Emergency and Trauma Department, Hospital Bintulu, Malaysia
Introduction: Novel oral anticoagulants (NOAC) are a new generation oral anticoagulant which are gaining favour due to its ease of monitoring and less risk of bleeding. We present a case of acute anterior ST elevation myocardial infarction (STEMI) secondary to in-stent thrombosis despite on dabigatran.
Case Report: A 51 years old gentleman presented to the Emergency and Trauma Department complaining of severe left sided chest pain. He has underlying atrial fibrillation and ischemic heart disease with history of left anterior descending (LAD) and left circumflex coronary artery (LCx) stenting in 2008. Stent study in 2016 was patent. Patient was on oral Dabigatran 150mg bd and he took the last dose 12 hours prior to the onset of angina. Initial 12-lead ECG showed ST elevation over lead V2-V5. The clinical history and the ECG was suggestive of acute anterior STEMI. Patient was then decided for thrombolytic therapy using intravenous Tenecteplase due to no immediate percutaneous coronary intervention (PCI) service, however failed thrombolysis. Patient was subsequently transferred to Sarawak Heart Centre (PJHUS) for PCI, which showed LAD occlusion at the stented segment.
Discussion: This is the first known incident of patient developing stent thrombosis despite on dabigatran in East Malaysia. Dabigatran is a direct inhibitor of thrombin (DIT) that is used for prophylaxis of stroke and systemic thromboembolism in patients with nonvalvular atrial fibrillation (NVAF). The thrombin inhibition should have reduced the incidence of stent thrombosis. Dabigatran paradoxically increased the risk of myocardial infarction in patients with atrial fibrillation as reported in RE-LY trial and this case. The theory behind this still remains speculative.
Conclusion: We suggest that healthcare providers to consider the increased risk of myocardial infarction over the benefit of dabigatran, especially in patients with NVAF.
Clinical Hospital Centre Rijeka, Croatia
Every year 165 children and adolescents per million under the age of 19 are diagnosed with cancer. Because of major treatment advances in recent decades, 84% of children with cancer now survive 5 years or more. The early recognition and the appropriate management of emergent cancer- and anticancer therapy-related complications are critical in maintaining and further improving outcomes for children with malignancies. Oncologic emergencies in pediatric patients can occur at any point in the course of the disease. Some emergencies are the initial presentation, some arise in the patient with an established diagnosis as complications of therapy, and some develop at the time of disease progression or recurrence. The emergencies can be classified to mechanical, metabolic and hematologic. Mechanical oncologic emergencies are usually divided by system to cardiothoracic, gastrointestinal, genitourinary and neurologic. Metabolic emergencies comprise tumor lysis syndrome, hypercalcemia and syndrome of inappropriate secretion of antidiuretic hormone / hyponatremia. Hematologic emergencies include hyperleukocytosis associated with metabolic derangements accompanying tumor lysis syndrome, emergencies associated with cytopenias (thrombocytopenia with hemorrhage, neutropenia with fever) and abnormalities of hemostasis. The awareness and knowledge of emergency team and other care providers for possible oncologic emergencies in children with cancer is of fundamental importance. Earlier identification of life-threatening complications, rapid assessment, and proper management strategies significantly contribute to positive outcomes.
Jelena Roganovic has completed her medical education from Rijeka/Croatia, Padua/Italy, and Cincinnati/USA. Currently she is the Full Professor tenure of Pediatrics and Chair of the Department of Pediatrics School of Medicine University of Rijeka, the Head of the Division of Pediatric Hematology and Oncology, and the Head of the Department of Pediatrics, Clinical Hospital Centre Rijeka, Croatia. She published more than 300 papers, book chapters, proceedings and abstracts. She is a certified member of many national and international pediatric societies, a reviewer for a number of indexed journals, and an editorial board member of several journals of international repute.
Marma Health Centre, India
We have been hearing for centuries that ‘fever is not a disease but a symptom’. Physicians say that fever is a symptom of diseases like flu to cancer.
The conservative fever definition, diagnosis, and treatments are based on fever as a symptom.
All the studies related to fever as a symptom of a disease have been done without knowing the Purpose of the temperature of fever is.
Without knowing the Purpose of the temperature of fever, how can fever included in the symptom definition?
Temperature between 38° to 41° centigrade can be symptom of a disease?
Most of the diseases may not have a fever. Sometimes it disappears. Then, is fever a symptom of which disease?
Symptom Definition is the only parameter necessary for a Symptom. As with any or all other definitions, symptom definition should describe the symptom scientifically. If it cannot describe clearly, there is no use of a symptom definition. A symptom is a departure from normal function or feeling which is noticed only by a patient, indicating the presence of disease or abnormality. One cannot be understood directly the temperature is elevated in the hypothalamus. A mechanical device is necessary to measure elevated temperature in the hypothalamus. In symptom definition, fever definition canʼt be found. The elevation of body temperature is not included in symptom definition.
Different cause of diseases never shows the same symptoms.
Different causes of diseases like virus, bacteria, fungi, venom, horror scene, horror dream,... never shows the same symptoms.
Its actions are different and sometimes opposite. No similarities can be seen between their actions.
Elevated temperature or increased temperature never make fever or symptoms of fever. It may create hyperthermia.
None of the diseases or causes of diseases require fever as its symptom.
If the mosquito bites its virus, bacteria, venom gets deposited in the body as a result according to nature and strength of Viruses, bacteria, venom symptoms like itching, pain, and signals like colour change, inflammation may occur.
we can see the symptoms, Signals, and indications of the virus, bacteria, the venom which multiple or spreading or damages(disease) the body before fever emerge. Patients who have flu to cancer may not have a fever.
How can we separate symptoms of the disease and symptoms of fever and symptoms of rising temperatures?
In fever, both symptoms of disease and symptoms of Fever are included. Deduct symptom of disease from total symptoms, we will get symptoms of fever.
(Disease +Fever)- Disease =Fever.
(Symptoms of disease +Symptoms of Fever)- Symptoms of disease =Symptoms of Fever (bitter taste, body pain, fatigue to mind and body, reduced appetite, reduced motion and indigestion, internal and external discomfort,…)
Like that we can separate signs, signals, and actions of both fever and disease. (Signals of disease +Signals of Fever) - Signals of disease =Signals of Fever(high temperature, shivering, unconscious,....)
(Signs of disease +Signs of Fever) - Signs of disease =Signs of Fever.
(Actions of disease +Actions of Fever) - Actions of disease =Actions of Fever. In fever does not show any actions of temperature rise.
How can we prove the fever is not a symptom.
The fever is not symptom when examined in various directions. In fever, both symptoms of disease and symptoms of fever are included. Deduct symptom of disease from total symptoms, we will get symptoms of fever. we can separate signs, signals, and actions of both fever and disease and rising temperature.
Temperature between 38 degrees and 41 degrees cannot be a symptom of any of the diseases.
A different cause of diseases like virus, bacteria, fungi, venom, horror scene, and horror dream never shows the same symptoms.
Fever has never been scientifically proved as a symptom of a disease. Fever has the properties of adaptation.
If we ask any type of question-related to fever by assuming that the fever is not a symptom we will get a clear answer. If we avoid or evade from this we will never get a proper answer to even a single question.
Yacob Mathai is a practicing physician in the field of healthcare in the state of Kerala in India for the last 30 years and very much interested in basic research. He has interests in spread across the fever, inflammation and back pain. He is a writer. he had already printed and published nine books on these subjects. He wrote hundreds of articles in various magazines.
After scientific studies, we have developed 8000 affirmative cross checking questions. It can explain all queries related to fever.
Nottingham University Hospitals NHS Trust, UK
The current COVID-19 pandemic has posed many challenges across the world. Our NHS has faced unprecedented challenges, balancing the dynamic needs of managing integrated ‘hot’ or ‘covid suspected’ with non-covid suspected areas within the healthcare system.
Virtual command and control leadership played an important role in managing our Emergency Department (ED), balancing issues such as infection control and staff covid risk assessments. Telemedicine is a recognised and increasingly validated tool that was strategically adopted as an information and communication technology (ICT) adjunct to help facilitate and undertake the process of frequent ‘rounding’ (review of each patient) in the ED ‘hot area’ during the first COVID-19 wave.
This retrospective survey, powered at an 8% margin of error with 95% confidence intervals, aimed to identify gaps in staff perceptions on the use of telemedicine whilst working in the ‘hot area’ of a UK major trauma centre ED.
Open to all ED staff, including those who may not have worked in the hot area due to shielding et cetera, 103 colleagues (59 females, 44 males) participated in questionnaire completion through survey monkey or in paper format over a designated one- week period following governance approval.
Demographic data was collated on job title/band, sex, age bracket and whether the respondent had worked in the ‘hot area’ (n=95) or not (n=8).
Likert scale referenced statements on knowledge, confidence, safety and utility of telemedicine were transcribed into metric data for analysis (1-strongly disagree, 2-partially disagree, 3-neither agree or disagree, 4-partially agree, 5-strongly agree).
Survey participants were from all ED team roles and reflected the workforce proportionately. Respondents believed that telemedicine is useful, effective and appropriate in the context of their job role and function in Hot ED (3.62-4.36, p<0.001). Colleagues recognised this approach can assist team performance during virtual patient rounding (3.93, p<0.001). Having the knowledge and confidence in how to use telemedicine, especially through video conferencing as opposed to rounding over the telephone remotely, brought about more confidence in using this virtual tool (p<0.01). Staff recognised their initial perception to prefer physical senior presence in the Hot area for rounding (3.97, p<0.01). Perceptions on safety were relatively neutral (3.07, p<0.001).
Written feedback on questionnaires evidenced feelings of ownership and empowerment with progressive tool familiarisation. Self-recognition, staff acceptance and participation in adopting a cultural shift in senior leadership style changes during the Covid-19 first wave were evident. Feedback was consistent from a wide spectrum of ED workforce about standardising the approach to virtual rounding locally and demonstrated an eagerness to participate and contribute.
Respondent subgroup analysis demonstrated positive attitudes to using telemedicine as an adjunct across all spectrums of the workforce. Noticeably, the majority of Junior Doctors and Advanced Clinical Practitioners believed using telemedicine during rounding allowed them to develop their educational needs (n=36, 35%, p<0.0001). A subgroup of CESR (Certificate of Eligibility for Specialist Registration) and Core Trainees (n=11, 11%) believed this virtual approach allowed them to fulfil their portfolio requirements (p<0.01).
Overall, themes relating to respondentʼs perception of confidence and knowledge in the use of telemedicine as an adjunct tool to rounding in Hot ED were very positive. This survey provides a valid and transferable platform for developing and exploring the balanced use of telemedicine for virtual rounding and adds to current emerging evidence considering itsʼ use more broadly in Healthcare for the future.
Chou E et al. Onsite telemedicine strategy for coronavirus (COVID-19) screening to limit exposure in ED. Emergency Medicine Journal 2020;37:335-337.
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Timothy Mossad is a Consultant in Emergency Medicine working in the United Kingdom. He has interests in human factors and medical education. His academic interests are focussed on exploring gaps in perception and experience applied to functions and processes within healthcare systems to improve patient care. During the 2nd International Conference on Emergency Medicine and Critical Care, Timothy will be presenting work looking into perceptions of virtual delivery of senior leadership in the covid-19 era within the Emergency Department assessment areas. Timothy is also an avid musician and is very proud to be the Solo Trombone of Hammonds Band, a famous brass band in Yorkshire, England.
Baylor College of Medicine Houston, USA
Background: It is estimated that improved infection control practices by health providers can prevent up to 70% of Healthcare Associated Infections (HAIs), which supports the growing societal demand for provider accountability, transparency and quality of care. To minimize HAIs, institutions have targeted health care workersʼ hand hygiene practices as a source of quality improvement (QI). Residency accreditation mandates programs integrate QI into the residency experience. Despite variable interventions, emergency department (ED)hand hygiene compliance rates remained amongst the hospitalʼs lowest.
Objectives: We designed and implemented a project to significantly improve hand hygiene compliance rates while engaging emergency medicine (EM) residents in departmental QI. We hypothesized that implementation of resident-led educational and procedural interventions would improve hand hygiene compliance.
Methods: Hand Hygiene audits were collected from March 2018 to December 2019 via internal and external auditing. Various interventions that did not significantly impact audit results included portable hand sanitizer bottles, large signs throughout the ED, rewards and punitive measures. In March 2019, residents became involved as Just-In-Time (JIT) coaches.
Results/Discussion: Hand hygiene compliance prior to intervention with JIT coaches from January 2018 thru March 2018 was 55.5% for EM attending physicians and 66.3% for EM residents. Compliance for both groups studied for this period was 61% (CI +/-26% for p <0.05).Compliance averages during the intervention period (April 2018 thru March 2019) was 80.3% for EM attending physicians and 67.6% for EM residents. Handwashing compliance overall for all groups for this period was 74% (CI +/-9% for p <0.05).Post-intervention (March 2019 thru December 2019) compliance was 97.3% for EM attending physicians and 95.8% for EM residents. Handwashing compliance for all groups studied for this period was 96% (CI +/-2% for p<0.05), which is statistically significant from both overall preintervention and overall intervention time periodsʼ compliance averages.
Time-sensitive care, variable acuity, non-traditional care areas, frequent interruptions, numerous provider-patient interactions, and simultaneous care of patients are just some of the challenges to hand hygiene compliance in an ED. QI involvement allows residents to reflect on clinical practice outcomes, to understandmethods and processes that lead to practice improvement andto reduce HAIs.
Sara Andrabi is a board certified Emergency Medicine Physician. Her leadership experiences at the local, state, and national level have earned her several recognitions including Emergency Medicine Residents Association Resident, Chief Resident(s), and Fellow of the year. She completed an administrative fellowship at Ben Taub Hospital after completing her residency and chief residency at Baylor College of Medicine. She transitioned out of fellowship into Assistant Medical Director of Ben Taub Emergency Center. Melding the worlds of Administration and Education has become a passion of hers as she is currently the Assistant Program Director for the Emergency Medicine Residency at Baylor College of Medicine.