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HKSEMS eNewsletter Issue 006
2018 Jul

香港急症醫學會

Hong Kong Society
for Emergency Medicine & Surgery

Our society has sponsored the HK-Taiwan Young Fellows/Trainees Exchange Program in Jun this year. Please click here to read more about the trip. You can also read the reports by Fiona YY Chan, Ralph KH Cheung , Alex Law and other participants on the exchange trip.

Our president, Dr Ludwig Tsoi will continue on apology ordinance. Please click here for further reading.

Please click here to read the final part of Dr Chan Kwok Hei 's journey to become a NLP trainer.

Amendment of Newsletter Issue 005 2018

We would like to apologize that there was an error in the Council News column of our Newsletter Issue 005 2018 Apr. The CPR marathon was organized by the Emergency Medicine Unit of the University of Hong Kong and HKSEMS was the supporting organization instead of the co-organizer

Message from the President
From the Editors
Council News
Members Area
Medical Tips
Leisure Corner
Upcoming Events and Conferences

Message from the President Dr. TSOI Chun Hing, Ludwig

Making apology (Part 2 or 2)

Medicine and human error

In the famous book To Err is Human: Building a Safer Health System, the Institute of Medicine estimated that adverse events occurred in 3% of

hospitalizations. However, adverse events do not necessarily mean litigation. Whether these events will end up in court would depend on many factors like the interpersonal relationship of the clinician, how the management handles the incident etc. In general, it is said that where a doctor who neither inform the patient of the diagnosis nor respect the value of the patient, would attract more lawsuits. On the contrary, doctors who care about their patients and are frank to disclose the facts would get sued less often.

Emotional needs

It is believed that a timely apology can defuse anger in an adverse event (1). A sincere apology can achieve the following:
1) To express regret;
2) To indicate an intention to compensate;
3) To reduce the hostility of the victim.

A study published in the Lancet (1) found that open disclosure and apology could have avoided at least some disputes. Historically, the medical profession is very sensitive to the allegation of “medical negligence” in adverse events, and hence reluctant to apologize. However, from the patient’s perspective, a timely apology is therapeutic in itself. The Lancet study showed that 41.4% of the patients/relatives felt no need to take legal action if they could see the hospital had taken some remedial actions after the incident. Regarding the resolution, more people preferred explanation and apology to payment of money.

Open disclosure

Open disclosure is a timely disclosure to maintain mutual trust and mend the relationship after an adverse event. Open disclosure, apology and the intention to compensate should go hand in hand to contribute a safer healthcare culture. The Council of Europe mandates its constituent states not to subject health workers to disciplinary proceedings just for the sake of incident reporting. Australia also stipulates that medical institutions should create an atmosphere in which all employees are encouraged and be able to identify and report adverse events. In Hong Kong, the Hospital Authority also follows the same philosophy – incident reporting and disciplinary actions are delinked from the outset. The overseas experience showed that open disclosure did not cause more litigation.

Obstacles of apology and open disclosure

The beliefs on the relationship between open disclosure and litigation will have an impact on the behavior of health professionals – it is believed that the risk of being sued is often overestimated. Apart from the fear of lawsuit, the “norms, values and practices that constitute the culture of medicine” (2) might also play a role in discouraging people from acknowledging mistakes and offering apology. In particular the expectation of being perfect, by self or others, makes admitting errors extremely difficult. Lastly, the lack of skills in disclosure (3) and lack of information at the beginning of the adverse event also constitute barriers.

The way forward

The new legislature can help promote changes in the society and medical profession – the culture of medicine is always evolving. The Apology Ordinance could help the evolution of this culture. The next round of evolution will be on open disclosure and intention for compensation. Apology is just one element of open disclosure. It is obvious that making apology is an important ingredient of the package. However, medicine is complicated, and just an expression of regret or sorrow will not solve the dispute. Moreover, one must not be fooled by the premise that apology is a pretense to avoid compensation. In a recent study in the States, it was shown that the apology legislature has not reduced the number of doctors being sued, nor the amounts paid out (4). Although there are benefits of making apology and open disclosure, motive to avoid compensation should not be one. However there are alternative means to settle disputes, like mediation, which could cut the legal cost. While compensation may be unavoidable, the legal cost of mediation is far lower than that of litigation and hence costs can be reduced in the resolution process. Improved organization performance and blame-free culture should not be intertwined with the false hope of compensation avoidance. The “just culture” of medicine should always be the basis of any evolution.

(Part 2 or 2)

References:

Vincent C, Young M and Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994 Jun 25; 343(8913):1609-13
Hobgood C, Hevia A, Tamayo-Sarver JH, Weiner B, Riviello R. The influence of the causes and contexts of medical errors on emergency medicine residents’ responses to their errors: an exploration. Acad Med. 2005;80:758–764
Jennifer K. Robbennolt. Apologies and Medical Error. Clin Ortho Relat Res 2009 Feb; 467(2):376-382
Apology laws do not reduce medical malpractice suits, study finds. Madison – St Clair Record. 10 Feb 2017. https://madisonrecord.com/stories/511080760-apology-laws-do-not-reduce-medical-malpractice-suits-study-finds (last visted 3 Jul 2018)

From the Editors Dr Chor-man Lo & Dr Sam Siu-ming Yang

Medical systems differ in different regions owing to historical reasons and cultural diversity. As a colony of the United Kingdom from 1842 to 1997, Hong Kong adopted the British style of public medical system. A public medical system is one in which the medical services are mostly run and funded by the government. While its people can utilize the medical services at a low cost, the

government pays the majority of the health expenditure.

On the other side of the world, the United States adopts a mostly free market medical system. There is minimal involvement from the government on financing the medical expenditure. The medical cost is mainly paid ‘out-of-pocket’ by patients, or more accurately, private insurance companies.

In between these two, there exists the social insurance system, in which a central independent insurance organization is set up by the government, and mostly funded by premium from its people. With the feature of ‘money-follows-patients’, it nurtures a regulated competition between the public and private markets and allows a fast advancement of its medical care.

In order to develop a global perspective of young emergency physicians, HKSEMS and HKCEM sponsored a group of their members to have a three-day exchange trip to Taiwan. The trip included a visit to the emergency departments of three leading hospitals in Taiwan, as well as participating in the annual emergency medicine conference held by Taiwan Society of Emergency Medicine (TSEM). We were privileged that TSEM reserved a session of its conference to hold a HK-Taiwan Young Fellows/Trainees Exchange Forum. This enabled young emergency physicians from both sides to introduce to each other the medical care system of their own. Although a trip of three days could only allow a very brief understanding of local healthcare services, this would serve as a primer for our young emergency physicians to collaborate with the global emergency medicine network.

Council News

Dear Members,

Various activities were organized by HKSMES in the past three months.
As a major event in the second quarter of 2018, the Hong Kong Taiwan Young Fellows/Trainees Exchange Program jointly organized by HKSEMS, HKCEM(Young Fellows Chapter & EM Trainees Network(HK)) and the Taiwan Society of Emergency Medicine(TSEM) as well as Emergency Medicine Residents Network(EMRN) successfully completed. Apart from that, as a charitable organization to-be, we were committed to community health education. Health talks were held in the public library, Hung Hom community and secondary schools in the last quarter. Let’s have a look into the details of the events!!

The Hong Kong Taiwan Young Fellows/Trainees Exchange Program

Hong Kong and Taiwan are neighbors, having similar climates and cultures, yet there are significant differences in their health care systems and emergency service. The health care system in Taiwan is well known for its low cost which only constitutes ~5% of GDP. The majority of service is provided by private market(~70%) which is in contrast to Hong Kong where most inpatient service is provided by public health care service.

During the 3 days of stay, our team of 16 paid visits to three hospitals and participated in the HK-Taiwan Young Fellows/Trainees Exchange Forum in the annual conference of TSEM.

The emergency medicine training system in Taiwan, being similar to the United States training system, is different from that in Hong Kong. The below table shows the differences:

There is a single licensing examination for all medical graduates in Taiwan after internship which is different from that in Hong Kong. Working hours differ between different areas in Taiwan. Monthly salary varies in proportion to their working hours for the month.

Both trainees and young fellows from Hong Kong and Taiwan gained valuable experiences in this program. It is hoped that we can make this exchange program into a regular activity. For those who missed the event this year, please do join us in 2019!!.

Work for the community

Dr. KWAN Ka Lik, a private Psychiatrist, presented a talk on adolescent psychosis, mood disorders and suicidal intention for the teachers in Pope Paul VI college.

Community Talk

To increase the health awareness of the general public, HKSEMS organized two health talks with Hung Hom District Council. Dr. Chan Chi Ming from PMH spoke on dizziness and syncope on 23/6/2018.

Hong Kong Medical Association(HKMA) Youth Committee Career Seminar

The HKMA Youth Committee Career Seminar 2018 was held at the campus of Li Ka Shing Faculty of Medicine, the University of Hong Kong on 9/6/2018. Over 200 medical students attended the seminar. Representative from HKSEMS shared with young doctors to-be their experience and life as an emergency physician.

EEEM Preparatory workshop

The 2018 EEEM preparatory workshop was held successfully on 21st- 22nd June. This workshop prepared EEEM candidate for the examination with practical examination skills and the revision of essential knowledge.

Members Area

HK-Taiwan Young Fellows/Trainees Exchange Trip

Dr Fiona YY Chan

Resident, TMH AED

Visiting various hospitals and attending the 2018 Annual Conference of Taiwan Society of Emergency Medicine has been a very good learning experience.

On the first day, we visited the National Taiwan University Hospital. We learnt that the old hospital building was built during Japanese Occupation and adopted a European architecture style. It is now currently used as Specialty Outpatient Clinic and rehabilitation wards. We also visited the simulation training lab. It is used for practice for both medical students and doctors, and for examination purpose.

Their emergency medicine department is a very busy department. As only not more than 30% of the beds are acute beds, admission block is a common phenomenon. Patients who are not yet admitted to acute wards will stay in the emergency department observation area. While waiting for acute beds, treatment and investigation are started. There is also an Intensive Care Unit run by emergency medicine and intensivist double fellows.

On the second day, we attended the first day of the 2018 Annual Conference of Taiwan Society of Emergency Medicine. The Public Speaking Contest was very interesting. The finalists were very good speakers. They talked about various non-academic aspects of work at emergency medicine including communication skills, attitude towards patients, psychology of patients, and emotion and stress of doctors.

We visited Taipei Veterans General Hospital (VGH), another one of the largest hospitals in Taiwan. The Taiwan National Poison Center (PCC-Taiwan) is affiliated with the Taipei VGH, and is a referral center for poisoned patients nationwide. It also serves as a training centre for emergency physicians, clinical toxicologists, and poison information specialists. The hospital also has its own hyperbaric oxygen therapy chamber.

The Taipei Veterans General Hospital is also famous for its Centre for Geriatrics and Gerontology. They have an integrated geriatric clinic, and designated physical and occupational therapy areas for reconditioning of geriatric patients and assessment of their capability so that they can be discharged home safely.

On the third day, the first HK-Taiwan Young Fellows/Trainees Sharing Forum was held. We discussed the residents’ training programme in Hong Kong and Taiwan, and the work hours, remunerations and prospects of emergency physicians. We also visited Linkou Chang Gung Memorial Hospital. They have a very impressive clinical management system program which is efficient for patient management. They also have a trauma room especially for paediatric patients.

In summary, we have learnt a lot of things in this trip. We learnt about the workflow in the emergency department in Taiwan, their management of admission block, emergency-intensive care and residency training and prospect of emergency physicians. It has been an enjoyable and memorable experience.

Short report for Taiwan Trip

Dr. Ralph KH Cheung

Associate Consultant, Prince of Wales Hospital

In this trip, we visited A&Es of National Taiwan University Hospital on 21 Jun 2018, Taipei Veterans General Hospital on 22 Jun 2018, and Linkou Chang Gung Memorial Hospital on 23 Jun 2018. We attended annual conference of Taiwan Society of Emergency Medicine on 22-23 Jun as well. I presented “work hours, remunerations, and prospects of emergency physicians in Hong Kong” on behalf of Young Fellows’ Chapter in the conference. Taiwanese emergency physicians treated us warmly with hospital tour guides and dinners.

Taiwanese emergency medicine conference had similarities to Scientific Symposium of Emergency Medicine (SSEM) in Hong Kong with regard to topic coverage and level of discussions. Conference in Taiwan has more varieties of ingredients than ours: the former has academic speech competition, ultrasound game competition, and Hong Kong-Taiwan trainee resident forum (this year). Their conference venue was equipped with ice-cream booth attended by ice-cream ladies! The language used in Taiwan conference is traditional Chinese presented in mandarin, unless the speaker is a native English speaker. Whereas in Hong Kong emergency medicine conference, language used is English, except in greater China tract.

I tabulate a few characteristics of the 3 A&Es we visited:

	National Taiwan University Hospital	Taipei Veterans General Hospital	Linkou Chang Gung Memorial Hospital
	國立臺灣大學醫學院附設醫院	臺北榮民總醫院	林口長庚醫院
Location	Near “NTU Hospital” station 2 campuses (East and West) connected via the underground Tunnel	Near “Shipai” station	Near “Linkou” station
A&E setting & doctor training	Resemble North America
No. of beds in hospital	2400	2736	3148
A&E Attendance per day	300	240	500
Triage	5 categories
Doctor manpower	Attending: 47 Professors, associate professors, assistant professors, lecturers; Residents: 18	Attending: 12 Surgery attending: 5 Disaster attending: 3 Fellows: 6 Residents: 10	Attending: 50 Associate professor: 5 Assistant professor: 6 Lecturer: 5 Residents: 30
Number of patients awaiting beds on day of our visit	88	16	87
Number of patients awaiting beds on day of our visit	(number of patients awaiting bed available real-time)
Feature area (Area of strength) during the tour	Strong historical background of teaching and research hospital	Centre for geriatrics and gerontology	Paperless (electronic) patient management system
Other facilities	EICU A&E based CT +/- MRI suite
Other facilities		Hyperbaric oxygen therapy
Challenges	Admission access block (different degrees)

Emergency service of Taiwan. Our past or our future?
A note on the Taiwan trip organised by the Young fellow chapter of HKCEM

Alex Law

Resident Specialist, Prince of Wales Hospital

“Ten days to wait for admission. Twelve hours to wait for a bed to lie on. How is it even possible?” I asked, in awe of the numbers on the signboard when we entered the heavily crowded space of the emergency department of the National Taiwan University Hospital (台大醫院, NTUH), one of the top hospitals in Taiwan. “The truth is around three to four days; we exaggerated the numbers to stop people from urging” explained Dr Rick Lin, a young specialist, in an attempt to calm our shock while a patient walked pass with her relative holding an IV bottle over his head. The area was filled with patients on stretchers in the corridor, the lobby, and in virtually any space that they could fit

I could not get the scene out of my mind as we continued our three-day trip, visiting the emergency departments of NTUH, Veterans General Hospital (榮總醫院), Linkou Chang Gung Memorial Hospital (林口長庚醫院), and joining the annual conference of Taiwan Society of Emergency Medicine (TSEM 2018). The visits were always eye-opening, and sometimes jaw-dropping. For example, the proclaimed “Asia-best” simulation training centre in NTUH, the comprehensive geriatric centre in Veterans General Hospital, and the computer system in Linkou Chang Gung Memorial Hospital. It allowed users to track patients’ whereabouts, treatment plan, to generate suggested management and medications and read all investigation results, all with a few keystrokes. Remarkably, the system had promoted patients’ safety and eliminated the use of paper, making us all jealous with a sentiment of shame.

The computer system at Linkou Chang Gung Memorial Hospital

Yet, apart from the advances of those hospitals, they all shared the same strangling problem: access block. I had a strong feeling of the topic since I am from a hospital which undoubtedly has the most severe problem of access block in Hong Kong. But even I was stunned by their situation. Every hospital suffered to a different extent, but usually, patients had to wait for more than 24 hours; and direct admission was non-existent. To cater to the problem, all the hospitals seemingly had the same solution: a large number of observational beds situated in numerous observation wards. In NTUH, they had more than ten observation wards, but even that could not fulfil the need of more that one hundred boarded patients. When asked about emergency medicine ward, all the delegates in the three hospitals responded that they did not have it, and it seems that they did not understand the concept of extended emergency medical care.

It would also be interesting to draw a comparison of the systems in Taiwan and Hong Kong. Firstly, they are more resourceful, both in the workforce and in hardware like the working space and CT machines. For instance, the emergency department of Linkou Chang Gung Memorial Hospital has a strong team of 50 specialists and 30 residents. All three hospitals have one to two CT machines dedicated only for the use of the emergency department. Secondly, our workflow is different; they triage patient not only into various categories but also into different “treatment areas” like resuscitation room, medical, surgical and paediatrics; all served by a committed team of doctors and nurses. Undoubtedly this division of labour had improved their efficiency, for example in NTUH, all patients could be seen within ten minutes after triage. Thirdly, their ambulances are bound to deliver to a particular hospital at the demand of the patient, often labouring famous hospital like NTUH.

Hospital	Daily attendance	Number of bed	Daily Access Block
National Taiwan University Hospital (台大醫院, NTUH)	320	2400	120
Veterans General Hospital (榮總醫院)	240	2947	30
Linkou Chang Gung Memorial Hospital (林口長庚醫院)	478	3148	85
Prince of Wales Hospital, HK	360	1650	20

A comparison of the three Taiwan hospitals and PWH, HK (approximate figures)

In some ways, Taiwan’s emergency departments are like our past when there is no emergency ward, and the emergency departments served the mere function of triage, stabilisation and admitting patients or discharging them with simple treatments. In some other ways, they are like the future that we are moving towards: Simulation-based training, comprehensive geriatric services and paperless clinical systems. And would that distressing scene at NTUH be our future too? Nobody knows, but I can certainly see a dangerous trend. Something should be, and can be, done to stop that from becoming our reality.

Medical Tips
ECG Basics

An ECG records the electrical activity of a patient's heart as it beats. An ECG machine records these different electrical impulses and results in a strip that has the electrical impulses of multiple heart beats.

The Y-axis represents voltage in mV. Each small square represents 0.1 millivolt (mV) which denotes the electrical strength of the signal. The X-axis represents time in seconds with each small square representing 0.04 seconds. Thus each big square represents 0.2 seconds.

P wave:
The P wave results from atrial contraction. The morphology of P wave can be used to assess atrial size e.g. hypertrophy, or the origin of electrical impulse i.e. intrinsic pacemaker of the heart.

PR Interval:
The PR interval is measured from the start of the P wave to the start of Q wave. It represents the duration of atrial depolarization.
Normal PR interval ranges from 0.12 to 0.20 seconds, which are equal to 3 - 5 small squares. PR interval greater than 0.20 seconds is indicative of an AV block.

QRS Complex:
The QRS complex is measured from the start of Q wave to the end of S wave. It represents the duration of ventricle depolarization. An QRS is said to be wide complex or narrow complex based on whether its duration is longer or shorter than 0.12 seconds respectively, which is equal to 3 small squares. If duration is longer, it might indicate presence of bundle branch blocks.

QT/QTc:
The QT/QTc is measured from the start of the Q wave to the end of T wave. QT interval represents the duration of activation and recovery of the ventricular muscle. The QT/QTc duration varies inversely with the heart rate.
The QT is corrected with the heart rate with the following formula to get QTc:

ST Segment:
The ST segment is measured from end of S wave to the start of T wave. The elevation or depression of ST segment is indicative of pathology such as myocardial infarctions and ischemia.

T wave:
It represents the ventricular repolarization and is usually in the same direction of QRS complex

Leisure Corner

Beyond EM---The Unending Quest Dr K.H. Chan Paul FHKAM(Emergency Medicine)

Dr Ng Fu became the President of HKSEMS in 2009. He proposed to me to conduct internationlly certified NLP training workshops in the A&E Training Centre (AETC) of RH-TSKH. The idea was for personal and clinical growth and development for health care professionals, because he had witnessed the positive effect and encouraging results in CMC. The business model was that of Win-Win-Win-Win. The participants paid only one third to half of market prices, AETC received rentals and later splits of revenue as resources for other development, the workshop trainer got the chance of practice and a bonus of honorarium, and HKSEMS had another source of regular income to support and sponsor her activities.

In the several years since March 2010, there were a total of 4 NLP Practitioner Courses (10 days each), 1 Master NLP Practitioner Course (12 days), and 1 NLP Self-Actualizing Psychology Diploma Course (15 days) being held. The participants were mostly HA nurses, allied health professionals, and about 5 percent were doctors of all grades from different specialties.

Due to some unforeseen circumstances, I had to change gears to conduct Coaching instead of NLP Training Workshops. Many thanks to Dr Wong Yau Tak for his assistance.

What is Coaching then?

Coaching and coaching skills are the future in general management and leadership. Coaching is a systemic collaborative partnership. Coaching is Self-Actualizing Technology for the 21st Century. Coaching is actually Process Facilitation for a well-formed outcome or Goal with a unique set of skills

Jack Welch, the CEO of General Electric (GE) once said “if you don’t know coaching skills, you do not know how to lead (& manage)…”

The Coaching Conceptual Framework is as follows:

Starting from 2014, and up to now, I had conducted 2 Manager Certified Coach-MCC Courses (10 days each) and 4 Basic Coaching Essentials Certificate Courses (3 days each) at AETC. Concurrently with these, I went over to TMH and now POH Clinical Training Centre regularly to conduct one day Primer Training on weekday every 2 months for their staff. Dr CW Kam had greatly facilitated the process. They are on 5 main themes with a set of skills for the participants to bring home and eventually apply them in work or private life. The metaphor is that of a Golden Star.

5 Key Themes主題/skill sets:
1. Meaning意義 ( Positive Psychology skill set)
2. Creativity創意 ( Mind Map skills set )
3. Communication溝通 ( NLP skill set
-Neurolinguistic Programming )
4. Goal 目標 ( Meta-Coaching skill set)
5. State狀態 ( Mindfulness skill set )

Similar training had also been conducted In PMH since mid-July 2017 through the Hospital Welfare Committee. Each theme is run in 4 evening sessions (6-8 pm) in 4 weeks after my clinical duty. I am planning to roll out the Primer Series in a simpler version to the youth in secondary schools, boy scouts or girl guides in summer 2018. Liaison has been established and proposal has been submitted, awaiting reply and approval. Hopefully they will be materialized in due course.

In summary, I would like to quote from Abraham Maslow that “what one can be, one must be...” That is the essence of Excellence, Expertise or Mastery. Ideally, I believe that is also the aspiring vision, passion and action of each and every EM Trainee or Fellow in the spirit of Collaboration

Dr K.H.Chan, Paul
FHKAM (Emergency Medicine)
8-Jan-2018

Upcoming Events and Conferences

1.中華醫學會急診醫學分會第22次全國急診醫學年會
Chinese Medicine Association Emergency Medicine Chapter
Date: 4th-5th Aug
Location: Tianjin 天津

2.首都急危重症醫學高峰論壇
Capital Forum on Emergency and Critical Care Medicine
Date: 26th Aug
Location: Beijing(北京)

If you are interested in joining the conferences or event, you can email kenjiwendy@gmail.com.

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