 So good afternoon, everyone. Thank you for coming. So my name is Stuart Holmes and I'm the President of EYFDM, which is the European Young Family Doctors Movement. So today's webinar is a collaboration between ourselves, the EYFDM and also the Emergency Medicine Special Interest Group of Wonka World. So the series of webinars is organised by the global Wonka Young Doctors Movement and the President of Wonka Young Doctors, Sankar, wanted to be here, but unfortunately he cannot join as he's in South America. So I'll just read out a message from him and then we'll get started. So I guess if you're not speaking to present, if you could keep your microphone off, that would be really helpful. And also if you want interpretation in either Mandarin or Chinese, if you go to the bottom of the screen beside reactions, there's a button which says interpretation and you can choose to hear live interpretation in either Spanish or Chinese. So I'll just read out the message from Sankar who can't be here and then I'll hand over to the Emergency Medicine team and we'll get started. So Sankar wanted to say dear young doctor colleagues around the world, greetings from Colombia. Thank you for joining this webinar organised by EYFDM, the Wonka Young Doctors Movement in Europe, in collaboration with the specialist group on Emergency Medicine. This is our seventh collaborative webinar. Emergency Medicine is one of the most important areas that should be practised by all family doctors as it is directly related to first contact care and can be life-saving. In addition, family doctors in some countries are an integral part of emergency departments and in countries like Nepal, Emergency Medicine is solely practised by GPs so it is part of their postgraduate training. So therefore it's of the utmost importance that we understand the subject. Today's webinar has been, has includes very interesting and relevant topics for all family doctors and as a member of the team, I saw the hard work put on by the organisers and I'd like to sincerely appreciate the work led by Elena and Stuart. Congratulations. Thank you and I hope that the participants will grab the most of this useful webinar. So that was the words from Sankar on the right. And yep, we're glad to have you with us and I'll hand over to Elena who will take it from here. Thank you very much Stuart. Okay guys, so very, very welcome to our webinar. My name is Elena and I am the chair of the Wonka Special Interest Group on Emergency Medicine and I would like to tell you a couple of things about us. First of all to present our incredible team. These two guys are Russian from Nepal and Miriam from Bolivia and they are our small young candidates from the young doctors movement to represent this movement in the Wonka Special Group on Emergency Medicine. And here we would like to say very, very warm thank you to these beautiful two girls Komalia and Chloe who are our colleagues and our interpreters in Chinese and Spanish. And here we are and we are the joint team of the Wonka Special Interest Group on Emergency Medicine and the founders of a great project on ultrasound which is starting to be organized in the young doctors movement of Europe, IFDM. So now we start our webinar already officially and I would like to explain you just one concept, very important concept for us as Wonka Emergency Special Interest Group. And this is that our group includes family doctors who are passionate about emergencies from all over the world and therefore we wanted to adapt the content of our webinar to different levels of complexity which can be useful for the doctors with different level of knowledge requirements. It depends on the profile of the work of family doctors in each given country, their involvement in their response to emergent pathologies with different levels of complexity, the infrastructure of each region's health system and the economic capacity to provide its professionals with means of diagnosis and intervention. So we know that the emergency medicine made by family doctors is not the same. In Spain, in England, in India, in Nepal, in mountainous regions of Bolivia or large rural territories of Australia. And the service portfolio to family doctor who works in emergency can offer in each country is very, very different. For this reason, we wanted to offer a material for different levels of difficulty as well as present your selection of typical health problems chosen by professionals from different regions of the world. We hope you will like the diversity of our material and especially its presenters and the lively and vibrant spirit of our group. To begin, I would like to introduce you to our young colleagues from European movement of young family doctors. They are the heart of ultrasound group project. This is their first appearance on the Wonka stage and I invite you to give them the warmest welcome and all your support. The project coordinator, Dr. Eva Leciara from Catalonia, Spain couldn't be with us this afternoon but I give the word to her team, the core block of the group that we hope will soon be an official IFDM working group. And the stage is yours, Anna. Thank you, Elena. Thanks everyone for joining us. We are presenting, first of all, the ultrasound EYFDM team and we are going to teach you some of the basics of the ultrasound for emergency departments. Next, please. This is the index, the program we are following today. We are first speaking about the basic principles then the indications of the ultrasound in emergency departments and last but not least the EYFAS protocol for polytrauma and the RASH protocol for SHOP. Next, thank you. This is our team, the ultrasound team. The first one is me. In the left, I'm Anna. The next one is Ravi, which is teaching us the first protocol. The next one is Drago, which is going to teach us the RASH protocol and the last one is Eva, the person who was the main organizer of this but couldn't attend in the last moment, so that's it. Thank you. Well, first of all, we are going to talk about the choosing the right ultrasound probe based on application. Next, please. There are only three kinds of probes in the ultrasound system and we would like to begin for the first one, which is the smallest one. The sectorial one just for the cardiac images and you just have to remember that it's so small that you can pee between the ribs, so it's just only used for cardiac images. The last one, the C one, it's called the convex one, which is the deepest one. It's only used, well, it's used for abdominal cavity. Sorry, yeah, it's used for the abdominal cavity and if you don't remember you're not used to it, just remember that it has like a belly, so it's for the belly, okay? And the one in the middle, the sectorial one, the linear one, it's just flat like the skin because it's for superficial structures, such as anything that is just below the skin or, for example, the theory, which is so superficial, right on the neck. Next one, please. We would like you to remember from anatomy classes the three main planes of the human body, right? The coronal one just also called the frontal plane, the sagittal one, which is just in the middle, and the last one, which is the transverse plane, it's my favorite because whenever if you're not used to ultrasound image, you can always compare it to a CT scan because it's the same image you get from a CT scan, so it's easier to compare it. Then in the image below, you have to remember every probe has a marker, an indicator, a small light that gives us the hint to remember where are we because we can see the light in the probe and we can also see an image, a red point on the screen, so we remember where are we going and where are we coming from. We have three kinds of movements from the probe. The first one is next Elena because it's not moving the image, sorry. No, before. That's it because it's a video. Sliding on a surface, you just slide it, right? Tilting, which is you get the probe from here from the top and just tilt in the same, you have to stick it to a point and then move it towards the front and to the back, just like this, like this, if you cannot see. And then rotating. As you rotate the probe, you can change from a transversal image to a sagittal one. Next one, please. There are lots of buttons on the ultrasound computer on the console, but we only have to remember there are a few of them that can give us the opportunity to adjust the depth, the focus, the gain and also we can freeze the image to take a picture or to compare to do some measures in the ultrasound. And the most important one, I think, is the color Doppler one because it makes you, for example, when you have like a transverse cut from a vase, you don't know if it's a vase, if it's a fist or something and you use the ultrasound Doppler and you say, okay, there's fluid inside that it's coming to me and there's fluid that is going to the opposite direction so you can differentiate if it's a blood vessel or if it's another structure. Okay, next one. And then these are like the basic names, the basic terminologies or ultrasound. You have to remember that where is anechoic means it's pitch black. Like nothing of the ultrasound can go in there so it's liquid. The opposite would be hyperechoic which means it's brighter, like bright white like metal or bones, for example. And then there are other two terminologies. There are isoechoic, which means two structures have the same color, the same texture, the same ecogenicity. Like, for example, the spleen and the kidney and hypoechoic, which means some structure is hypoechoic, it's darker than the other one. For example, the liver is hypoechoic, it's darker than the right kidney if you can see it in the picture. Right, okay, next one. And well, these are some of the indications of the ultrasound as you can see or you can read in the slide. There are so many of them, just pulmonary, cardiac, vascular, in some kind of patients such as shock patients or Arduino pathologies. So let's go for the next one, please. Your turn, Ravi. Hello everybody, I'm Ravi. So let's start using ultrasound in emergency. Our first case is the bullet trauma patients. So it's an 18-year-old male who was transferred to the emergency department after having a motorcycle accident with multiple contusions. Next, please. In order to assess a bullet trauma patient, we can use this algorithm. So ultrasound scan, the fast protocol, can help identify general region of bleeding in trauma. Imagine an unstable patient with fast positive, means bleeding, should go directly to the operating room. If the patient is stable, we can do a CT scan. An unstable patient with a negative fast, we still need a CT scan to diagnose area of bleeding. And if the patient is stable, we can observe and repeat the E-fast to reevaluate. Next, please. Next, please. Okay. So the E-fast stands for extended focused assessment with sonography and trauma. So the text, pericardial fusion, hemoperitunium, and nemothorax within the emergency department. There are many different sequences for the E-fast. We choose this one. We chose this one. You can choose whatever suits you, but just make sure not to forget any of the views while doing the exam. So we'll use the same transducer during the exam. It's the convex probe with the pre-set of fast or abdominal. We start with number one. So it's the cardiac or sub-cephaled view. It answers the question, does our patient have a fluid in the pericardium? So for this view, you point the probe indicator towards the patient's head and aim the beam towards the patient's left shoulder. You can, as you can see here, there's an area, a black area, an echoic area around the heart, which indicates that he has pericardial fusion. Next, please. So for the next two views, number two and number three, remember to look for free fluid, both above the diaphragm and below the diaphragm. So above for hemothorax and below for hemoperatoneum. So number two is the right upper quadrant view. This is usually the most sensitive view of the EDFAST exam because since the liver is the most common commonly injured organ. So maybe our patient has an injured liver and we can detect here if he has the problem. So the probe indicator towards the patient's head also again, sorry, in the mid-accelery line at the 10th intercostal space. We can here see the black area in the hepatorenal space or the Morrison pouch where it's usually identified free fluid. Next, please. And moving to the third number three, the left upper quadrant view, the question here is, our patient has a free fluid in the abdomen or the left thorax. So again, the probe indicator towards the patient's head and in the, sorry, in the posterior axillary line in the eighth intercostal space and free fluid is most frequently seen in the perisplinic space. The Morrison, sorry, perisplinic space between the spleen and the diaphragm as shown here in the photo below. So next, please. Okay. Now, number four is the, the fourth view is the pelvic view. So it answers the question, does my patient have a free fluid in the abdomen or pelvis? It's important here to consider the sex of the patient, as free fluid has a tendency to accumulate in different locations depending on the patient's gender. So you point the indicator towards the patient's head and they'll launch it to the left view in the patient's midline right above the bubic synthesis and you tilt the probe to point down towards the pelvic cavity. So you have in the lower image at the right, you have for the transverse view, you center the bladder as in before and then rotate the transducer 90 degrees counterclockwise and you have this to tilt the indicator points to the right of the patient. So in the, in the, in male patients, you, the free fluids can be found in the recto-visical boat and in females, you can identify the recto-uterine pouch, which is the pouch of Douglas where you can find free float in the pathological exam. Next, please. And finally, we go to the lung views to identify if our patient has an nemothorax. You point the indicator towards the patient's head in the mid-clavicular line at the second intercostal space to the right and the left lung respectively. So this point is the most sensitive spot for looking for nemothorax in the patient. But first, the ultrasound finding to confirm you are in the correct position is to look for the two-rips shadow, the black area below the bat and which is the bat wing sign. So here, you look for the lung sliding. If you may, the next, please, we can see the video. So now it's moving. It's the lung sliding during respiration. If lung sliding is present, you can rule out nemothorax at that ultrasound point. And that's it. Remember that this view will also help you with another protocol. It's called the blue protocol looking for the lung pathologies. So we saved that for another webinar. Thank you. So yeah, now it's my turn. Thank you, Ravi, for this presentation. And thank you, Ana, as well. Now we have a patient that is in shock. It's a 19-year-old patient that comes to the hospital because he is in shock in superior hypotension in the rash. And we're going to find out very fast why is he in shock. Can you move the slide? This is the rapid ultrasound for shock and hypotension. And we thought we've a patient that has low hypotension, low ejection fraction, and we're going to have to look for the heart. We're going to have to look for the heart if the ejection fraction is high or low. If the right ventricle has a strain or not, so for pulmonary embolism, if there is a cardiac diffusion or not. If there is a high or low cardiac output, we're going to check for the inferior vena cava as well to see if it's collapsible or not to know what type of shock we're talking about. We'll have to look also with a part that overlaps with the fast exam that Ravi presented to see if there is bleeding inside. So this is why we're going to watch around the abdomen to see if the pulmonary sonar, the E-fast exam will present it if there is an amperitoneum. Afterwards, we're going to check for the aorta and in the end for the lungs, for the pulmonary part, we'll check if there is a pneumotorax. We're not going to cover all of them because this is only a presentation to keep you interested into ultrasound. But we have a little mnemonic for this with a high map. If the patient is low, we're going to make it high map in order to check if there is an amperitoneum coming on correctly and to correct all these parts. So what we have in the rush examination, we have several views of the heart, the parasterner, the long cardiac view. We have the apical full chamber view, the inferior vena cava, a part that overlaps with the E-fast examination. Then we're going to check for the aorta and a pulmonary view. Can you move the slide? I have myself a little probe because we don't have to talk about that, but there are always some innovative ways to make ultrasound. This is a more cheaper alternative, but it is not as qualitative as the bigger and more expensive ultrasound machine, but this is a little butterfly machine that can help us make a bedside ultrasound, a point of care ultrasound. I'm going to show it on myself, how do we put the probe? For the parasterner and look axis, we're going to have the marker of the probe onto the right shoulder, like in the image next to it. I'm going to show you my heart to see if I'm still alive and we're going to evaluate the heart to see if everything is going okay. Usually you can see also the heart. Here, my heart is moving. I'm going to have the best of images because I'm doing two stuff at the same time. What we're going to see, we're going to have the left ventricle. We're going to have the left ventricle that we're going to see here. I think I'm going to point it more on the screen because it's easier, but you can see that it's something that we can do it very easily as I'm doing it live for you now. We're going to have the left ventricle. We're going to have the left atrium. We're going to see how it contracts. In the image in the middle, we have a normal ejection fraction. At the third image that is on the right side, we have a reduced ejection fraction just to make you have the image that we can evaluate with our eyes. There are more quantitative measures, but we're not going to talk about them because this is only an introduction. Next slide, please. There is another view that is called the apical four chamber with the pointer towards the left shoulder and we're going to put it into the fourth to five intercostal space and more on the mediocre line or on the left side. What do we see here? We see the four chambers of the heart. We're going to check the right ventricle, the left ventricle, the right atrium, the left atrium. We're going to look if there is free fluid and if one of the ventricles is more enlarged and if they are contracted as they should. So now I'm going to have a question for you. I know that I'm checking out that we do not have to interact a lot, but you can put your answers into the chat. What do we see on the image on the right? We see a black spot that is around the heart. And I'm going to let you point the answers into the chat if you want to. But yeah, exactly. It's an econometric image. So we're going to see fluid around the heart. Exactly. Very well. I see that people are already starting to respond. Next slide, please. So yeah, now we're going to see another image of the heart. So I'm going to make you work right now. What does the pointer point to in that image? Come on. Let's chat a little bit. You can put some text into the chat. So yeah, this is the right ventricle. It's an enlarged right ventricle. It shows the right ventricle strain. So yeah, very well. So you can see that we feel fast and rapid. Yeah, we think about the pulmonary embolism. Very good, Mohammed. Very good. Exactly. That patient that shows with this enlarged right heart has a pulmonary embolism. Very good. Next slide, please. As I said, we're going to check also for the infrared vena cava to see if there is collapsible or not collapsible in order to see what type of shock do we have? If it's more like, if it's collapsible, our shock is mostly a distributive shock with the heart that's going on and it's dilated. We have another type. Yeah, exactly. Mohammed is right on there to check about this all. Let's go on to the next slide. So now we can also check for the water. I'm not going to give all the details and we're going to keep all the other questions at the end of the presentation because I'm not having a lot of time. I'm going to just put a normal presentation of the water. Exactly, Mohammed, you're right on top as always. The image that is in the middle shows a normal water. How do we see it? We have a type of the water. We see the vertebral body. Again, the probe orientation is like this. It's in the abdomen. And we add the abdomen. And on the image on the right, we see an abdominal aortic aneurysm. You see it very enlarged. You see it's just a spot on diagnosis. Next one about the pelvic views. So that overlapses with the EFAS examination. We're going to check if there is blood somewhere in the body in order to correct that. That can explain the shock. Next slide. And then we also had the lung part that Rabi also magnificently explained in order to see if there is a pneumotorax or not. Exactly through pelvis. In the pelvis, Mohammed is always on top as well. Very engaged. Thank you. So yeah, this is, I think this is the last slide. We want to thank a lot, Pocus 101. That's a very cool ultrasound website. You can find a lot of images and we have to thank them for these images. I'm giving. Okay. Magnificent presentation guys. Thank you so very much. You are our stars, our promises. Very good luck with your project of the ultrasound special interest group in the ICDM organization. Okay. And now we continue with the next team and next team presented by another team. And these another team are Rocio from Madrid, Spain, Nissan, Kerala, India, and me, Elena from Balearic Island, Spain. We are members of the Wonka special interest group on emergency medicine. And we decided to present to you very shortly one small project of ours. We have many of them and it is the approach to the aggressive patient in the daily practice of family doctors. Now here, Gail, right. Sorry questions. How many of you did experience aggression during work in healthcare or as general practitioner during a consultation? Now how many of you did experience the verbal aggression? And how many of you did report the verbal aggression? Next question. How many of you did experience physical violence? And what about the sexual harassment during the work? Next interesting question. How many of you thought that this is a form of violence, the sexual harassment in the work? And finally, how many of you reported any form of aggression against the health workers? So these are completely rhetoric questions just for us to analyze, but we start from the who definition of the aggression and we speak about the aggressive patient. When we speak about the aggression, it refers to the behavior that is intended to harm another individual and it can be emotional or impulsive or not intended or instrumental or cognitive, which is planned and intention. But then there is another point of view and then there is another aspect. We are speaking not about the physical violence, if not just about the difficult patient in the consultation. And the difficult patient is defined as the one who provokes strong negative emotions in their physicians. So why is it so important for us to know how to manage this kind of difficult patients? First of all, because if we have them in our consultation, we start making a defensive medicine. We start making the prescriptions for unjustified treatments or unnecessary diagnostic tests. If we have difficult patient in our consultation, we're not comfortable working really. There is something quite related to the burnout. We don't want to go to work to feel so unpleasantly bad there. We are afraid in many occasions to get complaints or narrative publicity or narrative reports, which can influence the money effect in our consultation or just can be quite bad image for our reputation. And so finally we decide to have peace than to be right. So there are two types of factors that influence when classifying the patient as difficult. And one of those are derived from the characteristics of the patient himself. But there is the other group and they are derived from the feelings or emotions that the patient generates in us as professionals. So there are three types of those reasons that make the patient-doctor relationship difficult. One of them are in the patient himself. The pathology that the patient can present, that it can be complicated for us. The patient's personality or the circumstances in which the patient develops. It can be a frequent in our consultation and many times we are speaking about elderly people who perceive the visit to the primary care consultation as a social life. And they come there to speak with their neighbors, friends, to speak about their nephews, to speak about their pains and their diseases and to speak to you. And they wait that you listen with all attention everything what they want to tell you about their life. So there can be another type of people and they are just bad character or histrionic characters or demanding people or bad-mannered patients with whom it is very complicated to reach to an understanding. Or there can be just a language barrier so these will make you the relationship with the patient complicated. There is another side of this coin and there are reasons that depends on us as professionals. It can be our own personality, our own character. There can be our own health disorders and our personal family problems. We can have multiple jobs that lead us to express during the consultation, in case we can have our complicated character difficult to deal sometimes with the people and we can have our personal communication barriers. And there is the third side of this multi-site point. And this is the environment something that doesn't depend on nobody of us not on the patients and not on the professionals just the inappropriate reception organization and the circuits of the user attention. So the patient is unsatisfied and many occasions that this unsatisfaction has lots of reasons. So the patient can suffer because of the excessive waiting times for the consultations of the specialists. Or during the consultation he feels frequent interruptions or feels that the doctor has lots of paperwork which is unable to manage. There are some social problems with our patients which are difficult to resolve and really don't depend on us but because of that we are family physicians and we are supposed to treat not only body but also the soul and the brain so all these problems come to us and to our consultation. Rafael, could you please explain us these matters? Yeah, I'm going to speak about the psychological declaration of violence. So first thing we have to understand is that it's not the same frustration and intimidation. A patient which is frustrated is not under control and you are feeling angry also irritated and you have some empathy with your patients but you feel almost the most of the time angry. And the depression that we have to do in these situations when our patients are frustrated is empathizing, understanding what's happening to the patients, what's the problem with them and why they are so, so angry. We have also to understand what's intimidation. Patient when is trying to intimidate you is focused and is in control. He knows what he wants to do. It makes you feel scared and angry and you can't empathize with him or with her. And the intervention would be in these occasions, boundaries. Also, if you don't understand exactly if they're frustrated or intimidated the second one is the one you should do. Please. What happens if you can't find this empathy that we are asking you to find? Why is this patient in my allergy zone I should ask to me? To try to understand. I have to do these kind of questions. What does this say about my best core quality? What are my weakness and the challenges into this? So in these cases, if I am visions and too much of these ambitious would be make me be impatient. Which is we shouldn't be the best way. We should change to the opposite one. We should which is patients will have to be patients and we have to be ambitious because too much patience is not good neither because we go to passivity. And the opposite of activity is ambitious. So we should stay in this too. Ambitions and patient. Okay, I follow. Okay. Good. Okay, so from these points, there are several situations to be avoided. Thank you very much. The situations to be avoided is hard to overlook the situation and to overlook the situation can be because of that. We don't play the situation or because we ignore the patients feeling because we really don't consider this feeling to be justified. And then there is one very important thing to be avoided. We must never blame the patient for provoking unpleasant feelings in us. So here there are some recommendations to improve the relationships with our patients in these complicated situations. First of them is always be respectful. Avoid using first names in Spanish. Don't forget to call it Tupel. Even if there is cordiality and tenderness and understanding in our relationship. But please keep everybody in his place. Keep a distance. Be very careful with the nonverbal communication since a gesture that we make can be distorted by the patient and the relatives. And it can create very serious unnecessary situations that even fail in our therapeutic intervention. Another recommendation is kindness and affection. It is free to smile. It is easy to smile. So try to present the smile to your patient. And then another very wise suggestion. The family plays a fundamental role in the communication since it can be a great ally of ours. So always be ready to give as many explanations as are necessary and requested to position the family on our side. The empathic management of security. It is very important that we don't get in tune with the aggressiveness. And the objective is to avoid escalating the situation with our own emotional response. We need to practice the active listening and to show empathy and understanding even if we disagree with the viewpoint of the patient. Nonverbal cues should convey to the patient a sense of calm and nonaggression. Transmit with your body and with your face these good feelings. Explain your position to the patient and be firm setting boundaries. And let the angry patient speak as the aggressiveness will go away by itself if you do this. Often it is enough for the aggressive patient just to feel that you sincerely want to help him and so to become one of our most loyal patients. Here we have quite a terrifying video. This video comes from Russia. The text, the voice is completely distorted. It is impossible to understand nothing what they are speaking. But we want you to see one minute of the video to continue speaking about the measures of protection and our safety in the consultation. Here we go. Okay, horrifying images as I told you without text without the possibility to understand what they are speaking about themselves. Please, Rothea, explain us these secure office setup. Yes, Elena. I want to explain one way to make your office more sure and effective in case that someone wants to... Unmute yourself another time, Rothea, please. Excuse me, sorry. Yes, I want to explain or to give you some pieces of advice about how you should think about your office in order to make it sure and in case someone is going to be aggressive and wants to make something bad to you. So imagine that you have one door in your office and you should think where to put the desk in order that you escape the more efficient way. In this case, if you have the desk in the middle of the room, the patient is closer to the door so you won't be able to escape. Continue, please, Elena. The patient will lock you in the middle way between you and the door so you won't escape. In this case, I suggest you to put the desk in the middle of the door. You have more space but who cares? The first thing you have to think about is your own security and in this case, you have the door very close and you could escape in case you need to. The thing is easier if you have two doors. Please. In this case, of course, if you have the door in the other part of the room, it will be impossible to escape. I suggest you to do it this way putting as before the desk in the middle so you are closer but as I was saying this is easier if you have two doors. Many offices have two doors in Spain, it's very common. I don't know in other countries. Please, Elena. In this case, it's really obvious if you have a door back to you, you just run. But sometimes you never thought about you have two doors and both doors are close to the patients and you don't have a way to go out so the patient will be closer to those doors and you won't escape. In this case, you put the desk closer to both doors and if you can have one only for you, it will be the best. In that case, you will escape easily. That's all. Thank you. Thank you, Rossi, very much. Nissan. Hi. I would just like to highlight a few cases from the international scenario of two case studies from India. The one which you see on the left side of the screen that happened somewhere in the northeast of India where a 73, 74-year-old doctor, a senior doctor was beaten to death. As you can see in the image he was surrounded by a mob of patient relatives or bystanders as you call it in your country. We call them as bystanders here. So as many as 30 of them barged inside a room so I'm just taking back your attention to what Rossi just mentioned about a single room clinic of a doctor where he was seated inside the desk was inside and the doctor was seated opposite to the door. As you can see, the door is on the left side of the screen and almost 30 relatives barged in and manhandled the doctor and he was beaten to death. Then another case scenario which we recently had another tragic one was of a young doctor in my own state the southernmost part of India that is Kerala and she was a young doctor a 24-year-old doctor who was getting trained to practice as a doctor and that was another unfortunate event where a prisoner was brought without handcuffs by the police and the prisoner was in a mood to attack people and the rest of the hospital staff and doctors they ran inside their rooms whereas a young doctor who didn't have any idea of what was to be done was alone with this prisoner in a hall. So that was again a place where she was to confront with the prisoner who stabbed her to death with whatever was available in the corridor. So those two are like a reminder that you should have an escape route in place and also not to confront any patient or their relatives whenever they are in a mood to attack or manhandle you. Can I just move on to the next slide? Yeah. We'll also be covering about the pharmacological restraints an easier thing that we usually do in ED but there are certain norms in specific countries like in India we have the patients are not to be restrained manually without their consent but when you have patients who are coming as aggressive patients because of intoxication you have to have some manual restraints with the help of some car for something to tie up their hands or feet if possible but if that is not possible we go for pharmacological restraints and the one shown in this picture is a nasal atomizer device or the mucus atomizer device as you call it it's not that much of use in my country so I'm not very much using this other than for pediatric anesthesia I gather that this is fairly simple to use and an easier thing to be used for patients who are agitated and the drugs which are commonly used are the benzodiazepines in which midazolam is a short-acting and a sweeter drug compared to long-acting things like diazepam and lorazepam then you could use ketamine especially for pediatric patients then halopyridol fentanyl, glucagon these are the usual drugs but from an Indian perspective a few other common drugs which we use are something like pentazosin which is an opioid or narcotic and promethazin which are given in combination as a high dose sometimes then something like a comma cocktail for those patients but we could also try using for patients who are agitated because they could be because of hypoglycemia so dextrose would be a good addition then they might be under influence of alcohol so again dextrose and thymine could be used then flumazenil if you consider the patient to be in a post-ictal state after seizures due to various reasons you never know so flumazenil and naloxone so these are probably the pharmacological approach to patients who present as agitated patients in the ED so over to you Alina thank you very much Nisan and it is just one very important recommendation for us as family doctors is to be attentive to that moment when we need to distinguish being a patient and becomes an aggressor it is so complicated for us because we are family doctors we are the people who accompany patients and their families during all their life and to catch this moment and to change our aptitude from receiving a patient to meeting an aggressor is complicated so here is the end of our presentation and there are 10 very helpful tips for dealing with an angry patient from a professional point of view evidently so first of them stay calm speak calmly and respectfully avoid escalating the situation with your own emotional response learn how to do it second don't take nothing personally never practically never nothing of the aggression is personal to you third listen to the concerns of the patients find a way to connect with the patient and look for support from the family members show empathy and understanding smile and show understanding even if you disagree with the viewpoint of the patient be firm setting boundaries when the patient becomes aggressive firmly and de-saturday communicate boundaries and expectations and learn how to address the concerns of the patient proposing their honest and realistic solutions never lie ensure your personal safety rothio and nissen spoke you about this keep in mind how to protect yourself from a combative patient and the last suggestion please don't doubt to seek assistance if it is necessary if the situation is complicated just look for help so this is our part thank you very much rothio and nissen and we pass to the last part of our webinar and it will be dedicated to the emergencies which we normally attend in primary care which is very common very often in general practice so I give the floor to Miriam helping that she is able to connect correctly that she is on trick right now so Miriam, stage is yours thank you very much Alena amazing presentation for now I would like to talk about anaphylaxis because it's something that we can face everywhere hospitalary setting but for us primary care doctors we have to manage so please pass the slide please as you can know so many countries have different guidelines have different approach but as a review different continental ones from the UK to Australia to America and to even European ones the basic approach and the treatment is the same in all the guidelines the first a little bit not in the basics but in the next part so a little bit of them and I will use the European sorry the resuscitation cuts in the UK because for me they seem like the more visual appealing for us what it is anaphylaxis is the word allergy organization said is a serious systematic hypersensitivity reaction that is usually rapid in onset and might cause death so it's potentially like threatening, compromising airway, breathing circulation, you can be affected one or the three parts so of course you can see that most events of course as food anaphylaxis drugs anaphylaxis or even insects what's please the next one please, thank you you have to be careful because most of the time we think of anaphylaxis on rash flashing or ticaria and geodema but this is maybe in the 20% of the process is not going to happen so you have the different ones the poster presentation for you to understand that the difference are minimal but I choose the council UK please you can like for me to explain the situation because it's really really visual appealing we can change the line please okay as you can see it's really easy but you can have to change the line usually there are skin change but not all the time and airway breathing or circulation is a airway we talk about throat and talk swelling, horse voice, history there is a high pigeon's territory noise for breathing we talk about increase of work, bronchospas, patient become tired, they have fatigue, they have hypoxemia, the saturation is lower at 24 and maybe they have central cyanosis, respiratory we're talking about circulatory where there are things of shock that are tachycardia, dizziness, arrhythmia or maybe cardiac arrest what do we have to do if they earlier stage we call for help remove the trigger if it's possible I mean drugs you can put it off and stop an infusion like the patient flat or then sit down don't stand up with the patient if the sprain is left on the side and give intramuscular adrenaline half on the of the ampoule, the ampoule is one milliliter one milligram adrenaline you can put half of it and of course flow decision and give another adrenaline in the next five minutes if it's necessary what's more fluids you can have to give fluids you have to give at least for 500 milliliters to one liter for adults and 10 milliliter per kilo per child one more we have to understand that we have to if it's not responding to fluids, to adrenaline even two doses we have to think on refractory anaphylaxis we have to send them to the hospital and we have in the hospital setting an infusion of adrenaline but that is not for primary care that is for the hospital next please some review for you to understand that maybe if the airway is affected can use some inhalers inhalers in stabilization or a spacer if you don't have an stabilization but you have a spacer you can do it you can use you can use salbuterol you can use salbutamol and you can use it different types about steroids they say in the guidelines they say not in the first part of the treatment maybe there is a refractory refractory anaphylaxis before you can use a sprenizol on oral or either cortisone in the venus and what about antistaminic the same don't wait to put adrenaline for putting antistaminic you have to put adrenaline first and then the testaminics and maybe one don't generate dizziness because then you can lose focus and there is not complicated shock there is no complicated breathing problem is that antistaminic working next please as we can talk about we repeat those we have to put the intramuscular adrenaline 0.5 milliliters in the ties in the ties all the time you have to put intramuscular for the people if they are recovering it differs the guys like here differs from the european and the australian to the american ones the most lay down guideline is the american say if you only need one dose and the patient is asymptomatic they go home in one hour of observation the others one they say at least two hours and the australian why they say okay four hours maybe it's more it's better if they did need two doses of intramuscular or they have a passive reaction they have to have a heart anaphylaxis before they have to six hours most of the guidelines they say at least 12 hours of observation if they have hypotension during the process 12 to 24 hours of course you need more than two doses of adrenaline they have a severe asthma severe allergies is not to shift in a place that has difficult to access the medical environment please let them stay until the morning okay and go home with an autonegator especially referral education and information and you have all the info in the slides thank you very much and then russian will speak to you about ear pathology thank you very much Donny thank you we are going to have another session on ear pathology department this is one of the common presentations that we say in the emergency department and basically I presented here over the three basic variants they are the otitis external acute otitis media and ear foreign body this otitis external is of clinical diagnosis and it can be a localized localized pattern like to the diffuse otitis external that extends from pinna to whole of the external auditory canal so in this case the treatment mainly is the analgesics like acetaminoprene or combination of acetaminoprene and diapropropene use of the topical antibiotics has also shown benefits in these cases but for the uncomplicated one but in those cases who have diabetes were in the immunocompromised state topical antibiotics as well as systemic antibiotics is preferred before because it will shorten the duration of the illness this use of the topical corticosteroids it also provides soothing effects and the use of these external auditory canal packing is frequently done for this and we can use the compounds like hydrocellulose we can use the glycerol in our path and we often use the pack make-up that even got that mixed with these topical corticosteroids and topical antibiotics combinations formula and we put that back into the external auditory canal and remove reassess that patient after two days maximum of 48 hours for the air pack and by doing this we can dispose these cases from our emergency department and make and follow up in the OPT basis next place another one is these acutotitis media acutotitis media is mainly of clinical diagnosis also because in clinically what we have is like air pain which can be unilateral or bilateral followed by minimum amount of discharge and examination of the tympanic membrane looks of very rate presentations like that and when we do the pneumatic otoscopy there will be no movement of this tympanic membrane we really do these pneumatic otoscopy in the emergency department over here and minimum amount of discharge can be there in case of these acutotitis media also treatment the main treatment for this is analgesics systemic analgesics like stamina pain and a combination of these with ibuprophone and next is the antibiotics antibiotic systemic antibiotics is preferred for these acutotitis media than the topical one because it can land up in the complications like corporation of tympanic membrane and mastoditis while going for this treatment we also practice this safety net prescription strategy where we give these medications for only a short duration of the time and just let it go and again we provide these antibiotics for the next types and twice of the antibiotics also differ over here for example the first drug of twice here is the amoxicillin with cavulinic acid or the amoxicillin stroke and the second drugs of twice for these are the cephalosporin that originates in cephalosporins we prepare over the year for this case once managed in emergency department can be discharged and need to follow up in 2-3 days we need to assess for the pain and look for these complications development over here next please this year foreign body is another commonly seen presentation in the emergency department the diagnosis again clinical personality history of something entering into the year it can be any living body it can be a non-living body it differs and the treatment is removal of this foreign body can be done it must be done under the direct visualizations but we have different techniques to remove this foreign body and the basic use of these concepts and the instrument depends upon the type of the foreign body we can use the probe methods where we can use j-s-probe rubber catheter suction methods and disarranging methods but there are few things that we need to consider during this like if there are some spherical agents then spherical bodies like balls, steel balls we should avoid the use of these forceps you know these are the things that need to be considered and when removing these live insects we need to immobilize them first and do both for the syringing immobilization can be done by use of these whale or olive whale or aqua eardrops followed by the syringing but while being syringing also what we need to consider is either that foreign body has any injury to the tympanic membrane or not if the tympanic membrane has been that live insects then we should avoid the syringing we can go for the suction evacuations in this case also and if force is formed suction evacuation can be done next please now this use of this instrument basically depends upon the types of the foreign bodies for example if these foreign bodies are easily grapsable like piece of paper, cotton or foam we can use these allocated forceps we can use this suction tip foreign bodies for suction tip this instrument for removal of these non grapsable foreign bodies which are round and smooth like bead and these wire loop instruments can be used for the removal of these types of the foreign bodies like beads and irrigation syringing can be done for the removals of foreign bodies like live insects and these small beads also it can be used for that next please now this is the video that's showing one live insect in an external auditory canal near this tympanic membrane and we have removed these foreign bodies using the techniques of syringing which is done in our emergency department okay I stop this one and pass to the next one yeah okay if I am able yeah so this is the syringing fantastic and the life of the patient is saved yeah an insect too an insect too thank you very much thank you thank you russian and now we have our last and for sure not least presenter and it is Mirian from Bolivia Mirian will speak in Spanish and we will ask our interpreter to English to translate her text to you to English thank you very much for your help and thank you very much Mirian the stage is yours very good good morning to all my name is Mirian I am a resident of my second year in family medicine I am in the hospital in the hospital in in Potosí Bolivia well today I am going to talk about the issue of acute disadaptation of the altitude I am currently in the hospital in Potosí I am in 4,070 meters above the sea level so many people come here to do tourism that come from different countries so there is a process of the acute disadaptation so well, within the pathologies of the altitude we have these 4 and the one we are going to touch this morning is the acute disadaptation called the altitude of the other are the acute acute disadaptation of the altitude and an acute chronic adaptation of the altitude the next well we can indicate that the acute disadaptation of the altitude is going to depend a lot on the speed of the altitude above 2,000 meters above the sea level and it is also going to go in relation to age and the acclimatization time that the person has 25% of the people who do from 2,000 meters above the sea level tend to present acute disadaptation of the altitude and 53% of the people who continue to present the acute disadaptation from 4,000 meters above the sea level well, as a nation there is a variable parameter between demonstrations of which signs and symptoms are presented to some individuals 1,800 meters above the sea level and 3,500 meters above the sea level the installation of what is the acute disadaptation of the altitude can be presented in minutes, hours and the evolution time between the adaptation and it is produced between 3 to 4 days presenting the symptoms of greater intensity in what is during the night and during the morning well, within what is the pathology of the disadaptation between the acute disadaptation of the altitude between what is the pathology of the altitude it is important to talk about two situations that are part of this one, which is the hypoxemia the hypoxemia is the partial disadaptation of oxygen that goes in relation to the disadaptation of the hemorrhometric and this one that is given by the disadaptation of the column of air that is in relation to the measure that is ascending it is above the 2,000 meters above the sea level and also it is important the one that causes us the problem of acute disadaptation at the altitude is the acute hypoxia the acute hypoxia is given by the hypoxemia that at the level of our body this one is captured as there is a reduction of oxygen a reduction of partial oxygen at the level of the blood there is also a reduction of oxygen or oxygen transport and this is captured by the regulator centers or sectors at the altitude at the altitude that these send signals that are activated when there is a lower pressure at 70 millimeters of mercury and this is activated at the level of the center of the vulva which makes it increase the frequency and the depth of the breathing and increase the volume of the breathing minutes generating a elimination of carbon dioxide that is a moment of pH of pH causing a respiratory alkalosis and this blocks the carotid receptors and the timid receptors at the level of the heart and at the level of the vulva decreasing the respiratory frequency but as we know that there is a reduction of oxygen capture then this is repeated it is a constant cycle we inside the physical mechanism of what we have in our body and what is how it produces a respiratory alkalosis we have compensatory mechanisms that make our body the bicarbonate at the level of the blood that makes the pH at the level of the blood good good inside what are the symptoms of what is the high-level disadaptation the most frequent symptoms are the sepalea alterations of sleep vertigo, freckles digestive symptoms nausea and when it is much more acute there are mental alterations but we already talked about these two points in relation to what is the acute lung and the cerebral edema we are based on what is the scale of the close and it is classified as the high-level disadaptation of the human eye of the mountain as leve of 1 to 3 points, moderated from 4 to 6 points and serious greater than 7 points the center of what is the treatment that we can offer in primary care when we talk about a mild disadaptation it can be administered what is paracetamol, ibuprofen paracetamol is 1 gram bioreal every 6 hours, ibuprofen 400 mg bioreal every 8 hours ibuprofen of imenidrate between 5 to 100 mg bioreal every 4 to 6 hours when they are mild pictures and when we talk about a moderate to serious it can be administered or added to the treatment what is the ketosolamide what is the balance of the alkylosis that is the respiratory that is produced at the level of our body this ketosolamide eliminating what is the bicarbonate and I know that it is the disadaptation the symptoms that we have can be made 125 to 250 mg bioreal every 12 hours in dose and prevention and 250 mg bioreal every 8 hours, 11 hours in dose and treatment can also be administered as the ketosolamide the dexamethasone 2 mg bioreal every 6 hours dose and prevention 4 mg bioreal every 12 hours in dose and prevention or 4 mg bioreal every 6 hours in dose and prevention in dose and prevention but this in general will be administered at the level of the lung in this case the next we can indicate within the general measures that we can recommend to the people who come to visit us is to have a slow action avoid extreme diseases avoid the ingest of alcoholic beverages maintain a de-adaptation which is the most important and also the medical prevention can already be done when the symptoms start to be presented when they are ascending at the level of the lung and a quick action in 24 hours it is important to do a paulatin of 300 meters from the 3 thousand meters to rest 200 meters tonight and ascending 300 meters later and the people who have cardiological pathologies if they want to ascending it is important to have oxygen to help them to support them above the 2 thousand meters at the level of the lung well this is the topic as I wanted to present a cordial greeting from the city of Potosi 4070 meters thank you thank you thank you very much lots of hugs to these height of 4 thousand meters over the level of the sea so guys our webinar is coming to the end before Stuart give you the last words and last thanks I would like you to point our contact numbers our contact email directions here on the left you have the email of the team of the ultrasound of the young doctors though it is the European movement of young family doctors still in Wonka world the ultrasound specialist group where you can join if you are not the European citizen and here to the right you have the emergency medicine specialist group from Wonka and you will be more than welcome to join our group to participate in our projects in our amazing workshops which we are giving in the Wonka congresses all around the planet so very welcome will be we will try to answer some questions because I see here some raised hands and I give the floor to Stuart thank you so very much thanks Lena so do you want us to take the Q&A now or are we wrapping up whatever you consider so we have a couple of minutes so we can have one or two questions Mohamed your hand was raised first yes first of all I express my gratitude for the wonderful session today and the great platform for the family medicine and raising the concerns of emergency medicine on this floor and the wonderful presenters and amazing talk today my first question regarding the resuscitation what should be our protocol when we resuscitate patient with anaphylaxis it should be remove the trigger first then call for the help and resuscitate simultaneously I need to repeat the question or Stuart you can help me to understand better a question please Mohamed I didn't catch it either could you repeat the question again oh you write asking the chat just one phrase so that we resume your question and give you a good answer regarding the treatment of anaphylaxis I want to ask one thing the removal of the trigger effect triggering agent that leads to the anaphylaxis okay yes this is the question for Miriam just give us a second yes I'm here sorry oh you're here I'm very very happy thank you so for you the triggers remove the trigger yeah the triggers you have in the slide you can receive later but most of the time for children the triggers will be food related usually it's milk nuts and depends on the country you were born some countries like Spain or Italy has a high percentage of peach allergies and some other countries wet or celery during that children's it's useful for adults would be drugs usually are adults anaphylaxis and we are talking about hospital settings the trigger would shoot drugs administration so if something happens when a drug is going on you have to stop it the administration of the drug or infusion so when you remove the trigger you start another endovenous treatment and you start the adrenaline at the same time fluids adrenaline that is the basic protocol then if it's a refractory and maybe the drugs you're putting on there are a long life process then you have to administrate other treatments and maintain the patient in observation but this is usually for hospital settings we talk about contrast we talk about other type of drugs and then we have the last part usually the insect biting that depends on this up to 6.45% of death for insect biting in the UK so you have to be very careful with the insect bites because some of them you have to remove the sting but others don't have a sting to remove so you have to check I think I answered the question again I could search and send more information Thank you for your detailed discussion on this topic I want to ask one more question from the Dr. Dragos Paul TQ regarding the EM course in the first ultrasound course in the trauma phase or in the rest protocol I extend my hand we are a team of the doctors from Pakistan named as London global emergency medicine program we have launched a program named as London global emergency program which is led by UK NHS acute physician consultants and they are doing the emergency ultrasound courses workshops and on practice workshops here in Pakistan and we joined the hand with them we can separate the most positive words here in Pakistan regarding the family medicine so it is a great help for us if you help us the BWONCA helps with the joint venture with the London global emergency medicine led by Dr. Aspar Thames Suratia so it will be a great help for Pakistan because we should follow the guidelines and the guidelines by the BWONCA UK research council and regarding the any suggestions regarding the reservation ultrasound team Dr. Anna left I know that she was busy Dr. can you give a short answer please to Mohammed I think for us it is a pleasure to collaborate with you we can try to contact with if you send us an email and we can try to arrange either a meeting or just to talk about this so for us it is a pleasure for sure thank you thank you so much for your support meeting Dr. Mood Parry last question and then we will finish can you my name is Dr. Parry I am the emergency medicine specialist in the University of Hofstra Lucknow in UK so I would just like to add a suggestion rather than a question because one of the lectures about ABD Acute Behavioral Disturbance it was suggested there is something called Coma Cocktail which I believe is not evidence based yeah it used to be there decades back but I don't think we should encourage the use of either any of the components of Coma Cocktail currently it's not evidence based at all and giving philomenazel is a catastrophe I mean there are very limited indications why you need to use a philomenazel you won't use it I mean routinely that's it I don't want I don't have any questions just a recommendation that's it thank you Thank you Moot Yeah thank you very much Moot for your commentary I don't know if Nisan is with us and he would like to answer here but I can do it all because here in Spain and in the place where I live I live in Ibiza Ibiza Island I think many of you know quite well it is quite famous by its electronic music and so we have lots of aggressive patients or patients with alteration of behavior owing to drugs or alcohol intoxications going beyond of the psychiatric disease or just the bad character and bad manners of patient so this is true that philomenazel is very very poorly used basically in the intoxications and not in the aggressive patient if not in the unconscious patient whom you are trying to save the life from the cardiac arrest or from deep coma while intoxicated with some opioids for example but when we are speaking about cocktail in Spain we really don't use it I don't know exactly even the composition of this kind of cocktails I know that they are used in some countries but not in Europe actually so I quite agree with you in this concept yes we do use benzodiazepines a lot we use midazolam a lot we use sometimes ketamine but it is not so very extents because ketamine you know alterates the conscious of the patient it is the medication which is used to provoke hallucinations so it is not exactly the medication which we normally use in this kind of patients and if it is really necessary to use the ketamine because the patient is asthmatic or whatever and there is a pain component in the aggressive behavior of the patient in the majority of the occasions when you are trying it with midazolam or properfol or some kind of opioids or benzodiazepines sell to control these secondary effects of the ketamine but yes totally agree with you Dr. Maud and thank you very much for your commentary excellent I just added in the comments because you know I just rushed through that part of the evidence based and I have not suggested that coma cocktail can be used as such but the components like dextrose should be in the back of our minds if it is something like hypoglycemia which is causing the patient to be combative yeah specific theme to speak and I hope that we will prepare for the next wonka by the way we will try to prepare another session with the aggressive patient paying more attention to the psychiatric pathology or elderly people that these patients are more the category of complicated difficult patients so if you are interested in we will maintain you informed okay thank you everyone that brings us to the end of the webinar today so thanks very much for coming we have recorded it and we will upload it to the channel of the wonka young doctor movement so as Elena was saying the webinar was a collaboration between the European young family doctors movement and the wonka emergency medicine SIG so the contact details of the wonka emergency medicine SIG are on the slide and also of the EYFDM ultrasound group on the bottom left for any of you who don't know this is wonka Europe's young doctor movement and we organise exchanges and educational conferences for trainee and recently qualified family doctors across Europe I'll put our website in the chat so if you're interested I hope you can look us up and that's it for today and have a nice rest of the weekend thank you very much Stuart before I go I think special thank you to Elena for coordinating everyone because it was a lot of work to do the webinar and she really kept us all in check and thanks also to our interpreters thank you so much thank you, thanks a lot thanks Elena, thanks to it have a nice day everybody night night thank you all see you later thank you Miriam thanks Miriam we already know it's been super complicated yes but it's worth it thank you so much bye see you later thank you all thank you Carlos thank you