emergency medicine:the most wanted medical speciality in india
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Emergency Medicine A most wanted specialty in India
DrVenugopalanPPDADNBMNAMSMEM[GWU-US]
Director Emergency Medicine
Aster-DM Healthcare ndashIndia
Site Director MEM program GWU
Deputy Director ndashMIMS Academy
PG ndashTeacher Emergency Medicine ndashNBE
Founder ampExecutive Director ndashANGELS
Part AbullWhat is emergency Medicine
bullHow it is different
bullWhat is its uniqueness
Emergency Medicine
The medical specialty with the principal
mission of evaluating managing and
preventing unexpected illness and
injury
Emergency Medicine
Encompasses
a unique body
of knowledge
reflected in the
ldquoModel of the
clinical practice
of Emergency
Medicinerdquo
Clinical E MInitial evaluation
treatment and disposition of any person at any time for any symptom event or disorder deemed by the person or someone acting on his or her behalf to require expeditious medical surgical or psychiatric attention
ACEM
Emergency
Any condition perceived by the
prudent layperson or some one on
his or her behalf as requiring
immediate medical or surgical
evaluation and treatment
Emergency
It is a situation or condition having a
high probability of disabling or
immediate life threatening
consequences requiring urgent intervention including first aid
ACEM
ER physician
A specialist who
has been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness
and injury
ER Physicians
bullNot provide long
term or continuous
care
bullThey diagnose a
wide range of
diseases and
perform
interventions to
stabilize the patient
ER Physicians bull See a large number of
patients treat their
illness and arrange for
disposition either
admitting them to the
hospital or releasing
them after treatment as necessary
ER physician Broad field of
knowledge and
advanced procedure
skills including
surgical procedures
trauma
resuscitation
advance cardiac life
support advanced
airway management etc
bull Good ER physicians
know every single
details of
resuscitation and
treatment methods
of sick and injured
relating to almost every specialty
Emergency Medicine
bull Demands excellent communication skills and knowledge of human psychology
bull The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Part AbullWhat is emergency Medicine
bullHow it is different
bullWhat is its uniqueness
Emergency Medicine
The medical specialty with the principal
mission of evaluating managing and
preventing unexpected illness and
injury
Emergency Medicine
Encompasses
a unique body
of knowledge
reflected in the
ldquoModel of the
clinical practice
of Emergency
Medicinerdquo
Clinical E MInitial evaluation
treatment and disposition of any person at any time for any symptom event or disorder deemed by the person or someone acting on his or her behalf to require expeditious medical surgical or psychiatric attention
ACEM
Emergency
Any condition perceived by the
prudent layperson or some one on
his or her behalf as requiring
immediate medical or surgical
evaluation and treatment
Emergency
It is a situation or condition having a
high probability of disabling or
immediate life threatening
consequences requiring urgent intervention including first aid
ACEM
ER physician
A specialist who
has been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness
and injury
ER Physicians
bullNot provide long
term or continuous
care
bullThey diagnose a
wide range of
diseases and
perform
interventions to
stabilize the patient
ER Physicians bull See a large number of
patients treat their
illness and arrange for
disposition either
admitting them to the
hospital or releasing
them after treatment as necessary
ER physician Broad field of
knowledge and
advanced procedure
skills including
surgical procedures
trauma
resuscitation
advance cardiac life
support advanced
airway management etc
bull Good ER physicians
know every single
details of
resuscitation and
treatment methods
of sick and injured
relating to almost every specialty
Emergency Medicine
bull Demands excellent communication skills and knowledge of human psychology
bull The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Emergency Medicine
The medical specialty with the principal
mission of evaluating managing and
preventing unexpected illness and
injury
Emergency Medicine
Encompasses
a unique body
of knowledge
reflected in the
ldquoModel of the
clinical practice
of Emergency
Medicinerdquo
Clinical E MInitial evaluation
treatment and disposition of any person at any time for any symptom event or disorder deemed by the person or someone acting on his or her behalf to require expeditious medical surgical or psychiatric attention
ACEM
Emergency
Any condition perceived by the
prudent layperson or some one on
his or her behalf as requiring
immediate medical or surgical
evaluation and treatment
Emergency
It is a situation or condition having a
high probability of disabling or
immediate life threatening
consequences requiring urgent intervention including first aid
ACEM
ER physician
A specialist who
has been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness
and injury
ER Physicians
bullNot provide long
term or continuous
care
bullThey diagnose a
wide range of
diseases and
perform
interventions to
stabilize the patient
ER Physicians bull See a large number of
patients treat their
illness and arrange for
disposition either
admitting them to the
hospital or releasing
them after treatment as necessary
ER physician Broad field of
knowledge and
advanced procedure
skills including
surgical procedures
trauma
resuscitation
advance cardiac life
support advanced
airway management etc
bull Good ER physicians
know every single
details of
resuscitation and
treatment methods
of sick and injured
relating to almost every specialty
Emergency Medicine
bull Demands excellent communication skills and knowledge of human psychology
bull The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Emergency Medicine
Encompasses
a unique body
of knowledge
reflected in the
ldquoModel of the
clinical practice
of Emergency
Medicinerdquo
Clinical E MInitial evaluation
treatment and disposition of any person at any time for any symptom event or disorder deemed by the person or someone acting on his or her behalf to require expeditious medical surgical or psychiatric attention
ACEM
Emergency
Any condition perceived by the
prudent layperson or some one on
his or her behalf as requiring
immediate medical or surgical
evaluation and treatment
Emergency
It is a situation or condition having a
high probability of disabling or
immediate life threatening
consequences requiring urgent intervention including first aid
ACEM
ER physician
A specialist who
has been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness
and injury
ER Physicians
bullNot provide long
term or continuous
care
bullThey diagnose a
wide range of
diseases and
perform
interventions to
stabilize the patient
ER Physicians bull See a large number of
patients treat their
illness and arrange for
disposition either
admitting them to the
hospital or releasing
them after treatment as necessary
ER physician Broad field of
knowledge and
advanced procedure
skills including
surgical procedures
trauma
resuscitation
advance cardiac life
support advanced
airway management etc
bull Good ER physicians
know every single
details of
resuscitation and
treatment methods
of sick and injured
relating to almost every specialty
Emergency Medicine
bull Demands excellent communication skills and knowledge of human psychology
bull The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Clinical E MInitial evaluation
treatment and disposition of any person at any time for any symptom event or disorder deemed by the person or someone acting on his or her behalf to require expeditious medical surgical or psychiatric attention
ACEM
Emergency
Any condition perceived by the
prudent layperson or some one on
his or her behalf as requiring
immediate medical or surgical
evaluation and treatment
Emergency
It is a situation or condition having a
high probability of disabling or
immediate life threatening
consequences requiring urgent intervention including first aid
ACEM
ER physician
A specialist who
has been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness
and injury
ER Physicians
bullNot provide long
term or continuous
care
bullThey diagnose a
wide range of
diseases and
perform
interventions to
stabilize the patient
ER Physicians bull See a large number of
patients treat their
illness and arrange for
disposition either
admitting them to the
hospital or releasing
them after treatment as necessary
ER physician Broad field of
knowledge and
advanced procedure
skills including
surgical procedures
trauma
resuscitation
advance cardiac life
support advanced
airway management etc
bull Good ER physicians
know every single
details of
resuscitation and
treatment methods
of sick and injured
relating to almost every specialty
Emergency Medicine
bull Demands excellent communication skills and knowledge of human psychology
bull The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Emergency
Any condition perceived by the
prudent layperson or some one on
his or her behalf as requiring
immediate medical or surgical
evaluation and treatment
Emergency
It is a situation or condition having a
high probability of disabling or
immediate life threatening
consequences requiring urgent intervention including first aid
ACEM
ER physician
A specialist who
has been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness
and injury
ER Physicians
bullNot provide long
term or continuous
care
bullThey diagnose a
wide range of
diseases and
perform
interventions to
stabilize the patient
ER Physicians bull See a large number of
patients treat their
illness and arrange for
disposition either
admitting them to the
hospital or releasing
them after treatment as necessary
ER physician Broad field of
knowledge and
advanced procedure
skills including
surgical procedures
trauma
resuscitation
advance cardiac life
support advanced
airway management etc
bull Good ER physicians
know every single
details of
resuscitation and
treatment methods
of sick and injured
relating to almost every specialty
Emergency Medicine
bull Demands excellent communication skills and knowledge of human psychology
bull The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Emergency
It is a situation or condition having a
high probability of disabling or
immediate life threatening
consequences requiring urgent intervention including first aid
ACEM
ER physician
A specialist who
has been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness
and injury
ER Physicians
bullNot provide long
term or continuous
care
bullThey diagnose a
wide range of
diseases and
perform
interventions to
stabilize the patient
ER Physicians bull See a large number of
patients treat their
illness and arrange for
disposition either
admitting them to the
hospital or releasing
them after treatment as necessary
ER physician Broad field of
knowledge and
advanced procedure
skills including
surgical procedures
trauma
resuscitation
advance cardiac life
support advanced
airway management etc
bull Good ER physicians
know every single
details of
resuscitation and
treatment methods
of sick and injured
relating to almost every specialty
Emergency Medicine
bull Demands excellent communication skills and knowledge of human psychology
bull The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
ER physician
A specialist who
has been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness
and injury
ER Physicians
bullNot provide long
term or continuous
care
bullThey diagnose a
wide range of
diseases and
perform
interventions to
stabilize the patient
ER Physicians bull See a large number of
patients treat their
illness and arrange for
disposition either
admitting them to the
hospital or releasing
them after treatment as necessary
ER physician Broad field of
knowledge and
advanced procedure
skills including
surgical procedures
trauma
resuscitation
advance cardiac life
support advanced
airway management etc
bull Good ER physicians
know every single
details of
resuscitation and
treatment methods
of sick and injured
relating to almost every specialty
Emergency Medicine
bull Demands excellent communication skills and knowledge of human psychology
bull The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
ER Physicians
bullNot provide long
term or continuous
care
bullThey diagnose a
wide range of
diseases and
perform
interventions to
stabilize the patient
ER Physicians bull See a large number of
patients treat their
illness and arrange for
disposition either
admitting them to the
hospital or releasing
them after treatment as necessary
ER physician Broad field of
knowledge and
advanced procedure
skills including
surgical procedures
trauma
resuscitation
advance cardiac life
support advanced
airway management etc
bull Good ER physicians
know every single
details of
resuscitation and
treatment methods
of sick and injured
relating to almost every specialty
Emergency Medicine
bull Demands excellent communication skills and knowledge of human psychology
bull The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
ER Physicians bull See a large number of
patients treat their
illness and arrange for
disposition either
admitting them to the
hospital or releasing
them after treatment as necessary
ER physician Broad field of
knowledge and
advanced procedure
skills including
surgical procedures
trauma
resuscitation
advance cardiac life
support advanced
airway management etc
bull Good ER physicians
know every single
details of
resuscitation and
treatment methods
of sick and injured
relating to almost every specialty
Emergency Medicine
bull Demands excellent communication skills and knowledge of human psychology
bull The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
ER physician Broad field of
knowledge and
advanced procedure
skills including
surgical procedures
trauma
resuscitation
advance cardiac life
support advanced
airway management etc
bull Good ER physicians
know every single
details of
resuscitation and
treatment methods
of sick and injured
relating to almost every specialty
Emergency Medicine
bull Demands excellent communication skills and knowledge of human psychology
bull The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
bull Good ER physicians
know every single
details of
resuscitation and
treatment methods
of sick and injured
relating to almost every specialty
Emergency Medicine
bull Demands excellent communication skills and knowledge of human psychology
bull The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Emergency Medicine
bull Demands excellent communication skills and knowledge of human psychology
bull The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Challenges
bullDeal with crying children
bullChild abuse
bullViolent patient attendants
who more often than not think
that the problem is not worth
admitting the patient
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Challenges
bull Patient who do not trust
doctors
bull Anxious and depressed
patient
bull Over worked staff
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Other Responsibilities [ACEM]
bull Administration research and teaching of all aspects of Emergency care
bull Follow up care (observation medicine)
bull Provision for emergency care to hospital patient on request
bull EMS and pre hospital care
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Other Responsibilities [ACEM]
bull Disaster planning and management (both natural and man made events)
bull Toxicology and poisons center development
bull Education of Healthcare providers and the common public
bull Preventive care medicine
bull Basic and clinical research especially in resuscitation and acute care
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
bull Disaster Planning Consultants
Opportunities
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR Trauma and
Pediatric Resuscitation
o Medico Legal Consultant
Opportunities
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
EM team bullEM Physician
bullPhysician Assistant
bullNurses
bullEMT Paramedics
bullRadiology team
bullAmbulance Assistants
bullMedico-socio worker
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
ER APPROACH
bull EM has unique aspects such as approach to patient care and decision-making
Hidden life threatening issues
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
APPROACHbull Comprehensive history
examinations routine lab
test specific diagnosis
procedures and problem
oriented medical record
constitute conventional
methodology which is
not appropriate in ER
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
APPROACH
Most important
question that must
be answered is
ldquoWHAT IS THE LIFE THREATrdquo
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
A General rule
ldquoOnly 10-20
percent of
people who
present to an
ER truly have
Emergent problemsrdquo
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Three components are
necessary to quickly identify life-threatening patient
Chief complaints
Vitals
V-A-T
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
bull Symptoms
bull Allergyanaphylaxis
bull Medical history
bull Past medical Surgical history
bull Last meal
bull Event
bull Social History
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
VITALS
PULSEBLOOD PRESSURERESPIRATIONTEMPERATURE
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
V A T
ASCULTATE TOUCH
VISULAISE
LOOK-LISTEN -
FEEL
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
bull Vital sign and Chief
complaints when
used as Triage Tools
will identify majority of
life threatened
patients
bull Familiarity with
normal vital signs for
all age groups is
essential
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Beware of the special
groups
Extremes of AgesAthletes
PregnancyPacemakers
Beta blockers
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Approach
The idea of
performing a
complete
examination in the
ED is misleading
because most
frequently a
complete
examination is
neither required nor appropriate
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
ldquoDo an adequate examinationrdquo
amp
ldquoDecide - The patient is stable or unstablerdquo
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Once a life threat has identified
Intervene to reverse the life threat
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
FOCUS
OXYGEN
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Stabilize
As fast as possible
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
bull The DD must begin with the most serious condition possible to explain the patients presentation
bull Not the most common diagnosis
DIFFERENTIAL DIAGNOSIS
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
bull It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED
bull Even in specialties sometimes it will take days weeks or months for the final diagnosis to be made
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
DIFFERENTIAL DIAGNOSIS
ldquoThe role of ED physician is to rule out serious or life threatening cause of a patients presentation Not to arrive at the definitive diagnosisrdquo
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Do
FOCUSED INVESTIGATIONS
TIME
BOUND
And
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Focused Tests bull12 lead ECG should be taken and read within 10 minutes of ED arrival ndash Chest pain
bullFAST - Trauma
bullCT and MRI ndash Stroke Spinal Cord Injury
bullBlood tests and CampS immediately in sepsis and septic shock
bullToxicological survey
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
No role for X-Ray Chest to rule out Tension pneumothorax
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
CHRONIC PATIENTS AND ED
APPROACHES
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
A patient with recurrent migraine head ache on this presentation ERP should rule out the possibility of Acute subarachnoid bleed
ldquoWhat is different nowrdquo
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
HOSPITAL ADMISSION -DECISIONS
bullIs there a medical need that can be fulfilled only by hospitalization
bullDoes the patient need intravenous therapy
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
DECISIONS
bullDoes the patient need oxygen therapy or cardiac monitoring
bullWhether the patient can be safely observed in outpatient setting
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
ED DISPOSAL
bullAdmission to hospital Wards I C U OT etc
bullObservation
bullReferral to specialists
bullED discharge ndashwith advice or against medical advice
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
ED discharge
bull The ED discharge should be with specific follow up instruction which include specific mention of most serious potential complication of the patient condition
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Before discharging the patient from ED
Two Questions should be answered 1Why did the patient come to the ED 2Have I made the patient feel better
Relieve the Physical Physiological and Psychological Pain before ED disposal
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
MEDICALRECORDS
bullOne should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered
bull Must contain appropriate follow up instructions
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
MEDICO LEGAL RECORDS
Writing proper Medico legal Case records Intimating Police Issuing wound certificates are the primary job of EPs
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
EMERGENCY MEDICINE
CRITICAL CARE
Both deal with very sick and injured patients
Both require personnel (doctors nurse assistants etc) who are specifically trained in these respective specialties
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
EMERGENCY MEDICINE CRITICAL CARE
EM personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
Procedural skills are the same for both specialties
Resuscitations and deaths are common in both specialties
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
EM versus CCM
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
EM versus CCM
EMERGENCY MEDICINE
Emergency room
Emergency Physicians
Pre hospital care
Disaster management
CRITICAL CARE
Intensive care units
Intensivists
Not much role
Limited role
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
EM versus CCM
Patients are
unlimited
Short-term management
Spectrum of patients and
Problem is vast
Patients limited by number of beds
Long-term management
Spectrum limited to the specialty of Intensive care Unit
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
EM versus CCM
Diagnosis is not required
Diagnosis necessary and required for continuation of treatment
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
New BranchNew Challenges
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Part BEM inception and growth
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Academics ResearchProtocols
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
When looking back hellip
Sept 21 1979 that
the American Board
of Emergency
Medicine was
recognized as a conjoint specialty
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Emergency medicine had
its beginnings as early
as 1961 when four
physicians in Alexandria
VA formed the first
group dedicated to
providing care in an
emergency department
setting which became
known as the Alexandria Plan
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
September 21 1979
the ABMS Assembly
approved the ABEM as
a conjoint modified
board and included it in
the membership
recognizing emergency
medicine as the 23rd
medical specialty
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
bull Fellowships
bull Certificate Courses
bull Degree Courses
bull MCI
bull NBE
bull Government
bullGovernmentEM
Indiahellip
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
INDIA
bull MCI recognized EM as the 30th Primary specialty in INDIA
bull Another important Milestone
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Part CEM Indian Scenarios
Few issues from day to day practice
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Scenario
bull DrEqbal is fresh graduate scored excellent rank in NEET exam and he is very much interested to join MD EM He seeks a second opinion with his role model professors
bull Medicine professor advised him ldquoDonrsquot take such dirty specialtyrdquo
bull Microbiology professor ldquo What is ithellipI am not aware of such specialty ldquo
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
1 Concept
bull What is emergency medicine
bull Where exactly the boundaries
bull Know your strength and weakness
bull Name of the specialty
Casualty
EMERGECY
ME DICINE
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Specialty has been recognized by MCI on 21st July 2009
It is not Critical care It is not Anesthesiology
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Take opinions
from those persons
who know about it
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Scenario
bull DrVineetha knows about the speciality of Emergency medicine She also knows some courses are available
bull She was so much worried about the placement job responsibilities payments recognition etchellip
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
2 Emergency Physician
bull Qualification
bull Academics and visibility
bull Faculty from other specialties
Involve as much as
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Emergency Physician
bull A specialist who has
been trained to
engage in the
immediate initial
recognition
evaluation and
disposition of patient
with acute illness and
injury
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Emergency Physician
bull ER Physicians do not usually provide long
term or continuous care but they diagnose
a wide range of diseases and perform
interventions to stabilize the patient
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Emergency Physician
bull Attitude
bull Aptitude
bull Alertness
bull Aggressiveness
bull Adaptability
bull Awareness
bull Accomplishment
7 A
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Qualifications
bull MD
bull MCI recognized other specialists like surgery anesthesia Medicine Pulmonologist
bull DNB
bull MEM
bull MCEMFCEM
bull Fellowships
bull PGDEM
MoRe
DEmaNd
Less people
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Scenario
bull 55years gentle man presented to emergency department with giddiness and tachypnea at 2 AM Known case of CAD and APD had stent and on anticoagulant
bull P A to state transport minister and he was not even willing to do initial evaluation
bull He want to see his cardiologist
bull Cardiologist is not taking phone
bull More than 10 bystanders around
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
3 People
bull They are not much bothered about who you are
bull 1000 peoplehellip more than 10000 ideas
bull Competency and care up to their expectations
bull Quality and professionalism
bull Ethics Transparency and Truthfulness
Passionate always
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Scenario
bull 23yr old female brought to ED following RTA Had suspected C-spine injury Humerus and Femur
bull Attending did Primary survey and Secondary survey as per ATLS protocols
bull Later new bystanders started agitation and abusive language for tearing dresses for exposure in Primary survey
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
4 Patients
bull Have a problem and sometimes many hellip
bull Distress
bull Rewards are helliphow fast you make them comfortable
bull Need physical physiological and psychological resuscitation
bull Culture Race and Religion
Bystanders are the real problem hellip
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Scenario
bull 25 year old lady present abnormal behavior and hyperventilation Case was referred from rural Kerala Vitals normal 12 bystander crowding around patient Few of the shouting Some are on mobile phone Chaotic casualty
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
5Premise
bull ER is the front office
bull Good reception lead good care lead to comfort and confidence
bull Plan Performance and Perfection
bull Implement what exactly you want
Be live hellipsave lives hellip
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Pediatric Emergency Medicine
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Family system
Joint family Nuclear family
Ultra Nuclear
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Scenario
bull 5 bedded rural casualty 1 OT No CT facility 3 doctors 6 Nurses One ambulance and 2 ambulance assistants
bull 8 patients brought to casualty following a collision of Jeep versus Autorickshaw
bull 5 Walking patients 1 case with fracture femur of Hypotension 1 case with facio-maxillary injury with obstructed airway and one case fracture dislocation of shoulder
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
6 Team
bull Doctors Nurses Paramedics Ambulance assistants Security hellip
bull Training modulation and empowerment
Team work is the success
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
You can winhellip
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
When resources are exhausted hellip
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Scenario
bull 78 year old lady Known case of DM CKDCAD and COPD presented to ED with SOB and Signs of Sepsis
bull Attending EP initiated early stabilization and contacted different consultants
bull Medical ICU beds are full except crash bed
bull Consultants are not very keen to take case
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
7 Destination
bull When destination is not clear hellip
bull Overcrowding
bull Dumping
bull No man area
bull Multisystem cases and Poly trauma
Protocol based practice
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Scenario
bull 37 year old gentleman brought to Ed with shortness of breath palpitation and dizziness
bull Vital Pulse 210 mt reg BP 110 SpO2 94 RA
bull ECG ndash supra ventricular Tachy
bull Not responding to Vagal maneuver and responds to one dose of adenosine and called cardiologist for expert opinion
bull He shouted to EP like anything and asked to do the rest of the management as well
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
8 Consultants
bull Supportive
bull Incompatible
bull Lazy
bull Egoistic
bull Money
bull Over work Burn out
Evidence based MedicineDo for the best interest of patient
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Scenario
bull 25 year old male presented with Tachypneaand pleuritic chest pain He was just travelled from Washington yesterday
bull PGY2 order D-Dimer
bull PGY 3 objected and they are in Arguments
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
9 Academics
bull Regular academics
bull Multiple levels
bull Different modalities
Teaching is the best way to learn
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Scenario
bull A corporate Emergency department claimed to do good works They reported the they treated 65000 cases per year Resuscitated many cases
bull NABH auditors visited in the department declared that department is not meet the standards
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
10 Quality assurance
bull Regular follow up
bull Documentation
bull Know about the errors and its chances
bull Fix measurable Parameters process and protocol
bull Errors
bull Audit Only way to get into next level
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Assessment-Diagnosis-Treatment-Management-DispositionTriage
Admit
Discharge
EMS
Patient Presentation
ED Design
Triage Cueing
Over crowding
Information Gap
Lab errors
Report Delay
Authority Gradient
Orphaned Pt
Team work problem
Transition of Care
ResourceConstrain
SenseMaking
Affective state
RadiologyError
Fatigue ampShift work
Cognitive properties of the mind
Violation producing factors
Proceduralfactors
Medication errors
InadequateDischarge Plan
Long waiting time For Bed
Follow upfailures
Sources of Failures and Errors in ED
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Acad Emerg Med 2000 Nov7(11)1204-22Promoting patient safety and preventing medical error in emergency departments
Schenkel SAuthor information
AbstractAn estimated 108000 people die each year from potentially preventable iatrogenic injury One in 50 hospitalized patients experiences a preventable adverse event Up to 3 of these injuries and
events take place in emergency departments With long and detailed training morbidity and mortality conferences and an emphasis on practitioner responsibility medicine has traditionally faced the
challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners Yet no matter how well trained and how careful health care providers are
individuals will make mistakes because they are human In general medicine the study of adverse drug events has led the way to new methods of error detection and error prevention A combination
of chart reviews incident logs observation and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order
review In emergency medicine (EM) error detection has focused on subjects of high liability missed myocardial infarctions missed appendicitis and misreading of radiographs Some system-level
efforts in error prevention have focused on teamwork on strengthening communication between pharmacists and emergency physicians on automating drug dosing and distribution and on
rationalizing shifts This article reviews the definitions detection and presentation of error in medicine and EM Based on review of the current literature recommendations are offered to enhance the
likelihood of reduction of error in EM practice
PMID
11073469
[PubMed - indexed for MEDLINE]
bull108000 preventable deaths from iatrogenic injuries per yearbull1 in 50 hospitalized patients experiences preventable adverse events bull3 from ER
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Finally hellipThe most important Tool of ER
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Communication
Communication
Communication
Communication
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Summarizinghellip
hellipLook at the picture
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
Look and relook
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
EMERGING
EMERGENCY
MEDICINE
Thank you so much
wwwdrvenunet
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