Indian Journal of Emergency Medicine

Emergency Departments (EDs) are critical to delivering timely care, yet they often face operational inefficiencies that result in extended patient Length of Stay (LOS). This dissertation explores the application of Six Sigma’s DMAIC (Define, Measure, Analyze, Improve, Control) methodology to reduce LOS in the Emergency Department of The Mission Hospital, Durgapur. The study identifies key contributors to prolonged LOS, including exit block due to bed unavailability, delays in diagnostics and ancillary services, communication gaps, and infrastructural limitations. A mixed-method research design was adopted, analyzing data from 7,380 patients over a six-month period. Root cause analysis tools such as Fishbone diagrams and Pareto charts were used to identify process inefficiencies. Targeted interventions including triage optimization, diagnostic prioritization, and workflow redesign were implemented durng the Improve phase. These efforts led to a statistically significant reduction in average LOS from 321 minutes in January 2025 to 164 minutes by March 2025, marking a 49% improvement. The study demonstrates that structured, data-driven interventions using the DMAIC framework can lead to measurable and sustainable improvements in ED efficiency. The findings provide actionable insights for healthcare administrators seeking to enhance patient flow, reduce wait times, and improve overall service delivery in emergency care settings.

Background: Cardio-pulmonary resuscitation (CPR) is a critical life-saving intervention in cases of sudden cardiac arrest or respiratory failure. Despite its widespread use, survival rates after cardiac arrest vary significantly across different populations, largely influenced by factors such as healthcare infrastructure, resource availability, and training, especially when comparing developed and developing countries. Objectives: The aim of our study is to assess the effect of duration of cardiopulmonary resuscitation (CPR) and initial cardiac rhythm in predicting the return of spontaneous circulation (ROSC) in adults of in-hospital cardiac arrest. Methods: We conducted retrospective clinical record audit of 94 adult patients (age ≥18 years) between April 2025 and May 2025 who had cardiac arrest and received CPR in our hospital. Appropriate statistical analysis was conducted with SPSS software version 27 and p-value set significant if less than 0.05. Results: The mean age of patients was 58 ±10 years, male accounted 67.74%. Cardiac arrest is most common in elderly population and outcome is poor. Most common initial cardiac arrest rhythm was asystole (88.29%). We observed that there was no significant association between initial cardiac arrest rhythm and survival outcome (p=0.243). We also observed significant association between shorter duration of CPR in survival group (ROSC) of 21 to 40 years age group. Conclusion: In this study, we observed that there is an association between duration of CPR and return of spontaneous circulation. These findings highlight the importance of prompt and effective resuscitation efforts to optimize survival rates during cardiac arrest management.

Painful swelling in the neck is a frequent complaint in emergency settings, though identifying the exact cause can be complex. Among the less common diagnoses is Eagle syndrome, a condition involving either an unusually elongated styloid process or calcification of the stylohyoid ligament. These anatomical abnormalities can irritate nearby nerves or blood vessels, resulting in various symptoms such as throat pain, difficulty swallowing, ear discomfort, or a sensation of something being stuck in the throat. Due to its rarity and symptom overlap with other conditions, Eagle syndrome can be easily overlooked, making clinical awareness crucial for accurate diagnosis and treatment. In this case report, we discuss an interesting yet complicated case of Eagle syndrome, the prompt emergency diagnosis based on radiological findings and its management.

Headaches are a common symptom encountered in clinical practice, yet they can sometimes obscure more serious underlying conditions. This case report describes the diagnostic journey of a 52-year-old male presenting with an atypical headache, followed by progressive neurological symptoms, and initially inconclusive investigations. The diagnosis of viral encephalitis was established through cerebrospinal fluid (CSF) analysis, despite negative results for common viral pathogens. This case underscores the critical importance of maintaining a high clinical suspicion and conducting a comprehensive work-up, even in the face of normal or negative initial diagnostic findings.

Central venous catheterization (CVC) via the internal jugular vein (IJV) is a fundamental procedure in emergency and critical care practice. Traditionally, this has been performed using landmark-based techniques followed by chest X-ray (CXR) to confirm tip placement and rule out complications. However, with the evolution of point-of-care ultrasound (POCUS), the necessity of routine CXR is being reconsidered. This article reviews evidence comparing landmark-guided CVC with postprocedure CXR versus ultrasound-guided CVC with sonographic confirmation. Numerous international studies demonstrate that ultrasound guidance increases first-attempt success rates, reduces procedure-related complications, and allows for immediate confirmation of line position and exclusion of pneumothorax using lung sliding and saline flush echo methods.1-3 In Indian emergency departments (EDs), where ultrasound accessibility and operator training vary, adopting selective CXR strategies tailored to clinical context can optimize both safety and efficiency. The review emphasizes evidencebased practice and supports the integration of POCUS training into ED protocols to enhance procedural outcomes. Introduction: Central venous catheter insertion is an indispensable skill for emergency and critical care physicians. The internal jugular vein (IJV) is preferred due to its predictable anatomy and lower infection risk. Traditionally, cannulation relied on anatomical landmarks with post-procedure CXR for tip confirmation and pneumothorax detection.4 However, real-time ultrasound guidance has become the global standard, endorsed by the National Institute for Health and Care Excellence (NICE) and the Agency for Healthcare Research and Quality (AHRQ) as a best-practice safety measure.5-6

We report a case of a 70-year-old male who presented to the emergency department with throat pain for 1 week, which had worsened in the last 3 days. Initial impression on history and clinical examination was that of a peritonsillar abscess, but on further investigation, he was found to have a disseminated deep neck space infection involving the epiglottis as well as the trachea. This case report enlightens the need for a high index of suspicion in emergency physicians for supraglottic as well as infraglottic involvement in a patient with eritonsillar abscess, which could lead to an impending airway emergency with a difficult anatomical airway.

Anterior superior iliac spine (ASIS) avulsion fractures are uncommon injuries, primarily affecting adolescent athletes during sudden, forceful physical activity. Traditional diagnosis relies on radiography, though small bony fragments can be missed. We report a case of a 15-year-old female presenting with acute left groin pain following a rapid directional change while playing “kho-kho”. Physical examination showed localized tenderness, and estricted hip movement. Pelvic X-ray unfortunately skipped the diagnosis when the Point-of-care ultrasound (POCUS) performed in the emergency department revealed a hyperechoic apophyseal fragment displaced from the ASIS, suggesting an avulsion injury. Given minimal displacement, the patient was managed conservatively. This case highlights the value of POCUS in Indian emergency settings where quick decision making and limited imaging facilities make bedside diagnosis essential

Background: Graves’ disease is the most common cause of hyperthyroidism, but its initial presentation in the emergency department (ED) may often be subtle or masked by concurrent acute illness. Influenza A associated pneumonitis is also a serious infectious condition that can present with high-grade fever, cough, and hypoxemia. The co-occurrence of these two entities is rare, and incidental detection of Graves’ disease in such a setting is clinically significant. Case Presentation: We report the case of a 24-year-old male who presented to the DAOH Emergency Department with acute onset high-grade fever, cough, throat pain, and reduced oral intake. On arrival, he was febrile, tachycardic (160/min), and severely dehydrated. Initial evaluation suggested left lower lobe neumonitis, later confirmed as Influenza A (H3)-associated by respiratory viral panel. Despite adequate hydration and antipyretic therapy, persistent sinus tachycardia prompted further workup. Thyroid function tests revealed suppressed TSH with elevated T3 and T4, and thyroid ultrasound demonstrated diffuse enlargement with pervascularity, consistent with Graves’ disease. The diagnosis was confirmed with elevated TSH-receptor ntibodies. The patient was managed with supportive care, oseltamivir for influenza, antibiotics for pneumonitis, nd initiated on neomercazole with beta-blockade for hyperthyroidism. He improved clinically and was ischarged in stable condition on day

Double vision, or diplopia, is a symptom that can stem from a variety of causes, ranging from benign to life-threatening conditions. We present a case of an adult patient who experienced sudden onset double vision, initially suspected to be a neurological disorder. However, further investigation revealed an unexpected underlying cause that mimicked neurological symptoms. This report outlines the diagnostic challenges, management trategies, and outcome of the patient, highlighting the importance of considering atypical causes of diplopia and the need for thorough evaluation in such cases.

Background: Cresylic acid and tributyltin oxide (TBTO) are prevalent industrial compounds utilized in household biocides and disinfectants. Oral intake, particularly when coupled, can result in significant systemic toxicity, even though human exposure often occurs through inhalation or dermal routes. Case Presentation: A 19-year-old woman from rural India intentionally ingested a disinfectant that contained TBTO and cresylic acid, which caused multiple organ poisoning in an unusual case. She responded to supportive therapy and eventually made a complete recovery. Conclusions: This case emphasizes the possibly life-threatening risks associated with exposure to phenolic and organotin compounds and highlights the value of early supportive treatment and careful supervision. Because there isn’t a lot of information on co-ingestion in humans, clinicians should treat such poisonings as if they were novel exposures.