terms of burnt-out nurses and doctors is worrying and apart from the RCEM nobody seems to be bothered. Meanwhile in India the standards in emergency medicine has gone many folds up and, in some ways, possibly better than many emergency departments in UK. However, there is a lack of standardization of care, lack of adequate audit and research and most of the high-quality emergency services are in private corporate hospitals in bigger cities. This has meant the quality of care is often variable and frequently substandard in smaller towns and villages. Only a concerted effort from all players involved in the delivery of emergency services would change this scenario. There needs to be a constructive collaboration between public sector and private sector hospitals and the leadership for this needs to come from the health minister and health departments in every state in India. Will we see that one day. At the moment it is looking unlikely for the following reasons- nobody is bothered or interested in this issue. And the few hardy souls who are battling to achieve this are frequently fighting a lonely battle. 

Thank you for reading my random thoughts and observations. Please feel free to add your comments and views. Have a beautiful day filled with happiness and health everyone.

Epadikku 

Anamika Begum (just for today to get a free Biriyani from her Musalman friends!!!)

Happy Eid everyone. 

Remember that Eid is not just about biriyani, know the real purpose behind this festival and follow the real values. Insha Allah.

Winter Pressures..................... a test for every emergency physician

It is coming up to that time of the year when I start to question why I choose emergency medicine as a career. Yes, winter is here and along with it a crisis in most emergency departments around the country. Patients left for long hours in the corridors of an emergency department waiting for a bed. It is possibly the single most inhuman thing we do to our patients in NHS. Somehow we forget the basic decency any human deserves, privacy and dignity. Somehow it seems acceptable to leave a sick human being in the corridor of an emergency department. After all these years in NHS and emergency medicine, this is the one thing I fail to get my head around.

Overcrowding of emergency department does a lot of collateral damage. It leads to poorer care for patients in emergency department because the same number of nurses and doctors are now expected to look after sometimes twice or thrice the capacity of a department. It leads to delay in getting a patient seen by a clinician in a timely manner. Then there is the effect of all this on the morale of the doctors and nurses in emergency medicine. Every winter this issue is raised by everyone in emergency medicine. A sticky plaster is provided to temporarily silence the issue. Roll on another winter and the fundamental issues have still not been dealt with. In addition there is the year on year increment in number of patients with more or less no increase in workforce.

Is it possible to fix this issue or do we just moan about it and then shut up? ED overcrowding is a complex issue with a variety of factors which influence it. Below are some of the main issues.

1-Inadequate primary care access leading to patients not able to see their GP in time to sort out minor ailments and they end up coming to the emergency department. In particular elderly patients in a  nursing home who could have their problem sorted in the community by a GP ends up using a lot of resources to make the journey to the emergency department in an ambulance.

2-Annual increase in number of patients visiting the emergency departments with very little increase in number of health care professionals to deal with it.

3-Inadequate provision of minor injury/ailment centres in most areas. This leads to every patient attending the sole emergency department in each area.

4-Lack of adequate number of acute care beds and nursing home/residential home places. This is probably the single biggest factor leading to what is traditionally called exit block.

Even to a casual observer there are immediate solutions available and it does not need a rocket scientist to work it out. However the NHS management is riddled with short term thinking and a reluctance to invest money in the right place to fix this issue. Politicians would play their usual games of appearing to support the NHS, media would intermittently show some interest in the issue, the management of NHS meanwhile will appear to tackle the issues with predominantly short term plans and we will go through all this another year in ever worsening numbers. Meanwhile it is left to the individual doctor and nurse to somehow maintain their sanity in the madness of an overcrowded emergency department whilst trying our best to provide the best care possible.

There is absolutely nothing new in the above the blog which has not already been written about and discussed in various channels. Apologies for that. Somehow just putting it in writing here is cathartic for me and I might just have that little extra energy to go through another winter knowing that nothing will ever change in an overcrowded emergency department.

- a very tired disheartened emergency physician hoping that we put our foot down and say 'A BIG NO TO ANY PATIENT BEING LEFT ON A ED CORRIDOR'. Can we?

EMEC 2019

I booked for this course a few months back purely out of curiosity. I have often wondered how we achieve the balance between teaching and service provision in a busy emergency department. I was glad that I attended this conference where it was inspiring to hear from colleagues who described ideas on promoting teaching and making our own jobs more enriching in spite of the busy nature of our work. It is all about getting the balance right. I thought I will reflect on some of things I learnt and maybe inspire a few others who did not have the opportunity to attend this excellent meeting.

First of all kudos to the organising team for choosing such an inspiring venue, The Studio, in Birmingham city centre. The studio is one of the many new age meeting centres which have come up in our city centres which challenge and break rules with regards to meeting places. The place was conveniently located in the city centre with good rooms and an excellent dinner area. The choice of the after meeting catch up drinks, The Botanist, was excellent too.

The morning started with a stimulating talk about sex or should I say CEX by Simon McCormick. Although I found the frequent sexual innuendos tiresome, I was in the minority and the vast majority enjoyed such an unconventional speech. I completely liked the core message of the talk to embrace WPBA and to make it more useful and meaningful. If there is one thing I would take back to work it would be this because I have always found such form filling a bit tiresome and never really bought into it.

Next it was time for Rob Rogers from USA and Medutopia who talked eloquently about the importance of creating your own legacy but more importantly that education saves lives. Like me, if you have not come across Medutopia before I would strongly urge you to have a look at the website. Personally I found it quite inspiring because I do think we need to think of innovative ways to provide medical education for the future clinicians. The days of sitting and reading big textbooks is gone.

www.blog.mymedutopia.com

My favorite speaker of the day was Liz Herrieven. I loved the way the talk was delivered with not a single word to read on the slides, just pictures from 'Game of Thrones'. There were so many ideas I thought every emergency department could copy from her but my favourite was the educational resource box. Just a cupboard in the department with useful props to deliver short burst of teaching in emergency department.

My first work shop was the simulation lab. The team from Leicester, which by the way is the busiest emergency department in the whole of the country, were excellent. It made me wonder if such a busy department could commit itself to teaching then the other less busy departments have no excuse at all. Enjoyed making the model for lateral canthotomy. Most impressed by the #EM3 resus drills. These are essentially 15 minute drills which is broken into a 5 minute simulation scenario, a 5 minute reflection and a final 5 minute repetition of the scenario with the hindsight of the reflection and learning.

www.em3.org.uk

Ross Fischer's masterclass on how to do a presentation was excellent. The message was so basic sometimes it amazes me how most of us get it so wrong. I liked the idea of breaking it down into the the three fundamentals of Message, Media and Delivery.  He calls it the p cubed presentation style. It made me think about the innumerable times my presentations have fallen flat because I have messed up on one of the three fundamentals.

www.ffolliet.com or #htdap

Louis Daniels a counter terrorism officer was our mystery speaker. I liked the way he equated our ambulance pre alert to a phone call his cell would receive about a potential threat. Although the comparission was a little flattering I could see what he means by it. The key messages were to have a clear operational strategy, be familiar with your team, constantly reassess situation based on new information and finally remember to have hot and cold debriefs. If there is only onething I would take back it would be about the importance of debrief after every critical patient in resus like a poly trauma or a cardiac arrest.

John carter a very interesting and enterprising emergency physician from Edinburgh gave an inspirational talk about more or less his life story and how he approaches teaching in his own style. I could not help wonder how his creative talent could have easily been snuffed out by traditionalists. His way was to make pictures and art for teaching. He has one of the most creative brains and they maybe be difficult for us lesser mortals to replicate. However it was inspiring and I can only imagine how entertaining and stimulating his teaching sessions will be for the Edinburgh trainees.

www.prezi.com
www.pechakucha.com
www.mentimeter.com

Anu Mitra and Kamran Zafer from Charing cross hospital shared their experience of how they made the mundane departmental induction into a useful, entertaining and engaging experience for the new doctors. I think each and every department could learn something from them because we are letting down the young doctors through a rather forgetful day called 'Induction day'.

Finally it was time for the rather entertaining eduwars. This was a completely new thing for me and made me realize why can't other educational conferences be this entertaining and useful. Overall I was very impressed with the team behind EMEC and would like to thank them for one of the most entertaining and useful conferences I have ever attended. Special mention must be made of Nikki Abela who had the arduous task of making multiple short presentations on the theory of teaching.

Thank you for reading this. Have a great day and enjoy whatever you do because as per the chaos theory everything is connected. So go on and make a little change in the world around you so that you create a tsunami of enjoyable medical education for the future doctors.

RCEM Belfast 2019 Day 2 post Lunch session

Roof of Revolucion de Cuba restaurant in Belfast. excellent food and brilliant atmosphere.

Stella Smith(Manchester) started the afternoon session with a recount of experiences during the Manchester bomb an year back. It was quite personal for me having been at work on that night at Salford Royal Hospital. I still remember the first patient we took to the CT scanner and the radiographer asking us to check if there is some metal object behind the patient's neck after the initial scanogram. Soon we realised the metal object was a bolt lodged in the cervical spinal cord of this lady. I still get an uncomfortable feeling deep in the heart when I think about that day. The key learning points from the talk were the need for dedicated trauma surgical training for surgeons, improving communication at all levels and the need for dedicated training at all levels. Unfortunately we live in a dangerous time as reminded by the bombs last week in Sri Lanka.

Peter Hulme(Manchester) gave an account of his personal experiences dealing with injured children after the Manchester bomb. It was a well balanced beautiful account of the various simple yet practical difficulties a paediatric emergency physician encounters when an incident of this sort happens. 

Paul Russel(Salisbury) gave an excellent talk summarising various CBRN events around the world including the Novichok in Salisbury. I learnt that a Ram gene meter is used to monitor radiation. There was a brief mention of Bhopal gas tragedy which even today stands as the worst CBRN incident ever. The company responsible for the disaster conveniently avoided penalties by quietly closing down operations and selling the company to another company. He then went through the other incidents world wide from Sarin gas in Tokyo to Polonium in London. As emergency physicians we always are at risk of being the first to encounter a CBRN event. He rightly pointed out that the most dangerous agent will be the innocuous one with delayed onset of symptoms. I do not think there is enough regular training or education on this important aspect of emergency medicine.

Phil 'O' Connor(Belfast) gave a talk on his top 5 critical care papers. Use of high flow oxygen was the first paper and soon we should be seeing this used more in adult emergency medicine. Preoxygentation was the next topic followed by comparison of stylet and bougie for intubation. Then it was about generation of oxygen free radicals due to therapeutic use of oxygen. I do not think there is should be any department/hospital which should use oxygen without a clear prescription from the clinician as to its use.

Rob McSweeney(Belfast) continued where his colleague left off. This was a rapid fire round of critical care updates and he went through a trial every 30 seconds and it was difficult to keep up with the pace at which he was going. He went through the following- POLAR trial for prehospital cooling in traumatic brain injury, RESCUEicp for decompressive craniectomy followed by 20 other trials. I was lost after the first three and was glad that the day was over because my mind was already thinking about which pub and what drink to have that evening.

That was the end of day 2. Going to a conference is a bit like sitting in a classroom all day. I have not done that for a while and struggled to sit down for such prolonged periods of time. Anyhow soon it was drink'o'clock.


It was great to catch up with my brother at the conference.

RCEM spring CPD day 1 post lunch session

Above picture taken inside Fibber Magee, next to the crown opposite Europa.

Lunch was brilliant with a choice of Irish stew, salmon and tortelloni. I went for Irish stew and probably had one too many potatoes. This was the reason I had to excuse myself from one of the afternoon lectures. Apologies to one of my bosses Dan Horner. However to be fair I have read and referred to his excellent trust guideline on the hospital website many times over the last couple of years. It has always been a pleasure to learn from his in depth knowledge on every aspect of VTE.

Emma Greenwood from Belfast spoke about  her top five medical papers in 2018. LOMAGHI study has conclusively proven the benefit of IV magnesium in atrial fibrillation and I would change my practise on this topic. In pregnant patients with suspected VTE I learnt that d-dimer is relevant and pregnancy adapted YEARS algorithm is a useful decision making tool. I also learnt that there is current evidence which shows no correlation between IV contrast and AKI and the next time there is a delay in imaging due to 'waiting for results', I will be able to counter it with current evidence. OVIVA study has shown the lack of superiority of intravenous antibiotics over oral in orthopaedic infections. However I am not sure I will change current management before this is accepted by orthopaedic colleagues who will be most affected by this change in practise and the medico legal pitfalls are too high to make this change.

Ian Beardshell from Belfast gave an entertaining and energetic presentation on how we are practising emergency medicine the wrong way around. I would not change departmental practise of waiting for investigations until the clinician has seen the patient. However I will try and practise the habit of not looking at the results even before seeing the patient. I think the right order would be ambulance notes, triage notes, history from patient, examine patient, provisional diagnosis including differentials and then look at the results. It was good to have a gentle revision on snouts, spins and likelihood ratio. I am sure I will remember it for another 24-48 hours.

James Shawbrook from Belfast talked about Chest Radiology in ED patients. Key messages were difficult chest drains in loculated pneumo thoraxes(luckily we can leave that headache for the interventional radiologists, however identifying one is our headache), looking at the aortic calcific plaques in relation to the arch of the aorta, use of ECG gated CT to improve imaging(ECG gated CT is a nifty way to scan during the diastolic phase of the heart) and a message as simple as clotted blood is more dense than liquid blood.

Madeline Sampson(Belfast) gave a talk on radiology in blunt trauma. She focused primarily on CXR with useful tips on apical pleural cap, mediastinal shift, mediastinal widening, aortopulmonary window etc. It was a bit of a throw back to pre whole body CT for trauma times. Working in a MTC we often have a low threshold for CT and therefore sometimes often overlook the usefulness of a CXR. Since coming back from the conference I have had at least 2 patients with blunt thoracic trauma who had significant findings on CT which could have been missed on CXR. I do have my sympathies for colleagues in non MTC units where it can be rather difficult to get the radiologist to agree on a CT.

Tajek Hassan(President RCEM) gave a fantastic lecture on various issues he faces as President. He is like a movie star and I enjoyed his candid comments on how difficult the job of the President can be. Political correctness and risk of being misreported by the media is a potential hazard. I think he has done a remarkable job during his tenure and I am certain the president elect Katherine Henderson would continue to build on the work and success of her predecessors. I was disappointed to learn that the Indian foreign office refused to give Dr.Hassan a visa because of his Pakistani ancestry. I am ashamed of this silly stupid behaviour and I hope in future such stupidity does not happen and citizens of both countries can live in peace and visit each other's countries.

That brought us to the end of day 1. The drinks reception was excellent with informal conversations and wine flowing well. The canapes were excellent. Personally it was only marred for me by the unfortunate experience of having a unpleasant conversation with one of the vice presidents of RCEM, who took objection to my comments on twitter about the RCEM presidential elections. I think such behaviour should not happen in a meeting of fellow professionals and it was more like a silly confrontation at 11 pm in a local bar with a drunken man. The vice President of RCEM is a respected position and in a forum of colleagues he should have behaved in a more civil manner irrespective of his feelings about my twitter comments. On my side I can only apologise for my twitter comments and in future will avoid any personal comments on social media.

That's all for now.

More about day  2 and 3 in subsequent blogs.

Ps. Irish whiskey and live traditional music in Irish bars are a delight and I had an excellent evening at the Crown and Fibber Magee.


Picture below taken in Salford Quays. Maybe it will tempt somebody to come work for the excellent team at Salford Royal ED.