Sunday, April 5, 2015

Of Maladies And Medicine (An emergency physician's perspective)

The other day, a particularly pompous neurosurgeon in my hospital likened the emergency room where I work in, as "a mere transit station, devoid of significance".
Now at that very moment, taken by surprise I was at a loss for words. Words always have in the past failed me during the most trying of circumstances.
Although absolute rage and loathing did set in much later. But the damage was done. He walked away with a harebrained comment presumably content with his over inflated ego as he verbally denounced the very department that is the backbone of our hospital.
Now a significant lot of you might not be aware of the very concept of emergency medicine. Not just the non medical personnel but even the so called "esteemed" medical consultants of many a institution.
That is because the emergency room in most multi specialty hospitals consist of something known as "casualty". Its where a "casualty medical officer," a doctor of particularly limited expertise and perhaps intellect, twiddles his/her thumbs as they wait for a consultant to show up while a patient is probably going into cardiac arrest before their very eyes.
An emergency room and an emergency physician however are a different cup of tea.
Our days begin and end on the note that every patient who walks through our doors must be immediately catered to. Not in a matter of hours but in minutes or if need be seconds. International medical protocol has standard door to needle times for patients presenting with a heart attack or a stroke. Moreover every patient who presents to the emergency room is an absolute priority.
The very concept and aspect of stabilizing a medically unstable patient falls in the hands of a emergency room physician.
Most medical consultants, however long and illustrious their practice might be, are ill equipped to deal with acute medical emergencies and catastrophes. Their so called training is best kept for medically stable patients who walk casually into their OPDs and narrate a years worth of information regarding their maladies and afflictions. The consultant in return listens patiently and informs the patient and the concerned relatives the due course of action he will be taking with regards to their treatment and the time it would take for the full resolution of the patients symptoms. All in a day's work for the patient and the physician.

Now picture a different scenario when the same patient presents to the hospital unconscious. The patient is unresponsive due to some medical catastrophe, like say an accident, a cardiac arrest, a stroke or perhaps low blood sugar known as hypoglycemia. The same relatives are now distraught, inconsolable, screaming for the consultant who earlier saw the patient in the OPD. Chaos reigns and no one is in the right state of mind to actually narrate what went wrong.
Under these circumstances the so called consultant has probably retired for the day. He is unreachable and not in the hospital premises. The assistant doctors (or resident doctors) of the so called consultant are clueless in the chaos that follows.
This is where the emergency physician comes in.
The patient is attended to in seconds according to the triage system. His vital parameters are evaluated, diagnosed without the aid of sobbing relatives and effectively stabilized depending on whatever that malady caused his unconsciousness and shifted for further intensive care.

Its these very minutes and seconds that make all the difference between life and death.
Emergency medicine is acute medicine. Where issues are dealt with immediately without waiting for the consultant or his harebrained assistants to show up.
I've seen many a medical consultant who are utterly clueless in times of chaos like these.
Moreover the chaos around them causes them to panic further which is different from their placid OPDs which probably have some tribal chanting or a mini waterfall rumbling in the background to soothe their nerves.
Most senior consultants panic in the face of a medical emergency. Many cannot even perform basic CPR. Most trained consultants subject a patient of massive blood loss to a series of CT and MRI scans without first correcting the patients vital parameters. One of the first rule of emergency medicine is to desist from diagnostic scanning of any sort if the patient is medically unstable.

This is the sorry state of affairs in India where emergencies occur everywhere at a fraction of a second. Its even worse as majority of the hospitals do not have a properly designed emergency system in place.
Millions die on account of the lack of timely intervention. Unlike the NHS guidelines in the UK or the emergency system in US, India has no proper emergency system in place.
Moreover expecting a medical consultant to respond to emergencies is pointless as that is not his field of expertise.
That is why the very branch of emergency medicine exists.
And that is why it is the need of the hour for the public and the medical community to realize the absolute importance of emergency medicine and the role of an emergency physician.
We're not a mere transit station who ferry patients to and fro.
We're the ones who make all the difference between life and death.