Emergency Medicine Update 2018

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The training program in Emergency Medicine is quite new in Pakistan. College of Physician and Surgeon (CPSP) recognized Emergency Medicine as a field in 2010. Since then although progress has been slow but it is in right direction. Two programs started training and it was difficult to move forward initially, with plenty of disappointments and setbacks were dealt with by equally powerful team work and enthusiasm. These two programs became the pioneers and slowly the number of programs started increasing. As of November 2018 now we have 7 programs and two programs waiting to be accredited. We have 7 FCPS trained Emergency Physicians emerged now, as final product of the training and a busy training pipeline of about 90 trainees in various years of training.

We have a robust faculty of Emergency Medicine at CPSP, whose work is to find ways to improve programs, improve curriculum, develop examination and also conduct the examination. During this period we were able to create more supervisors of the training and from a meagre 5 supervisors in 2011 we now have more than 15 supervisors.

Our work in the field of Emergency Medicine have reached new heights and some of our trainees spend last 2 years of their training in either Ireland or England. After spending two years they came back to Pakistan and are eligible to appear in FCPS part II Emergency Medicine. We have now 07 FCPS Emergency Medicine Physician including 01 female physician.

We have a budding society of the Emergency Medicine staff called Pakistan Society of Emergency Medicine (PSEM) , established in year 2017 conceptually it was formally registered in year 2018 to serve the physicians and nurses of the Emergency Department. The society aims to give platform to discuss ways of enhancing training of Emergency Medicine and its spread in public institutions of Pakistan. It also strive to bring education and skills to people and serving in the emergency department in all public or private hospitals.

The international interest can be seen here now in terms of job opportunities and training posts for physicians working in emergency department. Also we see the interest of foreign emergency medicine faculty of Pakistani origin to come to Pakistan and provides skills to local physicians. Although the effort are not well directed still the level of interest is warmly welcome. It helps to enhance the basic skill set of the people working the emergency departments. Being a resource poor country we may not have expensive equipments but we can develop important lifesaving skills to provide reasonable care to all patients of the emergency department.

In the near future I expect more targeted efforts from within the country as well as outside. I feel UK physicians and especially Royal college of Emergency Medicine can play a very positive role in enhancing the capabilities of the people working in the emergency departments of Pakistan. Our enhanced capabilities will be our assets to be utilized for the treatment of common citizen in times of extreme need in the emergency.

Research review process

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Abdus Salam Khan, MD FACP
October, 2018
The medical field improve through the research work of plenty of people. They work hard in making their work known to the other physicians and so they are the reason for the medical field to progress. Their work creates the basis for the guidelines and improvement of the care delivered to the patients. Their work done usually goes through a rigorous process of critique and review before it could be printed in various journals to be considered worthy. It also goes through another round of critique after it get printed, so only those kind of work is accepted as guideline making work which is gone through extensive review process.I have taken this opportunity to write about this aspect of research where the work done by the researcher is enhanced further to make it more focused to create a greater difference in the practical implication of the research.What happens when the researcher finishes the work and tries to get that published. After the article is submitted, it has to go through the peer review process. The editor of the journal takes the role of directing that process till the point that the editor is satisfied that it is fit to print. This work is done with the collaboration of the researcher and the reviewers. So looking at the process after the research work we can create a list of most important people involved in bringing it to the readers. It includes:

  1. The researcher or the author.
  2. The reviewer.
  3. The editorial board.
  4. The Editor.

Let us look at these roles in a bit detail.

  1. The researcher/Author.
    • The author or the researcher is the main person everything revolves around. He/she does the most important work or creating an idea and making it happen to produce a paper or research. The effort can be done by a single person or a group of people. Only those people should be claiming the credit for the article who has any meaningful contribution into the creation of the research or the writing of the article.
  2. The reviewer.
    • The reviewers usually are the subject specialists who look at the work of the author or researcher and critically appraise it. They help the author find if there are any flaws or mistakes that can be corrected before the article reaches the audience. They are the helpers both for the author and the Editor to review the article as an expert of the subject. They can attain this value by either their clinical experience and work on the similar area as of the author or by virtue of their work in the relevant field of review. Sometimes two or three people need to review the article if it is so required like a subject specialist and a statistician.
  3. The editorial board.
    • This comprises of team of individuals that work directly with the editor to develop the journal and promote new initiatives. The editorial board is crated by invitation. The editor invites those individuals who he thinks are aligned to the journals idea and will work as the team. The editorial board routinely shuffles and individual people come and serve on the board for a specified period of time and leave to make room for the new members. There is no set member for editorial board and so it varies from journal to journal. The editorial board sets the direction of the journal with the help of editors, they promote the research and they also broaden the expertise the journal has to help the decision making process of accepting or rejecting the research.
  4. The Editor
    • The editors are the critical readers and the lovers of the words.They have the most important duty of making sure that the articles that are published are well polished and refined and so their readers gets the best research. They seek the value in the work of the author and make it further presentable. They help the author to make his/her work clear and precise, improve the flow and clarity and correct any mistake.

Now that we understand the people involved in the process of review and bringing research to the audience through the journal, let us see the process in a bit detail.

Peer review process.

Peer review is done in a defined way with the editor directing the process. It is designed to assess the validity, quality and relevance to the strategy of the journal. Its ultimate purpose is to maintain the integrity of science by filtering out invalid or poor quality articles. It is in the best interest of the journal and the publisher to make sure that the best articles and best research is presented through the journal so they can create a name for the journal and also help the audience rely on the information presented.

How to do peer review

The process of peer review maybe double blind or single-blind or open. It means the reviewer does not know the author, or they both don’t know the identity of each other or the identity is revealed. These are ways to decrease the bias of the reviewer towards the researcher or the article presented.

Editors mediate all the interactions between reviewers and authors and try to do it in the best way they think can serve the purpose. The process may have an informal structure or a formal structure. The editor looks at the article and sees if it is aligned with the policies of the journal and the research is aligned with the scope of the journal. They normally check the articles to see if they meet the minimum criteria for publication in the journal and if not then they can send some of the articles for additional work by the author in order to maintain the quality of the journal. Once gone through the eyes of the editors and deemed acceptable, the editor sends the article to the best person the editor think should review this. Now the article comes in the hands of the reviewer. Following the invitation to review the reviewer acts as the helper for the editor as well as the author is adding value to the article. They do it by a methodical way so they can give good feedback to the author on areas that need improvement.

The reviewer makes sure that the main question is addressed by the researcher and is relevant and interesting for the readers of the journal. Then they see if it is well written and free from any grammatical mistakes or factual errors. They also see if the conclusion is consistent with the evidence and argument presented. If the paper includes tables and figures, what do they add to the paper. They also look into the article by the way of the title properly reflecting the subject of the article. The also look at the abstract to see that the abstract provides an accessible summary of the paper and that the keywords accurately reflect the content.

If it’s a research article the authors should have included ethical statement regarding permission for the research to be conducted but also if human subjects involved it is also important to include a statement concerning protection of the research subjects. It is good practice to ensure that authors have considered all the open guidelines for the journal in relation to the article structure and content.

The role of the editorial board.

The editorial board offers their expertise in their own area and judge the article for the alignment to the policies of the journal. They work with the editor to ensure ongoing development of the journal and also addressing the hot topics of the present time. . They also recommend a conference which would help promote the research and presenting to the public. They also attract new and established authors an article submission, and also  submit some of their own work for consideration ensuring that there are no conflict-of-interest. It is important that the editorial board have a regular communication either face-to-face in person or through other medium.

If it’s a research article the authors should have included both and ethical statement regarding permission for the research to be conducted but also if human subjects involved it is also important to include a statement concerning protection of the research subjects period

It is good practice to ensure that authors have considered all the open guidelines for the journal in relation to the article structure and content.


The scientific and clinical research is presented to the audience through the medical journals. The content of the journal follow the policy of the journal and through its editors and editorial board. The contents are selected by the editor and then it goes through the peer review process. The reviewer does extensive critique both for the scientific validity and the construct to make sure that when it gets printed it should be well written in the language of the journal with a good abstract. It should fit within scope of the journal and should add to the established knowledge on the topic. The review process should make sure that it results in positively elevating the level of research article and body of knowledge of the author and resulting in better article published in the journal.

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Why it is necessary to improve the emergency care, and how can we do it.

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Abdus Salam Khan, MD FACP
September, 2018


Since the change in power has taken place in Pakistan, every concerned citizen has hope that a change in government will bring more possibilities for the improvement. We as the torchbearers of emergency care in Pakistan also are hopeful for the change. We feel that improving emergency care is in the best interest of the citizen of Pakistan and is a genuine demand from the new government. Being the president of the society of emergency medicine I am giving these suggestion with the benefits insight that are not just far reaching but also very workable and basic in nature.

Almost all of us has the uncomfortable experience of visiting the emergency room some times in our life time. I talk to plenty of people and it is easily understood that the experiences of people across Pakistan are more or leas the same when it comes to emergency care. The day that someones gets sick to the point that a mere visit to the local doctor is not enough and the specialist can not be seen is usually a dreadful day. Not because of the disease process but the ordeal that the patient and the attendants have to go through. The long line and the wait, then the junior most doctor treating without proper manners of care. The lack of staff and the lack of concern. This list is quite exhausting. Now rather than looking into the culprits and wasting our energies we should look at the ways to improve this system.

We at the level of society have discussed these issues and have good grasp on what can be done. We will give a workable outline for anyone to pick these and start building on it. These points are mostly known to the world and have been tested and have proven value.

Although there can not be two opinions regarding the need for the trained people looking after the sick in the emergency department, but where would those people come from. A massive reverse brain drain is not unthinkable but not practical as monetarily we are not able to attract physicians who are trained. We also can not ignore the current work force providing the care presently in our emergency departments. We need to think about short courses, medium courses and regular length courses in emergency care. These courses will be easy to built and be delivered across different modalities of teaching like lectures over internet, web sessions and podcasts. This way we can have a quick update in the capacity of our emergency room doctors. This will utilize our current staff and thus will lead to improved satisfaction of already working but neglected physicians.

The second yet most effective intervention is triage. A triage when done by trained nurse is the most effective tool to minimize the risk. It improves the satisfaction and decreases the risk of bad outcome by early recognition and providing care to the most sick. It has been shown that death of an untreated patient is the most devastating event that the emergency departments deal with. So picking these patients quickly and treating them not just improves the outcome but also results in increased level of trust and satisfaction regardless of the outcome. And the best way of sorting people out is triage whether we follow American system or the British.

After these important interventions we can think about other ways to improve emergency care in Pakistan. It includes but not limited to:

  1. Attracting emergency physicians from outside world with attractive salary packages.
  2. Improving district and tallaqa level Hospitals emergency department by staffing trained nurses and providing them with basic equipment which should be clearly defined at the highest level.
  3. Routine data collection of the workload including the severity of the patients presented to the emergency departments to adjust the equipment, supplies and the personnel serving at these hospitals.
  4. Supporting City area Government Hospitals in their bid to start the residency of Emergency Medicine. Help them have the manpower in the emergency department to achieve this level.
  5. Help incorporate emergency medicine into undergraduate level education, so awareness is created regarding the emergency care.
  6. Start mandatory audit is all emergency departments, across the nation. Begin with basic level audit and then start with a bit more complex ones.
  7. Do patient care surveys and the patients opinion survey to see the level of satisfaction. This is to motivate the emergency staff and then show if there is any improvement at the care improve the satisfaction level.
  8. Take the consultation from the thought leaders of the emergency medicine in Pakistan including the Society of Emergency Medicine. (PSEM)

There can be plenty of suggestions that can be put out, but all require persistent and Government level efforts with input from the people working in the field. It is doable and has been done at the private institution level. Support at the education and training front is extremely important and is the need of the hour. My hope is that the new Government will see this as an opportunity to bring Pakistan ahead in the emergency care among the SAARC countries and become a leader. We have a reasonably good chance in leading our region when it comes to emergency medicine.

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