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Heat wave emergencies.

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Abdus Salam Khan, MD FACP
July, 2019

Global warming causes weather changes and one of the width is the heat waves. The resultant public exposure to this heat wave phenomenon can be very diverse dating. The experience of 2015 in Karachi tells us that we all need to be ready if something of that magnitude happens again. Today we will discuss the medical and other aspects of heat waves and see how we can act to make other patients safe.

Hit with don’t have any strict definition but defined around early 1900s it was considered as “. Of excessive hype temperature lasting at least one day, but conventionally last for many days to several weeks”.
The criteria varies from area to area based upon its usual temperature, so a temperature of 32°F may be excessive for Canada but the usual day in Pakistan. What is the heat index when the hot temperature associated with humidity then the temperatures feels like higher than it’s actually is. This is called heat index. The same temperature with humidity may feel very pleasant but with extreme humidity can be very bothersome. These extreme conditions causes different clinical issues and can be summarized as following.

A) Heat rash
B) Heat edema
C) Heat cramps
D) Heat syncope
E) Heat exhaustion.
F) Heat stroke.

Of all the above the most significant are the heat syncope, heat exhaustion and heatstroke as they can be life-threatening. The mechanism responsible for defects are following.

1. Direct cell damage from the temperature
2. Multi organ failure due to volume depletion and the cell death causing inflammatory response.
3. Volume depletion due to excessive fluid loss.
4. Electrolyte disturbances due to improper replacement of salt.

Patients who are exposed to the heat wave can show signs and symptoms of exposure to excessive and prolonged heat or may also show exacerbation of or complications of their already present medical issues. For an emergency doctor it can be a challenge to separate out heat related issues from other medical illnesses, and also to think about the effects of heat exposure on the illnesses.

Our emergency departments should be in tune with the weather service to have first hand info regarding weather related issues, so the emergency departments should be ready to deal with the patients exposed to weather conditions whether it is extremely cold or is very hot. It is also a dream that our emergency departments need to be integrated with each other in such a way that right information can be disseminated within appropriate time, so our patients can get the maximum benefit and feels safe coming to the emergency department for the treatment.

Pakistan Society of Emergency Medicine is finalizing the recommendations and the guidelines for the emergency physicians of Pakistan to deal with the patients exposed to heat waves. These recommendations are based upon the local experiences and consensus opinions of Pakistani Emergency Physicians and as they are local oriented, these are very relevant. It is also important to point out that these guidelines are based upon local resource information and that all these recommendations can be accomplished in any emergency department of the country.

My hope is that our emergency physicians will consider these guidelines when they deal with patients suspected of having heat related exposure. Guideline based treatments will be safe and also standardized.

I can be reached at askhan65@yahoo.com.

Starting of EM educator.

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Abdus Salam Khan, MD FACP
May, 2019

Although we usually think the treatment of any condition is the responsibility of the doctors, yet it is well understood that a well educated patient about his disease or condition has a better chance of dealing with situation in much better and calmer way. (1)

In the spirit of being educator to the doctors themselves it is our duty to teach patients also. We do it through one to one teaching at each visit, which is the proper way of educating the patients by the doctors regarding their illness.(2) With the same spirit, through all kind of print and other electronic media the common man or the public is expected to be informed regarding their health and different aspects of sickness and disease prevention.

There is enormous need to educate people in terms of prevention and also treatment aspects in emergency situations. As a veil of focus is mostly emergency care, so we decided to educate people regarding aspects of emergency care and the process of treating the patients in emergency departments. This can, not only give them a perspective regarding emergency conditions, but will also enhance the understanding regarding steps of treatment. Afterall the medical decision making should be a shared responsibility of the physicians and the patient and the caregivers, as addressed by Chen et al in Dec 2016 in Academic Emergency medicine. (3)

It is our desire to have such an impact through education that the people should be aware of the steps to avoid the disease and sickness, and if they get afflicted with any condition they should be able to understand the way forward to deal with it as an informed patient. It will enhance treatment outcome and improve the level of satisfaction, decrease the burden of stress on the system. The education is being imported through the use of Internet and then through the social media. We have used the local language through short video messages and visuals to let people absorb the complex steps through stepwise approach. You can see that at YouTube as the EM educators channel. Our efforts are to match the needs of the patient with the required knowledge to make the illness as less problematic as possible.

The EM educators channel had been planned to be interactive in the way that the questions of the audience will be entertained regarding any topic that they feel the need to know more about. We will also include other specialties like cardiovascular diseases, neurology, gastroenterology, surgery and other aspects of treatment to give advice in the matters relating to the emergency situations. Although we have not seen any evidence in the emergency department regarding this but Irewall et al in Jan 2019 has shown the value of telephone based prevention in cases of follow up in TIA/ Stroke. (4)

I would hope is to educate our citizen and the people of the region and to fill the knowledge gap. We would appreciate your input and advice in this regard.

I can be reached at askhan65@yahoo.com.

References:

1- Paterick TE, Patel N, Tajik AJ, Chandrasekaran K. Improving health outcomes through patient education and partnerships with patients. Proc (Bayl Univ Med Cent). 2017;30(1):112–113.

2- Education for health promotion and disease prevention: convince them, don’t confuse them.

Beitz JM. Ostomy Wound Manage. 1998 Mar;44(3A Suppl):71S-76S; discussion 77S. Review.

3- The Role of Education in the Implementation of Shared Decision Making in Emergency Medicine: A Research Agenda. Esther H. Chen MD, Hemal K. Kanzaria MD, MSc, Kaoru Itakura MD, Juanita Booker‐Vaughns MaED, EdD, Kabir Yadav MD, Bryan G. Kane MD, https://doi.org/10.1111/acem.13059

4- Trials. 2019 Jan 15;20(1):52. Nurse-led, telephone-based secondary preventive follow-up benefits stroke/TIA patients with low education: a randomized controlled trial sub-study.

Irewall AL, Ögren J, Bergström L, Laurell K, Söderström L, Mooe T. doi: 10.1186/s13063-018-3131-4.

Quality improvement programs in Emergency Department.

Posted on by Abdus Salam

Abdus Salam Khan, MD FACP
May, 2019

Patient care is a team work especially in all emergency departments. It is because of the fact that the care is dependent on multiple factors. The patients are either unstable or have the potential to become unstable. They may be in pain and need immediate relief. There is always a mismatch between the Emergency Department resources and the load of the patients presented to it. Many tasks of different nature happening at the same time in a limited space in the emergency. Sometimes it is rightfully labeled as mini-hospital within a hospital. (1) (2)

People who work in the emergency departments know that it is a very complex task and providing care is not easy. The difficulty is both on the clinical as well as non-clinical fronts. On the clinical front it is the broad-based problems presented to the emergency care that has to be sorted out quickly thus requires a physician and nurse staff that is well versed in all most all disciplines from Pediatrics to gynecology to neurosurgery. On the non-clinical front, it is equally daunting task to make sure that all the work is done smoothly. Starting from the availability of bed in the emergency to the electricity, water and stationery on one hand and then all functioning equipment to availability of ward and ICU beds on the other hand, is all considered equally important.

The patient satisfaction hangs well in balance due to the interplay of all the above factors and then some more. The satisfaction depends upon the quality of clinical care as well as the process of care delivery. Improving the quality will improve the satisfaction. Although a good team of physicians and nurses who are well trained in emergency care would mean provision of better care, yet there is always room for the improvement(3). Similarly improving the process of care delivery improves the satisfaction.
Every modern emergency department should have a program of quality improvement. This way the ED assures that the care delivered is of the highest quality and that the points of care which require enhancement are identified and being worked on. There are plenty of quality improvement ways, like the PDCA cycle (Plan-DO-Check-Act), Six Sigma and lean management and plenty of others. These process improvement modalities work within the system and show the result by improving the process and decreasing chances of error. These work as a continuum and with the completion of each cycle the system is improved and then the people continue for the second cycle to improve it further. (2,4–6)

In the emergency departments across the world there are plenty of processes that need continuous improvement and so the emergency department staff takes these projects as part of the self-improvement as well as part of the improvement of patient care, and make it a lifelong commitment. This way the safety of the patients is ensured and there is trust of the patients and satisfaction level with the system. Without the trust the whole care is compromised. (7)

Quality projects that the people working in the emergency department can choose like outcome based audits and studies or satisfaction centered audits. In outcome based studies, we see different mon satisfaction centered audits, we see how satisfied the group of patients were with the care they received in the emergency. Both types of studies actually aim to look into the areas and points where improvement brings satisfaction to the patients and also can lead to better outcome. (7)(8)

Our emergency department should adopt these ways to improve the care and make it safe as well as trust worthy for our patients. Being a leading emergency department of Pakistan, we are hoping on the quality improvement journey to get all the benefits of improved and safe care for our patients as well as to teach our newly trained residents the mindset needed to provide the safe and effective care. We also plan to teach these initiatives to all our fellow emergency physicians across Pakistan so that what we feel is the benefit for all should come to all in the literal sense.

I can be reached at askhan65@yahoo.com.

References:

1. Gagel BJ. Health Care Quality Improvement Program: a new approach. Health care financing review. 1995;16(4).

2. Lattimer V, Brailsford S, Turnbull J, Tarnaras P, Smith H, George S, et al. Reviewing emergency care systems I: insights from system dynamics modelling. Emergency medicine journal : EMJ. 2004 Nov 1;21(6).

3. Wilson M, Welch J, Schuur J, O’Laughlin K, Cutler D. Hospital and emergency department factors associated with variations in missed diagnosis and costs for patients age 65 years and older with acute myocardial infarction who present to emergency departments. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2014 Oct;21(10).

4. Dellifraine J, Langabeer J, King B, King B. Quality improvement practices in academic emergency medicine: perspectives from the chairs. The western journal of emergency medicine. 2010 Dec;11(5).

5. White BA, Baron JM, Dighe AS, Camargo CA, Brown DFM, Brown DFM. Applying Lean methodologies reduces ED laboratory turnaround times. The American journal of emergency medicine. 2015 Nov;33(11).

6. Maniago E, Ardolic B, Peana J. ED Patient Flow: Utilizing the Six Sigma Approach to Reduce Emergency Department Overcrowding. Annals of Emergency Medicine. 2005 Sep 1;46(3).

7. Boudreaux ED, O’Hea EL. Patient satisfaction in the Emergency Department: a review of the literature and implications for practice. The Journal of emergency medicine. 2004 Jan;26(1).

8. Arts DGT, de Keizer NF, Scheffer G-J. Defining and improving data quality in medical registries: a literature review, case study, and generic framework. Journal of the American Medical Informatics Association : JAMIA. 2002;9(6).