Emergency medicine as a specialty in Asia

Key challenges in prehospital and emergency care in Indonesia and Malaysia: a survey of frontline clinicians

Rapid economic growth in Indonesia and Malaysia has widened the gap in emergency care supply and demand, intensifying challenges. Our study, from August to November 2022, assesses current diverse challenges in both countries' emergency care systems from frontline staff perspectives. The online survey involved emergency department (ED) personnel from 11 hospitals in Indonesia and Malaysia, drawing from an existing network. The survey collected data on respondents' characteristics, factors affecting prehospital and ED care quality, missing clinical information, and factors influencing patients' ED stay duration. With 83 respondents from Indonesia and 109 from Malaysia, the study identified common challenges. In both countries, inadequate clinical information from ambulances posed a primary challenge in prehospital care quality, while crowdedness during night shifts affected ED care quality. Frequent gaps in essential clinical information, such as family and medication history, were observed. Prolonged ED stays were associated with diagnostic studies and their turnaround time. This study offers insights into shared challenges in Indonesia and Malaysia's emergency care systems. Our findings stress recognizing common and country-specific challenges for enhanced emergency care quality in Southeast Asia, supporting tailored interventions.

Should an emergency physician be a "surgeon" in a rural area? A case of blunt cardiac rupture successfully treated by an emergency physician

Objective

Blunt cardiac rupture is a life-threatening injury that requires surgical repair by cardiovascular or trauma surgeons. We report a case of blunt cardiac rupture in a rural area in which emergency physicians performed emergency department thoracotomy and surgical repair to save the patient's life.

Patient and Methods

This case involved an 18-year-old female who was injured in a traffic accident and underwent emergency thoracotomy and surgical repair.

Results

The patient's left thorax was deformed, and sonographic assessment revealed pericardial effusion. She experienced cardiopulmonary arrest 13 min after hospital arrival. An emergency physician performed an emergency department thoracotomy. The clots were removed from the surface of the left ventricle, followed by wound compression to control bleeding from the ruptured left ventricular wall. After the recovery of spontaneous circulation, the emergency physician sutured the ruptured heart. The patient survived with good neurological function.

Conclusion

In rural areas, blunt cardiac rupture may require emergency department thoracotomy and cardiac repair by emergency physicians. The establishment of educational systems that include continuous education on trauma surgical procedures and consensus guidelines is needed to assist rural emergency physicians in performing surgical procedures.

Emergency medicine research in the Philippines: A scoping review

Objectives

In this review, we aim to synthesize the current emergency medicine literature in the Philippines in order to determine the depth of research available in the country while delineating the gaps, helping to provide focus to future research in the field.

Methods

A literature review was done using 4 databases to identify emergency medicine studies in the Philippines. To explore the research trends among eligible studies, data on study type, countries, and institutions involved as well as study themes were collected and described.

Results

A total of 845 studies were screened, and 43 were included in this review. Results show that only 25% of emergency medicine studies were published before 2015. Most studies were observational (37.2%) or descriptive (37.2%) in nature with the University of the Philippines/Philippine General Hospital being the most common contributing institution (17.4%). Metro Manila was the most common study site with more than half of studies conducted in the area. Lastly, among the variety of study disciplines, disaster medicine was the most frequent topic comprising 30.2% of studies reviewed.

Conclusions

Compared to the global scene, Philippine emergency medicine research still has a long way to go. This study was able to provide a landscape of the current literature and highlight the study trends. Further, the findings here emphasize the need to expand the scope of emergency medicine studies in the country as it is still a young and growing field with studies tending to cluster around just a small number of institutions and regions.

Twelve tips for developing a systematic acute care curriculum for medical students

There are inadequacies in the practice-readiness of junior doctors for providing acute care in areas of clinical deterioration. In addition, the existing undergraduate curricula are fragmented in how acute care is taught in medical schools. We propose twelve tips for developing a systematic acute care curriculum, including what to teach, how to teach it and, how to assess. Furthermore, we propose and incorporate an acute care learning dashboard as an assessment tool which collates and demonstrates the occurrence of learning, faculty feedback, and students' reflection. We also summarise the existing online resources available for acute care training. We hope to address the existing issues and improve acute care training to prepare the graduates to become practice-ready professionals.

Airway managed by emergency physicians or anaesthesiologists in trauma patients: A retrospective cohort analysis of outcomes

Objectives:

In some trauma centres, anaesthesiologists have the primary responsibility of managing airway in trauma resuscitation. However, as emergency physicians establish a separate specialty with airway management and endotracheal intubation being one of the core skills, role delineation within trauma members may vary. In this cohort study, we aim to determine the difference in mortality of trauma patients requiring intubation in the emergency department between emergency physicians and anaesthesiologists.

Methods:

We screened all 1588 patients in the hospital trauma registry from 2015 to 2018. We included all patients requiring endotracheal intubation and aged 18 or above but excluded those with pregnancy, presented with cardiac arrest and secondarily transferred from other hospitals. A total of 349 eligible patients were sorted into two cohorts according to the physicians who performed intubations (anaesthesiologists = 205 patients, emergency physicians = 144 patients). Patients’ baseline demographics, 30-day all-cause mortality and other predefined secondary outcomes were compared by statistical tests. Stepwise logistic regression of 30-day all-cause mortality was performed.

Results:

Our study has shown that intubation by emergency physicians was not associated with higher 30-day all-cause mortality after potential confounders were controlled by logistic regression (adjusted odds ratio = 1.253, p = 0.607). Both groups also did not differ in other clinical important secondary outcomes, including proportion of successful intubations, use of surgical airway or rescue manoeuvres, respiratory and airway complications, mortality in intensive care or high-dependency unit, post-intubation cardiac arrest, post-intubation hypotension and post-intubation hypoxia.

Conclusion:

Endotracheal intubation by emergency physicians is not associated with increased 30-day all-cause mortality when compared to anaesthesiologists after accounting for confounders.

Characteristics and Outcomes of Patients Referred to an Emergency Department-Based End-of-Life Care Service in Hong Kong: A Retrospective Cohort Study

BACKGROUND

This study describes the characteristics and outcomes of patients referred to an emergency department (ED)-based end-of-life (EOL) service in a tertiary acute hospital in Hong Kong. We examine how emergency physicians (EPs) perform in recognizing and managing dying patients.

METHODS

From September 2010 to April 2018, patients referred to this EOL service in this hospital were included. A group of 5 EPs assessed whether the referred patient would die within a few days. Dying patients (EOL group) were admitted to ED-based EOL service whereas those not likely dying within few days (non-EOL group) would continue management in respective specialty wards. Baseline characteristics of these 2 groups were compared. The time-to-death and use of opioids and anticholinergics were compared.

RESULTS

In total, 783 of 830 patients assessed were recognized as being in dying phase, with 688 admitted under ED-based EOL care. Their demographics and characteristics were described. Mean time from assessment to death (time-to-death) was significantly less in EOL group (38.93 hours) than in non-EOL group (250.36 hours; P = .004). Mean time-to-death was not significantly different between those under EP-based EOL service or not. The ED-based EOL care had significantly more patients receiving symptomatic treatment.

INTERPRETATION

The characteristics of patients under an ED-based EOL service are described. Emergency physicians are capable of recognizing dying patients. Emergency department-based EOL service does not alter the dying process and offers adequate palliation of symptoms. Emergency physician should assume a more active role in providing adequate EOL care to suitable patients.

Factors Affecting Mortality in Patients Admitted to the Hospital by Emergency Physicians despite Disagreement with Other Specialties

Background

Emergency physicians (EPs) face critical admission decisions, and their judgments are questioned in some developing systems. This study aims to define the factors affecting mortality in patients admitted to the hospital by EPs against in-service departments' decision and evaluate EPs' admission diagnosis with final discharge diagnosis.

Methods

This is a retrospective analysis of prospectively collected data of ten consecutive years (2008–2017) of an emergency department of a university medical center. Adult patients (≥18 years-old) who were admitted to the hospital by EPs against in-service departments' decision were enrolled in the study. Significant factors affecting mortality were defined by the backward logistic regression model.

Results

369 consecutive patients were studied, and 195 (52.8%) were males. The mean (SD) age was 65.5 (17.3) years. The logistic regression model showed that significant factors affecting mortality were intubation (p < 0.0001), low systolic blood pressure (p = 0.006), increased age (p = 0.013), and having a comorbidity (p = 0.024). There was no significant difference between EPs' primary admission diagnosis and patient's final primary diagnosis at the time of disposition from the admitted departments (McNemar–Bowker test, p = 0.45). 96% of the primary admission diagnoses of EPs were correct.

Conclusions

Intubation, low systolic blood pressure on presentation, increased age, and having a comorbidity increased the mortality. EPs admission diagnoses were highly correlated with the final diagnosis. EPs make difficult admission decisions with high accuracy, if needed.

Feasibility of sonographic access to the cricothyroid membrane in the presence of a rigid neck collar in healthy Chinese adults: A prospective cohort study

Objectives

(1) To study the dimensions of cricothyroid membranes (CTMs) in healthy Chinese adults in two neck positions, one with rigid neck collar (RNC) and neck extended by ultrasonography (USG). (2) To evaluate how body habitus and neck positions may affect the access time of CTMs, and thus the feasibility for ultrasound‐guided cricothyroidotomy.

Methods

We scanned 39 adult staff of a local emergency department. Their CTMs were measured by two emergency physicians (EP) separately. The subjects' gender, weight, height, age, neck circumferences and BMI were collected. Image qualities (graded in ‘inadequate, adequate and good’) and image acquisition time of the CTMs were also recorded to ascertain proper CTM measurements.

Results

The mean depth of the CTM (neck extended) was 5.6 mm, and the standard deviation (SD) was 1.52. The mean depth (with RNC) was 5.97mm with SD 1.61. The mean length of the CTM (mm ± SD) with the neck extended and with the RNC was 10.5 ± 2.15 and 9.97 ± 2.24, respectively. The median image acquisition time for neck extended was 6.36s with interquartile range (IQR) of 2.32–8.4 s, while for RNC the median time was 5.60 s (IQR = 3.71–7.49; P = 0.539). Image acquisition time between the first and the second sonographers was similar. All subjects’ CTM could be identified readily by USG.

Conclusions

The CTM can be located quickly and reliably by bedside USG, even in overweight/obese persons with or without an RNC in place. We recommend that further study on the feasibility of bedside cricothyroidotomy with RNC kept on should be explored.

Impact of emergency medicine training implementation on mortality outcomes in Kigali, Rwanda: An interrupted time-series study

INTRODUCTION

Although emergency medicine (EM) training programmes have begun to be introduced in low- and middle-income countries (LMICs), minimal data exist on their effects on patient-centered outcomes in such settings. This study evaluated the impact of EM training and associated systems implementation on mortality among patients treated at the University Teaching Hospital-Kigali (UTH-K).

METHODS

At UTH-K an EM post-graduate diploma programme was initiated in October 2013, followed by a residency-training programme in August 2015. Prior to October 2013, care was provided exclusively by general practice physicians (GPs); subsequently, care has been provided through mutually exclusive shifts allocated between GPs and EM trainees. Patients seeking Emergency Centre (EC) care during November 2012-October 2013 (pre-training) and August 2015-July 2016 (post-training) were eligible for inclusion. Data were abstracted from a random sample of records using a structured protocol. The primary outcomes were EC and overall hospital mortality. Mortality prevalence and risk differences (RD) were compared pre- and post-training. Magnitudes of effects were quantified using regression models to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

From 43,213 encounters, 3609 cases were assessed. The median age was 32 years with a male predominance (60.7%). Pre-training EC mortality was 6.3% (95% CI 5.3-7.5%), while post-training EC mortality was 1.2% (95% CI 0.7-1.8%), constituting a significant decrease in adjusted analysis (aOR = 0.07, 95% CI 0.03-0.17; p < 0.001). Pre-training overall hospital mortality was 12.2% (95% CI 10.9-13.8%). Post-training overall hospital mortality was 8.2% (95% CI 6.9-9.6%), resulting in a 43% reduction in mortality likelihood (aOR = 0.57, 95% CI 0.36-0.94; p = 0.016).

DISCUSSION

In the studied population, EM training and systems implementation was associated with significant mortality reductions demonstrating the potential patient-centered benefits of EM development in resource-limited settings.

Chief Complaints of Elderly Individuals on Presentation to Emergency Department: A Retrospective Analysis of South Korean National Data 2014

PURPOSE

We aimed to assess the chief complaints (CCs) of elderly individuals on presentation to the emergency department (ED) according to gender, age, and disease-related and injury-related visits.

METHODS

The 2014 registry database of the National Emergency Department Information System in South Korea, which included data on 908,761 ED visits by individuals aged 65 years and over, was reviewed.

RESULTS

We found that 80.7% ED visits were related to disease, whereas the remaining visits were related to injury. The most common CCs presented by elderly male and female individuals with disease-related visits were dyspnea and dizziness, respectively. The 10 most common CCs accounted for 45.5% and 49.2% of the total disease-related visits for male and female individuals, respectively. The most common CC in male and female individuals with injury-related visits was headache and hip pain, respectively. The CC rank showed minimal variance among the different age groups, but a difference was observed between male and female individuals. The most common mechanism of injury in elderly male and female individuals was slipping, wherein females showed a higher occurrence rate than their male counterparts.

CONCLUSIONS

These findings can be used to establish an ED training curriculum for nursing students and ED nurses, particularly for ED triage in the elderly.