Emergency medicine and critical care: A new horizon

Almost every hospital large or small, whether run privately or by Govt. has a designated area culled "JORURI BIVAG" or Emergency Room. Large cities have better emergency facility than smaller cities or towns. Again what is available in a smaller town is not available at Thana level. Emergency care at Village level is mostly non-existent for critically ill or injured.

Our only hope in a large city' like Dhaka is our well known Dhaka Medical College Hospital which is supposed to offer the best Emergency care in the whole country. People generally know that a victim of a severe road traffic accident, severe burn or patient with Stroke (Cerebro vascular accident) or Heart attack (Myocardial Infarction) or patient who is severely ill or in Coma need to be taken to the nearest Emergency Room, Preferably to that of a Medical College Hospital.

The usual scenerio is like this. The Emergency physician attends the patient who may be in severe distress or in Coma or may be in Cardiopulmonary arrest. What does he have to do? Unless there is a patient with a minor injury, laceration or treatable abdominal pain' etc, Emergency physicians are required only to triage the critical patient. By triaging, I mean to screen the patient according to a suggestive destination inside the hospital.

The road traffic accident victim is usually taken to the Casualty ward or Surgery ward or to the Operation threatre or patient whose heart has just stopped beating face essentially similar fate. They are taken to the inpatient medical wards.

What happens inside there? 'Patients who are still, lucky to be alive get to be seen by a House officer on call or a clinical assistant or registrar. The luckiest patient is' someone who is seen by the departmental Professor or Consultant who happens to be there at that time.

If one has to review the setup of our best Emergency care facility it can be compared to a so called 24 hour walk in Emergency facility in a small hospital of a Western country. The difference is that, there the critically ill patients are transferred out to a larger secondary or tertiary care facility. Here in Bangladesh the critically ill patients are admitted inside the hospital before being treated in E.R.

Let us discuss some important factors that are the integral part of Emergency Room operation.

 Time

We do not have to tell you all, how important the time factor plays in life or death of a critical patient. The more time is wasted in the process of treatment, the mortality and morbidity tend' to rise. Patient requiring immediate resuscitation can not afford to wait tobe transferred to inpatient unit before the resuscitation is performed. His only hope lies in the care he gets by the Emergency physician as soon as he enters the Emergency Room, Let us give you an example. Highest mortality from Acute Myocardial Infarction takes place during the first 2 hours of the infarct.

Physician's Credentials

A well trained & well qualified Emergency physician, who knows how to identify the life threatening illness and who knows how to initiate, the resucatation process is an asset to the Emergency department.

Emergency Room Supplies

Supplies of life saving equipment and drugs, appropriate investigative facility go hand in hand with good staffing. A well qualified physician can not work effectively without a well equipped and well stocked Emergency Room. He also needs the support of qualified nurses, para professionals, and the help of prompt Radiology and Pathological services.

Consultation Services

Availability of appropriate backup consultation services-influence the success or failure of the Emergency physician. This happens when patient requires ,continuous resuscitation and treatment by Specialists. Any major hospital in a Western country maintains backup Medical, General Surgical, Obstetric; Trauma, Neuro Surgical, Cardio thoracic, services etc. These backup services have well defined response time, during which they have to respond & appear in the premises of the Emergency Room.

Critical Care Facility

In house critical.ca{e facility like Coronary care Unit (C.C.U.), Medical and surgical Intensive Care Unit (LC.U) become the final destination of a resuscitated patent who is still alive and needs intensive care.

Continuous Medical Education (C.M.E)

Availability of round the year continuous medical education for Emergency physicians and other hospital physicians are needed to train and prepare them for Disaster management, Basic and Advanced life support delivery. Availability and implementation of a well coordinated Disaster management policy of the entire hospital goes a long way in helping the Emergency department in handling mass disasters.

Pre-Hospital Care

Availability of a dedicated and organised pre-hospital Emergency Medical Service (E.M.S) System not only reduces the mortality of critically ill or injured in the community, it also improves the success rate of a model Emergency care facility. Such E.M.S. System is usually composed of ambulances staffed by trained physicians or para-medics and equipped with life saving devices, first aid, Oxygen etc.

Recently I had a change to visit Emergency and Critical care facilities belonging to a few large hospitals of the city of Dhaka. The outcome of my observation are as follows.

Concept of Emergency care, Critical" care or Trauma care, which have been so popular in Western" countries is unknown among our young medical graduates. Some of them who worked in overseas hospital seem to know about it. Specialist physicians whom I have spoken to are painfully aware of this situation but also add that even an inpatient of a reputed hospital has little chance of survival if he goes intocardio pulmonary arrest.

Physicians who work in our Emergency Rooms act merely as a traffic police directing the flow of critically ill patient.

There is not a single Western style Emergency care facility and Trauma Center currently operating in the whole country.

With the exception of few, most Emergency care facilities do not have appropriate back up services. Even if they are available, the services offered by them are so slow in majority of cases that it creates serious misunderstanding among our general public. The public usually blames the physicians for negligence rather than blan1ing the system.

Even our best Emergency Rooms do not keep life saving equipments or drugs to resuscitate patient with cardio pulmonary arrest.

Our country has still not introduced the subject of Emergency and Critical care medicine in the curriculum 1for graduate medical students. The Basic and Advanced life support courses are still not introduced as integral part of physician credentials in our hospitals, specially for those who work in Medicine, Pediatricas, Anaesthesia, Emergency etc.

Prehospital Emergency care by E.M.S. System is virtually non-existent in our country. The ambulances that we typically notice being parked in front of the hospitals are used to transport patient but not used to treat patient. A few Ambulances may be carrying Oxygen tank.

We are a progressive nation and can not afford to sit idly while the rest of the world is moving fast in health care delivery.

There has been a trend among our wealthy people to visit our neighouring countries for medical care. If you are critically ill or injured your fate will depend on how fast you are taken to the best and closest Emergency care facility and will not depend on your wealth alone.

Every citizen of Bangladesh deserves the right to receive appropriate resuscitative care if he goes into cardiopulmonary arrest or if he is critically ill or injured: May we present the following recommendations.

Let us popularise the concept of Emergency medicine and Critical care among our medical community. Let us recommend to include these subjects in the curriculum of graduate and post graduate medical courses. Our Past graduate Institutions should offer training and Fellowships in these fields.

The Basic and Advanced life support should be part of our physician credential process especially for those who work directly with patient care.

Let us use our resources to promote and establish Emergency care facilities with Trauma-center within our medical college hospitals or private hospitals. We need to utilise the blessings from both Govt, and private sector Govt. run facility can be made cost-effective and private run facility can be made commercially viable.

Let us train appropriate personnel like paramedics, nurses and physicians with the goal of organizing an effective pre-hospital E.M.S. System. This will require the establishment of an E.M.S. Training Institute.

Let us promote the concept of Emergency and Critical care to our public by offering life support training. We can use the help of mass media like T.V. Radio, News paper and our school systems.

Conclusion

Bangladesh has seen the birth and growth of numerous hospitals, clinics and Medical Colleges since its independence. Emergency health care exists in name not in real sense. Emergency department every where needs to be reorganised and staffed with trained physicians and nurses.

These speciality needs to be recognised as a vitally important' Medical speciality at our national level. It is a pity that Emergency physicians are poorly qualified and trained.

They are also the youngest, most frustrated and demorilised group of physicians who are given the job of treating the sickest patients of the community.

Emergency medicine and critical care: A new horizon

Almost every hospital large or small, whether run privately or by Govt. has a designated area culled JORURI BIVAG or Emergency Room. Large cities have better emergency facility than smaller cities or towns. Again what is available in a smaller town is not available at Thana level. Emergency care at Village level is mostly non-existent for critically ill or injured. Our only hope in a large city like Dhaka is our well known Dhaka Medical College Hospital which is supposed to offer the best Emergency care in the whole country. People generally know that a victim of a severe road traffic accident, severe burn or patient with Stroke (Cerebro vascular accident) or Heart attack (Myocardial Infarction) or patient who is severely ill or in Coma need to be taken to the nearest Emergency Room, Preferably to that of a Medical College Hospital. The usual scenerio is like this. The Emergency physician attends the patient who may be in severe distress or in Coma or may be in Cardiopulmonary arrest. What does he have to do? Unless there is a patient with a minor injury, laceration or treatable abdominal pain etc, Emergency physicians are required only to triage the critical patient. By triaging, I mean to screen the patient according to a suggestive destination inside the hospital. The road traffic accident victim is usually taken to the Casualty ward or Surgery ward or to the Operation threatre or patient whose heart has just stopped beating face essentially similar fate. They are taken to the inpatient medical wards. What happens inside there? Patients who are still, lucky to be alive get to be seen by a House officer on call or a clinical assistant or registrar. The luckiest patient is someone who is seen by the departmental Professor or Consultant who happens to be there at that time. If one has to review the setup of our best Emergency care facility it can be compared to a so called 24 hour walk in Emergency facility in a small hospital of a Western country. The difference is that, there the critically ill patients are transferred out to a larger secondary or tertiary care facility. Here in Bangladesh the critically ill patients are admitted inside the hospital before being treated in E.R. Let us discuss some important factors that are the integral part of Emergency Room operation. Time We do not have to tell you all, how important the time factor plays in life or death of a critical patient. The more time is wasted in the process of treatment, the mortality and morbidity tend to rise. Patient requiring immediate resuscitation can not afford to wait tobe transferred to inpatient unit before the resuscitation is performed. His only hope lies in the care he gets by the Emergency physician as soon as he enters the Emergency Room, Let us give you an example. Highest mortality from Acute Myocardial Infarction takes place during the first 2 hours of the infarct. Physicians Credentials A well trained well qualified Emergency physician, who knows how to identify the life threatening illness and who knows how to initiate, the resucatation process is an asset to the Emergency department. Emergency Room Supplies Supplies of life saving equipment and drugs, appropriate investigative facility go hand in hand with good staffing. A well qualified physician can not work effectively without a well equipped and well stocked Emergency Room. He also needs the support of qualified nurses, para professionals, and the help of prompt Radiology and Pathological services. Consultation Services Availability of appropriate backup consultation services-influence the success or failure of the Emergency physician. This happens when patient requires ,continuous resuscitation and treatment by Specialists. Any major hospital in a Western country maintains backup Medical, General Surgical, Obstetric; Trauma, Neuro Surgical, Cardio thoracic, services etc. These backup services have well defined response time, during which they have to respond appear in the premises of the Emergency Room. Critical Care Facility In house critical.ca{e facility like Coronary care Unit (C.C.U.), Medical and surgical Intensive Care Unit (LC.U) become the final destination of a resuscitated patent who is still alive and needs intensive care. Continuous Medical Education (C.M.E) Availability of round the year continuous medical education for Emergency physicians and other hospital physicians are needed to train and prepare them for Disaster management, Basic and Advanced life support delivery. Availability and implementation of a well coordinated Disaster management policy of the entire hospital goes a long way in helping the Emergency department in handling mass disasters. Pre-Hospital Care Availability of a dedicated and organised pre-hospital Emergency Medical Service (E.M.S) System not only reduces the mortality of critically ill or injured in the community, it also improves the success rate of a model Emergency care facility. Such E.M.S. System is usually composed of ambulances staffed by trained physicians or para-medics and equipped with life saving devices, first aid, Oxygen etc. Recently I had a change to visit Emergency and Critical care facilities belonging to a few large hospitals of the city of Dhaka. The outcome of my observation are as follows. Concept of Emergency care, Critical care or Trauma care, which have been so popular in Western countries is unknown among our young medical graduates. Some of them who worked in overseas hospital seem to know about it. Specialist physicians whom I have spoken to are painfully aware of this situation but also add that even an inpatient of a reputed hospital has little chance of survival if he goes intocardio pulmonary arrest. Physicians who work in our Emergency Rooms act merely as a traffic police directing the flow of critically ill patient. There is not a single Western style Emergency care facility and Trauma Center currently operating in the whole country. With the exception of few, most Emergency care facilities do not have appropriate back up services. Even if they are available, the services offered by them are so slow in majority of cases that it creates serious misunderstanding among our general public. The public usually blames the physicians for negligence rather than blan1ing the system. Even our best Emergency Rooms do not keep life saving equipments or drugs to resuscitate patient with cardio pulmonary arrest. Our country has still not introduced the subject of Emergency and Critical care medicine in the curriculum 1for graduate medical students. The Basic and Advanced life support courses are still not introduced as integral part of physician credentials in our hospitals, specially for those who work in Medicine, Pediatricas, Anaesthesia, Emergency etc. Prehospital Emergency care by E.M.S. System is virtually non-existent in our country. The ambulances that we typically notice being parked in front of the hospitals are used to transport patient but not used to treat patient. A few Ambulances may be carrying Oxygen tank. We are a progressive nation and can not afford to sit idly while the rest of the world is moving fast in health care delivery. There has been a trend among our wealthy people to visit our neighouring countries for medical care. If you are critically ill or injured your fate will depend on how fast you are taken to the best and closest Emergency care facility and will not depend on your wealth alone. Every citizen of Bangladesh deserves the right to receive appropriate resuscitative care if he goes into cardiopulmonary arrest or if he is critically ill or injured: May we present the following recommendations. Let us popularise the concept of Emergency medicine and Critical care among our medical community. Let us recommend to include these subjects in the curriculum of graduate and post graduate medical courses. Our Past graduate Institutions should offer training and Fellowships in these fields. The Basic and Advanced life support should be part of our physician credential process especially for those who work directly with patient care. Let us use our resources to promote and establish Emergency care facilities with Trauma-center within our medical college hospitals or private hospitals. We need to utilise the blessings from both Govt, and private sector Govt. run facility can be made cost-effective and private run facility can be made commercially viable. Let us train appropriate personnel like paramedics, nurses and physicians with the goal of organizing an effective pre-hospital E.M.S. System. This will require the establishment of an E.M.S. Training Institute. Let us promote the concept of Emergency and Critical care to our public by offering life support training. We can use the help of mass media like T.V. Radio, News paper and our school systems. Conclusion Bangladesh has seen the birth and growth of numerous hospitals, clinics and Medical Colleges since its independence. Emergency health care exists in name not in real sense. Emergency department every where needs to be reorganised and staffed with trained physicians and nurses. These speciality needs to be recognised as a vitally important Medical speciality at our national level. It is a pity that Emergency physicians are poorly qualified and trained. They are also the youngest, most frustrated and demorilised group of physicians who are given the job of treating the sickest patients of the community.