Lessons Learned From ICEM 2010 (Part B)

Lessons learned from:
The George Podgorny Lecture - Healthcare Reform, Professionalism and Emergency Medicine by Prof V. Anantharaman

Using the metaphor of a "safety net" to describe the current status of the many emergency departments around the globe, Prof Anantharaman addressed the limitations and ills of such system pattern. In his own words, he said that although we often regard ED as the safety net, but the question is: "Who are we a safety net to?"

He then posed the many challenges and the increasing burdens an ED has to bear in becoming a safety net. This includes the role of being a hospital gate keeper in ensuring and improving patients' flow. He gave the impression that due to an increasingly heavier load an ED has to bear, up to a point, the safety net will give way and begin to break. An ED cannot afford to be a community safety net forever, often treating the patients at the terminal end of their diseases progression.

So, what are the solutions proposed in the way forward?
1. Emergency physicians should adopt a new paradigm shift. We should truncate disease progression and sequelae through early care and interventions. Primary prevention and health education should become increasingly more important in emergency medicine. This indeed is one area of healthcare reforms that an emergency physician can participate in - becoming a leader in primary care and preventive medicine. Emergency care should start at the patient's site, or as what Prof Anantharaman called it, the community-based emergency care. The question is, will we be seeing a merging of primary health care and emergency medicine as one form of hybridization of the new emergency medicine? I personally would not brush aside such possibility.

2. Know your community. Closely related to the above first point, is the great need to know our communities. Many researchers have undertaken the challenge to look into pertinent issues such as bystander CPR in their communities. But Prof Anantharaman posed another related challenge - i.e., how many of us know the bystander first aid performed by our communities before bringing the patients to the EDs? We should also get to know our patient's perspective and expectation on our emergency medical services. Why do they come? What do they expect?
Prof Anantharaman also touched on the issue of professionalism in emergency medicine, re-iterating a well-known dictum in emergency medicine: "an emergency doctor is first and foremost a patient's advocate". Do we place our patients' interest above all else?

He also debunked the myth that developing a good emergency care must grow in tandem with having more and more sophisticated hi-tech equipments. This is an echo of what Prof Kellermann said in his talk that technology is not necessary the answer for healthcare reform during an economic recession.

My research ideas drawn from this talk: This lecture is loaded with lots of research suggestions. For one, we can begin to look at the rate of bystander first aid. We can narrow down into specific first aid intervention that can make a difference between life and death - for example, first aid measures to stop a bleeding wound. Out of the many cases of bleeding wound cases that arrive in the EDs, how many have received first aid measure of proper direct compression and elevation prior to arrival? How effective is this measured applied? Has the bleeding stopped prior to arrival? There are also many health education and preventive medicine that we can embark on in collaboration with our colleagues from primary care medicine and public health medicine.

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Lessons learned from:
The Most Successful Public Access Defibrillation Program in Japan by Prof Tetsuya Sakamoto

I must say that I am personally very impressed with this Public Access Defibrillation program in Japan. They are placing AED in many public areas such as halls, museums, schools, offices, railroads, shopping centers, nursing homes, hotels, etc. AEDs are placed next to vending machines, with 1.38 AED per every 1000 population in Japan.

The speaker specifically discussed on the article recently published in New England Journal of Medicine, viz.,

Kitamura T et al. Nationwide public-access defibrillation in Japan. N Engl J Med 2010 Mar 18; 362:994.

From that article, I learned that a total of 25% of public-access AEDs in Japan are located in schools, 19% in medical or nursing facilities, 16% in workplaces, 4% in sports facilities, 3% in cultural facilities, and 3% in public transportation facilities.

It is extrapolated that if the number of public-access AEDs increased from 1 per square kilometer (i.e., a unit placed every 1000 linear meters) to more than 4 per square kilometer (i.e., a unit placed every 500 linear meters), the rate of survival with minimal neurologic impairment in the area could increase about four times.

This Japanese study supports the recommendation that public-access AEDs be made available within a 1.0-minute to 1.5-minute brisk walk from any public place.

It would mark a significant milestone of emergency medicine achievement if we could one day successfully implement a nationwide public access defibrillator program in Malaysia. For this to be successful, it would require a strong political will, a major commitment and undying passion among the major stakeholders in emergency medical services in Malaysia to improve the quality of resuscitation medicine in Malaysia. Another major obstacle to overcome is the mentality of our Malaysian public. Unscrupulous public member in Malaysia is notorious for vandalizing and stealing public properties for their own gains.