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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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