Copyright Issues

Copyright issue regarding online materials (texts, pictures, videos, multimedia, etc), whether materials that I am downloading, or materials that I am uploading, has always been an evasive issue to me until I read an article by Brad Templeton on TEN BIG Myths on Copyright Explained (URL: http://www.templetons.com/brad/copymyths.html).

From that article, the first thing mentioned is that: even if there is no copyright notice attached in that particular material that you found, it DOES NOT automatically mean that it is not copyrighted.

The rule of thumb is:

Whenever you are not sure whether the material is copyrighted or not, it is always safest to assume that it is copyrighted.

This is especially so as most countries (including Malaysia) are signatories of the Berne Convention on international copyright law (currently the bureau in charge is named World Intellectual Property Organization, an organization within the United Nations).

Nonetheless, if you are like me, where you just love to share the materials that you have created, teaching notes that you have written, power point slides that you have painstakingly made, strictly for educational, non-commercial purposes and at the same time, you want to protect and retain some copyrights of your materials so that your "kindness" would not exploited, the EASIEST way to do so is to sign up for a copyright license under Creative Commons. In fact, creative commons allow you the flexibility to choose whether you would want to allow your materials for commercial purposes, whether modification of your work is allowed, the name and URL such work should be attributed to, etc, etc. By keying in the relevant information, within minutes, an HTML code would be automatically generated. Just copy and paste the html code in your relevant blog post or webpage. Click here to start using Creative Commons license.

To protect your images/pictures/diagrams, etc, etc, you can watermark your work with a copyright notice together with the URL such work is attributed to. The best is PicMarkr, this website allows you for FREE customizable watermarking (protecting) of your work.

Necrotizing Fasciitis

Necrotizing Fasciitis can potentially be a life-threatening and limb-threatening bacterial soft tissue infection. Although it is commonly polymicrobial, one of the notorious organism is Group A Beta Hemolytic Streptococcus (GABHS). The organisms are commonly anaerobic types as these organisms thrive well under the local tissue hypoxia environment although the anaerobic organisms can co-exist with the aerobic types.

Unbeknownst to the patient, often the organism enters the subcutaneous tissue due to very trivial trauma. Nonetheless, as expected, there will be certain predisposing factors which render the host to be immunocompromised for such severe soft tissue infection to occur; viz, diabetes mellitus.

To differentiate necrotizing fasciitis which may rapidly lead to fulminant sepsis and septic shock from cellulitis, one of the key clinical feature of necrotizing fasciitis is that:

the pain and tenderness that the patient experiences may be "out of proportion" to the visible skin lesion externally (in fact, the overlying skin changes are often milder compared to the degree of necrosis occurring underneath).

Secondly, some patients with necrotizing fasciitis may have subcutaneous emphysema which probably is not present in simple cellulitis.

Thirdly, from the external look as well, the picture of necrotizing fasciitis just appear "uglier" with bullous lesions with serous discharge (as in the picture above).

Pathologically, in necrotizing fasciitis, the organisms are notoriously aggressive by invading the underlying fascia (thus the name, fasciitis). This also earns them the title "flesh eating bacteria syndrome". In contrast, in simple cellulitis, the organisms seldom go beyond the underlying fascia, although, if left untreated, necrotizing fasciitis is a sequelae of cellulitis.

Read an article from e-Medicine online here.

Download a FREE BMJ Review article on necrotizing fasciitis here.
Download another excellent FREE review article here.

Note: kindly report any broken link to cksheng74@yahoo.com

© 2010 by Dr. Keng Sheng CHEW.


Necrotizing Fasciitis by Dr. Keng Sheng CHEW is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.

Introduction To Cancer Biology

There has been tremendous advances in cancer biology and cancer medicine from the time I studied basic medical sciences.

In my preparation for the next Problem Based Learning for the medical students on neoplasm, I found that there are so many new advances that do sound alien to an emergency physician. As mentioned by Harold Varmus, MD, in his lecture on Why Cancer Biology and Cancer Medicine is Finally Emerging (YouTube video attached below), in the era of the 1970s - 1990s, the sphere of cancer biology and cancer medicine are actually two different worlds with little interaction between them, but as from 1990s onwards, these two spheres are beginning to overlap more and more and in fact, is starting to emerge as one due to the fact that more and more specific target therapies have been developed and already used in clinical setting; one of the most popular example is the poster-child drug in CML, imatinib (brand name, Gleevec)

Basically a neoplasm is defined in many text as “… is an abnormal mass of tissue, the growth of which exceeds and is uncoordinated with that of the normal tissues, and persists in the same excessive manner after cessation of the stimuli which evoked the change”. (This would differentiate a dysplasia, where the process is usually reversible when the stimuli is removed).

From my understanding, basically cell growth is regulated by the balance between the activities of proto-oncogene and the tumor suppressor gene. A proto-oncogene promotes cell growth and gene transcription whereas a tumor suppressor gene (the famous one, being p53) acts as a "genomic guardian" that plays an important role in maintaining the DNA integrity. It does so by sensing genomic changes, thereby halting the cell cycle and initiating DNA repair. If the DNA is beyond repair, apoptosis cell death will be initiated. Unfortunately, the proto-oncogene can undergo point mutation, resulting in an oncogene, and thus causing uncontrolled, invasive cell growth. On another hand, the tumor suppressor gene can undergo mutation as well resulting in cancer. Mutation in p53 gene for example, has been cited to cause more than 50% of cancer.

Take a look at the video below and see the role of proto-oncogene and tumor suppressor gene.

But how does a proto-oncogene becomes an oncogene? See the video below.

The 6 Hallmarks of cancer cell:

1. Self-sufficiency in growth signals
2. Sustained angiogenesis
3. Insensitivity to anti-growth signals
4. Evasion of apoptosis
5. Limitless replicative potential
6. Tissue invasion and metastatsis capability

The Mechanism of Action of Imatinib (Gleevac)

Normally, tyrosine kinase proteins respond to external cellular messaging proteins which then translate into a series of reactions that culminate in cellular replication.

Conversely, mutated chromosome, for example, the Philadephia chromosome due to reciprocal translocation of chromosomes 9 and 22 results in the BCR-ABL genetic domain within chromosome 22.

This encodes for a mutant form tyrosine kinase. Unfortunately, this BCR-ABL is constitutively active and does not require activation by cellular messaging proteins in order to stimulate cellular replication. This results in acceleration of cell division, an inhibition of DNA repair, overall genomic instability, and the fatal blast crisis characteristic of CML.

By specifically targeting and competively inhibiting the ATP binding site on BCR-ABL tyrosine kinase, it prevents the phosphorylation the tyrosine residue, and thus, rendering it inactive to further abnormal cellular replication.

Watch the video below:



Apoptosis vs Necrosis

Apoptosis is a form of programmed cell death, and is not due to some external stimuli. It does not have the elements of inflammation. The cellular organells are intact. Rather, it involves chromatin aggregation with nuclear and cytoplasmic condensation. These cellular blebs will then phagocytosed by the macrophages. On the other hand, necrosis is due to an inflammatory reaction to external stimuli including chemical toxins and hypoxia. It results in cellular disintegration with influx of H20 and ions causing cellular swelling.



Though it may seems that cancer biology has nothing much to do with emergency medicine, it is always good to fill in the knowledge gap, and to be constantly upgrading your knowledge. That's one of the reasons why I love to facilitate a PBL discussion. Furthermore, although, oncology is probably the first specialty where the demarcation between clinical medicine and molecular research has been blurred; but who knows, as the impact of molecular medicine is getting more and more important, that it may play an important role in other clinical specialties as well, including emergency medicine!

Finally............a one hour lecture by Nobel Prize winner, Harold Varmus on recent advances on cancer biology (he highlights particularly on myc and K-ras gene):

My First Lesson In Med School

Credit: Picture from stock.xchng

One of the first lessons that I was taught when I entered medical school is this:

"To be a good doctor, you need to have the eyes of an eagle, the hands of a maiden (or woman) and the heart of a lion"

This lesson, which I still remember vividly, was taught by Prof Mafauzy Mohamed who is now the campus director of the medical school of Universiti Sains Malaysia.

Although I have found variants of this quote in the internet here and here, that statement made a tremendous impact in my medical career, and 16 years later as I look back, I realize how true it is not only for surgeons, but for all doctors as well (and is very true for an emergency physician too).

We need to be sharp, like an eagle's eye - to pick up warning early signs and symptoms that the patient is deteriorating.

We need to be gentle, like the hands of the maiden (although most versions in internet, use the word "lady" or "woman"), I particularly like the word "maiden" to depict the gentleness and kindness of our touch.

We need to be courageous, like the heart of a lion - when the emergency situation calls for such action to be taken swiftly and boldly to save the life of the patient.

As the saying goes,
"A teacher affects eternity, no one can tell where his influence stops" - Henry Adams

That's the rewarding part of being a lecturer.

Bundling two separate pdf files in a single pdf file

As an academician, one of the most needed software is a software that can convert a Office document into a pdf format.

Fortunately, the Microsoft Office 2007 that I am currently using has such option by clicking "Safe as" and choosing pdf from the top-down menu option.

But the other equally needed program that I need is a software that can bind two separate pdf files into a single pdf.

This would be useful in cases where the pagination system used in the two separate files are different, e.g. one in Roman numerals, and the other in Arabic numerals. This happens in cases like preparing a dissertation, where the first few sections, viz, the Table of Contents, List of Figures, List of Tables, etc, etc are usually paged in Roman numerals, whereas the main text of the dissertation is paged in Arabic numerals. As such, you would need a software to bundle these two files together. Other cases include when you want to bind all the related journal articles you have downloaded into a single file.

You can do all these, if you are Adobe Acrobat Professional version (not the free reader). Unfortunately this professional version can be quite costly.

Another option that I have found is using A-PDF Merger software (see the screenshot above). A-PDF Merger is a simple, lightning-fast desktop utility program that lets you combine two or more image files or Acrobat PDF files into a single PDF document. Office files can also be merged if A-PDF Office to PDF also installed. A-PDF Merger provides special merge methods that allow you to combine documents and document parts in a number of different ways to make your work more effective. Best of all, it is cheaper, especially with current special pricing.

You can try downloading the trial version by clicking here. The trial version is actually fully functional except that it contains a watermark at the first page whereas for the full version, with a license code, the watermark is removed.

The 2009 COPD Malaysian Guidelines - What's Important From Emergency Medicine Perspective?

The new 2009 Malaysian CPG on Chronic Obstructive Pulmonary Disease is out.

Download the guideline here at the Malaysian Thoracic Society Website here or here at the Academy of Medicine Malaysia website (scroll to the Respiratory Medicine section).

I have also given a talk on COPD last week.

Here's my five points summary of the importance of this guideline from Emergency Medicine perspective:

1. COPD is no longer just considered a lung parenchymal pathology, but one with significant systemic effects
2. Spirometry is required for both diagnosis and assessment of severity. Every effort should be made to refer patient for spirometry.
3. Smoking cessation is the single most cost effective - intervention to reduce the risk of developing COPD and stop its progression. Even a brief 3-min of counseling may result in smoking cessation rates of 5-10%.
4. The combination of LABA/ICS has been shown to improve lung function, quality of life and reduce exacerbation compared with placebo in COPD patients with FEV1 <>
5. Consider NIV in patients with persistent hypercapnoeic respiratory failure despite optimal medical therapy.

The 2009 COPD Malaysian Guidelines - What's Important From Emergency Medicine Perspective?

View more presentations from Chew Keng Sheng.

The 2009 COPD Malaysian Guidelines - What's Important From Emergency Medicine Perspective? by Dr. Chew Keng Sheng is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.


Conflict of Interest:
This set of slide was prepared for my talk during lunch time in the department I am working in. The lunch was sponsored by Astra-Zeneca (M) Sdn Bhd ["AZ"] and I have received educational grant from AZ to attend MTS scientific meeting on Asthma and COPD.

Managing Cardiovascular Emergencies In A Malaysian Hospital - Challenges and Issues

This is the talk I gave during ICEM 2010 under the International Experience of Cardiology Track. In this presentation, I highlighted some of the challenges I see within the Malaysian setting, I focus mainly on prehospital and A&E setting. Issues that are conventionally under the care of the cardiologists are not discussed.

Managing Cardiovascular Emergencies In A Malaysian Hospital - Challenges and Issues

View more presentations from Chew Keng Sheng.

Managing Cardiovascular Emergencies In A Malaysian Hospital - Challenges and Issues by Dr. Chew Keng Sheng is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.

Lessons Learned From ICEM 2010 (Part G): 22 Emergency Medicine-Related Research Ideas and Tips Gained From ICEM 2010

22 Emergency Medicine-Related Research Ideas and Tips Drawn From ICEM 2010

1) Conduct a study to look into the influence of economic recession and inflation on Malaysian patients’ preferences of medical treatment (public healthcare including emergency department facilities versus private healthcare facilities).

2) As a paradigm shift, carry out more preventive medicine in emergency medicine to truncate diseases early in the course of illness.

3) Conduct studies to look into the effectiveness of empowering patients and family or engaging them in a form of partnership in patient management. Common example: mild head injury advice on discharge – does it reduce the rate of admission without compromising on care?

4) Conduct study to look into not just bystander CPR rate of your community, but also bystander First aid rate. Pick specific life saving first aid interventions – e.g. bleeding control prior to arrival to hospital

5) Especially in times of economic recession, sophisticated technology is not always the answer to good emergency care. Conduct studies that are simple, cost-effective and yet have profound clinical benefit for your community.

6) Conduct study to look into public access AEDs in your community. How many of the public places and buildings have AEDs? Are the staffs working in that particular place with AEDs know how to use them?

7) Collaborate, collaborate, collaborate

8) Innovate, innovate, innovate…... often research methodologies can be designed by giving existence researches a “tweak” to suit them into your setting and patient population.

9) Be creative, as no idea is just too crazy for innovation.

10) In order to generate a research idea, one should always an inquisitive mind. One should always ask “Why?” “Why not?” For example, “why should treatment X better than treatment Y?”

11) There are many areas or domains of research one can embark on, among which: Cellular level, organs and system, disease process, patients, family, organization, hospital staffs, treatment modalities – drugs, surgery, etc, diagnosis, prognosis, prevention, screening, communication, attitude.

12) Translate research done in one area into another area related to emergency medicine

13) Do validation studies of newly formulated clinical prediction rules, scoring systems, etc

14) If a drug or a mode of treatment works in one group, try postulating and ask whether the mode of treatment will work well in another group or not; e.g. adults vs pediatrics, prehospital vs hospital settings, etc.

15) Do studies on incidences of clinical errors, misdiagnosis, etc.

16) Ask advice and be willing to share ideas. Worrying that someone else may steal your research ideas is a recipe for failure and disaster.

17) Be pragmatic. If you want to a study on rare diseases, first of all, ask yourself, how often do you see these cases? Can you finish the study on time?

18) Get your biostatistician involved early in the course of the research! Good, valid research depends more on getting the methodology right rather than towards the end of research completion, when the data has been collected.

19) Do not become a “p-value worshipper”! Remember that p-value can be manipulated by increasing the sample size, but the clinical significance cannot be manipulated

20) How about a study on the influences on TV medical shows and dramas such as ER, House, etc on the choices of future career?

21) As the world progresses, more and more psychiatric cases may be seen in emergency departments. Psychiatric emergencies or mental health is an evolving research area in emergency medicine. Yet, this is one area where not many researches have been done. Bear in mind that ethical issues and getting consent may be challenging in such area.

22) Studies from western countries are not always applicable within the Asian context because Asian population may have different genetic make-up, with different disease manifestation, different socio-economic background, different infectious disease patterns, etc.

I have compiled the entire series of my "scribbled" notes during the talks I attended in ICEM 2010 into a brief report. This report will also be submitted to the university besides the handouts of my own presentations.

You may download the entire series as an ebook. Click here to download in Scribd.

The content in this ebook may be freely distributed for non-commercial, educational purposes provided that nothing is added or removed, including this copyright notice.

If you are placing the ebook link in your site, please provide a link back to the URL of Emergency Medicine Blog at http://emergencymedic.blogspot.com/

For any other queries, please contact cksheng74@yahoo.com


A Brief Report On Lessons I Learned From Selected Talks In ICEM 2010 and 22 Emergency Medicine-Related Research Ideas and Tips Gained From This Conference by Dr. Chew Keng Sheng is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.

Lessons Learned From ICEM 2010 (Part F)

Lessons learned from:
Engaging Asia in Pediatric Emergency Medicine Multicentre Research – Opportunities and Challenges – by Dr. Fu Sheng

In this talk, Dr. Fu Sheng conceded that there is need for an Asian collaboration for pediatric emergency medicine research projects. Studies from western countries are not always applicable within the Asian context.

The Asian continent, with the biggest population group, has different sets of pediatric disease threats as compared to western countries. Infectious diseases are a prevailing cause of morbidity and mortality in many Asian countries. These include dengue and malaria.

Besides, Asian children seem to manifest disease responses differently. For example, the H1N1 infection seems to have a milder progression among Asian pediatric population. Thirdly, Asian countries have different sets of environmental-related diseases. Haze from forest fire in Indonesia results in respiratory diseases and this is a major problem in the South East Asia region.

Lastly, Asian countries also have different sets of problems related to their own socio-cultural perspective. He cited renal diseases related to melamine poisoning due to milk products consumption. He said that such projects should be cost-effective and pragmatic, to aim towards diagnosis, treatment and prevention of acute illnesses involving Asian children.

**************
Lessons learned from:
Barriers and Enablers In Chest Pain Guidelines Implementation by Dr. Peter Pang

It is often unrealistic to expect everyone to change their clinical practice in order to follow a new guidelines or clinical pathway. In every organization and in every new implementation, there will be those who are the “early adopters” (willing to change), and there will be those who resist changes.

Dr. Peter Pang shared his experience during the implementation of chest pain guidelines in Hong Kong. In the very first place, one should a build a curriculum of Evidence-based medicine (EBM) culture in our local workplaces. And according to him, whenever we want to implement new guidelines, identify those “early adopters” – those that are willing to go the extra mile to support the changes. Invest in these “early adopters” with the hope that those who resist will sense the “observer effect”, thus, creating a hawthorne effect among these resistant ones.

He shared that in many occasions, the implementation process fails because the leaders themselves do not lead by examples. Leaders should do it themselves first. And those who are policy makers often do not get feedback and opinion from the grassroot users before implementing any guidelines. Thirdly he also shared that to create a sense of urgency to change, the guidelines must be clinically relevant, and the end users must see the urgent need themselves. For example, if the guideline is regarding issue related to life and death matters, then more people would be willing to follow. Implementing too many guidelines including those that have no clinical consequence will result in a low compliance rate. Fourthly, is the guideline user-friendly enough, easy to be remembered or is it rather taxing, complicated and results in many constraints in terms of manpower, time and facilities?

Dr. Peter Pang then came up with his own fishbone diagram to help him identify the reasons behind the implementation issues. The four categories of issues he studied, represented by four “bones” of the fish are: the Policy makers (+ stakeholders), the End-users, the Guideline characteristics, the Environment (Physical and social). He then used a to a Haddon Matrix approach chart to consolidate his findings.


Appendix: Fish bone diagram
My further literature search shows generic fishbone diagrams have been used to analyze cause-effects relationship. Also known as Ishikawa diagram, it was first described by Dr. Kaoru Ishikawa, a Japanese quality control statistician.

This fishbone diagram is an analysis tool that provides a systematic way of looking at effects and the causes that create or contribute to those effects.

The “head of the fish” represents the problem or issue to be studied. And each of the "bone of the fish" represent categories of causes that contribute to the problem. Typically they are remembered by the 4‘M’s: Methods, Machines, Materials, Manpower. Other ‘M’s frequently cited are: Mother Nature (Environment), Measurement (Inspection), Maintenance, Money Power, Management. Other variants include 4’S’s, 4’P’s, etc, etc (see Wikipedia: Ishikawa diagram. URL: http://en.wikipedia.org/wiki/Ishikawa_diagram)

Haddon matrix, on the other hand, as many are well versed with, deals with prevention of diseases or injuries, etc. It has three phases: pre-event, event and post-event; and the factors are typically divided into Host or human, agent, environmental factors

Lessons Learned From ICEM 2010 (Part E)

Lessons learned from:

Researcher-Biostatistician Symbiotic Relationship – by Dr. Chan Yiong Huak

According to the speaker, the success of a research depends on the following:

Stages of research	Percentage contribution to validity of clinical results obtained
Stage 1 Proper study design	30 – 40%
Stage 2 Conducting the study/data integrity	50 – 60%
Stage 3 Proper database setup/statistics	Only about 10 – 20%

Therefore, as the speaker said, seek input from the biostatistician right at the very beginning of the study to ensure a good data integrity. That is more important than seeking the biostatistician’s help only towards the end of the project when the data collection has been completed.

In that talk, the speaker also warned against becoming a “p-value worshipper”!!! One should know the difference between statistical significance versus clinical significance. Remember that statistical significance can be manipulated by increasing the sample size, but one cannot manipulate the clinical significance anymore than a doctor can force a patient to take drug A for his hypertension.

Key Lessons learned from:

Research Trends in Emergency Medicine – by A/Prof Andra L Blomkalns

This is another talk that I have truly learned so much from. Lots of research ideas can be gleaned from this talk.

The speaker started off by showing how emergency medicine, by itself, has grown be to be ever popular, respectable specialty by itself, and in line with that, the number of publications in the field of emergency medicine has not only grown substantially, but, diversified and evolved from simple anecdotal case reports historically back in the 1970s and before to high impact original research articles currently. Various consortia, collaborations, including highly specialized networking links such as PECARN (Pediatrics Emergency Care Applied Research Network) have been established to facilitate and propels vigorous research works in emergency medicine. The speaker also partly attributed to the growing interest of the general public to emergency medicine to the popularity of TV shows such as ER that depicts stories and happenings pertaining to emergency medicine.

Yet, as emergency medicine continues to grow as a specialty, its focus would inevitably change. Its landscape changes to a more global focus. And as the types of diseases seen in developing countries may differ from developed countries, the trends in emergency medicine research will therefore, change as well. Below is the partial list of future research trends in emergency medicine that she predicted:

· Mental Health and Psychiatric disorders in emergency medicine such as unipolar depression, dementia disorder, etc (Note: this is one area that have not been studied extensively in emergency medicine but may become more important due to increasing number of such cases as the world progresses)

· Domestic Violence cases in emergency department

· Self-inflicting Injuries

· Infectious diseases such as tuberculosis, HIV, diarrheal diseases

· Combat Medicine, War medicine

· Basic sciences research

Other conventionally existing trends that will continue to grow include:

· Motor vehicle accidents

· Cardiovascular Diseases

· Neurovascular Diseases

· Critical Care Interventions

Lessons Learned From ICEM 2010 (Part D)

Lessons learned from:
Overcoming the Barriers to Undertaking Research in Emergency Medicine and Creative Ways of Sustaining Your Academic Research Funding – A/Prof Kevin Ward

To create a sustainable research platform in emergency medicine within our local setting, the speaker repeatedly mentioned three basic ingredients:

Educate
Collaborate
Innovate

One discipline that emergency medicine can collaborate with would be biomedical engineering. Experts in biomedical engineering would probably be interested in our projects. Ask them: “What can you do to help me save more lives?” Use “we”, not “I” or “you”. Some examples cited include microcirculation and oxygen transport, biomathematics and physics, tissue injury and repair, etc. He also shared on the need to protect our ideas early in the process of the research. Bottom line is to be creative, as no idea is just too crazy for innovation.

***********
Lessons learned from:
How To Formulate a Good Research Question and Choose A Suitable Study Design by Dr. Henry Guly

I must say that this is the talk that I benefited the most from. Dr. Henry Guly stated that the very basic step in formulating a research question is to have the idea. And in order to generate an idea, one should always an inquisitive mind. One should always ask “Why?” “Why not?” For example, “why should treatment X better than treatment Y?” There are many areas or domains of research one can embark on:

• Cellular level
• Organs and system
• Disease process
• Patients, Family
• Organization
• Staffs
• Treatment: Drugs, Surgery, etc.
• Diagnosis
• Prognosis – for example, management by ED doctor vs management by hand surgeon?
• Prevention
• Screening
• Communication
• Attitude

Other tips in formulating research questions:
1. Translate research done in one area into another area related to emergency medicine

2. Do validation studies of newly formulated clinical prediction rules, scoring systems, etc

3. If a drug or a mode of treatment works in one group, try postulating and ask whether the mode of treatment will work well in another group or not
3.1. Adult population vs pediatric population (for example, if drug A works in children, can it be work in pediatrics as well?)
3.2. Prehospital vs hospital care
3.3. Developed countries vs developing countries

4. What is the incidence for misdiagnosis?

5. Why do these errors occur?
5.1. Clinical?
5.2. Misleading X-ray findings? Missed radiological findings?
5.3. Subtle ECG abnormality, etc, etc.

6. Functional results? Think of how to measure this.

7. Return to work/schooling? Number of days absent from work/school

8. Economic cost

9. In many of these cases, it is about giving a tweak on what has been done and make it into something relevant.

Research methods
1. One should rigidly and clearly define the intention/research outcomes. Use PICO model.
2. Do thorough literatures search. What has been done? What’s not?
3. Ask advice – be willing to share ideas. As the speaker said, worrying that someone else may steal your research ideas is a recipe for sure disaster.
4. Lastly, be pragmatic. For rare diseases, ask, how often do you see these cases.

Lessons Learned From ICEM 2010 (Part C)

Lessons learned from:
Resuscitation in Asia by Prof Hwang-Sung Oh

This talk is relevant to those working within the Asian setting, and it is certainly a wake-up call to me that there is much to be done to improve the outcome of resuscitation, particularly for out-of-hospital cardiac arrest cases.

As highlighted in Prof Oh from the Republic of Korea, only few Asian countries have their own national resuscitation guideline, and national data registry.

In terms of ambulance response time, for example, in Malaysia it is about 17 minutes, and we are only slightly better than Vietnam, which records a 30 minutes response time. Even China which is such a big, populous country, is better than us, at 13 minutes and Singapore records a 11 minutes’ response time.

Public access AEDs are almost non-existent and Prof Oh reported that the number of AEDs available in Malaysia is 0 until I told him in a smaller scientific track later that we have at least public access AEDs in KLIA and LCCT Sepang. The challenge for us is to play our different parts, abeit small roles, and together, we hope we can develop and construct a registry system as well as strengthening our chain of survival.

********************
Lessons learned from:
Evolution and Hybridization of Emergency Medicine by Prof Gunnar Ohlen

Re-iterating what Prof Anatharaman has said, emergency medicine department cannot continue to become the safety net forever. There is a need for a paradigm shift. In some countries, for example, in China, traditional medicine or complementary medicine has been incorporated into Western medicine. As the speaker shared, one of the problems of modern medicine that has evolved over the years is the fragmentation of medicine – specialties within the specialty (subspecialties). There may come a time where there is need to tear down the ivory towers of clinical departments in order to offer a more wholistic, intergrated medicine to the patients. We must also arrest waste and over-production – for example, ordering tests that do not change the patient management. Ultimately, at the end of the day, the speaker shared that in the beginning, we shape the buildings we want to build, but afterwards, our buildings shape us. Therefore, it is better not to build when the building is going to be is sub-optimal; it is better to build on something small but optimal.

“We must not look back in hopes of recreating what once was. We must look forward and create what has never been.”

***************
Lessons learned from:
The Three Things That Improve Outcome in Hospital Arrest by Dr. Michael Parr

The speaker shared these three interventions:
A. Treating the underlying causes of the arrest.
For cases of ACS, for example, he shared of performing emergency PCI even while CPR is being carried out (e.g. using mechanical device)

B. Therapeutic hypothermia
Therapeutic hypothermia seems to be the “in-thing” for the new resuscitation guidelines. More and more papers have been published regarding the use of mild therapeutic hypothermia, among which:

1. Bernard SA et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002 Feb 21; 346:557-63.

2. The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002 Feb 21; 346:549-56.

3. Cheung KW et al. Systematic review of randomized controlled trials of therapeutic hypothermia as a neuroprotectant in post cardiac arrest patients. Can J Emerg Med 2006 Sep; 8:329-37.

In fact, the International Liaison Committee on Resuscitation (ILCOR) has issued two rather very specific recommendations for use of hypothermia in selected cardiac-arrest patients:
1. Unconscious adults with spontaneous out-of-hospital cardiac arrest and an initial rhythm of ventricular fibrillation (VF) should be cooled to 32°-34°C for 12 to 24 hours

2. Such cooling also may be beneficial for other rhythms or for in-hospital cardiac arrest.

According to ILCOR advisory statement, therapeutic hypothermia should not be used for patients with severe cardiogenic shock or life-threatening arrhythmias, pregnant patients, or patients with primary coagulopathy.

Various cooling methods are discussed in that advisory statement too.
Reference: Nolan JP et al. Therapeutic hypothermia after cardiac arrest: An advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation. Circulation 2003 Jul 8; 108:118-21.

C. Bundle of ICU interventions (much similar to those bundles of care in Surviving Sepsis Campaign)

Here, the speaker shared on the bundle of ICU interventions, known as “FAST HUG”. FAST HUG is a mnemonic proposed five years ago by Jean-Louis Vincent as a way of assisting healthcare workers looking after critically ill patients.

The mnemonic stands for:
➢ F = Feeding
➢ A = Analgesia
➢ S = Sedation
➢ T = Thromboembolic prophylaxis
➢ H = Head-of-bed elevation
➢ U = stress Ulcer prophylaxis, and
➢ G = Glucose/glycemic control.

All the components are evidence-based and have been used in many parts of the world.
Reference: Vincent JL. Give your patient a fast hug (at least) once a day. Crit Care Med. 2005 Jun;33(6):1225-9.

See my blog entry on FAST HUG here.

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.

Lessons Learned From ICEM 2010 (Part A)

Introduction
From personal experience of having attended many conferences in the past, both nationally and internationally, I realize that although I learned many things from these conferences, I hardly remember much of the precious gems that I have gathered months or years later.

This is where note-taking comes into the picture. For many of us, we think that note-taking is only for secondary and university students. Worse still, in today’s digital age, many think that taking notes is fast becoming a lost art. Read an article here on the “Recovering The Lost Art of Note Taking” at http://michaelhyatt.com/2009/08/recovering-the-lost-art-of-note-taking.html

The secret to effective note taking, according to that article by Michael Hyatt, is taking time to review your notes.

Besides giving two talks in two different scientific tracks in the conference, I must say I learned a lot from ICEM 2010. Most of the talks that I chose to attend are research tracks. And although most of the talks in the 13th International Conference on Emergency Medicine already have their salient points highlighted in the conference proceedings, this set of notes are compiled from the personal notes that I scribbled together with spontaneous ideas that came to me while listening to the talks.

Disclaimer:
Because these notes merely represent my understanding and interpretation of what the speakers are trying to say, they may not necessarily reflect precisely what the speakers originally intended message.

The notes here also, are by no means, comprehensive. I only scribbled down points that personally appealed to me. In some cases, I only took home one or two points from a talk. Furthermore, for other talks I attended where the information can be easily obtained from journals, textbooks and in the world wide web, I have not noted them down here. In some of these notes, I have incorporated points from the speakers as well as my own thoughts and ideas.
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Lessons learned from:

World Economic Recession: Impact On Emergency Care by Prof Arthur Kellermann

Professor Arthur Kellermann started off his plenary talk by alluding to the fact that although the world economic recession affects many countries, disparity exists in the way this recession affects the high-income countries as compared to middle and low-income countries.

For high-income countries, the mortality rate (particularly for traumatic deaths) in emergency departments (ED) may paradoxically decrease due to the fact that fewer people will have the luxury for over-indulgence. This leads to a slower pace and a more prudent way of life, a more prudent way of driving to save fuel, etc. On the other hand, morbidity may increase as more people will have less income to spend on medications, especially for chronic illnesses requiring long-term medications. As a result, many patients may default treatment. Therefore, we may see a resurgence of acute decompensation of chronic illnesses presenting to the EDs.

Conversely, for many low-income countries, where up to 60% of the people’s income may actually be spent on basic needs such as food, mortality rate may increase due to malnutrition, starvation, infective diseases, etc. In fact, for some of these countries, the healthcare system is heavily depended on external aid and sponsor, and therefore, the current crisis may result in a significantly reduced budget when people have less to donate. Child mortality, logically, would be increased as well. The number of motor vehicle crash cases would also be increased, and this increase usually involves pedestrians and bicycle riders.

During the audience feedback session, Assoc Prof Goh Siang Hiong’s sharing of continuing IV antibiotics in patient’s home is certainly a very creative and interesting idea of shifting the trend from a paternalistic healthcare model to a shared care model, where the community is empowered to a form of partnership in healthcare delivery system.

It would be interesting to see how this current economic recession actually impacts or changes the health seeking behavior of our Malaysian patients. The Malaysian government heavily subsidizes the public healthcare system. But one of the major problems of public healthcare system is the long queuing time. Many patients who can afford it will therefore go to a private healthcare center. As such the economic recession may actually cause a significant increase in patient load to the public healthcare centers, including EDs of public hospitals. Many patients who previously had the luxury to seek private medical treatment, may in this current economic crisis, “migrate” to the public healthcare centers, choosing to wait and pay RM 1 – RM 5 for treatment rather than paying an exorbitant fee in the private sector for the same types of medications. Hence, we may actually expect to see an increase in terms of the number of green zone cases presenting to our EDs. Unfortunately, while this economic recession results in an increase of patient load, it disproportionately results in shrinkage in terms of budgets and allocations, as experienced in many public hospitals in this year. Such studies can be carried out in collaboration with researchers in the field of business and economics. Certainly a research in this area is worth doing.

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Lessons learned from:

International Emergency Medicine Curriculum by Dr. Mike Clancy

In this session, the speaker shared on the current curriculum development for emergency medicine, specifically from the UK College of Emergency Medicine curriculum development. One of the things he mentioned that interest me is this: the development of the non-technical skills. According to the speaker, more and more colleges and academic organizations are recognizing the importance of non-technical skills. Non-technical skills (also better known as “soft skills” in the Malaysian context) include:

· Team working

· Communication

· Time management

· Management of patients’ flow

· Leadership skills, both within and outside, of emergency medicine

I feel that these non-technical skills are not tested enough in our local postgraduate emergency medicine training system. Our challenge is: how we can incorporate the teaching and the testing of these skills in emergency medicine curriculum development?

Another keyword that the speaker mentioned caught my attention: sustainability. The speaker said that in the process of curriculum development for emergency medicine, one should ensure sustainability, and not to be burnt out immediately after starting the program. The question that comes to my mind is: how? How can we ensure sustainability of our emergency medicine curriculum development? Or rather, putting it in another more challenging way: what are the factors that hinder sustainability of our program?

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