Improving delivery of our patient care

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Abdus Salam Khan, MD FACP
July, 2018

When patients present to the emergency department, they put their trust in the hands of the treating physicians and expect better care delivery and eventually outcome of the treatment. Ethically physicians are expected to do no harm and go good to the patients. The emergency department care delivery is no different than other aspects of medical care, yet due to its work flow and acuity of the condition, pose a very challenging situation for the physicians and nurses.

The situation is further complicated by our broken healthcare system in general when we go through patients after patients. Patients with limited history, delayed presentation, cost constraints and undue expectation. Lack of trust in the system further complicates the situation. Faced with all these negatives, how can we still improve the care delivery and be morally sound.

As physicians and nurses the burden is on us to set the environment that is safe for the patients, their attendants, ourselves and also our institutions. We need to create the trust between all involved in the care delivery. This is the most essential part of the care delivery and requires verbal and non-verbal communications as well as life saving competencies.

Our current system of emergency care delivery relies on junior and untrained doctors and nurses for the initial care of the patients. The emergency departments lack experienced and trained physicians and nurses, thus contributing to the lack of trust by the patients on the system of care in the emergency departments. It is also a painful fact that the emergency departments are usually less staffed while dealing with enormous load of patients and among those the sick patients also. Physicians and nurses are forced to do multitasking with most sick and be understaffed thus resulting in constant threats of bad outcome and disaster, which will further complicate the situation.

In order to improve this delivery of care so the care would be safe for all those who are involved in care delivery, it is imperative that we have a multipronged approach. In the center of all the care delivery rests the effective communication. In order for the communication to be effective, we need to have clear understanding and a team based approach. Our treating doctors and nurses should have a clear idea of the task at hand and know the population that they practice in. There is no short cut to the understanding about your own patient mindset. If we know how to approach the patient and do effective communication then we have done justice to the situation.

I am not discrediting the value and need for the scientific knowledge, but in the emergency department, this scientific knowledge is the necessary companion but not the most important tool for the effective care. The doctors and nurses working in the emergency department should definitely be knowledgeable and have to keep updating their knowledge through continuous learning process.

It is also must that the people working in the emergency department should be taught ways of effective communication and also be taught about situational awareness. The outcome of the medical treatment is not always predictable, but our response to it should always be. That standardized way of dealing with the emergencies result in effective delivery of care regardless of the result.

In the end, I like to stress again on acquiring competencies in effective communication and situational awareness. Our patients expect this from all of the people working in the emergency departments.

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Value of Research/evidence based treatment.

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Abdus Salam Khan, MD FACP
June, 2018

Emergency departments across the world provide care to vast spectrum of diseases and conditions. The teamwork required to provide the care needs to be safe care delivery especially to the most sick. As the pace of activity in the emergency department is quite high and too many decisions are made in too short span of time, it becomes more prudent to have a mechanism to ensure safety. To an outside person what seems like a chaos is all routine work to the ED staff.

As the custodian of the emergency care we all strive to be safe yet efficient, and achieving this balance is always important. Creating evidence based pathway driven care has a time tested and proven worth. All treatments that have shown benefit should be utilized and all modalities shown harm should be avoided.

These evidences come from meticulous reporting by the treating physicians, in terms of case reports, observational studies and the clinical trials. The collected data and body of information proves worthiness as well as provide treatment guidelines for the physicians. The value of research is thus in the worthiness of this body of evidence or information. If the research data is not good enough then the results will not be better by any chance. This leads to categorization of the research material into high quality and low quality evidence. Similarly according to relevance it will be highly relevant or irrelevant research. Different institutions create this system and people understand how to look at the research and what to take from it. The bottomline is how to use the research at the bedside in a meaningful way. This whole practice of medicine is called evidence based medicine (EBM). It should be at the core of our clinical practice. It comprises of the ability to trackdown in meticulous fashion and then critically evaluate the body of research and come up with the ways to update the practice of medicine.

It is always difficult to bring research to the bedside and do it is a safer and effective ways. We have to keep ourselves updated and then pick those features that have proven value and which are relevant. The institutions have this role to get into habit of developing strategies to stay on top. Review articles, bestbets, Cochrane review and clinical debates in journals are some of the ways the thought leaders bring academic or clinical research to the bedside.

As treating physicians we also have the duty to help in creating this evidence by participating in ways of documenting our practices and outcomes. Through case reports and prospective as well as retrospective studies, we let the other physicians know what has worked in our practice and what has not. Meticulous and correct data collection is one of the ways to keep our patients safe.

Last thing is the way we practice EBM. As explained above we utilize the uptodate evidence, and then we should involve the most important component of our practice, which is the patient himself. The preference of the patient and his or her customs and values should be carefully matched with the evidence and then the physician uses his/her experience to lump everything together. The treating physician has the greatest role in safeguarding the patients interest at the same time instituting the best treatment option available through keeping him/her uptodate regarding the treatment options.

Our patients rely on us for the best opinion, and we should reciprocate by practicing EBM (evidence based medicine).

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Poison Control Center

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Abdus Salam Khan, MD FACP
May, 2018

Doctors working in emergency department across the world see patients with drug overdose or poisonings and at times feel inadequate in properly managing those patients. They sort out books or call colleagues to get a hint of what could be the safe way of managing these patients.  Where can they turn if all they come across such situations. In the industrialized world, they call there poison control centers.

What is poison. Poison is a substance with an inherent property that tends to destroy life or impair health. And the science of dealing with the effects, antidotes, detection and control of poisons is called toxicology.

A poison control center is the medical facility that is able to provide immediate, free, and expert treatment advice and assistance over the telephone in cases of exposure to poisonous and hazardous substance.

The world started realizing the value of providing right information at right time to the treating staff. In Europe special poison units were started in 1940’s. First such center was initiated in North America in 1950s. Since then numerous centers are there, but mostly in industrialized countries. The task of these centers were well defined and limited to poison and injury information and care.

In Pakistan National Poison and Drug information center was initiated in 2012 in JPMC as Public sector. The JPMC service is run by one doctor, one nurse and one Pharmacist in a shift pattern. There is another public sector poison center in Faisalabad. Now there are two private sector poison information services providing information, one in AKUH( Aga Khan University Hospital) and other by Pharma company by the name of Pharmassist.

Functions of PCC (Poison Control Center):

It is a specialized unit providing information regarding poisoning to the whole community. It acts to provide toxicological information and advice and manages poisoning cases depending on the capability. With proper data collection, it can provide analytical input as well as Pharmacovigilence. The center can also be very instrumental in providing training in prevention and treatment of poisoning. There is also a good role in contingency planning and responding to chemical disaster.

Need for the PCC (Poison control Center):

Because of the poisoning case load there is a need for early and right treatment of exposed patient. It includes providing right information to patients or their relatives with toxic or poison substance exposure. The data collected serves as Toxicovigilence for the whole community. These information given in right time and through good and sound information service can avoid expensive treatments by going to emergency departments unnecessarily.

PCC(Poison Control Center) or DPIC (Drug and Poison information center) can be initiated and run by either a hospital or university, or it can also be part of the public health service.


Poison control centers provide excellent service to the population. Poison control centers are needed for the surveillance, and recognition of the pattern of poisoning in society. A drug information service is necessary component of any health care system, as it tends to provide necessary information to the general public to keep them safe.


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