Case Based Blended Learning Ecosystem on FHIR

In 2016 I had built a basic version using WordPress for implementing UDHC/CBBLE (presented at AIIMS Delhi in Jan. 2017), and then created this mockup of an app. My involvement in UDHC project (CBBLE is a subset and key element in UDHC system) helped me explore EBM and parallelly HealthIT in-depth finding my way to learn more and connect with amazing HealthIT evangelists globally and currently I am even having some experience in volunteering for HealthIT & FHIR projects and thankful for the opportunities to DHIndia and HL7India.

3 years back I had plans to learn implementing FHIR for this project for making this an interoperable platform and then help to evolve the ecosystem of various UDHC networks (mainly in medical schools) as I have a great interest in the UDHC idea. The journey is still going on with various volunteers, peer learners and mentors including Dr. Rakesh Biswas who pioneered the UDHC concept. He provides the opportunity to many students including me to explore the idea and implementation while benefitting the patients too. 

It was inspiring to find FHIR community have started implementation for case-based learning in the webinar by HL7 International "Case-Based Learning (CBL) on FHIR December 16, 2020 | 4:00 - 5:00 PM EST" and I am hopeful that the ecosystem will evolve more helping medical students and professional to be able to deliver better to the patients.  https://pubmed.ncbi.nlm.nih.gov/32025640/

Long way to go.

DISCLAIMER: Below are some videos, HAVING CLINICAL IMAGES AND DATA SO MAY NOT BE SUITABLE FOR SOME AUDIENCE.

Resources -

1. OpenMed app mockup - https://github.com/avi33tbtt/OpenMedApp/blob/master/OpenMed.pdf

2. Digital Health Records for Medical Education - https://www.youtube.com/watch?v=rWog_idt-KU

3. Patient As A Teacher - Developing a Case-Based Blended Learning Ecosystem CBBLE - https://youtu.be/xvE5b8Xk3vM

4. UDHC (User-Driven Healthcare) - https://classworkdecjan.blogspot.com/2020/01/udhc-resources.html

5. A Futuristic EHR - https://youtu.be/yrJ0DfmRg8E (I am yet to write the explainer blog as could not record the video when it was presented offline, will do it in coming weeks and update here).

6. Link to apply for electives under Dr. Rakesh Biswas - https://promotions.bmj.com/jnl/bmj-case-reports-student-electives-2/ (not necessary to have healthcare background)

 https://github.com/avi33tbtt/OpenMedApp/blob/master/OpenMed.pdf

Translating and Sharing a research paper to a patient

 Translating and Sharing a research paper to a patient 

1) open article in pubmed

2) on right side, click for PubReader format

3) Copy title and content of the Case Report (or research article)

4) Paste in a blank google docs

5) In google docs click on tools and then translate and choose your patient's langiage

6) Click share and then share to patient's email id or print to provide as paper document.

7) Can do corrections if needed, as translation tools are not 100% accurate but as they are very efficient, corrections may not be necessary. (It is recommended to have corrections and utilize for sharing copies to any number of patients.)

8) Ask the patient to highlight/comment and ask questions with you for clearing doubt online or in next consult or in meeting with patient group.

Patient themself can also follow the above way.

Patients must note that it is for learning and not for self-diagnosis or modifying treatment plan. The knowledge gained will help to better participate in own care process and make patient and doctor more impactful in care delivery. Doctor's must note to explain patient this point clearly.

There may be challenges with IP, and they should be solved by looking for best possible and articles shareable this way.

Use of a telemedicine registry

Since decades there were huge efforts by various govt. agencies , academia, and industry on not only implement telemedicine but scale it. Though some implementation happened, scaling was rare. Covid have made life very tough for many who seek care, some times made it nearly impossible to visit hospital and get help from the doctor. Those in any acute pain or mild problems suffered, those suffering chronic problems also suffered and got no follow ups, patients needing dialysis or patients who need Hydroxychloroquine suffered due to inaccessibility or shortage, the pregnant moms suffered by missing their important regular checkups, small kids missed their vaccinations and even those who got access to hospitals suffered by not having access to better and some suffered due to stress this pandemic have created in daily life. 

Telemedicine which includes tele-consultation, tele-Icu, etc can not solve all the patient problems but surely it easily and efficiently solves many of them and reduce patient's suffering during this pandemic and empower everyone for better with the new normal. It have capability to help bring relief to a patient having mild acute problem somewhere, to bring access to care in patient in remote rural place, to bring support for follow ups when hospital visit is not necessary, to empower for second opinion from another doctor somewhere, to empower ICUs by support from remote center, and a lot more. Having a Registry where Tele-medicine products are listed after evaluation from an expert panel will help the patients, doctors, hospitals, tele-medicine companies and all stakeholders in the tele-medicine ecosystem by having access to information about various products, their capabilities, their strength and weaknesses. These key information will help decision makers to find products best suited to them and accelerate the adoption which will directly accelerates the empowerment of our healthcare system in country by making impact in solving many patient problems like those listed above and reduce their suffering. It will also help the ecosystem with a direction that helps to innovate and improve for delivering better.

I am not emphasizing in the context of Covid pandemic much because I have first hand experience in being helpful to patients and also engage with doctors offering telemedicine to patients globally (and tele-education which is equally important for our country) for 3 years even before the pandemic began and so i believe in its tremendous capability not just for war against Covid but even beyond the pandemic.

I am currently involved in Tele Med Registry http://telemedregistry.in/ as student member of DHIndia.

I would also like to share a playlist I have made by compiling a few useful videos in youtube, which helps to understand good webside manners and physical examination on the webside which are very important in the care process. If you are interested then can check on this link - http://classworkdecjan.blogspot.com/2020/08/telemedicine-good-webside-manners-and.html

Telemedicine - good webside manners and physical examination

 "The whole art of medicine is in observation" - William Osler

Physical examination is very important in for doctors to get insights from the patients and find correct diagnosis and best treatment plan. Teleconsultation software nearly always have the physical examination as part of the clinical workflow but doing it well may be a challenge for the care providers.

So I made this youtube playlist which may help with tips on doing physical examination and following good webside manners. I hope this will be useful in covid times and later.

link to the playlist -  https://www.youtube.com/watch?v=4hRObfNyDvc&list=PL7NbfQr9rYIeU2GUIKLF4F-4DfpqZATMW

Email to Medical Education Unit (India) email group.

To - meu_india@googlegroups.com

Respected Teachers

Using paper based forms and then digitizing data to analyze is a painful task. Here is a google form I have made with guidance from Prof. Rakesh Biswas (KIMS, Narketpally) which you may copy and use for your students feedback. A Students need to fill form once for each subject. 

Form - https://forms.gle/AbD5feAAbu1241CN6

There are 2 ways this form can be used

1. You can send me a request on avi33tbtt@gmail.com so i can help you get a copy of this form which you may use to get feedback, get basic automated analytics and do advance analytics yourself if needed. Based on your need you can also make modifications to the form.

2. You can help us by sharing the above form link to your students so we get nationwide feedback data where no student identifier is recorded as all data is collected anonymously and we share the analytics openly. It can also be used for research purpose. 

Doing both also possible, all you need is to follow the first way and then share data with your consent (without any student identifiers) to include as data for national level analytics.

Regards,

Avinash Kumar 

Reply to teachers requesting form -

Respected Sir/Madam,

Thanks for your interest in Online Medical Education/Classes Feedback Form.

I am sharing this form with you and giving you owner access. You may then distribute this form to students using this link - https://forms.gle/************

If you wish to add any more questions like roll number, email id of student etc. then please let me know, i will be able to update accordingly. 

knowing roll numbers will help to know about which students haven’t filled the form and hence you can instruct them later to fill if pending, without roll numbers it won’t be possible to identify students pending to give response so you may prefer to add that field, please let me know.

Once you are ready to go ahead for sharing the form, you can remove my access to the form if you need. Please let me know in reply to this email, if you also want to share your student’s feedback data for national level analysis on Online Medical Education/Classes.

Regards,

Avinash Kumar

38yr old woman - Renal failure on MHD

This is a de-identified open-online-patient-record with initial information in patient's voice, posted here december 2016 after collecting informed patient consent (form downloadable here) by BMJ Elective Student.

Patient history by author -__

38 year old woman from ******* currently on hemodialysis in our hospital for renal failure.
She has been having a struggle  life since 1995 when her mother passed away due to a medical condition ( reason not known by the patients husband)  who was a known diabetic and a known hypertensive. In 1998, her father passed have because of an unknown cardiac condition. She got married in 2000 to her husband who works at a rice mill industry. She has 2 daughters, the elder daughter is 19yrs of age and currently in her btech 2nd year, 2nd daughter is 17yrs old and is in her inter 2nd year.
In 2006 she paid a visit to her dentist for getting a  rootcanal done that was when she got diagnosed with type 2 diabetes mellitus and was put on Tab Zoryl 2mg BD. She has been switching from Tab Zoryl 2mg to 1mg depending on her blood sugar levels on her own .
6 yrs back, her husband had to sell their *** store ****** because of road construction work, since then her husband says she has been more stressed and she would randomly throw tantrums It had got to such a point that she would throw objects aggressively at others and over the past 5 years she has also been having visual and auditory hallucinations. She was taken to a psychiatrist in **** (  hospital) and the doctor there started her on tab Sizodon Forte ( risperidone and trihexyphenydryl ) and Tab Dayo 250mg ( Divalproex) and they even consulted a neurophysician who advised for a CT brain which turned out to be normal. She got diagnosed to be a hypertensive 3 yrs back and has been using Tab metxl 25mg once daily on and off since then.
One and a half years back she consulted an obstetrician since she had amenorrhea since 3 months, her husband says that he even found her to be pale then and on routine investigations she got diagnosed with renal failure with a serum creatinine of 5mg/dl and Sr urea of 70mg/dl for which they consulted a nephrologist who started her on sodium bicarbonate and calcium supplements.
1 month back she presented to our hospital dyspneic with bilateral pedal edema extending to her thighs for which she was started on hemodialysis.






Day1 post admission
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Day 3 post admission
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Day 4 post admission
- 



Patient history by author -VV

38yr old woman
Renal failure on MHD
S - Complaining of non productive cough and aggravated dyspnea since last night.
She also complains of feeling febrile since last night.
O - Patient is pale and bilateral pedal edema present
Patient appears to be in respiratory distress
- PR-99bpm
BP- 120/80mmhg
Spo2-98% at 2 litres of oxygen
RR-24cpm
Cvs -S1 S2 present
Lungs- bilateral inspiratory crackles present
Abdomen-distended with everted umbilicus
A- ckd on mhd
Type 2 diabetes since 15 years on medication
Htn since 3 years
Schizophrenic since 5 years
? Pulmonary koch’s / ? Septic emboli
P- 2D ECHO in view of any infective endocarditis changes
Sputum for cbnaat to be sent
Coagulation profile to be sent
Debate on whether to start on antitubercular therapy













Conversational Learning/CDSS -


AT- Palpable skin lesions with Cavitary lung lesions and rapidly progressive renal failure. All roads lead to Rome (GPA in this case ?)
RB- Someone still has to carve out a generous amount of lung tissue from her to prove that Rome exists? 😅
AT- In an ideal non covid world, yes sir. However, a skin biopsy with cANCA titres would be helpful here.
RB- Or can we take a short cut to Rome through her skin tissue which would be more easier? 🤔
AT- What would you expect in the skin biopsy that would take us to Rome conclusively?




AT- Necrotizing granulomatous vasuclitis. I think I saw rim enhancement of the cavity walls in the CT and also the renal lesion appears aggressively active. Some system 1 learning says cANCA in active inflammatory lesions is strongly positive and suggests a small vessel vasculitis, particularly GPA.

RB- What would be the sensitivity and specificity of this finding?

Enough to consider immunosuppresives over Sepsis treatment as both are antithetical to each other
AT - Even a renal biopsy showing pauci immune glomerulonephritis can help. Will share some system 2 data.


AT - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5059091/#!po=0.943396

Between February 1, 2005 and February 1, 2015 a total of 8403 IIF for ANCA was performed of which 1238 tested positive (27% p-ANCA, 71% c-ANCA pattern, 1% aspecific pattern) in 279 patients. A total of 5370 immunoassays for PR3 and/or MPO ANCA was performed of which 1218 samples tested positive in 239 patients (Fig.1)


RB - Can we fit our patients to any of the patients in the study you quoted here?

What are the attributes she shares with them?

AT-


- The table explains quite a lot. Patients were initially diagnosed on clinical features and then ANCA samples were sent for.
RB - Looks reassuring.


DV -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4014960/

FIndconsult app project - closing

about swasth alliance -> "The idea is to provide free consultations as far as the corona pandemic is concerned and get as many doctors onboard to make sure that the healthcare infrastructure in the country is not overburdened by leveraging technology”.

i worked on same idea in very frugal way where patient had access to doctor directly in 1 click on social media platform. In case of emergency may be that was/is urgent beed to solve. I am happy to see it being done much better way than mine. I recently explored their APIs where they are building the registry part to verify doctors giving consult which in my case was one of the main reason for avoiding full launch of project as i had no full proof mechanism for that and it will be bad to make a platform for quackery, also one problem was securing doctors contacts as i was using one click access to list of currently online available doctors for free consult using social media platforms but as many doctors wanted to help and were circulating their contacts for helping people, it was ok to go ahead as more benefit than risk.

this website is down now, i have code, and here is the demo -

https://youtu.be/APAaIXCr2PQ

(there are various cons in  this way, it is less of a HIT work and more of a disaster medicine response.)

Chronic joint pain but its shifting joints

This is a de-identified open-online-patient-record with initial information in patient's voice, posted here after collecting informed patient consent (form downloadable here) by BMJ Elective Student.

45F obese lady having regular pain in one joint, but the painful joint is not same always, for few months it will be ankle, and then for few months it will be elbow or knee. Informal practitioner gaves tramadol recently which relieves for few hours, any other pain killer also helps a little. Past medication is very frequent use of calcium tablets since last 5-6 years. No hammer toe deformity. she is indian, brown skin, have discoloration on cheek skin since 10 years and have used various medication for that, it decrease/increases, and somewhat mostly in the butterfly shape area or sides of cheeks. Rheumatoid arthritis? what she should do for pain and minimize the side effects of medication?
she takes thyrox 100mg now. changes it based on her regular tests.

Quarantine Management System

CBBLE and A live case discussion

3:46 am - Avinash Kumar: 55M, very obese, bmi 39, woke up at 4am on day before yesterday which is very rare for him, he saw yoga in tv and did himself, did lying leg hold too as shown in image, he takes morning tea at nearby shop in hut mostly, rest all food in home during the lockdown. later in day time he complained of leg pain, had mutton in evening though he takes vegeterian food mostly and couldn't sleep whole night due to gas and pain in abdomen, he felt as if gas not passing ahead. next day he avoided any food , only took some ripe papaya pieces in evening and slept whole day. In evening he got paneer and heavy oily food in dinner and felt completely full and took ranitine 300mg before sleep, after 2 hours of dinner he felt too much gas in abdomen which is not passing out, and after 3 hours started vomitting at every 20-25 min., vomit was full watery only, very little quantity of food particles and large quantity of water, ranging may be approx 300-400 ml to 100 ml. everytime in total 7-8 times he vomited in next 2 hours.

after 2nd vomiting took pantoprazole+ domperidone and home made ors

after 8th vommiting his vommiting have stopped now since 30 min. but his abdoiminal pain which started with the gas issues is still there and incresed, dsen't seem to be severe though but he looks exhausted and he is unable to sleep. He is not feeling increased bowel sounds or any sounds, didn't had clear stools in morning and since a few days, its common to him but taking milk and less spicy food helps. He just took Lactulose 10ml, ranitidine 300mg and anafortan ( camylofin 25 mg + Paracetamol 300 mg ), got advice that if this dosen't relieve then may need IV saline in morning.

medication guided on phone consult with local informal healthcare practitioner.


vomitted again now, i.e. after 15 min. of taking above medicine, vomit seems to have some undigested rice which he ate 8 hours back.
3:47 am - Avinash Kumar: <Media omitted>
3:50 am - Avinash Kumar: <Media omitted>
4:15 am - Avinash Kumar: i am with patient, and local informal care provider is also coming as patient is feeling severe pain
4:24 am - Avinash Kumar: intestinal obstruction?
6:01 am - Avinash Kumar: dr. is having piles surgery so can't move. he suggested some medication - phenargan inj, RL iv drip, ondasetron inj, pantoprazole inj.

gave none, visited phc and got dicyclomine inj. and pantoprazole inj, 2 tabs liv 52, sarboline syp, and vomikind sublingual, had no fluids/ors/water since 45 min. so when reached phc, he was much relaxed and not rolling on ground with pain. back to his home and much relaxed now .

there are no radiology and labs here so no testing.

enjoyed to learn interesting things from our phc dr. (only mbbs staying in rural area rest most are not mbbs in all nearby areas) and also see covid situation here.


eager to see the interesting discussion ahead of this live case report, and also what you (anyone here) would have done at different point of time in this scenario.
6:02 am - Dr. Leelavati Maam Iqcity: Plz rule out acute pancreatitis
6:09 am - Avinash Kumar: again pain increasing and trying to vomit.
6:15 am - Dr. Rajesh Menon sir: if he has passed very little stool / no stool, would indicate obstruction. could mean a hernia due to his unaccustomed yoga and leg lifting workout. should be checked. usual care would be raise leg end of the bed if hernia is detected so that it resolves by itself or else surgical intervention...
6:21 am - Avinash Kumar: did dark brown vomit (due to 2 liv 52 tabs i think). after vomit he feels good. good to see frequency going down.
6:23 am - Dr. Leelavati Maam Iqcity: Rest of gut and iv fluids is going to give him relief
6:26 am - Dr. Rajesh Menon sir: tried soap water enema?
6:27 am - Avinash Kumar: thanks maam! interesting finding, that he had alcohol on the night it all started. 50-100 ml. mixed with water. social drinker, 2-3 times a week or less.

i just thought that cage questionnaire says nothing about dose and dose related outcomes.

he didn't had alcohol yesterday. his family is strictly against his alcoholism.


to rule out acute pancrititis, history is suggestive of it, physical examination i am unable to do and he is very ovbese so very tough to find what's happening inside. blood test for amylase and lipase is impossible here unless we travel 30km.
6:39 am - Avinash Kumar: thanks sir, very useful leanring points, there was no hearnia like issues and luckily i had learnt examining for hearnia but didn't tried. the pain is in full abdomen and shifting from one side to other, may be so the patient was lying on ground and rolling due to that shifting.
6:43 am - Avinash Kumar: thanks maam! yesterday he rested whole day without any food and so felt completely relieved by evening, he is resting again and nearly in sleep, so may be now same will happen today.

no iv given, ors is there with him but he is not drinking anymore.
6:45 am - Avinash Kumar: i had suggested to keep an enema from pharmacy, though it wasn't used. his stools are still not passing or any sign of that. it must past, to bring relief, will inquire about that and update here when it happen.
6:47 am - Avinash Kumar: i think, we can say then, that time will heal and rest (removing possible causes of issues though not known precisely).
6:47 am - Avinash Kumar: little stool yesterday and none today.
6:48 am - Dr. Rajesh Menon sir: please be careful though as sudden evacuation may result in hypotension..
6:49 am - Avinash Kumar: thanks sir, didn't knew that. no plans for that yet. i am not making clinical decisions but just supporting a lil. and trying to understand myself.
6:50 am - Dr. Rajesh Menon sir: if u remember piku movie, piku's dad who has chronic constipation passes away after he has jilebi which results in relieving his problem.
6:52 am - Avinash Kumar: thanks sir, noted to see it soon someday.😇
6:54 am - Avinash Kumar: one important question related to this case in above scenario, (any more clinical exam, refer to higher center 30km away, antibiotics, iv line, what medicines.

_what you would have done here and *why*?_
6:55 am - Avinash Kumar: As you said in the group..
For the patient the solution is one spoon of fenugreek seeds and in a cup of curd.. It will cure his pain too.. As we give to our patients.. I have seen the same cases.. So I said
6:56 am - Avinash Kumar: input from another care povider who want to stay anonymous.
7:00 am - Dr. Rajesh Menon sir: fenugreek.. well ive seen few newly diagnosed diabetics developing a lot of flatus and abdominal distension when they tried it..
7:05 am - Avinash Kumar: and it may be to cause flatus and help it all pass out quickly.  where curd may be mainly a medium with lactobascillus as added benefit.

but if its obstructive then same may cause more trouble?

@Ahmed any comments?
8:15 am - Avinash Kumar: got one phenergen inj. (Promethazine) and ondansetron inj. around 45 min. back while had 3 more vomits with lil. content only 20-30 ml. he is finally relaxed now and sleeping.

_symptomatic treatment_
8:18 am - Dr. Leelavati Maam Iqcity: Plz take him 30 kms away and get him a proper IPD care
8:19 am - Dr. Leelavati Maam Iqcity: you may not be able to handle the complications at home
8:20 am - Dr. Leelavati Maam Iqcity: He will need a lot of fluids and orally he will be unable
8:28 am - Dr Rakesh sir: 👏👏👏👍

Very nice presentation and discussion Avinash and others.

Let's hope he does well today with your homehealth care or else keep the local PHC in the loop about the patient.

Now is the time in India to get the local PHC doctors or nurse practitioners to make a home visit for such patients.

Avinash would you like to start a petition with change.org? Also ask Rajib and Tamoghna and Kaushik of recent project.
8:32 am - Avinash Kumar: thanks maam, i will convey to family.

but there are 3 problems

1) huge inflow of returning migrants workers have started here in district as its state border area and many of them visiting hospital for fever screening, perhaps they thing its test to help decide if they should go in family or not.

2) nearly all private clinics are closed.

3) I believe that small city nearby at 30km will also bring him same symptomatic treatment and with additional struggle for any local support. they will do some tests surely though may report with delay and analyse never or rare. sorry for sounding bad but i don't mean to speak bad of any real heroes ( healthcare workers) its just system fault i think.

next bigger city is 85km and aiims gorakhpur is there, gives better confidence but is he severe enough to go there, as family members are a bit upset about his occassional drinks and trying to delay medication, saying he will get relief in sometime, luckily doctors , informal health workers and formal and they all are really great and helpful to everyone here) are not in that mood and neither my opinion is for any delay.
8:33 am - Dr. Leelavati Maam Iqcity: Plz seee if the iv fluids can be arranged at home, as only good supportive treatment is all that is indicated
8:34 am - Dr. Leelavati Maam Iqcity: Great that the doctors are helpful at this time also
8:36 am - Avinash Kumar: sure sir, I will be happy to do that, and ask patient for consent to allow for that.

but i perosnally believe change.org petitions are an illusion of good happening. reason is when i ask anyone what will happen if i sign the petition you shared? how change.org will communicate it to relevant officials, and they never have any answer and neither i have. probably its just an overrated platform for showing the no. of people signing for a cause and in real no body see it though and the growth hacking tricks of IT are used to keep change.org growing its user base, audiance, signatures and petitions, and benefit to a business model and illusion of good happeing to all.


sorry for being too skeptic about it, but i will be very happy if proven wrong and for that @Rajib da or @Dr. Tamoghna sir may guide.
8:44 am - Avinash Kumar: thanks maam! this can be arranged.

there is ringer lactate kept already, suggested by informal healthcare worker, unused yet as the informal healthcare worker is himself suffering post elective surgery.

will inform mbbs dr. in phc for that.


to decide if its really needed,if its urgent, i checked for dehydration by pinching skin and it seems fine, also he vomitted 3 liters and now relaxed. 101 kg weight so 3 liters may be only 3% of loss so saline may not be urgent requrement, but a good supportive treatment. am i correct?


(this is for curiousity)
8:45 am - Avinash Kumar: i am yet to study rationale for use of iv fluids RL, D5/10, NS. will search and study later today.
8:47 am - Dr Rakesh sir: Agreed. Didn't realize you were able to see and touch the patient.

One important thing to do here which any hospital doctor would do and even you can do is to feel his abdomen and feel for guarding and rigidity to guage the severity of his abdominal inflammation (if any) as that would considerably help the decision making process. The only reason for referral would be operative intervention as everything else in terms of resuscitation can be done at home. Keep us posted on his abdominal findings. Check out the image of Chamberlain sitting by the bedside of the patient and looking at all the quadrants of the patient's abdomen move with a patient similar to yours
8:49 am - Dr. Leelavati Maam Iqcity: Surprisingly u come to detect hypovolemia very late in an obese patient by checking skin turgor, so don’t go by that, he is already 3ltres. behind fluid and will need this badly
8:49 am - Dr Rakesh sir: Try palpating a few normal abdomens among your family members or even yours to get an idea of what a normal abdomen feels like. This is basic system 1 learning at it's pristine best
8:53 am - Avinash Kumar: did that sir, 2 time, once in beginning of problems and once around 2 hours back..no rigidity.

i am unable to understand and find image of chamberlain sitting by the bedside, may be it means sitting on patient's right and observe for movements (normal movements), this i will try when possible.
8:55 am - Avinash Kumar: thanks maam! will discuss this with patient, family & dr. (who is far at phc)
8:55 am - Avinash Kumar: thanks sir! luckily have done that in a few healthy and a few sick already, so useful today.
9:04 am - Dr Rakesh sir: Yes normal movements in all quadrants of the abdomen to detect any localized inflammation of any abdominal organ 👍
9:04 am - Dr Rakesh sir: 👏👏👍
9:04 am - Avinash Kumar: thanks sir, will do
9:04 am - Avinash Kumar: 🙏🏻
9:04 am - Dr Rakesh sir: 👍👏👏
9:58 am - Avinash Kumar: still feeling vomiting,
iv fluids to be started (which one? ns, rl, d5/d10)

informal dr. asked to bring pt. (as he is not in situation to come) so he can observe and decide what to do further and what fluids to give.

abdomen - no rigidity, seems to be normal movements. rolling on sides while lying in bed to avoid pain that is also shifting sides.
9:59 am - Avinash Kumar: if the rigidity is in mid, below his 8 inches layer of fat layer approx, then i may have missed.
10:05 am - Dr Tamoghana sir: Avinash, is the patient passing flatus? Is he able to sit up? How frequently is he passing urine?
10:06 am - Dr Tamoghana sir: If the pain is shifting sides, is it crampy or colicky?
10:07 am - Dr Tamoghana sir: Plz see if there is any tenderness at any specific point. And the epigastrium
10:07 am - Avinash Kumar: flatus - not at all. want it since early night.

able to sit up- yes, short walk even after 30 min. of taking the injections
10:07 am - Avinash Kumar: only once tonight
10:08 am - Avinash Kumar: urine
10:08 am - Avinash Kumar: yes shifting sides. colicky
10:08 am - Dr Tamoghana sir: If the patient is not able to pass flatus, it might be indicative of an obstruction, which might be difficult to manage at home
10:09 am - Avinash Kumar: checked. not noticable to me.
10:09 am - Avinash Kumar: enema could help if its in end part? we have enema but don't know where the obstruction is. we don't have xray, usg here.
10:10 am - Dr Tamoghana sir: Colicky pain may be present in obstruction or ileus or sometimes even in simple acute gastritis
10:11 am - Avinash Kumar: 5 times vomiting in 1 hour. total 15ml may be.
10:11 am - Avinash Kumar: mostly nothing comes out
10:11 am - Dr Tamoghana sir: But shifting sides may suggest an intestinal pathology
10:14 am - Avinash Kumar: food in vomit. ate 8 hours back.

i am also guessing intestinal obstruction but now way to be sure.
10:18 am - Avinash Kumar: ng tube may help? should only put after its possible benefit confirmed (xray/usg?)

here no one is skilled for that, neither its available.
10:21 am - Suyash Gupta Sir: Bowel sounds?
10:21 am - Dr Tamoghana sir: Ng tube with stomach rest may be helpful. We need to put acute pancreatitis in d/d too, and in mild acute pancreatitis supportive care is possibly the only treatment
10:21 am - Dr Rakesh sir: Yes NG tube would help and perhaps a flatus tube.

Any hospital doctor would try to figure out if the obstruction is mechanical due to some organic pathology or due to ileus.

Please check his bowel sounds and let us know how many you can hear in one minute.

Check our past projects with MANIT Bhopal on bowel sound amplification as a technique to understand dysmotility in certain subsets of intestinal dysfunction
10:21 am - Dr Rakesh sir: 👍👏👏
10:26 am - Avinash Kumar: no steth but seems decreased since early night time - patient reported.
10:26 am - Avinash Kumar: will hear someway and update
10:27 am - Avinash Kumar: thanks sir. will check that project
10:28 am - Suyash Gupta Sir: At least blood investigations like serum amylase, lipase, and serum electrolytes, cbc, If manageable.
10:28 am - Avinash Kumar: impossible. (Update Later - There is a path. lab with some basic reports available, we got a few test later when patient was much fine and lab was accessible)
10:31 am - Suyash Gupta Sir: I remember a time in our phc posting we were asked to go out to some village for awareness purpose. And i forgot my stethoscope as I didn't think I would see any pt.

But as it turned out I had to auscultate some one. Some Cardboard tube, used to keep calenders in place helped. Original laennec stethoscope i guess😅
10:32 am - Suyash Gupta Sir: (it was not of much use though. In this case, I don't know)
10:34 am - Avinash Kumar: i will keep ears directly if i won't get steth from dr. whom we may meet in sometime
😊
10:35 am - Avinash Kumar: ear should work, i have tried in diarrhea patient where it was too many, here its too less but should be audible that way
10:36 am - Avinash Kumar: won't get if patient don't go there. depending on his ssituation
10:36 am - Avinash Kumar: 👏👍
10:38 am - Avinash Kumar: @919619613748 you may also like to try this one

http://classworkdecjan.blogspot.com/2020/01/stethoscope-hack.html?m=1
10:39 am - Avinash Kumar: i am not sure if you have already seen it or not, @Shikhar also did great improvements in idea and demo with it in his college.
10:40 am - Dr Tamoghana sir: If you place ears directly near umbilicus you will hear nice bowel sounds
10:42 am - Avinash Kumar: thanks sir. will do
10:45 am - Suyash Gupta Sir: Brilliant!
10:48 am - Avinash Kumar: thanks!😊
i had shared some sounds in whatsapp here when this group was new. its lost now. you may need to experiment and optimize for best output.
10:50 am - Suyash Gupta Sir: Will sure do
10:56 am - Joyoti Maam Ayurveda HIT: Wonderful👍
10:57 am - Avinash Kumar: thanks ma'am!
10:58 am - Avinash Kumar: bp - 137/89
pulse - 86
bowel sounds - 9 per min. (heard with ear on abdomen)

11:00 am - Joyoti Maam Ayurveda HIT: Just started following all your notes here...Fenugreek with curd is not a good idea at all at this point...if bowel sounds are good, then you may want to try plain luke warm water enema, you maybe already keeping him nbm..

11:03 am - Joyoti Maam Ayurveda HIT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5630621/ Here is a paper describing the steps for remote diagnosis of acute abdomen...just look at the figure ..you will get an idea
11:06 am - Avinash Kumar: thanks.
it will be useful only if obstruction in end parts of large intestine and rectum. right?
11:08 am - Joyoti Maam Ayurveda HIT: No, if patient is vomiting, then first rule would be to keep NBM...till the vomiting is controlled....
11:09 am - Joyoti Maam Ayurveda HIT: curds and methi would still not be useful in this patient..
11:22 am - Joyoti Maam Ayurveda HIT: How do you find the accelerometer in your phone?
12:21 pm - Dr Rakesh sir: 👏👏👍

12:25 pm - Dr Rakesh sir: Pleural effusion less than 100 ml may not be picked up on chest X-ray
12:26 pm - Dr. Rajesh Menon sir: thank you Sir.. will get back with the History.
12:28 pm - Dr. Rajesh Menon sir: my first impression was a boot shaped heart Sir. my mind instantly went TOF but then the age as per the X ray suggests an adult female..
12:30 pm - Dr. Rajesh Menon sir: was searching for life span of people with unoperated TOF.. very few and far between. i came across a  man who passed away at the age of 73 but survived till then with no correction.
12:31 pm - Avinash Kumar: ryles tube, ns pushed in, and green color liquid collected in uro bag and and kinely soda also pushed in 500 ml, now clear fluid coming out, around 200ml was darker greenish and rest is coming much clear and slow, the patient is relaxed, not complaining of much problems, medication provided - metrogyl drip, ns saline drip, pantoprazole, ranitidine, cefexime and tazobactum, ondasetron, all injections. will give DNS when the current NS is completed. stuff managed from various shops , they are not used frequently so tough to find, I got to assist a lil. bit to the informal care provider and his experiential learning trainee aka compounder.
12:32 pm - Avinash Kumar: so I guess it was obstructed initial part of the intestine.
12:34 pm - Dr Rakesh sir: Yes there are reports of even more older people
12:36 pm - Dr Rakesh sir: Kinley soda through Ryle's tube 😳

Whose idea was that?
12:38 pm - Dr Rakesh sir: The green liquid is bile and just indicates that the obstruction is beyond the second part of the duodenum.

He's being clearly overtreated with all the antibiotics none of which he probably needs.

I guess this is how a large volume of antibiotics enter in vivo in India
12:42 pm - Dr. Rajesh Menon sir: what could be the reason for this acute episode of obstruction?
12:43 pm - Dr Rakesh sir: Either mechanical aka structural aka anatomical or functional aka physiological
12:44 pm - Dr. Rajesh Menon sir: could it be Ca Pancreas?
12:46 pm - Dr Rakesh sir: That would be mechanical, structural or anatomical pathology but in the problem you cited it's unlikely to present acutely
12:47 pm - Dr Rakesh sir: However as others have stated the odds are high for it being an acute inflammation of the pancreas
12:51 pm - Avinash Kumar: thanks sir, i am happy that my thoughts matches to it, but i didn't discussed about it to treating care provider.
12:52 pm - Dr Rakesh sir: Yes mutual respect is very important in team playing 👍👏👏
12:53 pm - Dr Rakesh sir: Actually you have a tremendous opportunity to collect the world view of an informal healthcare provider that may help us to understand how to optimize it
12:54 pm - Avinash Kumar: soda helps with gas, specially if in upper part and also help digest food or stuff faster (i think, not sure of evidence). giving it via ryles tube was just a medical stunt i think, idk he invented or learned from someone)

12:54 pm - Avinash Kumar: thanks sir!
12:56 pm - Avinash Kumar: yes, same i was thinking sir, like alcohol with meat = day before yesterday, paneer = yesterday.  then what stayed in so proximal part of intestine
12:57 pm - Avinash Kumar: he asked me what is this, i said bile, he said no and then i asked twice without irritating him and he didn't answerd and so i understood not to ask more.
12:57 pm - Dr Rakesh sir: Soda scientifically is supposed to produce more gas.

What it does is because the gas it generates is effervescent, it makes the patient develop a placebo effect that the gas has come out while all that came out was essentially what had been introduced but for this placebo effect one may have to pay the price of gastric distension that could have led to perforation and increased gastric acid?
12:58 pm - Dr Rakesh sir: Show him a Google Image of bile
12:58 pm - Avinash Kumar: thanks sir, yes specially in lockdown. earlier I had shared about old lady with flank pain problem frequently, she is no more. just an update.
12:59 pm - Avinash Kumar: he learn by googling sir, and he may not like my interference. (He is nice person)
12:59 pm - Dr Rakesh sir: Would have been nicer if you can direct us to the link of all that we discussed about her
12:59 pm - Avinash Kumar: 👏👏 thanks sir, very interesting
1:03 pm - Dr Rakesh sir: Yes because you presented a detailed history I have a hypothesis that may be a physiological issue (if you see in Ganong's physiology) because of excessive fatty meal the gastric and duodenal emptying reduces and this can lead to this physiological obstruction. When it happens due to pure neural causes which is more common in diabetics due to autonomic neuropathy it's called Ogilvie's syndrome after the intern who first logged it
1:28 pm - Avinash Kumar: i missed to add hyoscin (inj.)
1:29 pm - Avinash Kumar: thanks sir, amazing info!


after current dns given slow, there will be RL.
1:36 pm - Avinash Kumar: after how many/much vomits prefer nbm and same way before what threshold prefer ors?

one more question to group.🙃
1:37 pm - Avinash Kumar: yes, on nbm since 3am and that did some improvement in vomits surely, atleast the water loss.


1:39 pm - Avinash Kumar: thanks, quickly checked it but then got busy with patient and doctor. checking again now.

accelerometer may be good to give data, but will see in paper how good insights it gives after doing the analytics.

1:41 pm - Dr Tamoghana sir: Yes. I have the same question. Probably a rural Indian Jugad.
2:16 pm - Avinash Kumar: now i need to remove dns and give RL, and also informal care provider advised me to give

pantop inj.
rantidine inj. 2 amp.
hyoscine 1 inj
ondansetron 2 amp.
and cefexime + tazobactum 1.5 gm

now to give or not?

guidelines or knowledge?

medically informed choice or legal choice?

eager to know opinions and why?
2:17 pm - Dr. Leelavati Maam Iqcity: No antibiotics indicated
2:22 pm - Dr. Leelavati Maam Iqcity: Only supportive- hydration nga and antacids
4:40 pm - Dr Rakesh sir: What we give depends on the patient's symptoms. If the patient is feeling better and is objectively better he may not need anything
4:40 pm - Dr Rakesh sir: 👍
5:11 pm - Avinash Kumar: i made the decision and gave medication accordingly at 3 pm.

i don't know how wrong i am here but what i did is

informed patient about my points briefly to not take uneccessary medications and informed about all the medication prescribed, dosase and symptomatic benefits.

and then asked patient to choose what he would prefer, he made the choice to follow the doctor's way so i did that.
7:55 pm - Avinash Kumar: please comment on it, positive negative both are welcome. i wish to understand what better i could have done.

7:56 pm - Avinash Kumar: i need to make similar decision again at 9pm for next dose of medication (different medication this time) so comments will help to do better.
7:57 pm - Avinash Kumar: 👍
7:59 pm - Avinash Kumar: i feel guilty of not doing the best possible in medicine based on tiny knowledge world have and much tinier of that i have.

but i have to value the doctor who own the patient and the patient who have right to choose his care and i have no evidence (yet) to say that those medication have more harm than benefit for this *individual*
8:00 pm - Dr Rakesh sir: Well said 👏👏👍
8:00 pm - Dr Tamoghana sir: You did the best possible thing. In absence of any imaging or laboratory support, even experienced doctors would hinge towards overtreatment (read antibiotics) to cover possible infections or peritonitis. So I guess its okay. What ultimately matters is whether the patient can be given relief
8:02 pm - Avinash Kumar: thanks, even i feel relief after reading this!😊👍🙏🏻
8:04 pm - Avinash Kumar: lavage helped, i was right. but i am not very clear how i had this in mind very early, i think just the abive history and some reading online while the events were happening.
8:05 pm - Avinash Kumar: may be just good guess narrowed with information (and lack of information too about differential i haven't learnt yet)
8:06 pm - Dr Rakesh sir: <Media omitted>
8:06 pm - Dr Rakesh sir: From our group members
8:07 pm - Dr. Leelavati Maam Iqcity: You have done wonders, believe me👍🏼👏🏻👏🏻
8:08 pm - Avinash Kumar: thanks maam!🙏🏻🙏🏻

Online Learing Portfolio - E log book

Case-Based Learning - Erythema ab igne.
- https://classworkdecjan.blogspot.com/2016/12/i-am-driver-by-profession-had-accident_27.html
- https://jbcr.net.in/JBCR-VOL-5-issue-1-2018-19/current-issues-volume5-issue-1-5.html

Long Case of the day - 60F with Coma, E Coli sepsis and upper motor neuron signs with albumino cytological dissociation in CSF.
- https://classworkdecjan.blogspot.com/2016/12/60f-with-coma-e-coli-sepsis-and-upper.html

Short case of the day - diabetes and a refractory skin ulcerations.
- https://classworkdecjan.blogspot.com/2017/12/oral-and-skin-ulcers.html

Instrument of the day - (Ascitic tapping) - 69 year old female having liver cirrhosis with diarrhea and ascites.
- https://classworkdecjan.blogspot.com/2016/12/69-year-old-female-having-liver.html

ECG of the day - 45 year male with Generalised Edema.
- https://classworkdecjan.blogspot.com/2016/12/45-year-male-with-generalised-edema.html

Chest X-Ray of the day - blood while coughing
- https://classworkdecjan.blogspot.com/2016/12/patient-history-by-pritam-gupta-age-41.html

Theory paper 1 and 2
Theory paper topic 1 of the day -  70 year old man with neck mass
- https://classworkdecjan.blogspot.com/2016/12/70m-neck-mass-of-large-size-and-unknown.html

Theory paper topic 2 of the day - 60 years man with Right pneumothorax and was earlier admitted for sinus pain, severe anemia and diabetes since 20 years.
- https://classworkdecjan.blogspot.com/2016/12/60-years-man-with-right-pneumothorax.html




Some more interesting learning outcomes.
Found undiagnosed rare disease - 42 F with severe regular edema with G6PD (Seattle variant) & AMPD1 deficiency.
- https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html

Innovation -
severe Obesity, SOB and talking in sleep -> Obstructive Sleep Apnea - low-cost device idea
- https://classworkdecjan.blogspot.com/2017/01/severe-obesity-and-hypoglycemia-even.html
- https://classworkdecjan.blogspot.com/2020/01/obstructive-sleep-apnea-low-cost-device.html

Covenant Translators and Volunteers

After the first case in January, In March the pandemic began growing in India in its very early phase. On 17th March, our team started building the Open Source "Covenant - COVID-19 Quarantine Management System" app. (Apache License 2.0). On 21 March we delivered our prototype and had already started pitching in India to various stakeholders and decision-makers while utilizing every opportunity to get a chance to connect and utilize the idea for containment and preventing the disaster. Soon super spreader events started which are the worst risk factor for failure of quarantine strategies. While we completed the beta version in 20+ languages without any funding, the scope for quarantine to be effective passed away. Now the project is moving ahead - https://covn.org/its-time-to-pivot-covenant/

Project website - https://covn.org

Here is the list of our volunteers https://covn.org/team/  and I am adding remaining volunteer's name below. 

Arabic

Ashraf Shorbaji - Ashrafshorbaji6@gmail.com

Musab - musabelnigoumi@gmail.com

Assamese
Dr. Rimy Dey - dr.rimy.p@gmail.com

Bengali
Swastik - https://www.linkedin.com/in/swastik-barat-013098152/
Dr. Julfikar - Mdzulfikarhussain@gmail.com

Chinese

Alanqicao - alanqicao@gmail.com

English UK, US
Senthil Nachimuthu
Avinash Kumar

French
Pooja Vikas Naik - poojanaik33@gmail.com

German
Xilia Faye - xiliafaye@gmail.com

Maithili
Avinash Kumar

Hindi
Lakshya Kumar - lakshyakumar20@gmail.com
Avinash Kumar

Kannada
Dr. Bhaskar - bhaskar@mediknit.org
Atul Bengeri - https://www.linkedin.com/in/atul-bengeri-42b7041/

Konkani
Divya D Pai - divyadikshita@gmail.com

Malayalam
Vinisha Venu - vinisha27venu@gmail.com

Maltese
Dr. Georgiana Farrugia Bonnici - https://www.linkedin.com/in/drgfbonnici/

Marathi
Atul Bengeri
Shraddha Naik - shraddhanaik1@gmail.com

Nepali
Surya Kusahawa - Kusawahasurya12345@gmail.com
Milan Majhi - majhimelawn@gmail.com

Odiya
Bhagyajyoti Priyadarshini - https://www.linkedin.com/in/bhagyajyoti-priyadarshini-264564179/
Samikshya Behera - samikshya.behera97@gmail.com)

Punjabi

Dr. Monika Pathania - anshupathania27@gmail.com

Persian

Abdy moghaddam - abdymoghaddam@yahoo.com

Sinhalese
Nirodha Abeywardhana - nirodhaa653@gmail.com

Spanish (LA & C)
Jose Jimenez Vega - jmjvega@msn.com

Tamil
Senthil Nachimuthu
Saravanan Kuppuswamy - skprkk@gmail.com

Telugu
Vidhatri Ramaka - rvramaka@gmail.com
Dr Dinesh Aravind - aravindinesh@gmail.com

Charan Singh - chandrapalsaicharansingh@gmail.com

Urdu
Ahad Khattak - ahadktk@gmail.com

Yoruba
Muhammod-Rabiu Salihu - ibnsalihu@gmail.com


Other Volunteers

Joyoti (Mukherji) Goswami

Dr. Deepak Chandra Badhani

Shivapuram Madhava Sai

Developers

Arun Singh

Thanks to all translators and volunteers!

LOW COST NGS BASED COVID TESTING

Avinash Kumar:

A Massively Parallel COVID-19 Diagnostic Assay for Simultaneous Testing of 19200 Patient Samples ->  https://docs.google.com/document/d/1kP2w_uTMSep2UxTCOnUhh1TMCjWvHEY0sUUpkJHPYV4/edit?usp=drivesdk
so the NGS devices given to BLS3 labs can help speed up testing like from IITs?

Rohit- Yes. The possible reason they weren't using it because of the cost involved in sequencing. The kits are usually expensive along with the reagents

A- but become useful when large  (not very large like 19200 but something like 200-300) patient samples to be tested?
200*145$ = 29000$ so then NGS way will be cheap and accurate?

R- Can't comment on this protocol. But looks interesting. However, the picture is blurred and I can't really understand wetlab much
Where is this cost coming from Avi?

Are we using biological replicates in this protocol. If yes how many??
A- 145$ is lowest cost from latest testing available afaik, and 300$ is for normal one that is used now. its approx and none of above info i have verified personally, but believe to be true

R- Depends Avi how deeply u sequence
only few parts you didn't get or many?

A- how deep we need to confirm if its no covid with high confidence? this can be extremely  useful to mass screen communities in batches and seize them to prevent much harm to the economy and there are good ways coming ahead to do that part

R- Okay so they are using 2 amplicons
And 1 control
In total 3
I can't comment on that avi. Haven't had experience handling sequencing data of a virua

A- ok so this info came for 145$ test I had found - Update: After this story was published, the U.S. Food and Drug Administration issued a warning that at-home coronavirus tests are unauthorized. Read story here.  https://www.statnews.com/2020/03/20/at-home-coronavirus-tests-are-here-should-you-take-them/

the at lab tests are arond 300 usd and in india around 10k afaik (govt.asked pvt.labs to do at 4500 let see how many does)




https://twitter.com/koeppelmann/status/1245037948099330048


B- The report suggests use of this kit the cost of which is following
A- R and i discussed same above. seems possible.
R- Yes Avinash. I think it's possible
We adopt such approach in NGS

R- I though doubt if the binary testing will actually save testing kits though
the grouping must be done carefully,Like all the samples coming from a single family will be a good idea In case if say out of 16 samples 8 tests positive

 it will not help when we are testing symptomatic, or high risk, but can help if we mass testing and saving them who are negative from infection.  like even a family or 2, unless whole family is high risk or having anyone symptomatic

R- Then if these guys are using some kind of index primers that are patient specific then this can really scale up testing
16/16 or 0/16 are ideal cases

Telemed - care for all

home care for all health issues by helping patients to avoid traveling far from home to get the clinical problem solved.

workflow ->

1) doctors who need CPS (clinical problem solving) emails case with records and patient contact to CBBLE email

2) A student check for deidentification takes online consent (from the patient) and post queries with case record on TR (a Facebook group of 2000 medicos)

3) TR network engages in solving problems, while student volunteer keeps track of it, and makes communication with a doctor and patient wherever any additional info required

4) summary with the whole discussion is forwarded to the doctor.



Demo Links-

1) Specific query and case details - http://classworkdecjan.blogspot.com/2016/12/69-year-old-female-having-liver.html

2) Progressive discussion with a case having multiple problems and diagnostic dilemma (with a copy of some part of discussion below)
http://classworkdecjan.blogspot.com/2016/12/70m-neck-mass-of-large-size-and-unknown.html


Detailed document ->
https://docs.google.com/document/d/19F5pLrkSFDUfR7J-gFdYzfiizuKHUTlq_VWMpMbnlAw/edit?usp=sharing

Video Tutorial -> https://youtu.be/5CO3FS26CS8 

Telemed-all care

Group to plan and operationalize the training of 5,00,000 doctors to use GOI’s Telemedicine Practice Guidelines correctly and efficiently within a month from March 26, 2020 (Commence on April 1, 2020 and complete basic training by April 30, 2020 at the latest)

The scope:
We are talking of training doctors to do the three things.
We have to plan and coordinate the creation and implementation of an online training program to train 5,00,000 doctors in 30 days starting April 1, 2020 who at the end of it should be able to do three things:
(i) proper use of the telemedicine practice guidelines issued by MCI
(ii) doing proper triage of ALL types of telemedicine patients (not just suspected Covid 19), and
(iii) then these trained doctors be able to take care of ALL patients, (not just Covid 19 suspects) including medical advice and prescribing permitted medicines to all those who are not referred to a health facility for an in-person consultation.


Below is convo from one of the focus groups.


group invite link to join - https://chat.whatsapp.com/J1eM7uh9xZ5GIaCfrDqaB7

[1:28 pm, 27/03/2020] RB Sir: Which module would you and your students like to focus on? Module 2 or Module 3?
[1:28 pm, 27/03/2020] RB Sir: (i) proper use of the telemedicine practice guidelines issued by MCI (ii) doing proper triage of ALL types of telemedicine patients (not just suspected Covid 19), and
(iii) then these trained doctors be able to take care of ALL patients, (not just Covid 19 suspects) including medical advice and prescribing permitted medicines to all those who are not referred to a health facility for an in-person consultation.
[1:28 pm, 27/03/2020] RB Sir: iii) ALL
[1:28 pm, 27/03/2020] RB Sir: Great. Please create a separate group for it and invite anyone you want from this or any other group or place.
[1:28 pm, 27/03/2020] RB Sir: What does point 3 exactly entail ?
[1:28 pm, 27/03/2020] RB Sir: Training on Point (i) is the simplest (and yet not simple), and progressively becomes challenging under point (ii) and (iii) where further referral and consultation becomes necessary. Better ability to triage reduces load on point (iii)
[1:28 pm, 27/03/2020] RB Sir: Sharing the keywords from each group

i) Inform

ii) Triage

iii) Care
[1:28 pm, 27/03/2020] RB Sir: https://chat.whatsapp.com/J1eM7uh9xZ5GIaCfrDqaB7   -> Point (iii)

...then these trained doctors be able to take care of ALL patients, (not just Covid 19 suspects) including medical advice and prescribing permitted medicines to all those who are not referred to a health facility for an in-person consultation.
[1:28 pm, 27/03/2020] RB Sir: In creating the Scope or Terms of Reference of Sub-Groups (i), (ii) and (iii) keep in mind the following: 1. Learning Outcomes 2. Curriculum 3. Structured modular lesson contents linked to each module and submodule: Text, PPT, Training videos, etc 4. Validation and verification of learning contents 5. Create MCQs fir formative self-assessment of each submodules within each module 6. Tracking training progression, 7. Summative Assessment through MCQs 8. Online certificate issued if 90% questions answered correctly, after unlimited attempts.
[1:28 pm, 27/03/2020] Avinash Kumar: good noon @sridhar sir sir
[1:28 pm, 27/03/2020] sridhar sir: Good afternoon.
[1:29 pm, 27/03/2020] sridhar sir: Kindly let me know what is the purpose of the group
[1:30 pm, 27/03/2020] RB Sir: 👆purpose trail
[1:30 pm, 27/03/2020] Avinash Kumar: sir above msgs are coming from telemed group where you joined. this group is focused for above points. and telemedicine group is focused for this overall.. (sharing below)
[1:30 pm, 27/03/2020] Avinash Kumar: The scope:
We are talking of training doctors to do the three things.
We have to plan and coordinate the creation and implementation of an online training program to train 5,00,000 doctors in 30 days starting April 1, 2020 who at the end of it should be able to do three things:
(i) proper use of the telemedicine practice guidelines issued by MCI
(ii) doing proper triage of ALL types of telemedicine patients (not just suspected Covid 19), and
(iii) then these trained doctors be able to take care of ALL patients, (not just Covid 19 suspects) including medical advice and prescribing permitted medicines to all those who are not referred to a health facility for an in-person consultation.
[1:32 pm, 27/03/2020] sridhar sir: Course content and Delivery of content are 2 aspects .
[1:33 pm, 27/03/2020] sridhar sir: The points listed have to be put under these sub headings
[1:34 pm, 27/03/2020] sridhar sir: PPTS,Articles,MCQs are all content.
[1:35 pm, 27/03/2020] sridhar sir: I have some knowledge of the delivery aspect as I run an E-Learning company.
[1:36 pm, 27/03/2020] RB Sir: Our content delivery is also related to real patient care delivery
[1:37 pm, 27/03/2020] sridhar sir: Let me put it this way. The content delivery tools , such as Moodle  are just tools. They will deliver whatever we add there. Patient care, Telemed, ENT whatever.
[1:37 pm, 27/03/2020] sridhar sir: The intent is to tech Telemed to doctors
[1:37 pm, 27/03/2020] sridhar sir: teach
[1:38 pm, 27/03/2020] RB Sir: Our intent is care and then support the information framework necessary for doctors to deliver current best care
[1:41 pm, 27/03/2020] sridhar sir: Can i say specifically that you want to teach Telemedicine using E-Learning tools?
[1:43 pm, 27/03/2020] RB Sir: No we want to involve doctors in learning medicine using tools that have been sometimes acknowledged to belong to Telemedicine
[1:45 pm, 27/03/2020] sridhar sir: Sorry, still a bit confused. So, its going to be about Telemedicine tools plus other techniques to learn healthcare .
[1:45 pm, 27/03/2020] sridhar sir: Anyway, the first thing to deal with it how the course material would be structred
[1:46 pm, 27/03/2020] sridhar sir: Structure, outcomes, how to asesss.
[1:46 pm, 27/03/2020] sridhar sir: e.g PPT of content, followed by MCQs.
[1:46 pm, 27/03/2020] sridhar sir: Or Video followed by MCQs
[1:48 pm, 27/03/2020] sridhar sir: Many tools and techniques are available. Once a teacher can state what is the intention of a course, how the content can be presented can be discussed.
[1:49 pm, 27/03/2020] sridhar sir: One thought, start with a free Moodle and create something. It could be a prototype and other can comment. Else this will be a never ending theortical discussion
You added Tamoghana sir
[2:06 pm, 27/03/2020] RB Sir: We already have lot of our own published information about our proposed workflow that we have shared in the past
[2:06 pm, 27/03/2020] Tamoghana sir: Hi. Since am new to the group, what is this group all about

Covid Project

Covid Project

The most important part is our project document - Documentation - https://bit.ly/covidprojectdocs

Flutter based mobile app for Covid quarantine tracking, to be connected with rest API to send data on the web.

Mentors 

Senthil Nachimuthu - https://www.linkedin.com/in/nacsen/

Bharat Gera - https://www.linkedin.com/in/bgera31/

Sridhar Bodapati - https://www.linkedin.com/in/sridhar-bodapati-6901a11/

Rakesh Biswas - https://www.linkedin.com/in/rakesh7biswas/

We started from discussions for tackling the Covid-19 disaster as we always get to discuss and learn from the discussions of various experts in CPS group. After pitching for the solution of enforced quarantine (and self-quarantine also as a possibility).

I made separate focused group and found developers  

Shashwat Mishra https://www.linkedin.com/in/shashwat-mishra-59754a179/  

Debjyoti  https://www.linkedin.com/in/debjyoti-banerjee-36116b181/

We started discussion and planning, coding, and documentation and kept doing it parallelly giving maximum energy together.

We came up with these deliverables-

Pitch - https://bit.ly/CovidPitch

Documentation - https://bit.ly/covidprojectdocs

Source Code - http://bit.ly/Covid-Source
Slack - http://bit.ly/Covid-Slack

Image by - Bharat Gera

Our Online Pitches to beat corona-

to FoundersVsCovid-19 

https://inc42.com/buzz/startup-founders-team-up-to-make-coronavirus-quarantine-app-for-india/

they received, retweeted and appreciated.

the dev team made this already to a good level, starting the same day as this team of 70 founders and VCs started, also we were 2 days before govt. of Poland launched a similar app.
https://play.google.com/store/apps/details?id=pl.nask.droid.kwarantannadomowa

we kept everything free and open access/source. 

to W.H.O. by raising the issue on a similar open-source project that just started a day before our team, requested them to have a look at our project and it may be useful for them as they are yet to build the geolocation features which were our specific priority target to do very well.

Waze for COVID-19 App made by W.H.O.  (under development)

We also ran 2 virtual simulations of enforced quarantine of 7 hours each in WhatsApp groups with the help of volunteers. for helping with that, thanks to Joyoti (Mukherji) Goswami https://www.linkedin.com/in/joyoti-goswami-3aa0028/

Some interesting stats of this project while we were racing against time -

Twitter

Github

Demo - 

Progress- We pitched to few governments and had a meeting with Secretary of a State govt. CM. Happy to see similar app just launched by the Govt. of India and more coming ahead by other state governments.

Avinash Kumar

avi33tbtt@gmail.com

https://www.linkedin.com/in/geekydoctoravi/

+918840653960 

CPS group = A WhatsApp network of excellent HealthIT experts.