NEPAL DISASTER AND EMERGENCY MEDICINE CENTER
	Vol 1	Number 4	May/June 2008

Editorial:

NEPAL DISASTER AND EMERGENCY MEDICINE CENTER (NADEM) is organizing 4th NADEM CME (Continuing Medical Education) for the doctors, nurses, paramedics and medical students working in Emergency of different hospitals in Nepal on Saturday, June 21, 2008 in Kathmandu. From this CME onwards NADEM center designs the Post CME Trainings for the participants according to their demand for day to day practice in their duty in the Emergency Department.
Disaster and Emergency Medicine is emerging specialty in this World with everyday occurrence of natural and human made disaster and emergencies. It is a need of training health workers to combat the present health situation of disaster and emergency in the country. Every health workers in the Emergency Department is experiencing a great deal of patient load to care immediately which needs high skill in this field. And, the expectation of the people is also high irrespective of problems that need to tackle by individual to team of health worker immediately. Moreover, it is also important to deal the situation by good communication skill which is very much challenging is such situation. Therefore it is important to develop good “Health Worker–Patient-Party (HWPP) Relationship” by good communication skills especially in every Emergency Department.
We need to learn from the natural disasters from Indonesia, China, India few months ago and human made disasters like bomb blasts in Sri Lanka, Pakistan. These events think to ask – ARE WE PREPARE TO TACKLE IF SUCH DISASTERS OCCURE IN OUR COUNTRY? Let’s hope and pray we won’t have such situation but we need to be prepared for any situation also. It is also important to know about Mental Health and Psychosocial aspects of the victims after such disaster and emergency occur. Hence, NADEM CME comes to make aware and updates on Disaster and Emergency Medicine even on very limited matter. We hope everyone join hand in hand to develop this field to combat the unexpected disasters and emergencies.
We would like to thank you United Kingdom friends – Dr. Robert Crouch, Dr. Ross and Sr. Grant for their most valuable effort to support NADEM CME providing the needful training materials. From 4th NADEM CME we are conducting Post CME Training with help of those available resources. We also like to thank you Chief Guest Dr. Govinda Prasad Ojha, Director General, Department of Health Services, Nepal Government, chairing the 3rd NADEM CME to make it grand success. We also express our heartfelt thanks to DJPL and members, guests, international elective students and all the participants. We believe “Together we can change Tomorrow”.

Note Writing in Emergency Care
Dr. Ramesh Aacharya*

What is note writing?
Note writing is documentation of the patient information which includes -

• History
• Clinical examination
• Investigations
• Treatment
• Advice and education

Importance
Note Writing is of utmost importance at all levels of healthcare. Documentation is the only proof that will last. There is a saying “Not documented = Not done”. It is the communicating tool with colleagues as well as clients. Writing good notes will facilitate the future activities like legal issues, medical audit and research.

Emergency is one of the more popular specialties among junior doctors because of its relevance to so many career paths and learning opportunities. Adverse events affecting patients are common but at times, these are understood by the public as cases of negligence.

Furthermore, documentation is more important in our emergencies because:

• Emergency rooms are always overcrowded and it is hard for us to recognize our patients.
• Patients are not admitted on time and we need to handover them to our colleagues.

What Makes Writing Effective?

1. Clear Objectives: In case of emergency care, our objective of note writing is to have a comprehensive document which gives a glimpse of the condition of the patient and the care provided. Thus, when another colleague reads it, he/she will have a clear understanding about the patient. Similarly the prescription is well understood by the pharmacist as well as the patient. Another objective is to utilize it for legal issues (of course, legal protection), medical audit and research.
2. Good organization: The notes should be clear, brief and concise. At times, arts or figures help in better understandings.
3. Appropriate language, correct spelling, grammar and punctuation.
4. Variation: The standard of documentation varies widely among individuals and may vary depending on physical or mental state, the time of day, and the number of patients seen.
5. Clinical documentation in a standardized format helps to improve patient care and provider communication.

Golden rules for note writing in medical care

1. The notes must be legible.
2. No record = not done.
3. Relevant negative results are as important as relevant positive results.
4. Never use derogatory or insulting terms.
5. Document the results of investigations.
6. Give your diagnosis.
7. Have a clear management plan.
8. Outline procedures performed. Record adverse events.

Legal implications:
The medical notes are a legal document and the importance of good note keeping can never be over emphasized. The first thing to note is the date and time that you saw the patient. Writing notes is constructing medical defense so that it ensures the careful consideration of all aspects of the case. It is human to err which applies to medical notes as well but unfortunately, this may not be an adequate defense for alleged malpractice.

References and further readings:

1. A P Gleeson How to write good accident and emergency notes http://student.bmj.com/back_issues/1196/st11ed1.htm
2. Casamento AJ, Dunlop C, Jones DA, Duke G. Improving the documentation of medical emergency team reviews. Crit Care Resusc. 2008 Mar;10(1):29.
3. Szauter KM, Ainsworth MA, Holden MD, Mercado AC Do students do what they write and write what they do? The match between the patient encounter and patient note. Acad Med. 2006 Oct;81 (10 Suppl):S44-7.
4. Grogan EL, Speroff T, Deppen SA, Roumie CL, Elasy TA, Dittus RS, Rosenbloom ST, Holzman MD. Improving documentation of patient acuity level using a progress note template. J Am Coll Surg. 2004 Sep;199(3):468-75.
5. Rothschild AS, Dietrich L, Ball MJ, Wurtz H, Farish-Hunt H, Cortes-Comerer N. Leveraging systems thinking to design patient-centered clinical Documentation systems. Int J Med Inform. 2005 Jun;74(5):395-8.
6. Graham DH. Motivation for documentation. Emerg Med Serv. 2004 Nov;33(11):39-40.
7. Harkins S. Documentation: why is it so important? Emerg Med Serv. 2002
   Oct; 31(10):89-90, 93-4.
8. Graham DH. Documenting patient refusals. Emerg Med Serv. 2001 Apr;30(4):56-60.
   * Coordinator NADEM, Email: raacharya@health.org.np

Doctor-Patient Relationship in Developing World
Shrestha R., Acharya R.

In developing world like Nepal, this culture still prevails and lagging far behind (the author observed how grave the situation is), a paradigm of primitive physician-patient relationship. Traditional medical practice has an unequal power relation: the doctor in the superior position and the patient in the helpless and often, hapless role (1), which is still in its zenith. The patient has to abide by the rules formed by the doctor, withstand the scolding even for their own indecipherable advices and management. Though patients are paying skyrocketing price for the treatment, doctors treat with misconduct, irrationally, and rudely and there are no strong controlling forces though there is code of ethics laid by authorities of the world over(2).
Scenario One: “Doctor Sahib what is happening with me? Will I be fine after the operation?” a hoarse voice raised the questions meekly. A grumpy doctor spoke in return in brusque tone immediately before the questions end, “I have given the date for the operation, you’re having the cancer, and don’t ask to repeat myself again.” That poor man is anxious and frightened. He is alone in the out-patient department. Now, he is confused and he doesn’t know what to do? Where to go? And whom to ask in detail about his illness, outcome, and treatment? He has no other option left other than to come to see the same doctor whom he has confronted just before. That poor man collects his documents rummaged around the table by the attending doctor. He makes his way, then, through disorganized, chaotic mass of patients in the queue who are in the same line for an appointment with the same grumpy doc.
This is not only the story of this man but almost every patient in our part of the world has to face the inhumane, insensitive and careless conduct like above.
Analysis: Despite growing concern about the patient’s right, these kinds (above mentioned) of misbehavior and inadequate and unpalatable encounter prevails throughout the developing world. Doctors lack the interest to counsel the patient regarding their disease, prognosis, treatment available and this may be due to the fact that our general public is illiterate or semi-illiterate, mostly. If there are any literate masses, they seek treatment from private, costly hospitals and clinics which directly or indirectly contribute to the fact that the doctors are directing their attention to the better source of income instead of low income government hospitals and the patients, reinforcing the low standard treatment in government hospitals.
Doctors are always in hurry to finish checking patient in out-patient department due to overflow. Inappropriate, inadequate, immature and underdeveloped health policy enhances centralization of health institutions, whereas periphery remains deserted with few of the trained health personals. So it sounds reasonable to have patients from all over the country for specialized tertiary care overburdening the existing services.

Above all, most of the people are not so well educated that they can understand every detail they were explained to, not enough intelligent that they can take their own decision regarding further management. Another major factor is language barrier. Due to developmental time framework, medical education is taught in English medium rather in vernacular system in our part of world. So, medical students and the doctors may find it hard to comprehend and express the written information from book or other resources to the patient or even student from English medium may find it Herculean task to express or counsel in local language other than English, a phenomenon that was observed in Singapore(1).
Idealism: The doctor-patient relationship is a two-person social system, which is determined by the expectations that particular roles will be assumed by both physician and patient and by their individual personalities(1).The physician provides psychological support and make sure that patient gets maximum benefit out of his knowledge, experience and conduct. Basically relation revolves around patient. In a good relationship both functions contribute significantly to the proper diagnosis of underlying condition, effective counseling, adherence to the treatment , symptom resolution(1) and for better outcome(1) and follow up. From the time of advent of medical education, the culture of this very education practiced on a kind of teaching and learning methodology which was focused on pathophysiological basis of disease per se rather than on holistic approach (patient centered)(1). The disease is the outcome of the derangement of normal physiology but the manifestation of that is affected by myriad of variables within and outside the patient. S/He is the result of interaction of all these factors. Yes, someone has rightly said, “half a sheep is mutton”. Diagnosing and treating the disease only without any compassionate consideration to the patient’s personality, socio-economic condition and mental condition is just a part of medicine but not an art, a clinical art.
Scenario Two: Now the scenario has changed; the role of the patient changed from a largely passive one to a largely active one (1). There is rapid rise of demands from patients for autonomy and self-determinism in medical decision making (1).The authoritative doctor who is supposed to make all medical decisions is being gradually replaced by a model of shared decisions making by physicians and patients together (1). But the public from the developing world and the rural areas are still less empowered, the poor masses have great respect for doctors, and some even believe that rather than the medicines, it is the doctor’s godly touch which helps heal a disease (3). So the patients are reluctant in asking for the unclear information regarding disease and its contributing and risk factor, the disease and its contributing and risk factor, the management alternatives, prognosis, cost, preventive measures if any.
After the advent of the “legal threat,” however, the relationship has been crushed before it blooms. Now, medics are behaving so mechanically with patients in hospitals that sometimes they seem just like robots (3). The relation is arrested in its developing phase. Neither doctors nor patients are aware of degrading value of the noble relationship.
Scenario Three: I met that gloomy guy just on the way to the bill counter. I could see great pain and fear of unknown in his face. Confusion was hovering over his sexagenarian face. Half hour long queue and his older age, superadded by the fear, anxiety and cancer he was having were crippling the old man. He asked me though in fear due to white coat which I was wearing, about his reports. I explained him in low, yet hopeful tone. He then was less perplexed about his condition and became more willing to communicate and share his experience with the doctor in the OPD. But I had to go for the ward round so I could not make time for him. I made a farewell and moved. He joined the queue line for the payment.
Improvement: It may not be necessary to make any comment on action executed by highly educated and talented people. Yet for the shake of the betterment of the fellow human, little compassionate and sympathetic attitude from the concerned people can cause drastic improvement. Will there be an end to time immemorial, way of practicing medicine in developing world and initiation of humanistic, holistic patient centered care? Can a doctor allocate sufficient time to listen to the patient? Can he be able to take verbal or written consent before any intervention? Can he explain alternatives of management? Can he impart the necessary health education in friendly manner? Can he write decipherable and legitimate advices? These are the questions that the author thinks; every concerned health professional should seek answer. This writer used to hear, “since god could not be everywhere, he created doctors.” Keep the nobility of the profession.

References:

1. Shankar P R, et al., (Ed.), 2006, “Attitudes of first-year medical students towards the doctor patient relationship”, Journal of Nepal Medical Association, Vol. 45, No. 1, pp. 196-203.
2. Timilsina Samir P, May 20, 2008, doctors’ code of conduct, the Kathmandu post.
3. Bagchi, Sanjit (2003) “Global perspectives on patients”, student.BMJ 2003; 11:219-262 July (online) (cited 4th June 2008). Available from <URL: http://www.student.bmj.com.
   Address for Correspondence:
   Rajesh Shrestha (Final year), Roshan Acharya (First year), MBBS, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Email: rajesh_889@yahoo.com.
   

ROLE OF EMERGENCY ULTRASOUND
Joshi B. R.

OBJECTIVES: Participants will be able to

1. define emergency ultrasound
2. enumerate types of emergency ultrasound techniques
3. identify common disorders which can be diagnosed by emergency ultrasound
4. share significance of emergency ultrasound

Background
Emergency ultrasound is a sonographic examination of persons who require early diagnosis for efficient management so as to result in favorable outcome. Ultrasound plays an important part in the management of emergency patients. Efficient management is dependent on correct and timely diagnosis. The social and economic pressures to triage, diagnose and rapidly treat patients have made the use of ultrasound a primary screening tool for the emergency patients.

Technique

1. Traumatic – In trauma patients, a special technique known as focused assessment with sonography for trauma [FAST] is used. Its main objective is the detection of free intraperitoneal fluid in blunt abdominal trauma. The FAST examination is performed by utilising 4 views: Morrison’s pouch, perispenic view, pelvic view and the pericardium. The morbidity and mortality associated with trauma increases the longer life-threatening injuries are left undiagnosed makes ultrasound [USG] a priceless tool. One cannot forget the limitation of this technique. However, when used appropriately, this technique allows the patient to be rapidly assessed and correctly managed.
2. Non-traumatic – A screening USG is a highly focused, limited, goal directed examination with the purpose of answering a select set of questions. Some questions include:
   - Are there gall stones present?
   - Is there hydronephrosis evident?
   - Is there free peritoneal fluid?
   - Is there a well-defined intrauterine pregnancy?

A screening USG is not a formal study. Follow-up confirmatory radiologic studies as an outpatient would be appropriate in the next 2-3 days.1 Screening USG is an accepted tool for rapid assessment of patient. Length of stay in the Emergency Department dramatically decreases thus increasing patient’s satisfaction while maintaining an even higher standard of care. Better quality of care has translated into improved patient satisfaction as well as better risk management. The patient is able to leave Emergency Department with a firm understanding of their diagnosis. At the same time, the physician has the comfort of discharging the patient in a timely manner and with a definitive diagnosis.1

Common conditions: Which clinical emergencies are best evaluated by ultrasonography has evolved and continues to evolve with clinical practice trends of the region 2. According to the study conducted by the author in 2003, the common conditions are 3 –

1. Appendicitis – 9 %
2. Cholelithiasis – 8 %
   [ 25 % Acute cholecystitis ]
3. Nephrolithiasis – 6%
4. Acute pancreatitis – 3 %
5. Visceral Injury – 3 %
6. Ectopic Pregnancy – 2%.
   

Significance

1. Cost-effective, operator-dependent and complementary investigation- A study was conducted by the author in 2008 regarding the impact of patient preparation for ultrasound and its findings on clinical practice.4 All thought qualified radiologists should perform the examination. Thirty percent marked that it should be done only in the morning. Fifty percent did not know if full bladder is needed. Only 20 % knew how to make bladder full by not passing urine after drinking one liter of water one hour before ultrasound. Improper preparation before the ultrasound examination causes loss of time and inconvenience to patients as well as medical professionals.
2. Efficient and non-invasive management tool- In this study all thought it was used to rule out cause of pain and collection. Fifty percent did not know if ultrasound was harmful or not. Sixty percent wanted it as part of general checkup.
   Ultrasound is perhaps the most diverse technology available today. Recent improvements in ultrasound image quality, combined with its use, have catapulted this technology into almost every branch of medicine. Ultrasound has been an impressive metamorphosis since its beginning and now occupies a pivotal role at the forefront of radiological practice and research. The specialty has progressed to encompass therapeutic options 5.

SUMMARY

1. It can be used as an audio-visual aid. It is the ‘stethoscope’ of this century.
2. The awareness regarding preparation for ultrasound should be increased by all .
3. Its use should be emphasized for better care.

References

1. Godwin SA. Introduction to Emergency Ultrasound-a review of justification, indications and significant findings. Jacksonville Medicine.1999 March.
2. Cohen HL, Moore WH. History of emergency ultrasound. J Ultra Med 2004; 23: 451-458
3. Joshi BR. Patterns and problems regarding Emergency Ultrasound in Nepal. [ submitted ]
4. Joshi BR. Impact of patient preparation for Ultrasound and its findings on clinical practice.
[ submitted ]
5. Joshi BR. Advances in Ultrasound. NERADS Souvenir 2006; 5:7-8.
Address for Correspondence:
Dr. Birendra Raj Joshi , MBBS, DMRD, MDRD, Dept. of Radiology & Imaging, Institute of Medicine, Tribhuvan University Teaching Hospital, P.O.BOX 56, Kathmandu, Nepal.
Email: bjoshi01@yahoo.com

Epistaxis in Normotensive individuals may lead to transient hypertension

Adhikari P., Pradhananga R. B., Pramanik T.

Key words: epistaxis, hypertension, association

Introduction:

Idiopathic Epistaxis is defined as any episode of bleeding from nasal cavity without any detectable cause. Although, epistaxis and hypertension are frequently in general population but their clear correlation is still controversial. Some authors reported that the patients presenting with epistaxis were hypertensive. On the contrary, according to some group of scientists the history of epistaxis was not associated with hypertension classified according to the WHO. This study was done to evaluate whether patients or individuals with epistaxis in emergency department were hypertensive or not.

Methodology:

It is an evaluation based prospective study done on 49 patients (male:33, female:16) having no prior clinical history of hypertension admitted in Department of ENT and Head and Neck surgery ward of TUTH. Patients with history of trauma to nose, local pathology, systemic diseases and bleeding disorders and children were excluded from the study. Blood pressures of them were recorded in supine position when they presented in Emergency Department in TUTH with active nose bleeding. Blood pressure was again recorded on the day of discharge. As, blood pressure measurement is a part of routine clinical check up, and is a non-invasive procedure, institutional ethics committee and the subject had no objection on our work.

Results:

It is evident the both males and females presented with active nose-bleeding showed significantly higher blood pressure compare to their causal blood pressure at the time of discharge from the hospital ( p value <0.5). For males during epistaxis blood pressure recorded was 142.42±19.20/91.5±12.27mmHg and for females the same was 141.87±20.72/91.25±16.68mmHg. After managing epistaxis, the blood pressure of males and females were noted as 119.39±12.23/75.15±7.55mmHg and 118.75±12.04/76.25±13.10mmHg respectively.
Discussion:
Epistaxis is common ENT emergency. The bleeding may occur from one or many bleeding points. The blood pressure of both male and female patients during active nose bleeding was noted about 142/91mmHg. The results of this study clearly indicated that the patients with active epistaxis had higher blood pressure presentation at ER in comparison with their causal blood pressure noted after treatment.
Epistaxis is usually of sudden onset. The subject suffers from anxiety which is associated with sympathetic stimulation and secretion of catecholamine which may increase the rate and force of contraction of cardiac muscle causing increase in cardiac output-leading to an increase in systolic blood pressure in both male and female patients.

CME Registration No. :
Name :
Hospital :
E-mail :
Mobile/Phone :

2. When there is hypotensive head injury case with intracerebral haemorrhage, are you going to start 20% manitol 1gm/kg to reduce intracranial pressure?

a. Yes
b. No

3. What is the importance of documentation in Emergency Department during patient examination? Write in only one sentence.

4. Are you sure you can intubate a child at the Emergency by yourself?

a. confident
b. Not confident

5. Epistaxis is always due to hypertension.

a. True
b. False

6. What are the most common three indications for Emergency ultrasonography in Emergency Department?

7. During CPR in your Emergency, which do you follow for chest compression and bagging?

a. 5:1
b. 15:2
c. 30:2
d. 200:1

8. How do you make a good Health Worker-Patient-Party (HWPP) Relationship in Emergency Department and during Disaster?

9. How can we establish coordination among all the Emergency Departments of different hospitals to cope the situation of Disaster and Emergency?

10. Comments, suggestions, opinion and better ideas to further develop NADEM, NADEM CME, NewsHealth.

DISCLAIMER: Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this NewsHealth have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of these free papers/articles do not warrant the information in these papers/articles are accurate or complete, nor are they responsible for omissions or errors in the papers/articles or for the results of using these information. The reader should confirm the information in these papers/articles from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert.

© 2007 NADEM NewsHealth
Editor:
Dr. Ramesh Kumar Maharjan, MD
Publisher: NADEM Center
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