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Background Patient abandonment in the emergency department has been reported in various parts of the world although the implications and social circumstances may vary in context to its definition. The current study intends to review the characteristics of twenty- four (24) abandoned patients in the emergency department of tertiary care hospital of Eastern Nepal. Methods This was a prospective observational study conducted among all abandoned patients presenting to tertiary care hospital in eastern Nepal from July 2018 to July 2020. Results Twenty four (24) patients were enrolled in the study. 22 (91.7%) were male and 2 (8.3%) were female with a mean age of 43.2 ± 14.4SD. The median length of stay (LOS) was 72 (Q1, Q3, 23.5, 960) hours in the emergency department. Seven, 7 (43.75%) cases of mortality were due to medical illness, 4 (25%) cases of mortality were due to surgical illness and 5 (31.25%) cases of mortality were with undifferentiated presentations (p= 0.012). 15 of 24 (62.5%) patients over 40 years of age experienced a longer LOS (p = 0.34) and (75%) 12 of 16 have a higher mortality than younger patients (p= 0.30). More than (USD) $50 was invested in an abandoned case that was taken care of by NGOs. 6 (25%) of abandoned patients were taken care of by other centers like NGOs and welfare centers. Conclusions Abandoned patients in the middle-aged adults with medical comorbidity experienced longer hospital stays and as an indicator of mortality. Financial disparities were observed among abandoned patients taken care of by charitable organizations and tertiary care hospital.

Introduction: With increasing of workload of emergency room employees, many of the community’s emergency hospitals are now facing another challenge, i.e. the abandonment of patient in emergency Department. It seems undesirable in most hospital service settings due to loss of revenue and ill-will. The hospital’s staffs feel that they have no option but to keep those sufferers until a further plan can be made. It presents a dilemma for the staffs of Emergency and for the hospital administrators as well. The current case report presents an abandoned patient in Emergency Department of B. P. Koirala Institute of Health Sciences (BPKIHS). Case Report: A 70-year old male brought by police and was left abandoned in emergency ward of BPKIHS in altered conscious state. The patient was managed in emergency ward with conservative management nearly for six weeks. Conclusion: The problem is multidimensional, is in conflict of the concept towards achievement of Millennium Development Goals (MDGs) and a challenge to social security.

Background: Sepsis and Septic shock are a common presentation in the Emergency Department with high morbidity and mortality. Serum lactate level increases substantially in the patients with septic shock. The objectives of this study were to determine serum lactate levels at the time of presentation, find out the outcome and correlate lactate levels with the outcome in the patients with septic shock. Methods: It is a prospective cross-sectional study of patients presenting to the Emergency, who met the criteria for septic shock defined by Surviving Sepsis Guidelines 2012. Patients’ demographics, co morbidity, triage vitals, laboratory and radiological parameters were recorded. The primary outcome was mortality and secondary outcomes were duration of stay in hospital and complications, if any, developed during hospital stay. Results: Eighty-four cases were enrolled, with male to female ratio of 1:1. Mean age was46.40 19.59 years. The significant variables were: serum lactate (p

Background: Basic Life Support (BLS) aims to maintain respiration and circulation in the cardiac arrest victim and involves a major focus on cardiopulmonary resuscitation (CPR) with minimal use of ancillary equipment. The raised standards of care demand that knowledge about BLS/ CPR be updated and include the lay persons as well as medical experts who have the potential to become the teachers of the skill. The objective of the study was to describe the knowledge and attitude of medical personnel (nurses and doctors) towards BLS/ CPR. Methods: This cross sectional study was done among the doctors and nurses working in Department of General Practice and Emergency Medicine, BPKIHS, Nepal after ethical approval. A pre-validated questionnaire (Shrestha et al, WJEM, 2012) with pre-structured questions was used for assessing the knowledge and attitude. Attitude was measured using 5 point Likert. Designation, previous training and demographics were used as describing variables. For data recording and statistical analysis; Microsoft Excel, SPSS 11 and EPI Info were used. Results: Total number of sample size was 84 medical personnel working in emergency department (consultant 12, junior resident 16, house officer 18, and senior nurse 3 and staff nurse 35). Nine (11%) respondents answered more than 10 questions, 57 (68%) answered 6-10 question and 18 (21%) answered less than 5 question. Average mean score (total 15) was 7.40 (SD 2.32, 95% CI 6.90-7.90).Mean score of the positive attitude (total 15) to CPR was 11.1807 (2.43, 10.65-11.71). The mean score for reluctance (total 5) to perform CPR was 3.25 (consultants and those who were certified in BLS or taken BEC course in the department had maximum score in knowledge (p

Background: Rose Angina Questionnaire (RAQ) is a useful screening questionnaire for ischemic heart disease validated in different settings; however, its diagnostic ability to predict myocardial infarction (MI) in the emergency is less clear. Objectives: To find out the usefulness of RAQ to predict MI in patients presenting to the emergency. Methods: A cross-sectional study was conducted at the BP Koirala Institute of Health Sciences (BPKIHS), a teaching hospital in eastern Nepal from 1 January to 30 March 2017, after ethical clearance from the Institutional Review Committee. Informed consent was obtained from the patients for their anonymised information to be published in this study The samples were collected from 100 patients with chest pain aged 40 to 70 years presenting to the emergency. RAQ was applied and its performance to detect MI was compared with emergency and cardiologist diagnosis of MI. Sensitivity, specificity, positive predictive value and negative value were calculated along with descriptive analysis. Results: A total of 100 patients were analysed with the mean age of 63.78 years (SD 11.60) and male to female ratio of 1.94. RAQ detected 58 cases (63.8%) with emergency department (ED) diagnosis of MI (true positive) and identified 3 (33.3%) cases with non-MI (true negative). The true positive rate for RAQ to detect MI after cardiologist consultation was 71.6%. RAQ had a sensitivity of 84.91% (95% confidence interval (CI) 72.41% –93.25%) to detect positive troponin, 63.74% (52.99–73.56) to detect positive electrocardiogram (ECG) and 71.60% (95% CI 60.5% to 81.07%) to detect final diagnosis of MI. Conclusion: RAQ is a good screening tool to detect MI in the emergency that can be used in isolation or in combination with other diagnostic modalities to detect it early.

Introduction: Domestic violence is certainly an important condition, and certainly carries significant health consequences. Screening is probably acceptable to most patients attending an emergency department. The objective of this study is to find out the frequency of domestic violence victims attending emergency department, to find out the factors related to domestic violence, type, and severity of injury and to identify the impact of domestic violence in the victims. Materials and Methods: This was a cross-sectional observational study done in the Department of General Practice and Emergency Medicine of BP Koirala Institute of Health Sciences from January 2014 to December 2014. Anyone presented with a physical injury intentionally caused by a relative, partner, or other household member (spouse, partner, sibling, ex-partner, child, and other wives/partner of spouse). Results: The total number of patient enrolled in this study was 423. Among which 71.9% were female and 28.1% were male. About 27% of female and 31.9% of male were in the age group of 20–30 years. Majority (42.4% females and 48% males) of the victim's family had agriculture for primary occupation. Among the study groups, 40.9% of cases were beaten by direct hit and 24.3 with weapon, 5% of cases were only reported as rape, and 23.6% as homicidal case. Conclusion: Domestic violence is particularly insidious form of gender-based violence. In the place where they should feel the greatest safety and security- the family-women often face terror form of physical, psychological, sexual, and economic abuse.

Acute organophosphate poisoning is the most common pesticide poisoning which can be manifested in three unique phases of toxic effects e.g. Acute Cholinergic Crisis, Intermediate Syndrome (IMS), Delayed Polyneuropathy. Looking at the previous cases reports the incidence of Intermediate Syndrome has been reported to be as high as 80%.The present study attempted to report a comparable form of incidences encountered in Emergency Department of BP Koirala Institute of Health Sciences (BPKIHS) in Eastern Nepal. Chlorpyriphos was the commonest compound associated with IMS. Early recognition with plasma acetylcholinesterase level as well as Peradeniya Organophosphorus Poisoning (POP) Scaled score might be useful tool in early diagnosis of Intermediate Syndrome.

Objectives Nepal is a least developed country, with limited healthcare resources. An 18 month Fellowship in Emergency Medicine has contributed some improvements to care. This study assessed time to first analgesia in higher and lower acuity patients. Methods A prospective observational study of 101 patients in each of the Australasian Triage Scale (ATS) 2, 3 and 100 in ATS 4 was undertaken at B.P. Koirala Institute of Health Sciences. Convenience sampling was used coinciding with researcher's duty hours. Pain scores and time to analgesia were recorded. Results A total of 302 patients were included. The doctors identified pain in 274 (90%, 95% confidence interval [CI] 86.74–93.65), severity recorded in 92 (30.5%, 95% CI 25–36). Median time from triage to analgesia was 30 min (interquartile range [IQR] 15–60) for ATS 2 patients, 60 min (IQR 40–70) for ATS 3 and 69 min (IQR 45–116) for ATS 4. Tramadol was the analgesic used most commonly (33%), followed by diclofenac (25%), morphine (16%), paracetamol (14%) and ketamine (2%). Analgesia was provided to 212 (70%, 95% CI 64.6–75.2), 65 (30.66%, 95% CI 24.5–37.3) with ATS 2, 85 (40%, 95% CI 33.4–47) with ATS 3 and 62 (29.2%, 95% CI 23.2–35.8) with ATS 4. A total of 44 patients (20.7%, 95% CI 15.5–26.8) with mild, 101 (47.6%, 95% CI 40.7–54.6) with moderate and 60 (28.3%, 95% CI 22.3–34.8) with severe pain received analgesics. Conclusion Time to analgesia for triage score 2 is lower compared to higher triage score. However, a large proportion of patients still do not receive analgesia. This is likely addressed by using a combination of strategies.

Trauma is a major and increasing global health concern in the recent world. It is now the leading cause of death among people less than 18 years old. The aim of this study is to analyze all injuries from trauma-related causes among children and adolescents under 18 years old of age.This is a retrospective cross sectional study done in Emergency Department of B.P. Koirala Institute of Health Sciences. Patients aged less than 16 years were included with history of trauma from January 1st 2013 to 31st December 2013.The details of patient were taken from computerized medical records of the hospital. The demographic data, pattern of injury, mode of injury, diagnosis and outcomes were tabulated in Microsoft Excel.Total 3958 pediatrics patient were enrolled in this study with Male: Female=3.6:1 and Mean age 9.6±3.2 years. The common modes of injury were fall injury 2596 (65.6%) and RTAs 1176 (29.7%). Whereas the commonest patters were Fractures 1385 (35%) and Soft Tissue Injuries 784 (19.8%).Fall Injury and Road Traffic Accidents are major and serious problem for children in Low Income countries like Nepal.

Objectives: Triage is recognized as important in providing timely care to emergency patients. However, systematic triage is only practised in two EDs in Nepal. The first objective of this study was to assess the performance of one of these departments in seeing triaged patients in a timely fashion. Second, an epidemiological survey of patients presenting to the ED was performed to describe the conditions seen and initial resuscitation undertaken. Methods: We performed a descriptive cross-sectional study in the ED of B.P. Koirala Institute of Health Sciences, eastern Nepal where the Australasian Triage Scale (ATS) is used. One hundred and sixty patients triaged as ATS 2 were recruited. The time taken for the duty doctor to see the patient was noted. The presenting problems, vital signs and level of consciousness were measured at presentation. The resuscitation measures were recorded. Results: The mean waiting time was 2.1 ± 1.7 min with a range of 1–10 min, which meets the benchmark for ATS 2. At triage, the most common presenting problems were circulatory shock (23.1%), altered consciousness (21%), respiratory difficulty (16.9%) and poisoning (15%). Oxygen, i.v. fluids and antibiotics were the most common therapies used in the initial resuscitation of patients. Conclusion: Patients triaged as ATS 2 were seen in a timely fashion. Seriously ill patients requiring resuscitation present commonly to this ED. This is a big challenge for junior doctors. Improved training, treatment protocols and equipment are needed to help manage this burden.

Acute appendicitis is among the commonest surgical diseases faced by an emergency clinician. A prompt diagnosis is mandatory to reduce morbidity and mortality, which may be difficult for junior doctors who first see the patient in the emergency department. This study was conducted to assess the efficacy of Alvarado score as a tool to improve the accuracy of diagnosis of appendicitis. We did a prospective pre- and post-test study in 381 patients with right iliac fossa pain in the emergency department of BP Koirala Institute of Health Sciences. Alvarado scoring was used for the post-test study. We found that the Alvarado scoring system is an effective diagnostic method, which decreases overdiagnosis of appendicitis in the emergency department, and at the same time reduces the risk of missing acute appendicitis cases. It is inexpensive and easy to implement by junior doctors with good results.

Background: Poisoning is common in Nepal. The objective of the study was to describe the profile of poisoning cases presenting to the emergency of a medical university in eastern Nepal. The specific focus was on to describe the presentation, demographics, delay to care and describe the triage parameters at presentation. Methods: An observational study was done. The secondary data from case files of all poisoning patients starting February 2012 to March 2013 were analyzed after retrieving them from Hospital record. Results: Poisoning constituted 3.89% of total emergency visits. Mean age was 24 years with female: male 1.32. Median time delay to presentation from the incident was 4 hours. Mortality rate was 5.1%, intubation rate 6.3%. Agricultural products ingestion (763/1399) was the commonest modality. The triage vitals were noted as median 110 mm of Hg (Q25, Q75 100, 120) for systolic blood pressure, median 87 mm of Hg (Q25, Q75 73, 93) for mean arterial pressure and median 97 (Q25, Q75 94, 98) for SPO2 by pulse oximetry. The level of consciousness was noted as alert (87.6%), response to verbal stimuli (3.7%), response to pain stimuli (7.1) and unconscious (1.6%). Comparison between mortality and no mortality groups showed significant difference for mean arterial pressure (n 1399, p

Priapism is a rare and unusual presentation in Emergency Department of Nepal and is really a challenge for the working Emergency Physicians. In Nepalese context it is a social stigma and is often a pitfall due to possible delayed presentation. A young Nepalese Hindu male presented to our Emergency Department with post coital priapism who seeked help only after ninety-six hours in request of his wife. In limited resource hospital settings with delayed presentation, aspiration and irrigation of corpora cavernosa with heparinized saline had shown good outcome in treatment of priapism without any postoperative complications regardless of prolonged stay in emergency department.

Sir,Methicillin-resistant Staphylococcus aureus (MRSA) has been endemic in Australian hospitals for more than 25 years, and in order to limit transmission the focus has been on screening in order t...

Introduction: Pain is a common presentation to the emergency department but often overlooked with little research done on the topic in Nepal. We did an observational retrospective study on 301 patients in the emergency ward of BP Koirala Institute of Health Sciences with the objective of finding the practice of analgesia. The specific focus was on the time to analgesia, drugs for analgesia and method of pain assessment.Method: Case file analysis of patients discharged home after presenting with pain was performed. Time to analgesia and other factors were analyzed with descriptive statistics. Results: Diclofenac injection intramuscular (80%) was the commonest analgesic used. Assessment methods and record keeping were poor. Pain in the abdomen was the commonest. The median time to analgesia from triage was 45 minutes (IQR 30 to 80) and the median time to analgesia from doctor evaluation was 40 minutes (IQR 20 to 70). Conclusion: Time to analgesia from triage and doctors assessment in our set up is comparable to others. The quality of documentation is poor. Problems with pain identification and assessment may lead to inadequate analgesia so reinforcing the use of pain descriptor at triage itself with pain score would be helpful in adopting a protocol based management of pain.Key Words: Analgesia, Emergency, Nepal