Sunday, May 26, 2019

Top five mistakes made by medical students during ACLS megacode exam

1. Unable to recognize ventricular fibrillation or ventricular tachycardia
There are some students who cannot differentiate VF from PEA.  This is a potentially fatal mistake because for VF, the one intervention besides CPR that is proven to increase survival to hospital discharge is defibrillation (but not for PEA).

AHA CPR Guideline 2015:
In addition to high-quality CPR, the only rhythm-specific therapy proven to increase survival to hospital discharge is defibrillation of VF/pulseless VT. Therefore, this intervention is included as an integral part of the CPR cycle when the rhythm check reveals VF/pulseless VT.

Other ACLS interventions during cardiac arrest may be associated with an increased rate of ROSC but have not yet been proven to increase survival to hospital discharge. Therefore, they are recommended as considerations and should be performed without compromising quality of CPR or timely defibrillation. In other words, vascular access, drug delivery, and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillation.

There are also students who are not able to differentiate VF from polymorphic VT. This mistake is still not too bad because, according to the AHA CPR Guideline 2015:
“…if a patient has polymorphic VT, treat the rhythm as VF and deliver high-energy unsynchronized shocks (ie, defibrillation doses). If there is any doubt whether monomorphic or polymorphic VT is present in the unstable patient, do not delay shock delivery to perform detailed rhythm analysis: provide high-energy unsynchronized shocks (ie, defibrillation doses).”

2. Not putting the paddles back and resuming CPR immediately after defibrillation.

The whole purpose of providing CPR immediately after defibrillation is to minimize interruptions to CPR. DO NOT check rhythm, DO NOT check pulse. It is only AFTER the 2 minutes CPR post-defibrillation, you check RHYTHM.

AHA CPR Guidelines 2015:
After the patient is “clear,” the second provider gives a single shock as quickly as possible to minimize the interruption in chest compressions (“hands-off interval”). The first provider resumes CPR immediately after shock delivery (without a rhythm or pulse check and beginning with chest compressions) and continues for 2 minutes. After 2 minutes of CPR the sequence is repeated, beginning with a rhythm check.

3. Checking pulse immediately after defibrillation and not resuming CPR immediately

AHA CPR Guidelines 2015:

When a rhythm check by an automated external defibrillator (AED) reveals VF/VT, the AED will typically prompt to charge, “clear” the victim for shock delivery, and then deliver a shock, all of which should be performed as quickly as possible. CPR should be resumed immediately after shock delivery (without a rhythm or pulse check and beginning with chest compressions) and continue for 2 minutes before the next rhythm check.

4. Checking rhythm immediately after defibrillation and not resuming CPR immediately

This mistake is almost similar to the previous one. Both should not be checked before CPR post-defibrillation. One does not need to re-look at the cardiac monitor but rather, CPR should be resumed immediately (with a sense of urgency)

AHA CPR Guidelines 2015:
…when VF is terminated, a brief period of asystole or pulseless electrical activity (PEA) typically ensues and a perfusing rhythm is unlikely to be present

But after a 2-minute CPR, the rhythm should be checked first; and only if an organized rhythm is found, the pulse check is performed. Otherwise, for persistent shockable rhythm such as ventricular fibrillation, one does not need to check pulse. It makes no sense.

AHA CPR Guidelines 2015:
Rhythm checks should be brief, and if an organized rhythm is observed, a pulse check should be performed.

5. Checking blood pressure, explaining to patient/taking informed consent, giving sedation, etc for a patient in VF.

Thursday, October 11, 2018

Beware of predatory or potentially predatory journals

Predatory journals from Chew Keng Sheng

This slide set is the presentation that I gave at the Faculty of Medicine and Health Sciences of Universiti Malaysia Sarawak on the issue of predatory or potentially predatory journals. “Predatory journals” refers to entities that prey on academicians for financial profit via article processing charges (APC) for open access articles, without meeting scholarly publishing standards. At the outset, allow me to make my stand clearly that I do not believe that "predatory" journals are illegal, but the issue with predatory journals is that they lack the scholarly and scientific rigour as expected in the academia. Although I would admit that it is hard to draw the line to say whether a journal is predatory or not predatory in nature, there are a number of tell-tale signs that may help us to identify that a journal is probably predatory in nature.

My 2 main references in this presentation are:
Shen C, Björk B-C. ‘Predatory’ open access: a longitudinal study of article volumes and market characteristics. BMC Medicine. 2015;13(1):230. Click here to access

Shamseer L, Moher D, Maduekwe O, Turner L, Barbour V, Burch R, et al. Potential predatory and legitimate biomedical journals: can you tell the difference? A cross-sectional comparison. BMC Medicine. 2017;15(1):28. Click here to access

Other resources mentioned in the presentation:
Laine, C & Winker, MA. Identifying Predatory or Pseudo-Journals (available in World Association of Medical Editors website). URL:

Think-Check-Submit website

Wednesday, November 15, 2017

The modern Physcian's Pledge to replace Hippocratic Oath?

One of the oldest professional oaths is the Hippocratic Oath, which is now as old as 2400 years old.
The practice pledging this oath begans at the University of Wittenberg in Germany in 1508.
The contents of the oath are still relevant, although pledging in the name of long forgotten medieval Greek gods is probably what makes it out-dated.

A new modern version of the oath, known as ‘The Physician’s Pledge’, encapsulates the essence of the Oath while removing the peripheries has been published in JAMA (click here).

The full text of the 2017 pledge now reads as:

I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;

THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;

I WILL RESPECT the autonomy and dignity of my patient;

I WILL MAINTAIN the utmost respect for human life;

I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient;

I WILL RESPECT the secrets that are confided in me, even after the patient has died;

I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice;

I WILL FOSTER the honour and noble traditions of the medical profession;

I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;

I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;

I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;

I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;

I MAKE THESE PROMISES solemnly, freely, and upon my honour.

A very interesting addition to the oath compared to Hippocratic Oath is this:
I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard”
This addition has been lobbied by Dr. Sam Hazledine.

To quote,
Dr Sam Hazledine from Queenstown, New Zealand made history by petitioning for the amendment last year, where he obtained 4,500 signatures to include a clause for doctors to focus on their own health as well as of their patients.

I guess it is a solemn reminder that physicians should do what they preach.


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