"Financially Palliative": The Need to Address a Perplexing Financial Conundrum in Emergency and Critical Care.

The terminology "Financially Palliative" is a pseudonym and refers to a unique challenge faced in countries where public healthcare insurance coverage is not robust and the percentage of out-of-pocket health expenditure continues to be high. Emergency and critical care healthcare expenditures in such circumstances usually pose additional burden as they are unforeseen expenses, disproportionately high, for which most people are unprepared. Such situations may lead into a vicious cycle that initiates with expenditure hesitancy and delay in definitive care, which in turn leads to deterioration in the patient's condition and delay-related complications. This further fuels expenditure hesitancy due to uncertain prognosis and outcomes. The future threats posed by this issue are manifold, which are not only restricted to poor patient outcomes and diminishing physician morale but also hinder progress in science by influencing research outcomes/endpoints in areas where it is highly prevalent. Identifying and defining the problem with terminology is only the first step in working towards solutions. The issue needs to be addressed and mitigated before it spreads its roots deeper into our healthcare system. How to cite this article: Bhat R, Ramaswami A. "Financially Palliative": The Need to Address a Perplexing Financial Conundrum in Emergency and Critical Care. Indian J Crit Care Med 2024;28(9):820-822.

Utility of Adrenomedullin in Predicting Outcomes in Patients with Acute Febrile Illness in the Tropics: A Prospective Observational Study.

Acute febrile illnesses (AFI) such as dengue, leptospirosis, and scrub typhus start with fever, but some patients can deteriorate rapidly. Identifying these patients at risk is necessary to ensure early referral. The study's objective was to assess the utility of serum adrenomedullin (ADM) as a biomarker in predicting outcomes in adult AFI patients presenting to the emergency department (ED). In this prospective observational study, all consecutive patients admitted with AFI through the ED between June 2023 and February 2024 were assessed for eligibility. Clinical and laboratory findings were noted. The serum samples sent routinely for biochemical tests were used to calculate ADM levels at admission and 48 hours later (whenever possible). Clinically relevant outcome variables were collected for all patients. The utility of ADM in predicting 7-day mortality was evaluated for primary outcome analysis using a stepwise binary logistic regression. A total of 181 patients were recruited, with dengue (n = 91, 50%) being the most common diagnosis. The median sequential organ failure assessment score at admission was 5 (IQR: 3-10). The 7-day mortality was 26 (14%, 95% CI: 9.3-19.5). The median admission ADM levels and difference in ADM levels at 48 hours were significantly higher in those who died by day 7. Adrenomedullin levels at admission were found to be an independent predictor of 7-day mortality (adjusted odds ratio: 1.002, 95% CI: 1.001-1.004, P = 0.005). High ADM levels can be used for early referral in patients with tropical AFI. There is a need to explore the utility of antibodies targeting ADM in clinical studies.

Case Report: Oral Candidiasis in Acute Flaviviral Infection.

Kyasanur forest disease (KFD) is an endemic flaviviral hemorrhagic fever in south India. We report seven cases of oral candidiasis in patients from Karnataka, India, who presented in March and April 2024 with the first phase of KFD. Except for lymphopenia, no other risk factors for oral candidiasis were identified in these patients. All patients were managed with antifungals and did well at the 28-day follow-up. We report this case series to highlight the possibility of transient immunosuppression and the occurrence of opportunistic infections in flaviviral infections such as KFD.

#CPR challenge: Impact of a social media campaign on cardiopulmonary resuscitation awareness and skills among young adults - A quasi experimental study.

Aim: The aim of our study was to explore the effect of nomination-based social-media campaign and CPR-skill-booth on change in knowledge as well as hands-only CPR skills among young adults. Methods: A quasi-experimental study was conducted in two non-healthcare-stream colleges, one intervention and other control arm. After baseline evaluation of CPR knowledge in both colleges, a 4-week nomination-based social media campaign '#CPR challenge' was rolled out in the intervention arm which included a CPR-skill-booth that was setup for one hour every day to train interested participants in CPR. The participants were encouraged to share the same on their social media handles and data of self-reported metrics were collected. A post-intervention assessment was conducted in both arms, to assess knowledge and its translation to hands-only-CPR skills using qCPR mannequin and qCPR app® for objective assessment. Results: A total of 690 assessments were done; Intervention arm (pre-intervention-214, post intervention -155) and control arm (pre-intervention -157, post-intervention -134). The baseline knowledge scores were comparable in both groups. Knowledge score doubled in the intervention arm, (p < 0.001) from a median value of 29% (IQR:14 - 43) in the pre-intervention-cohort to 57% (IQR:29 - 71) in the post-intervention-cohort. Median CPR-skill-score was higher in the intervention arm 67.5(IQR:39-92) in comparison to control arm 21 (IQR:1-53) (p < 0.001). In terms of social media engagement, 50% of participants had watched the videos and 40.6% attended the CPR-skill-booth. Conclusion: Strategies such as a nomination-based social media campaign can improve the awareness, knowledge and also skills regarding hand-only CPR.

Predictors of 28-day mortality in melioidosis patients presenting to an emergency department: a retrospective cohort study from South India.

BACKGROUND: Septic melioidosis is associated with high mortality in resource-limited settings. The current study aims to find 28-d all-cause mortality predictors within 24 h of admission in melioidosis patients presenting to an emergency department. METHODS: This retrospective cohort study (2018-2022) included melioidosis patients divided into two groups based on their primary outcomes (28-d mortality). All the clinically relevant factors significant in univariate analysis were selected for binary logistic regression analysis. Those factors significant in logistic regression analysis were considered independent predictors of mortality. RESULTS: Of the 53 patients with melioidosis, the 28-d mortality of melioidosis patients admitted to the emergency department was 51% (n=27). Respiratory involvement, renal dysfunction, haemodynamic instability, elevated aspartate transaminase, elevated activated partial thromboplastin time, elevated CRP, elevated procalcitonin, decreased albumin, decreased absolute neutrophil count, decreased absolute lymphocyte count and use of piperacillin-tazobactam or azithromycin were significant predictors of mortality on univariate analysis. Vasopressor requirement (p=0.03) and low serum albumin level (0.041) at presentation were independent predictors of mortality. CONCLUSION: Vasopressor requirement and low albumin levels at presentation in the emergency department are independent predictors of mortality. There is a need to create awareness among primary care physicians to enable early diagnosis and prompt initiation of treatment.

Comparison between a low-cost model (CPR Pillow) and a mannequin in training hands only cardiopulmonary resuscitation (CPR): A randomised trial.

Introduction: CPR is an important lifesaving skill that can improve outcomes of patients in cardiac arrest. Mass training of hands-only CPR is one of the ways to spread information and teach this skill. Need for expensive CPR mannequins are a limiting factor in conducting such mass training programmes. This study assessed the effectiveness of a low-cost CPR pillow model in training hands-only CPR. Methodology: Two hundred and six undergraduate students underwent a two-hour CPR training session. They were randomly divided into two groups - mannequin group and CPR pillow group and practiced hands-only CPR on a standard mannequin and a low-cost CPR pillow model, respectively. Knowledge, attitude, and skill acquisition were objectively assessed and compared between the two groups. Results: There was no statistical difference in hand positioning, chest compression rate and fraction, depth and overall CPR score between the two groups trained via mannequin and CPR Pillow (P > 0.05). The CPR pillow group had better percentage of chest recoil as compared to the mannequin group (86% vs 73%; P < 0.001). Conclusion: The use of low-cost homemade CPR devices such as our CPR pillow model is an acceptable alternative to mannequin for training hands-only CPR to lay rescuers.

Factors associated with unexplained sudden deaths among adults aged 18-45 years in India - A multicentric matched case-control study.

BACKGROUND OBJECTIVES: In view of anecdotal reports of sudden unexplained deaths in India's apparently healthy young adults, linking to coronavirus disease 2019 (COVID-19) infection or vaccination, we determined the factors associated with such deaths in individuals aged 18-45 years through a multicentric matched case-control study. METHODS: This study was conducted through participation of 47 tertiary care hospitals across India. Cases were apparently healthy individuals aged 18-45 years without any known co-morbidity, who suddenly (<24 h of hospitalization or seen apparently healthy 24 h before death) died of unexplained causes during 1 st October 2021-31 st March 2023. Four controls were included per case matched for age, gender and neighborhood. We interviewed/perused records to collect data on COVID-19 vaccination/infection and post-COVID-19 conditions, family history of sudden death, smoking, recreational drug use, alcohol frequency and binge drinking and vigorous-intensity physical activity two days before death/interviews. We developed regression models considering COVID-19 vaccination ≤42 days before outcome, any vaccine received anytime and vaccine doses to compute an adjusted matched odds ratio (aOR) with 95 per cent confidence interval (CI). RESULTS: Seven hundred twenty nine cases and 2916 controls were included in the analysis. Receipt of at least one dose of COVID-19 vaccine lowered the odds [aOR (95% CI)] for unexplained sudden death [0.58 (0.37, 0.92)], whereas past COVID-19 hospitalization [3.8 (1.36, 10.61)], family history of sudden death [2.53 (1.52, 4.21)], binge drinking 48 h before death/interview [5.29 (2.57, 10.89)], use of recreational drug/substance [2.92 (1.1, 7.71)] and performing vigorous-intensity physical activity 48 h before death/interview [3.7 (1.36, 10.05)] were positively associated. Two doses lowered the odds of unexplained sudden death [0.51 (0.28, 0.91)], whereas single dose did not. INTERPRETATION CONCLUSIONS: COVID-19 vaccination did not increase the risk of unexplained sudden death among young adults in India. Past COVID-19 hospitalization, family history of sudden death and certain lifestyle behaviors increased the likelihood of unexplained sudden death.

Learning to switch gears - Steering palliative care into emergency medicine.

Emergency care is largely seen as synonymous with resuscitation and saving lives. In most of the developing world where Emergency Medicine (EM) is still evolving, the concept of EM palliative care is alien. Provision of palliative care in such settings poses its own challenges in terms of knowledge gaps, socio-cultural barriers, dismal doctor-to-patient ratio with limited time for communication with patients, and lack of established pathways to provide EM palliative care. Integrating the concept of palliative medicine is crucial for expanding the dimension of holistic, value-based, quality emergency care. However, glitches in decision-making processes, especially in high patient volume settings, may lead to inequalities in care provision, based on socio-financial disparities of patients or premature termination of challenging resuscitations. Pertinent, robust, validated screening tools and guides may assist physicians in tackling this ethical dilemma.

Portable Biosafety Barrier Innovations to Limit Transmissibility of Infectious Diseases during Patient Care in Resource-limited Settings during the COVID-19 Pandemic.

Background: The coronavirus disease-2019 (COVID-19) pandemic has brought about a change in healthcare practices that are likely to persist into the foreseeable future. In particular, is the exposure risk to the healthcare practitioners in the emergency department (ED) and the intensive care units. Mitigating this issue in a low-resource setting remains challenging, and in particular, in developing nations such as India, where ED patient flows can overwhelm a system and its human resources, breaking down processes and infecting healthcare workers (HCWs). Technique: To tackle this and the possible lack of appropriate personal protective equipment (PPE), we designed and built biosafety barrier devices using local resources for use in patient stabilization, transport, and continued care in the ED or the intensive care units. Results: Four biosafety devices bio-safe levels 1 and 2, ultra-ductile portable interface of interventions in infections, and tented transport trolley for transmissibility (4T) were tested for the feasibility of usage for patient care during the pandemic with simulation. Conclusion: We anticipate that with time it may be common practice for in situ isolation of patients in the emergency departments with a suspicion of an infectious disease. With the proof of concept, simulation, hospital infection control committee (HICC) approval, and trial run, we look to close the gaps that exist in these initial innovations. How to cite this article: Balakrishnan JM, Sirur FM, Prakash N, Bhat R, Wilson W, Angadi B, et al. Portable Biosafety Barrier Innovations to Limit Transmissibility of Infectious Diseases during Patient Care in Resource-limited Settings during the COVID-19 Pandemic. Indian J Crit Care Med 2022;26(9):1036-1038.

Clinical characteristics and outcome of patients presenting to emergency department during the second wave of COVID-19.

Background: COVID 19 resurgence in multiple waves and the highly infectious variant of SARS-CoV-2 (B.1.617) has wreaked havoc across healthcare systems in India. We conducted a study to delineate the clinico-epidemiological profile of COVID-19 patients in this second wave of the pandemic. Methods: This was a retrospective, single centre, observational study at the Emergency Department(ED) of a teaching institute in North India. The ED health records were screened for patient files with the diagnosis of COVID -19, age > 14 years, presenting from 10th April to 30th of May. ED clinical notes, disposition, and mortality data were retrieved and analysed. Results: 1647 files were screened and 253 eligible patients of COVID-19 were included in the study. 60% patients were male, mean age (+ SD) was 54 (+ 14.8 years). Shortness of breath (74.7%), fever (71.9%), cough (57.7%) were the common presenting symptoms. 20% of patients were nil comorbid; Diabetes (44.7%) and Hypertension (41.5%) were the common comorbid illnesses. 73.1% patients had severe COVID illness, 39.9% had oxygen saturation <90% on arrival and 33.2% had <70%. More than 90% patients required respiratory support on arrival. 25% of people presented to hospital after home isolation, of which 81% had severe COVID at presentation. 39 % patients of mild illness had received corticosteroids. Conclusion: The second wave of COVID-19 with rapid upsurge of cases overwhelmed the healthcare system with a higher proportion of severe COVID-19 cases and higher mortality, thus stressing the need for prior planning, preparation and strengthening healthcare systems across tiers.

Patterns and Predictors of Emergency Medical Services Utilisation by Patients Attending the Emergency Medicine Department of a Tertiary Care Hospital in India.

Introduction: Establishment of strong emergency medical services (EMS) systems plays a pivotal role in reducing morbidity and mortality, especially in low and middle-income countries. We aimed to study the EMS utilization and resources available in the ambulances to deliver prehospital care among patients presenting to the Emergency Medicine Department in a tertiary care hospital in south India. Methods: Data regarding prehospital transport practices such as mode of arrival, utilization of EMS, resources available in the ambulance, presenting complaints, triage category, and demographic details were collected and analyzed. Subgroup analysis for time-sensitive complaints was done. Variables were subjected to univariate and multivariate analysis to find the predictors of ambulance usage. Results: The study included 3935 patients. The most common time-sensitive complaints were trauma (17%) and chest pain (11.5%). The most preferred mode of transport was the personal vehicle (45.6%). 29.8% of patients arrived in the ambulance. 97.7% of ambulances were not Advanced Cardiac Life Support equipped and 87.1% did not have an accompanying health care provider. 64.5% inter-hospital patient transfers were through ambulance, 83.8% transfers were unaccompanied. Among patients with time-sensitive complaints, EMS utilization was inadequate (46.8% in acute coronary syndrome, 34% in trauma, and 56.5% in early acute ischemic stroke). Conclusion: There was underutilization of the EMS services. Majority of the ambulances were not adequately equipped/staffed to deliver prehospital interventions. Policies at national level are required to encourage EMS utilization by the public and urgent measures are needed to improve services provided by them.

Study of pre-hospital care of out of hospital cardiac arrest victims and their outcome in a tertiary care hospital in India.

BACKGROUND: India does not have a formal cardiac arrest registry or a centralized emergency medical system. In this study, we aimed to assess the prehospital care received by the patients with OHCA and predict the factors that could influence their outcome. METHODS: Out-of-hospital cardiac arrest patients presenting to the emergency department in a tertiary care centre were included in the study. Prehospital care was assessed in terms of bystander cardiopulmonary resuscitation (CPR), mode of transport, resuscitation in ambulance. OHCA outcomes like Return of spontaneous circulation (ROSC), survival to hospital discharge and favourable neurological outcome at discharge were assessed. RESULTS: Among 205 patients, the majority were male (71.2%) and were above 60 years of age (49.3%); Predominantly non-traumatic (82.4%). 30.7% of the patients had sustained cardiac arrest in transit to the hospital. 41.5% of patients reached hospital by means other than ambulance. Only 9.8% patients had received bystander CPR. Only 12.5% ambulances had BLS trained personnel. AED was used only in 1% of patients. The initial rhythm at presentation to the hospital was non-shockable (96.5%). Return of spontaneous circulation (ROSC) was achieved in 17 (8.3%) patients, of which only 3 (1.4%) patients survived till discharge. The initial shockable rhythm was a significant predictor of ROSC (OR 18.97 95%CI 3.83-93.89; p < 0.001) and survival to discharge (OR 42.67; 95%CI 7.69-234.32; p < 0.001). CONCLUSION: The outcome of OHCA in India is dismal. The pre-hospital care received by the OHCA victim needs attention. Low by-stander CPR rate, under-utilised and under-equipped EMS system are the challenges.

The conundrum of Thiamine Responsive Acute Pulmonary Hypertension (TRAPH) syndrome in the Emergency Department.

BACKGROUND: Management of acute pulmonary hypertension in the Emergency Department(ED) can be challenging. The treatment is specialised, requires rapid identification and correction of the precipitating cause; failing which the patient enters a vortex of deterioration. We describe a lesser-known cause for the same, Thiamine responsive acute pulmonary hypertension (TRAPH) syndrome where timely appropriate treatment can result in dramatic improvement. METHODOLOGY: Medical records with ICD code E51.12 (Wet Beriberi) from Mar 2018 to Mar 2020 were screened. The data regarding presenting symptoms, initial vitals, lab and radiological investigations, and treatment received were retrieved from patient files and the Hospital Informatics System, entered into an MS Excel sheet and compared. RESULTS: The study includes eight cases, which we believe to be TRAPH syndrome. Majority were young adult males, ethanol users. All patients presented with acute shortness of breath with tachypnea and shock index more than 0.9. Gross right atrioventricular dilatation, tricuspid regurgitation and mild to moderate pulmonary arterial hypertension was identified in echocardiography. The initial blood gas revealed median pH 6.98 (IQR 6.81-7.09), Bicarbonate 3.4 meq/L (IQR 2.5-5) and lactate 172 mg/dL (IQR 132-200) which improved within 12-16 h of admission. Patients received median 400 mg IV Thiamine. The mean duration of ICU stay was 2.5 days and total hospital stay was 7 days. CONCLUSION: Thiamine Responsive Acute Pulmonary Hypertension (TRAPH) Syndrome is an under-recognised entity which should be included in differentials for acute right ventricular dysfunction in the ED. Early diagnosis and rapid protocolised management of the same can cause quick recovery of patients.

Clinical profile, management and outcome of patients with leptospirosis during the times of COVID-19 pandemic: A prospective study from a tertiary care centre in South India.

Leptospirosis is a rodent-borne acute febrile illness, classically seen after heavy rainfall and floods. This study aimed to describe the clinical profile, management strategies and outcome of patients with leptospirosis amidst the Coronavirus disease-2019 outbreak. A prospective study of adult patients with undifferentiated fever (5-15 days) was conducted in South India between October 2020 and February 2021. The demographic, clinical details, laboratory details, treatment and outcome of leptospirosis positive (based on serology) and negative patients were compared. A chisquare test was used for qualitative variables, while an independent t-test or Mann Whitney U test was used for continuous variables. Of the 206 patients with suspected acute febrile illness, a total of 63 patients were diagnosed with leptospirosis based on serology results. The median sequential organ failure assessment score was higher in those with leptospirosis (p<0.001). Myalgia, abdominal pain, jaundice, decreased urine output, myocarditis, and dialysis requirement were more common in patients with leptospirosis. Leucocytosis and raised procalcitonin/C-reactive protein were more common in patients with leptospirosis. The duration of stay and antibiotic consumption was higher in patients with leptospirosis. Acute febrile illness such as leptospirosis should be suspected in tropical areas with significant risk factors. The presence of conjunctival suffusion, hepatic and renal dysfunction should warrant a serology test for leptospirosis.