Another Milestone : Training The Indian Navy !

Another milestone for the Department !  - We had the honor to train the nation’s Navy  about Basic life support .

The group of Navy men were overenthusiastic to learn the art and science of saving lives!  Our doctors trained them about the basics of Cardiopulmonary Resuscitation . They were also trained how to use the AED  (Automatic External Defibrillator ) , manage drowning cases etc..

The course was followed by  a final exam following which successful candidates were certified as basic life support provider .

The aim of the course was to maximise the chances of survival of a sudden cardiac death victim in the The Indian Navy  in absence of a medical personnel.

Although the value of bystander  CPR was once debatable, virtually all recent studies show that early initiation of CPR by a bystander improves survival from cardiac arrest significantly, and it also results in improved neurologic outcome of survivors. The presumed mechanism by which CPR by a bystander improves outcome is the preservation of flow to the heart, brain, and other vital organs, providing a "holding action" until other therapies (e.g., defibrillation) can result in restoration of spontaneous circulation.

As per Professor  Judith E Tintinalli: University of North Carolina 

Public CPR education can improve the behavior of bystanders significantly when a cardiac emergency occurs in the community. However, there are a number of problems associated with training the public to perform CPR. Most citizens who have received CPR training never actually witness or participate in managing a cardiac arrest. Conversely, bystanders who witness a cardiac arrest usually do not know how to perform CPR. The typical cardiac arrest victim is male, age 50 to 75 years old, and usually arrests at home, often in the presence of a spouse of similar age. Most citizens who have taken CPR training are <30 years of age; typically, <10% live with family members known to have heart disease. Many laypersons who attempt to perform CPR out of hospital are actually employed or volunteer their services as health professionals. The best solution to the problem is to target CPR training to "high-risk" individuals, such as middle-aged persons, senior center residents and staff, and family members (particularly the spouse) of patients who are survivors of AMI or cardiac arrest or who have other risk factors for sudden cardiac death.”

The Training team consisted of
Dr Indraneel Das Gupta ,Dr Saptarshi Saha
Dr Prerit Sharma ,Dr Arun Chander , Dr Onkar Nath Thakur, Dr Amit Bhowmik.

His hand if not life was gone - Our Team effort saved both.

11th March 2014 will always haunt Amar (name changed)  as a nightmare for the rest of his life . This young carpenter was on his regular work when accidentally a Marble Cutter pierced his right hand  in such a way that the only connection between his hand and the rest of his body were parts of skin and few surrounding tissue , this immediately led to massive blood loss and the patient was in Shock. Under normal circumstances these hands cant be saved unless a vascular surgery is done but the patient was almost dead-any surgery in such patients are very risky! 

Background 

Limb Saving vascular Traumas are of frequent occurrence in War Medicine, extremity amputations  due to vascular injury were the most frequent procedures done by US surgeons in  the  second World War .  DeBakey et all calculated that during second world war  amputation rate was higher than 40% among survivors  ,60% died . However lot have changed since then , the earlier notion of saving “life over limb “ has been replaced by “saving Life and limb “  .However   the  simplicity of the concept ends at “ saving life and limb” caption complexity and challenges  of this concept  from step one haunt the most  renowned trauma centres of the world.

We had three main Tasks  1 To immediately stop bleeding   2 bring him  out of Shock   3  Immediate vascular surgery which may save his hand , in spite of being in a state of shock  .

Case Discussion 

The patient was brought to the ED 30 minutes following the incident , during this time his BP was un recordable and there was profuse bleeding from visible right brachial artery  below his right elbow . There was a visible open  fracture of the forearm . The Emergency Team  led by Dr Indraneel  Das Gupta( Emergency Director ) started its resuscitation  efforts  based on the principles of Damage Control Resuscitation (DCR)  , a second team led by Dr Sudeshna Barua (Consultant Emergency Physician ) and Dr Syed Mudassir focused on immediate control of bleeding using temporary measures  , the third  Orthopaedics team led by Dr Somnath De and Dr Nikhilesh Das   focused on the aspects of the injury  while a fourth team of Vascular Surgeon  led by Dr Ashim Kumar De and Dr Hasim De was summoned for immediate vascular surgery in the Emergency Operation Theater . The Emergency Team managed to bring the blood pressure back to a recordable range and temporaryly stop the bleeding though the patient was still in shock .  This paved the way for further intervention -crucial decision was taken that the patient will undergo vascular surgery while resuscitation measures are still going on because that was the only way to save his right hand and arguably his life .
The Vascular Surgeon Dr Ashim Kumar De performed End to End Anastamosis of Right Brachial Artery and bifurcation of Radial and Ulnar  arteries .  The Anesthesia Team maintained the patient in a stable condition during the surgery.


The operation was successful ..His hands were gifted back by the Vascular Surgeon and his life was saved  by the Emergency Team , the Orthopedics team repaired the fracture and injury, as a result of these   pulses were palpable  in the right  hands after the surgery and the patient was able to move his finger. Equally important role was played by the Emergency Nurses and Paramedics ,without their help all  plans would have never been implemented.
This was  a great example of successful  Team  effort  which played against all odds to save the life and hand of the poor carpenter .

NB : Clinical images showing  initial condition of the patients hand after the traumatic incident has not been  displayed as we believe its  un-ethical to display such a pathetic  and terrifying image online.

Emergency Skin Grafting by Dr Indraneel Dasgupta

This 45 year old man met with a road traffic accident with tissue loss in his legs.
His condition required plastic surgery. Generally these patients are referred to a plastic surgeon. A plastic surgeon may or may not be available during these times . Moreover very few patients can afford such a costly surgery .




The surgery was completed in our ED in 45 minutes by Dr Indraneel Dasgupta. And the patient was sent home on the same day.As the patient was very poor the Department took a humanitarian approach and he was charged a nominal amount(Rs 500 ) for the procedure .
Very few Emergency Departments in the world can exhibit such amount of efficiency.
We the proud of Dr Indraneel Dasgupta- He is the Sun of Emergency medicine in Kolkata.

                                     

Post Operative Day 3

Post Operative day 15

How we managed a CODE BLACK (Disaster) in our ED

At  2 AM  at night  08/3/14 no one in the Emergency Department (ED) had the slightest hint of what is on store for the next three hours .    It was just another relatively  relaxed night with occasional chest pain and diarrhea  patients after the day's battle in a crowded ED.But after fifteen minutes  the scene completely changed . The ED became a battle ground : There was a CODE BLACK- the NABH code for "Disaster".Time had come to put text book knowledge into real life  practice.
On 2:15 AM 8/3/15 the quietness of night was  replaced with sirens from ambulances and desperate cry for help  when Kolkata Police started bringing patients after patients in the ED. It was later confirmed that a mass casualty event has occurred as a bus carrying a marriage party met an accident and got overturned near Ajay Nagar Crossing , Kolkata .

A total of 37 patients were brought at the same time , two of them were declared brought dead and triaged as "black"

The Emergency Trauma team  led by Dr Indraneel Das Gupta and Dr Saptarshi Saha stated its Traiging :Nine of them  were found seriously wounded - they were categorized as Yellow. Five required CT Scan of Head and Neck and subsequent neurology opinion . Other six  had multiple fractures.
But the whole disaster was managed in just two hours  with close coordination with the Orthopedics and Neurology Department . Early intervention with oxygen ,splints ,blood ,fluids and ventilator  in this " golden hour " of trauma saved the lives of all the patients -many of whom would have faced significant mortality and morbidity if the treatment was delayed .

The  Emergency Physicians on duty gave evidence of their professionalism and dedication . The Department has been training its professionals  for years for such  disasters which are encountered more often in textbooks and newspapers than in real life. .

Our regards to the Emergency Trauma team for their expertise and professionalism. The ED Trauma Team consisted of :
Dr Indraneel Das Gupta , Dr Saptarshi Saha ,
Dr Pranab Barua ,Dr Sajid Nomani , Dr Vivek Goel , Dr Palash Mannna, Dr Abhijit Mondal , Dr Jayanta Mahato
it was later joined by Dr K Sridhar , Dr Sujoy Das Thakur and Dr Abhishek Mukherjee.

NB :
"Golden Hour" (Adapted)

Golden Hour Principle

In emergency medicine, the golden hour (also known as golden time) refers to a time period lasting for one hour following traumatic injury being sustained by a casualty or medical emergency, during which there is the highest likelihood that prompt medical treatment will prevent death. It is well established that the patient's chances of survival are greatest if they receive care within a short period of time after a severe injury;Some have come to use the term to refer to the core principle of rapid intervention in trauma cases, rather than the narrow meaning of a critical one-hour time period.

Principle: Cases of severe trauma, especially internal bleeding, require surgical intervention. Complications such as shock may occur if the patient is not managed appropriately and expeditiously. It therefore becomes a priority to transport patients suffering from severe trauma as fast as possible to specialists, most often found at a hospital trauma center, for definitive treatment. Because some injuries can cause a trauma patient to deteriorate extremely rapidly, the lag time between injury and treatment should ideally be kept to a bare minimum; this has come to be specified as no more than 60 minutes, after which time the survival rate for traumatic patients is alleged to fall off dramatically.

The late Dr. R Adams Cowley is credited with promoting this concept, first in his capacity as a military surgeon and later as head of the University of Maryland Shock Trauma Center. The concept of the "Golden Hour" may have been derived from French military World War I data.The R Adams Cowley Shock Trauma Center section of the University of Maryland Medical Center's website quotes Cowley as saying, "There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later — but something has happened in your body that is irreparable."

CPR training to Kolkata Police

Men in white tightens their belts to increase the list of common man trained to save lives. Peerless Hospital hosted Community CPR workshop for the Kolkata Traffic Police on the 1st June 2013 organized by the Deptt. of Emergency Medicine. The seminar hall was filled from end to end with police personnel who are otherwise seen to be managing traffic in our city. They took deep interest to understand how to manage medical emergencies when medical help is far away. The do’s and don’ts of Basic life support was demonstrated by Dr. Saptarshi Saha and his team members like Dr. Prerit Sharma and Dr. Sudip Chakraborty from the emergency department. The initiative was lead by Dr. Saptarshi Saha, Asso Consultant, Deptt. of Emergency Medicine to spread the awareness of saving lives. The men in white were seen actively learning and mastering cardio pulmonary resuscitation meant to be delivered to a person in cardio-respiratory arrest. This training will go a long way in managing emergencies and saving lives at the site of emergency until medical help reaches there. Peerless Hospital has already trained 90 traffic personnel in three batches and would continue to do the same for the next few of months.

Congratulations to Dr Pranab Barua and Dr Palash Manna for clearing MCEM exams

This adds up to the list of MEM students from Peerless Hospital having cleared MCEM(part one) earlier .

The laurels continued to pour in as our residents went ahead to take the membership examination of the Royal College of Emergency Physicians (MCEM), UK. The MCEM examination is one of the internationally approved and accepted advanced emergency medicine qualifications. It has also been approved by the MCI as an additional post graduate qualification.

Till date five of our residents have taken and cleared the first part of the MCEM examination. Our list of successful residents includes:
1. Dr. Indranil Mitra
2. Dr. Pranab Barua
3. Dr. Vivek Goel
4. Dr. Palash Manna
5. Dr. Rahul Bansal

MEM residents get UK placement prior to course completion

Recruiters from UK were highly impressed with performance of our MEM students during the MTI selection process . Six of our residents have been offered placement offers in UK (MTI scheme ) .


The Department of Emergency of Peerless Hospital has once again made a mark on the International platform of Academic Emergency Medicine. The latest feather in an already decorative cap has been added by the illustrious performance of the MEM residents in international examinations and prestigious placement interviews.




In the recently concluded interview conducted by NHS, UK trust hospitals as part of the Medical Training Initiative (MTI) six of our residents got selected and would be joining in senior registrar position on residency completion. Their job description would include supervisory and administrative responsibilities in addition to clinical placements.







An important point of note – one of our senior faculty members Dr. Subhajit Sen will also be joining one of the NHS trust hospitals. His role would include supervisory, administrative responsibilities and clinical placements in addition to teaching the junior registrars.



Our heartiest congratulations and best wishes to all of them.

Peerless MEM Residents Rock AIIMS -ATLS Jan 2014

Good News!! all our residents who went for ATLS course in AIIMS New Delhi , has cleared the exam in first chance. Two of our residents Dr Mahesh and Dr Vijay has been awarded with instructor potential.We are all proud of their success.


Trauma management is is one of the most important aspects of any Emergency Department .

When its a major Trauma every second counts ! This led to the development of "Golden Hour of Trauma " Concept which explains that the time just following trauma (Golden Hour) is very crucial for patients survival . Important management decisions during this period has shown to improve survival.

Advanced Trauma Life Support (ATLS) is a training program for medical providers in the management of acute trauma cases, developed by the American College of Surgeons. Similar programs exist for nurses (ATCN) and paramedics (PHTLS). The program has been adopted worldwide in over 60 countries,sometimes under the name of Early Management of Severe Trauma (EMST), especially outside North America. Its goal is to teach a simplified and standardized approach to trauma patients. Originally designed for emergency situations where only one doctor and one nurse are present, ATLS is now widely accepted as the standard of care for initial assessment and treatment in trauma centers. The premise of the ATLS program is to treat the greatest threat to life first. It also advocates that the lack of a definitive diagnosis and a detailed history should not slow the application of indicated treatment for life-threatening injury, with the most time-critical interventions performed early. However, there is mixed evidence to show that ATLS improves patient outcomes.


Presently ATLS course is provided by two centres in India AIIMS , New Delhi and Dr Ram Manohar Lohiya Hospital New Delhi.


High standards are maintained in the course and there are limited number of ATLS certified Doctors in India .In order to get instructor potential a candidate has to prove himself to be the best of the best.


Based on these facts its a great achievement for the Department .

Cerebral Infract Due to Snake Bite -11th Case reported world wide,

By
Dr Indraneel Das Gupta
Dr Sourabh Pathak


Abstract

This case report describes a Cerebral Infarct  following a  Russel Viper Bite .

  Heamorrhagic  complications of Snake bite  are  well known but thrombotic stroke following snake bite is a very rare occurrence with very few reported cases .

We came across one such rare case of thrombotic stroke in the Emergency Department of Peerless Hospital and B C Roy Research Centre . With this case report  we will briefly discuss about various aspects of Thrombotic Stroke following snake bite .

Case Report

On  24-07-2013 a 42 year old man was received in the Emergency Department (ED) of Peerless Hospital and B.C. Roy Research Centre .

The case will  be described as per our Emergency Department case  management protocol

The Primary ED Survey  was remarkable for a airway full of secretions , with bilateral crepts present and a GCS of   E 2  M 4  V 2(ie8/15)  , with left hemi paresis ,B/L plantar flexor , Pupilary reaction  present

¨  Exposure :  A small abrasion in right lateral aspect of forehead , no other signs of injury found

BP 140/80 mmHg , HR 90/Min , Spo2 88%, RBS 160 mg/dl , Temp 98 F

           

  Action :
 Oxygen started at 6l/min via face mask  Rapid Sequence   Intubation done to secure the Airway.                   

AMPLE  History

Allergies : None , 
Medications (past ) None ,
Past Medical History : None

Last Meal : Approximately one day  ago  ,           

Events leading to the incident :  The incident occurred in a village in Burdawn District one day  ago(ie 23/7/13) at about 10 AM  .The patient who was a farmer was about to climb a mango tree then he was bitten by a big “Chandra bora”  Snake .(local Bengali name for Russel’s Viper ).

Events following the Bite are illustrated  below  along with the time of each significant event (please see discussion for the

23 /7/ 13  10AM  Bite by Russel Viper  -à Ran for Help and reached a friend in 10 minutes and said that he has been bitten by a Russel’s viper snake  while describing the event and planning what to do( 20 minutes )  the patient  developed drooping of eye leads and then slurring of speech and the patient got semiconscious (as per description GCS appeared to be E 3 M5 V 3 )  → Villagers came for help ambulance called

23/7/13  11:30 AM  Ambulance came and the patient was transferred to the local Primary Health Center(PHC) without any tourniquet or pressure bandage . In the PHC the patient was given 10 units of Anti Snake Venom and referred to a tertiary center in Kolkata ( approximately 100 km away )

23 /7/ 13 6PM  Patient arrived at MS Bangur Institute of Neuro Sciences (a tertiary center in Kolkata ) where a CT Scan of brain was done(See CT plate below ) was done and for some reason the patient was referred to another center at about 11 PM .The patient moved to various hospitals and ultimately came to ED of Peerless Hospital at 11 AM 24 /7/13 during the time of presentation GCS was  E 2  M 4  V 2

Following this Secondary survey was carried which was significant for

1 left sided Hemiparesis

2 Small aberration 3 cm in forehead

3  A alleged Fang mark in Left foot  (The small black mark surrounded by circle  )

  

CT  Brain taken at MS Bangur Hospital one day ago

Other Reports done at ED Peerless Hospital :

 20 Minutes Whole Blood test – Negative ,

Hb 11 , TC 8000 , platelets 1,50,000 ,

Na 138 , K 4.5

PT  11 ,  INR 0.8 ,

Cr 1.4  Urea 35 ,

Urine output : 400 ml in 4 hours

Management :

Management was supportive and Monitoring  carried out  in the Resuscitation Bay of the ED   with IV fluids  and ventilator management .But in spite of our best efforts  the patient died after 8 hours of arrival to the ED .

Discussion :

From the description of the case it appears to be that this is a snake bite by Russel’s Viper which resulted to a large cerebral infract  and ultimately death of the patient . Venomous Snake bites has been traditionally   classified into neurotoxic and heamatotoxic  though their   cardiotoxic , local necrotic effects and  anti endothelial effects are well known . However prothrombotic effects  of venomous snakes  specially cerebral infracts are very rarely reported  in medical literature . Our case appears to be one of the rarest of the rare case .

Our review of medical literature revealed that till date there are only 10 cases of cerebral infract reported in medical literature .

Reported by	Year	Snake
Ittyachen AM  et al	2012	Thalamic infract by Russell’s Viper
Gupta S           et al	2012	Cerebellar infract by Russell’s Viper
Gouda S	2011	Cerebellar and occipital infract by Russell’s Viper
Narang Sk	2009	Left MCA territory infract by Russell’s Viper
Hoskote SS	2009	Bilateral Ant cerebral Artery by Viper
Magundhan K	2008	Bilateral cerebellar and right occipital infarction
Numeric P	2002	Multiple cerebral infract  by Bothrops caribbaeus, a species of the Bothrops complex, is found only in the island of Saint Lucia, West Indies.
Panicker and Madhusudanan	2000	Left frontal infract by viper
Murthy et al	1997	Cerebral infract by Viper
Basher R et al	1985	Left cerebral infract by carpet viper (Echis carinatus)

NB

¨  MOSQUERA et all studied 309 patients with complicated Snake Bite ..8 had CVA only one had Infract .

¨  There are also several reported cases of myocardial infraction and one reported case of intestinal infract following viper bite .

            

 Mechanism

The probable mechanism that is generally given to explain cerebral infract following snake bite are interplay between three pathological processes namely Hypovolumia , hypercoagulablity and Vasculitis  with vasculitis being the major process initiating a cerebral infract  .

¨  Hypovolumia  due to snake bite may  caused by Vomiting , Sweating  and  bleeding which leads to a low  flow state in the coronary arteries – however this doesn’t appear to be present in our case .

¨  Hypercoagublity is  casused by procoagulants in Venom  like Arginine,Esterase and Hydrolase

¨  Vasculitis which appears to be the major contributing  factor in our case is thought to be caused by Hemorrhagins : component mediated Toxic component of viper Venom which leads to vascular spasm, endothelial damage and increased permeability contributing to vessel occlusion ultimately 
leading to Infract.


These three mechanisms appear to expain the classical virchow's triad which describes the three broad categories of factors that are thought to contribute to thrombosis.:Hypercoagulability ,Hemodynamic changes (stasis, turbulence) , Endothelial injury/dysfunction.

It should be noted that had the patient got pressure bandage at an early stage and had the patient be transported earlier to Primary health care centre as suggested by WHO guidelines this event could have been prevented .

Conclusion

Cerebral infraction  can be a rare complication of snakebite  .