Comparing online and onsite simulation modules for improving knowledge and confidence in disaster preparedness among undergraduate medical students.

BACKGROUND: Disaster preparedness is one of the critical strategies for effectively managing disasters and has been an area of high focus in the healthcare sector over the past few decades. The current Indian medical undergraduate curriculum does not describe any novel methods for disaster preparedness training. There is a need for a better understanding of novel teaching-learning methods and modes for administering disaster preparedness training among Indian medical students. OBJECTIVES: Describe the undergraduate medical students' baseline knowledge and confidence level of disaster preparedness. Compare undergraduate medical students' knowledge scores and confidence levels on disaster preparedness after online and onsite delivery of the disaster preparedness module. METHODS: In this educational interventional study, 103 medical students were divided into two groups and subjected to an online or onsite session of the validated disaster preparedness module (based on the COVID-19 pandemic), encompassing a simulation-based tabletop exercise. Baseline testing was done for 52 participants in the online group and 51 in the onsite group of the study. Post-intervention, they were assessed with single-response type MCQs for knowledge and Likert scale-based questions for confidence scores. The pretest and posttest scores were collected, and the data were analysed using two-tailed t-tests for paired analysis of within-group (online group or onsite group) and heteroscedastic analysis of between-group datasets. RESULTS: One hundred and three participants completed the exercise-52 participants were from the online group, and 51 were from the onsite group. After the intervention, there was a statistically significant increase in knowledge and confidence in both online and onsite groups. There is, however, no significant difference in the 'percentage change' in 'knowledge' or 'confidence' between the groups. CONCLUSIONS: Our study indicates that the disaster preparedness module, delivered online and onsite, improves knowledge and confidence among undergraduate medical students. However, there is no superiority between one mode of delivery and the other. We conclude that online training can facilitate disaster preparedness training as a corollary to the prescribed traditional training methods for undergraduate medical students in India.

Removing Barriers to Emergency Medicine Point-of-Care Ultrasound: Illustrated by a Roadmap for Emergency Medicine Point-of-Care Ultrasound Expansion in India.

Point-of-care ultrasound (PoCUS) has a potentially vital role to play in emergency medicine (EM), whether it be in high-, medium-, or low-resourced settings. However, numerous barriers are present which impede EM PoCUS implementation nationally and globally: (i) lack of a national practice guideline or scope of practice for EM PoCUS, (ii) resistance from non-PoCUS users of ultrasound imaging (USI) and lack of awareness from those who undertake parallel or post-EM patient care, and (iii) heterogeneous pattern of resources available in different institutes and settings. When combined with the Indian Preconception and Prenatal Diagnostic Techniques (PCPNDT) Act, this has led to the majority of India's 1.4 billion citizens being unable to access EM PoCUS. In order to address these barriers (globally as well as with specific application to India), this article outlines the three core principles of EM PoCUS: (i) the remit of the EM PoCUS USI must be well defined a priori, (ii) the standard of EM PoCUS USI must be the same as that of non-PoCUS users of USI, and (iii) the imaging performed should align with subsequent clinical decision-making and resource availability. These principles are contextualized using an integrated PoCUS framework approach which is designed to provide a robust foundation for consolidation and expansion across different PoCUS specialisms and health-care settings. Thus, a range of mechanisms (from optimization of clinical practice through to PoCUS educational reform) are presented to address such barriers. For India, these are combined with specific mechanisms to address the PCPNDT Act, to provide the basis for influencing national legislation and instigating an addendum to the Act. By mapping to the recent Lancet Commission publication on transforming access to diagnostics, this provides a global and cross-discipline perspective for the recommendations.

E-HEART score: A novel scoring system for undifferentiated chest pain in the emergency department.

OBJECTIVE: Cardiovascular disease is the leading cause of death worldwide. As there is an increase in the global burden of ischemic heart disease, there are multiple scoring systems established in the emergency department (ED) to risk stratify and manage acute coronary syndrome (ACS) in patients with chest pain. The objective of this study was to integrate point-of-care echo into the existing history, electrocardiogram, age, risk factors, and troponin (HEART) score and evaluate a novel scoring system, the echo HEART (E-HEART) score in risk stratification of patients presenting with undifferentiated chest pain to the ED. The E-HEART Score was also compared with existing traditional scoring systems for risk-stratifying acute chest pain. METHODS: A diagnostic accuracy study involving 250 patients with chest pain at the ED of a single tertiary care teaching hospital in India was conducted. The emergency physicians assessed the E-HEART score after integrating their point-of-care echo/focused echo findings into the conventional HEART score on presentation. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE) within 4 weeks of initial presentation. The accuracy of the E-HEART score was compared with other conventional risk stratification scoring systems such as the thrombolysis in myocardial infarction (TIMI), history, electrocardiogram, age, and risk factors, Troponin Only Manchester ACS (T-MACS), and HEART scores. RESULTS: A total of 250 patients with a median age of 53 years (42.25-63.00) were part of the study. Low E-HEART scores (values 0-3) were calculated in 121 patients with no occurrence of MACE in this category. Eighty-one patients with moderate E-HEART scores (4-6) were found to have 30.9% MACE. In 48 patients with high E-HEART scores (values 7-11), MACE occurred in 97.9%. The area under receiver operating characteristics (AUROC) of E-HEART score is 0.992 (95% confidence interval: 0.98-0.99), which is significantly higher than AUROC values for HEART (0.978), TIMI (0.889), T-MACS (0.959), and HEAR (0.861), respectively (P < 0.0001). At a cutoff of E-HEART score >6, it accurately predicted ACS with a sensitivity of 92% and a specificity of 99% with a diagnostic accuracy of 97%. CONCLUSION: The E-HEART score gives the clinician a quick and accurate forecast of outcomes in undifferentiated chest pain presenting to the ED. Low E-HEART scores (0-3) have an extremely low probability for short-term MACE and may aid in faster disposition from the ED. The elevated risk of MACE in patients with high E-HEART scores (7-11) may facilitate more aggressive workup measures and avoid disposition errors. E-HEART is an easily adaptable scoring system with improved accuracy compared to conventional scoring systems.

Evaluating the Use of E-Learning in Indian Emergency Medicine Residency Programs During the COVID-19 Pandemic: A National Cross-Sectional Survey.

OBJECTIVE: The coronavirus disease (COVID-19) pandemic has necessitated e-learning strategies in academic emergency medicine (EM) programs. A study was conducted during the COVID-19 pandemic to understand e-learning in the Indian EM context. METHODS: After IEC/IRB approval, we conducted a multicenter national survey validated by experts and underwent multiple reviews by the research team. The final survey was converted into Google Forms for dissemination via email to National Medical Commission (NMC) approved EM residency program as of 2020-2021. Data were exported into Excel format and analyzed. RESULTS: Residents and faculty comprised 41.5% and 58.5% of 94 respondents. The COVID-19 pandemic's second wave in India significantly impacted response rates. Internet connectivity was cited as a significant barrier to e-learning, while flexible timings and better engagement were facilitators identified by the survey. The attitude among residents and faculty toward e-learning was also evaluated. CONCLUSION: This survey reveals a significant positive shift in medical education from conventional teaching strategies toward e-learning, specifically during the pandemic. It also shows the need for all stakeholders (learners/educators) to better understand e-learning and adapt to its requirements. We need more data on the efficacy of e-learning compared to traditional methods. Until then, innovative hybrid/blended strategies would be the way forward.

A Comparison between Ultrasound-guided Short-axis Approach and Oblique Axis Approach for Internal Jugular Venous Cannulation in the Emergency Department.

Background: Central venous catheter (CVC) placement is a frequently performed procedure in the emergency department (ED). We aim to compare two different ultrasound (US)-guided techniques, the short-axis (SAX) approach and the oblique axis (OAX) approach for the insertion of internal jugular vein (IJV) catheters in an ED setting. Methods: This prospective, observational study was conducted in the ED of a single tertiary care teaching hospital on patients requiring IJV cannulation. CVC placement was done using both the SAX and OAX approaches as per the ED physician's discretion. Outcome measures included acute complications, successful insertion of an IJV catheter, number of attempts, and access times. The Chi-square test was used to compare the study variables (acute complications, number of cannulation attempts, and successful cannulation) between the two approaches. Mann-Whitney U-test was applied to compare the mean differences of flash time and cannulation time. Results: Sixty patients were enrolled, of which 30 underwent IJV cannulation by the SAX technique and 30 by the OAX technique. We noted a total of 22 acute complications, 56.7% in the SAX group and 16.7% in the OAX group. A significant incidence of posterior venous wall puncture was noted in the SAX group (50.0%). No significant statistical differences were noted on analysis of other outcome measures. Conclusion: The OAX approach is a useful alternative technique to IJV cannulation in the ED setting. Further multicentric studies in this domain will be required to consider this technique as the primary approach to US-guided IJV cannulation in the ED setting.

Indigenously Developed Ultrasound Phantom Model versus a Commercially Available Training Model: Randomized Double-blinded Study to Assess Its Utility to Teach Ultrasound Guided Vascular Access in a Controlled Setting.

Background: The commercially available training phantoms being expensive, homemade models are popular surrogates for training. We intended to study how comparable our indigenously developed ultrasound phantom (IDUP) was with the commercially available model for ultrasound-guided vascular access (USGVA) training. We also assessed the change in confidence among trainees using a 21-h standardized program. Methods: A prospective randomized double-blinded, parallel design study, with sequential allocation, was done after a standardized point of care ultrasound training course. Over three consecutive courses, 48 trainees volunteered to take part in the study. The models (IDUP and commercial phantom) were allocated as model A and model B. In each course, participants were also allotted sequentially to either perform in-plane or out of plane approach first, at the testing stations. Wilcoxon signed-rank test was used to compare pretest with posttest scores. Results: There was a statistically significant difference between IDUP and commercial phantom with respect to the resemblance to human tissue on tactile feedback and ease to perform the procedure. However, both models did not show a statistically significant difference in terms of ease of use, visual resemblance to human tissue, needle visualization, and artifacts on ultrasonography display. A significant change in the confidence levels of participants was seen postcourse. Conclusion: IDUP was a comparable alternative to the commercial model for USGVA training in a resource-limited setting. A 21-h standardized training program improved the trainee's confidence in performing and teaching USGVA.

The Art of Sim-Making: What to Learn from Film-Making.

The components of each stage have similarities as well as differences, which make each unique in its own right. As the film-making and the movie industry may have much we can learn from, some of these will be covered under the different sections of the paper, for example, "Writing Powerful Narratives," depiction of emotional elements, specific industry-driven developments as well as the "cultural considerations" in both. For medical simulation and simulation-based education, the corresponding stages are as follows: DevelopmentPreproductionProductionPostproduction andDistribution. The art of sim-making has many similarities to that of film-making. In fact, there is potentially much to be learnt from the film-making process in cinematography and storytelling. Both film-making and sim-making can be seen from the artistic perspective as starting with a large piece of blank, white sheet of paper, which will need to be colored by the "artists" and personnel involved; in the former, to come up with the film and for the latter, to engage learners and ensure learning takes place, which is then translated into action for patients in the actual clinical care areas. Both entities have to go through a series of systematic stages. For film-making, the stages are as follows: Identification of problems and needs analysisSetting objectives, based on educational strategiesImplementation of the simulation activityDebriefing and evaluation, as well asFine-tuning for future use and archiving of scenarios/cases.

Chest Compression Fraction and Factors influencing it.

Introduction: Chest compression fraction (CCF) is the cumulative time spent providing chest compressions divided by the total time taken for the entire resuscitation. Targeting a CCF of at least 60% is intended to limit interruptions in compressions and maximize coronary perfusion during resuscitation. We aimed to identify the mean CCF and its relationship with various factors affecting it. Methods: Patients presenting to the emergency department in cardiac arrest at a single center were prospectively included in this study. Resuscitation was provided by trained health-care providers. The feedback device Cprmeter2™ was placed on the patient's sternum at the beginning of resuscitation. The total time taken for the entire resuscitation was noted by the device and CCF calculated. Results: The mean CCF was analyzed using descriptive statistics and was found to be 71.60% ± 7.52%. The total duration of resuscitation (R = -0.55, P = < 0.001, min-max, 2.02-34.31, mean 12.25 ± 6.54), number of people giving chest compressions (R = -0.48, P = < 0.001, min-max, 1-6, mean 4.04 ± 1.12), and total number of team members in resuscitation (R = -0.50, P = < 0.001, min-max, 4-10, mean 6.65 ± 1.32) had negative correlation with CCF. Diurnal variation (day, n = 35; mean 69.20% ± 7% and night, n = 20; mean 75.80% ± 5.6%, P = 0.001) and patients receiving defibrillation (receiving n = 10 mean 67.00% ± 4.11% and not receiving n = 45 mean 72.62 ± 7.42%, P = 0.005) were found to significantly affect CCF. Conclusion: The mean CCF for cardiac arrest patients was well within the targets of guideline recommendation. CCF decreased when resuscitation lasted longer, during daytime when the defibrillator was used, the total team members increased, and also when the number of people giving chest compressions increased. CCF during resuscitation may improve if there is a focus on improving these factors and requires validation in multicentric settings.

The mechanistic role of neutrophil lymphocyte ratio perturbations in the leading non communicable lifestyle diseases.

Inflammation plays a critical role in the development and progression of chronic diseases like type 2 diabetes mellitus, coronary artery disease, and chronic obstructive pulmonary disease. Inflammatory responses are indispensable for pathogen control and tissue repair, but they also cause collateral damage. A chronically activated immune system and the resultant immune dysregulation mediated inflammatory surge may cause multiple negative effects, requiring tight regulation and dampening of the immune response to minimize host injury.  While chronic diseases are characterized by systemic inflammation, the mechanistic relationship of neutrophils and lymphocytes to inflammation and its correlation with the clinical outcomes is yet to be elucidated. The neutrophil to lymphocyte ratio (NLR) is an easy-to-measure laboratory marker used to assess systemic inflammation. Understanding the mechanisms of NLR perturbations in chronic diseases is crucial for risk stratification, early intervention, and finding novel therapeutic targets. We investigated the correlation between NLR and prevalent chronic conditions as a measure of systemic inflammation. In addition to predicting the risk of impending chronic conditions, NLR may also provide insight into their progression. This review summarizes the mechanisms of NLR perturbations at cellular and molecular levels, and the key inflammatory signaling pathways involved in the progression of chronic diseases. We have also explored preclinical studies investigating these pathways and the effect of quelling inflammation in chronic disease as reported by a few in vitro, in vivo studies, and clinical trials.

Assessment of the Preparedness and Planning of Academic Emergency Departments in India During the COVID-19 Pandemic: A Multicentric Survey.

OBJECTIVE: Emergency medicine being a young specialty in India, we aimed to assess the level of disaster preparedness and planning strategies among various academic emergency departments (EDs) across India during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: A cross-sectional multicentric survey was developed and disseminated online to various academic EDs in India and followed up over a period of 8 wk. All results were analyzed using descriptive statistics. RESULTS: Twenty-eight academic emergency medicine departments responded to the study. Compared with pre-COVID period, COVID-19 pandemic has led to 90% of centers developing separate triage system with dedicated care areas for COVID suspected/infected in 78.6% centers with nearly 70% using separate transportation pathways. Strategizing and executing the Institutional COVID-19 treatment protocol in 80% institutes were done by emergency physicians. Training exercises for airway management and personal protective equipment (PPE) use were seen in 93% and 80% centers, respectively. Marked variation in recommended PPE use was observed across EDs in India. CONCLUSIONS: Our study highlights the high variance in the level of preparedness response among various EDs across India during the pandemic. Preparedness for different EDs across India needs to be individually assessed and planned according to the needs and resources available.

The 2021 Toolkit for Emergency Preparedness and Mitigation to Combat Surge of Pediatric COVID-19 Patients in India: The World Health Organization Collaborating Center for Emergency and Trauma in South East Asia Recommendations.

The authors of this toolkit focus on children under the age of 18 comprising approximately 41% of the total population in India. This toolkit has been created with an objective to prepare, mitigate the effects of any surge of COVID-19 in our communities, and help to optimally utilize the scarce resources. The toolkit design suggests the manpower, equipment, laboratory support, training, consumables, and drugs for a 10-bedded pediatric emergency room, 25-bedded COVID pediatric intensive care unit, and 75-bedded COVID pediatric high dependency unit/ward as defined for a 100-bedded facility. A dedicated and detailed chapter is included to address the psychological needs of the children. These data can be modified for other department sizes based on the facilities, needs, local environment, and resources available.

Door to balloon time in patients presenting with acute ST elevation myocardial infarction and time factors influencing it; an observational study from a tertiary care teaching hospital in India.

The objective of this prospective observational study was to assess the door-to-balloon time (D2B), in acute ST-segment elevation myocardial infarction (STEMI) patients and the time factors influencing it. The following timeframes were measured during the study: ED to ECG time, ED to coronary care unit time (ED2CCU), consent time, post-consent to balloon time (POSTCONSENT2B) and D2B. Effective D2B was 54 ± 12.2 min. Of the dependent variables, D2B had a strong positive correlation (ρ = 0.903) with consent time. This study sheds light on consent time a previously unrecognized entity as a significantly influencing factor for the D2B time.

Design, usage and review of a cost effective and innovative face shield in a tertiary care teaching hospital during COVID-19 pandemic.

BACKGROUND: A major challenge of the coronavirus pandemic is personal protective equipment (PPE) shortage. The open source community mobilised solutions to combat this using 3D printing technology. One such solution was the face shield, which protects facial areas from droplet contamination when used by orthopaedic and other front line health care workers (HCWs). OBJECTIVES: To assess the efficacy of an in-house developed face shield based on feedback by HCWs and its usage in triaging zones and operation theatre in a tertiary care hospital. METHODS: A protective face shield was developed and distributed among the orthopaedic surgeons and front line HCWs involved in the ICU in our hospital and neighbouring facilities. Feedback was obtained using a questionnaire utilising a Likert scale. RESULTS: 227 face shields were distributed to the HCWs in our hospital (157) and neighbouring facilities (70). Design modifications were done as per the needs of the HCWs. 37 HCWs provided feedback giving the face shields an overall mean score of 7.92 out of 10. The poly vinyl chloride (PVC) film visors were better for airway management procedures as it can be tucked into PPE suit and visors with overhead projector (OHP) sheets were suitable for ICU and operative procedures. CONCLUSION: A locally developed face shield design by an inter disciplinary team in synchrony with HCWs is found to increase its acceptability and efficacy. Face shields can be made more effective in different triaging and treatment situations by varying the device setup.

Are we prepared? Lessons from Covid-19 and OMAG position paper on epidemic preparedness.

Covid-19 has once again brought into focus our limited preparedness to deal with epidemics. Most nations, across the globe, have responded with a resolve to come stronger out of this crisis and leaderships across the world have shown great commitment to protecting its people from Covid-19. Covid-19 has also taught us a few things for the future. One such learning has been that a strong shift in focus towards non-communicable diseases driving health infrastructure across the globe for the last few decades has come at neglect of communicable diseases. In that sense, therefore, the current pandemic has been a wake-up call. Organised Medicine Academic Guild (OMAG), an umbrella organization of professional associations gathered a group of health experts to develop a policy document on epidemic preparedness to limit the influence of epidemics like Covid-19.

Infection Control Measures, in situ Simulation, and Failure Modes and Effect Analysis to Fine-Tune Change Management during COVID-19.

Coronavirus disease 2019 (COVID-19) was an impetus for a multitude of transformations - from the ever-changing clinical practice frameworks, to changes in our execution of education and research. It called for our decisiveness, innovativeness, creativity, and adaptability in many circumstances. Even as care for our patients was always top priority, we tried to integrate, where possible, educational and research activities in order to ensure these areas continue to be harnessed and developed. COVID-19 provided a platform that stretched our ingenuity in all these domains. One of the mnemonics we use at SingHealth in responding to crisis is PACERS: P: Preparedness (in responding to any crisis, this is critical) A: Adaptability (needed especially with the ever-changing situation) C: Communications (the cornerstone in handling any crisis) E: Education (must continue, irrespective of what) R: Research (new opportunities to share and learn) S: Support (both physical and psychological). This article shares our experience integrating the concept of simulation-based training, quality improvement, and failure mode analysis.

Utility of Point-of-Care Lung Ultrasound for Initial Assessment of Acute Respiratory Distress Syndrome Patients in the Emergency Department.

AIM: Lung ultrasound (LUS) has been extensively used in the evaluation of acute respiratory distress syndrome (ARDS) in the critical care setting. In our study, we aim to assess the utility of point-of-care ultrasound (POCUS)-LUS in the initial assessment of ARDS patients presenting to the emergency department (ED). SUBJECTS AND METHODS: We evaluated a prospective convenience sample of 73 adult patients presenting to the ED. The bedside LUS was performed by the trained emergency physician on patients with undifferentiated dyspnea with a clinical diagnosis of ARDS according to the Berlin's criteria. The four major LUS findings were examined on structured 12-zone LUS. The observed profile consisted of A lines, well-separated B lines, coalescent B lines, and consolidation among patients who were clinically diagnosed as ARDS. These LUS findings may vary depending on the severity of ARDS. The findings were analyzed using IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY, USA). RESULTS: Of the 73 study individuals, majority were male 46 (63%). The distributions of study individuals were as follows: 27% - mild ARDS, 37% - moderate ARDS, and 36% - severe ARDS. Coalescent B lines are present in about 70.4% and 92.3% of moderate and severe ARDS patients, respectively. Consolidations are predominantly present in moderate (100%) and severe (92.3%) ARDS. CONCLUSION: LUS in the initial assessment of patients' with ARDS yielded significant findings in the three clinically designated categories. This study opens up the possibility of using POCUS as an adjunct in the initial assessment of ARDS patient in the ED.

A Comparison of Internal Jugular Vein Cannulation by Ultrasound-Guided and Anatomical Landmark Technique in Resource-Limited Emergency Department Setting.

BACKGROUND AND OBJECTIVES: Central venous catheter placement is a frequently performed procedure in emergency medicine as well as critical care unit. We aimed to compare real-time ultrasonography (USG)-guided and the traditional anatomical landmark (AL) technique for the insertion of internal jugular vein (IJV) catheters in an emergency department (ED) setting. MATERIALS AND METHODS: Patients requiring IJV catheterization were prospectively recruited over a period of 1 year at a single center. Cannulation was done either by the AL or USG technique, according to ED physician's discretion. A preset pro forma was completed for each central line placed. Variables were compared using the independent t-test, Fisher's exact test, and the nonparametric Mann-Whitney U-test. RESULTS AND DISCUSSION: Seventy patients were enrolled, of which 35 patients underwent IJV cannulation by USG-guided technique (USG group) and 35 patients by the AL technique (AL group). There were a 100% success rate (35/35) for cannulation in the USG group and a 91.4% success rate (32/35) in the AL group. The catheter was placed on the first attempt in 17 (48.6%) patients in the AL group and 32 (91.4%) patients in the USG group. In th AL group, there were three failed cannulation attempts in comparison to the USG group. The mean start to flash time for the AL technique was 16.59 s (±10.67) and 4.86 s (±2.18) in the USG group. The mean cannulation time was 305.88 s (±66.84) in the AL group and 293.03 s (±71.15) in the USG group. A total of seven acute complications were noted, of which 2 (5.7%) in the USG group and 5 (14.3%) in the AL group. CONCLUSION: The real-time USG guided technique significantly reduces the number of attempts to cannulate, has a higher first-pass success rate, a quicker flash time, and fewer complications when compared to the AL technique. In EDs equipped with USG, insertion of IJV catheters under real-time USG guidance should become the standard of care.

A health care delivery model focusing on development of a cadre of primary care physicians-Recommendations of Organized Medicine Academic Guild.

Organized medicine is the academic guild of professional medical organizations in India. It was founded at the annual conference of Indian Academy of Pediatrics (PEDICON) on January 7, 2018. Organized medicine is constituted by leading professional medical organizations and mandated to support the sustainability of health agenda of the Government of India. A group of experts on behalf of Organized Medicine Academic Guild (OMAG) of India was constituted to facilitate adequate theories and models on how to make primary care integral to participation of people and intersectoral collaboration in equitable delivery of health care. A subtle, flexible, and comprehensive approach instead of a "compartmentalized existing in silos" approach is likely to be needed. This paper is a formal recommendation on behalf of OMAG with an aspiration to deliver to the people of India, what they need, focusing on discrete objectives with long-term plans.

Utility of Clot Waveform Analysis in Russell's Viper Bite Victims with Hematotoxicity.

INTRODUCTION: In Russell's viper bites, due to the lack of a better alternative, whole blood clotting test (WBCT) remains the standard test even though its reliability and sensitivity has been shown to be low. Activated partial thromboplastin time (aPTT)-based clot waveform analysis (CWA) is an optic absorbance assay that can be used as a global clotting test. In this study, the objective was to assess the changes in CWA and to compare CWA to WBCT and aPTT in patients with Russell's viper envenomation. METHODS: The datum was collected prospectively over 2 months as a pilot observational study in a tertiary care center. All proven cases of Russell's viper-envenomated individuals with preliminary CWA data and WBCT were included in the study. The clot wave (CW) of the five individuals, which met all the stringent inclusion criteria, was analyzed and interpreted. RESULTS: CW absorbance sigmoid waveform was deranged in all 5 cases, of which 4 showed a change in CWA even before an abnormal aPTT. Three of the 5 had a normal WBCT but showed early changes in CWA. Atypical biphasic waveform reported in disseminated intravascular coagulation in other prior studies is seen in venom-induced consumptive coagulopathy also. In all patients where a second derivative was plotted, the second (lower) phase of the second derivative showed a slow rise to baseline. CONCLUSION: CWA showed changes which provided information earlier than the conventional coagulation studies in the snakebite victims studied. While aPTT or WBCT reflects clotting time, CWA conveys the dynamic process of clot formation and stabilization. CWA may reveal disorders of clotting in snakebite victims before the conventional tests become abnormal. Future research should assess the speed and accuracy of the test in diagnosing hemotoxic envenomation and its potential role in guiding antivenom therapy.