3rd Malaysian International MMA Medical Students Conference on Trauma

The 3rd Malaysian International MMA Medical Students conference held at Melaka-Manipal college has just concluded (2nd - 5th June 2011).

I must say that it was a huge success given the limited resources they have, especially since the committee members themselves are busy medical students, many of whom are clinical students.

I wish that more medical students from Universiti Sains Malaysia could attend, and I hope that the Persatuan Sains Perubatan USM can play a bigger and more active role in promoting the conference to the students and at the same time, actively presenting free papers. I am impressed by the quality of the papers presented by the students, from Melaka-Manipal, Universiti Malaya, IMU, Penang Medical, UNIMAS, etc. And these student presenters are not just the 4th and 5th years, but many of them are 3rd years. In fact, one of the participants who won the 2nd place of oral paper is a 3rd year student from Universiti Malaya. I am pretty impressed by the methodology and statistics that he presented. USM students should actively get themselves involved in such projects -- projects that can be simple, yet meaningful and clinically relevant (instead of just doing it for the sake of doing as a chore or pre-requisite on something irrelevant).

I talked on 2 topics: 1) Pitfalls in the management and resuscitation of a trauma patient 2) Tips on interpreting X-rays in emergency department. Besides I was also asked to be one of the judges the oral and poster presentation. Overall, the clinical students were appreciative of my talks, but from my conversation with the pre-clinical students (year 2 and some year 3s), they were lost and not able to follow through the presentation. Nonetheless, the theme of the conference is a rather clinical one: Trauma - Constructing The Future, Growing From the Past.

In my first talk, I first talked about the various sources of errors (right from pre-hospital and triaging to patient disposition) in managing patients in emergency department, particularly in a case of trauma patient. I talked about the Rasmussen model of human error -- skill-based errors, rule-based errors and knowledge-based errors, and then move on to talk about three common erroneous attitudes that can render a healthcare provider prone to error: diagnostic labeling, false negative prediction and false attribution. Most of us as doctors are prone to commit the 'sin' of diagnostic labeling. I then use detection of hemorrhagic shock in trauma as a specific model of discussion because undetected hemorrhagic shock is one of the most tragic thing that can happen to a trauma patient. I talked about the dangers of depending on a drop of BP before diagnosing hemorrhagic shock, and how we should use Shock Index, Mean Arterial Pressure as well as newer markers such as lactate level and lactate clearance to assist us in early detection of hemorrhagic shock.

In the 2nd presentation, I talked about the common useful X-rays in managing a trauma patient -- I focussed particularly on three important X-rays - Cervical, chest and pelvic X-ray. I taught them about how to interpret cervical X-ray in the context of trauma and used hangman fracture and Jefferson fracture as particular topics for discussion. I talked about chest x-ray: criteria to qualify for an adequate good chest x-ray film, and discussed on pneumothorax and traumatic aortic dissection. I reminded the students that tension pneumothorax is not supposed to the radiological diagnosis, it is a clinical diagnosis; and a doctor is supposed to "destroy" the radiological evidence of a tension pneumothorax rather than allowing it to manifest. I also talked about the tips on interpreting a pelvic X-ray -- the importance of visualizing the integrity of the three pelvic rings, tracing the integrity of iliopubic and ilio-ischial line, radiologic 'U' as well as the tear-drop sign. I talked a bit on maxillofacial X-ray, tracing the elephant trunks of Dolan lines, as well as a quick introduction on tripod # and Le Fort #. And then we run through some important things on interpreting wrist, elbow and lower limb X-ray. It is not possible to go through every details in a single talk. I also made the disclaimer that I am not a radiologist, and my talk is geared rather on correlate X-ray findings in the context of clinical setting of managing a trauma patient and therefore the talk would be pragmatic rather than technical.

Below are the slides that I used for my presentations:

Pitfalls in the management of trauma patients2

View more presentations from Chew Keng Sheng

Tips for interpreting x ray in trauma

View more presentations from Chew Keng Sheng

Wellens' Syndrome

If I see a patient in Emergency Dept presented with history of typical angina pain but on arrival to ED, the patient said the pain has very much reduced, and on ECG there is deep T inversion in V2-V3 with no ST elevation, then I am not just seeing a relatively simple unstable angina case (even if the cardiac enzymes are 'negative'), but I may be seeing a patient who is considered a potential 'time bomb' for progression to full blown extensive anterior MI! This pre-infarction state is called Wellens' Syndrome.

It is very important for emergency physicians (EPs) to have a high index of suspicion for Wellens' Syndrome. A study has been done that shows that EPs at all levels of training commonly miss the diagnosis and significance of WS, with most EPs sending patients with Wellens' Syndrome to other than a critical care bed.

This is a potential pitfall for emergency physicians attempting to evaluate patients in chest pain centers!!!

A review of several chest pain center triage protocols reveals that a pain-free patient with so called "nonspecific" ECG changes, an atypical history, normal cardiac enzyme levels, may be given an appointment for exercise stress test (EST). Such ESTs are contraindicated in the presence of suspected left main or left main equivalent lesions.

Wellens' Syndrome is a preinfarction stage of coronary artery disease associated with significant obstruction (or critical stenosis) in the proximal left anterior descending (LAD) coronary artery.
Patients with Wellens' Syndrome are at high risk for development of an extensive MI of the anterior wall and death.

Once Wellen's Syndrome has been recognized, urgent coronary angiography (aggressive measures are needed)- and not stress tests of any sort - is required to evaluate the need for angioplasty or coronary bypass surgery.

This is because provocative testings, including stress imaging may precipitate AMI with significant sequelae.

Wellens and his colleagues first described the clinical and ECG criteria of this subgroup of patients with characteristic ST-T wave changes in the midprecordial leads (mainly T changes).

The following criteria for Wellens' Syndrome are:
1A. Either symmetric and deeply inverted T waves in leads V2 and V2 [ocassionally in V1, V4,V5,V6] *OR

1B. Biphasic T wwave in leads V2 and V3

PLUS
2. Little or no STE (less than 1mm)

3. Little or no cardiac enzyme rise (less than twice upper normal limit)

4. No precordial pathologic Q wave

5. Typical angina pain BUT often this pattern occurs in the pain free state**
Note:
* This pattern is the more common type on 75% of cases

** In fact, during an attack of chest pain, the ST-segment-T-wave abnormalities usually normalize or develop in ST segment elevation.
Reference:
1. Rhinehardt J, Brady WJ, Perron AD et al. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med 2002; 20 (7):638-43.

2. Tandy TK, Bottomy DP, Lewis JG. Wellens' syndrome. Ann Emerg Med 1999; 33 (3):347-51.

A photo quiz about Wellens' Syndrome can be viewed here