If you have problem reading this email, you can cilck this link,
or you can access our facebook or website at the bottom of the page.

HKSEMS eNewsletter Issue 007
2018 Oct

香港急症醫學會

Hong Kong Society
for Emergency Medicine & Surgery

The 11th Asian Conference on Emergency Mediicine (ACEM) will be held in Hong Kong from 17-19 December 2021! Please mark the dates on your calender!

Warmest welcome to the new trainees joining emergency medicine. Please click here for the induction program held on 10 Jul.

The president of HKSEMS, Dr Ludwig Tsoi will talk about "Relationship with Other Practitioners". Please click here for further reading.

The HKSEMS has been organizing teaching to health care staff at mainland China, Civil Aid Service and the general public. Please click here to read more.

Dr Cing Hon LAI will also introduce to us the establishment of EMEC subcommittee.

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

Message from the President Dr Ludwig Chun-Hing TSOI

Relationship with other practitioners

There was a heated discussion lately in the social media regarding the newspaper interviews surrounding a local doctor commenting the treatment and charges of another private medical doctor during the promotion of his book in the latest Hong Kong Book Fair.

One of those headlines¹ attracted my attention. It was reported that he remarked that the accused doctor was worse than a robber (“狠批該醫生連「盜亦有道」的底線也不顧”). I am not going to discuss his remarks; however, I would like to draw our members’ attention to the risk of disparagement and the conduct of medical practitioners.

Code of Professional Conduct
The “Code of Professional Conduct” is a booklet published by the Medical Council of Hong Kong (“MCHK”) for locally practicing medical doctors, as a guide of our professional conduct. And because the cover of the booklet is red, it is often called the little red book (紅書仔). The booklet has been revised regularly to keep up with legal development and technological advances. The latest revision is the 2016 version and is downloadable from the web². If you have not read it before, I encourage you to read it now. The booklet is explicit about this point:

“ALL registered medical practitioners should study this Code carefully, in order
to avoid the danger of transgressing accepted codes of professional conduct
which may lead to disciplinary action by the Medical Council.”

To express a view about colleague’s professional practice
Part II, Section E of the little red book deals with “Relationship with Other Practitioners and Organizations”. Section 19 of Part II stipulates “Disparagement of other medical practitioners”, under section 19.3 it is written:
“It is unethical for a doctor to make unjustifiable comments which, whether directly or by implication, undermines trust in the professional competence or integrity of another doctor.”

It should be emphasized that colleagues are allowed to give their opinion on the practice of other doctors in clinical audit and peer review (Section 19.1). When responding to a patient seeking second opinion, a doctor could express his view, provided the comment is honest, and “is carefully considered and can be justified, offered in good faith and intended to promote the best interests of the patient.” Other than that, colleagues should refrain from making unjustifiable comments on other doctors.

What is commercial disparagement?
The Merriam-Webster dictionary³ defines commercial disparagement as:
“Legal Definition of Disparagement
1: the publication of false and injurious statements that are derogatory of another's property, business, or product — called also business disparagement, commercial disparagement, disparagement of property, slander of goods, trade libel”

It is up to the MCHK to define disparagement in the medical profession. For commercial disparagement, it is said to have occurred when derogatory statements are made about a person's business with the purpose of discouraging others from dealing with the person. From the definition, we see four elements of commercial disparagement⁴:

A false statement is published, or communicated verbally or in writing to a third party;
With the intent or reasonable belief that the statement will cause financial loss for the business;
There is financial loss for the business;
The defendant makes the statement knowing that it is false or with reckless disregard of whether the statement is true or false.

The fourth element is particularly relevant to our profession. Very often we will meet patients who have had dissatisfactory treatment before coming to us, therefore we will hear facts and vent at the same time. A patient’s perception on previous treatment could be subjective, and even exaggerated. As a professional, we should verify the information from other reliable source(s). Spreading a one-sided story will render ourselves susceptible to professional misconduct.

Commercial disparagement and disparagement in medical profession
Disparagement in the medical profession is different from commercial disparagement. For one thing, the hearing held by MCHK is a disciplinary inquiry, not a court trial. The central question in the disciplinary inquiry is professional misconduct. In accordance with the little red book, Part II, “Misconduct in a Professional Respect”:
“…misconduct in a professional respect…has been interpreted by the Court of Appeal as conduct falling short of the standards expected among registered medical practitioners. It includes not only conduct involving dishonesty or moral turpitude, but also any act, whether by commission or omission, which has fallen below the standards of conduct which is expected of members of the profession. It also includes any act which is reasonably regarded as disgraceful, dishonourable or unethical by medical practitioners of good repute and competency.
It is for the Medical Council to judge whether a doctor’s conduct has fallen short of the expected standard after considering the evidence in each individual case...”

As such, it is up to MCHK to decide whether a doctor has contravened the code of “disparagement of another doctor”, and the definition of commercial disparagement is not applicable. For instance, the element of “financial loss for the business” may not be considered essential by MCHK. In the two cases of professional misconduct for contravention of section 19.3 below, the condition was “gratuitous and unsustainable comments about a registered medical practitioner”.

Use of health information from reliable sources
Nowadays, a patient is often taken care of by a number of different medical practitioners. And with the assimilation of information technology in the health system, we could get hold of patients’ medical records in previous encounters. We may also need to explain the current treatment plan in the light of previous health records. So, a medical practitioner has to be cautious in communicating health information to his patients and colleagues, because it is possible to disparage another doctor using the health information gained in this way (see the second case of the two cases below). The Code of Practice⁵ (“COP”) issued by the Commissioner for the Electronic Health Record under section 52 of the Electronic Health Record Sharing System Ordinance (Cap 625) provides guidance on the code of conduct with shared health information. This COP stipulates that:

“Healthcare professionals should exercise diligence of care in explaining any information accessed through ‘Electronic Health Record Sharing System’ to healthcare recipients and not to use them for alleging challenges or criticism in whatever means to disparage or depreciate the professional skills, knowledge, services or qualification of other healthcare professionals and/or healthcare providers.”

Although the document is on electronic health record sharing, the code is an administrative one and is applicable in other situations where a patient is under the care of more than one doctor. It deals with the conduct expected of a medical doctor in dealing with shared health information gathered from another reliable source. So even when a doctor is presented with the right health information of a patient from prior medical encounters, it is against the Code of Practice to use the information to disparage or depreciate another doctor.

Two cases of disparagement
For those who are interested in this topic, there were two cases gazetted for professional disparagement:

The first case⁶ was on 8 Nov 2004. Dr. AU YEUNG was charged with the disciplinary offence, "that he, being a registered medical practitioner, made gratuitous and unsustainable comments about another registered medical practitioner...."
- The Council was satisfied that in relation to the facts alleged, he has contravened section 19.3 of the Professional Code and Conduct for the Guidance of Registered Medical Practitioners, and has been guilty of misconduct in a professional respect.
- The council ordered on 8 Nov 2004 that the name of Dr. AU YEUNG would be removed from the General Register for a period of three months, and that the Order be suspended for a period of two years.
The second case⁷ was on 27 Jan 2005. Dr. TSE was charged with the following disciplinary offence, "being a registered medical practitioner, sent a document titled ‘xxx Hospital PET Scan Department: Case Presentation’, which was prepared by him and which contained gratuitous and unsustainable comments about a registered medical practitioner…”
- The Council was satisfied that in relation to the facts alleged, Dr. TSE has been guilty of misconduct in a professional respect.
- The Council ordered on 27 Jan 2005 that Dr. TSE would be reprimanded.

Conclusion
The MCHK is a regulatory body to govern conduct and behavior of medical doctors in Hong Kong. As a medical professional, one should familiarize himself with the Code of Professional Conduct issued by the MCHK. A patient may be dissatisfied with the treatment he had before coming to us. As professionals, we must not fall into the trap of spreading unverified hearsay and contravening the Code of Professional Conduct. Furthermore, when a patient is under the care of multiple doctors, one should exercise diligent care in explaining health information to patients and colleagues, and not to use the information to disparage or depreciate another medical practitioner.

Dr Ludwig TSOI
President

References

Apple Daily. 18 July 2018. https://hk.news.appledaily.com/local/daily/article/20180718/20453476 (last assessed 23 Sep 2018)
Code of Professional Conduct – for the guidance of registered medical practitioners. Revised in January 2016. Medical Council of Hong Kong. https://www.mchk.org.hk/english/code/files/Code_of_Professional_Conduct_2016.pdf (last accessed 23 Sep 2018)
https://www.merriam-webster.com/legal/disparagement (last accessed 23 Sep 2018)
Commercial disparagement. https://smallbusiness.findlaw.com/business-laws-and-regulations/commercial-disparagement.html (last accessed 23 Sep 2018)
Code of Practice for Using Electronic Health Record for Healthcare [Document Reference No. G80] [V1.4]. Commissioner for the Electronic Health Record. https://m.ehealth.gov.hk/filemanager/content/pdf/en/hcp/hcp_code_of_practice.pdf (last accessed 23 Sep 2018)
https://www.gld.gov.hk/egazette/pdf/20040851/egn200408518028.pdf
https://www.gld.gov.hk/egazette/pdf/20050910/egn200509101083.pdf

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

The first day of July marks the beginning of a new page in the life of interns, who have just gone through the challenging year of residency, when they learn to become a real doctor. During that year, they work as a “doctor” under close supervision. However, the end of internship may be more challenging when they

become a qualified registered practitioner, who, to a certain extent, cannot deny professional responsibility. We have more applicants than the number of posts for our big family of Emergency Medicine this year. In order to better prepare these new comers to adapt to the work as an Emergency Physician, an induction program on Emergency Medicine is conducted in early July every year to welcome our new trainees. This year, apart from the list of classical medical topics delivered by experienced Emergency Medicine fellows, representatives from the Emergency Medicine Trainees Network (under Hong Kong College of Emergency Medicine, HKCEM) were invited to join and share their valuable experience. The sharing session provided our new trainees an opportunity to understand the preparation needed to become an Emergency Physician, as well as some essential survival skills in the workplace.

This profession requires life-long learning, be it trainees or fellows, who have to keep abreast of the most recent development throughout their career. Moreover, it is not only the medical knowledge that needs to be updated, but also the interpersonal communication skills have to be continuously enhanced. We have close liaison with general practitioners, doctors of other specialties, and even Emergency Physicians from other hospitals. There may be different management strategies for the same clinical problem. It is of utmost importance for us to maintain mutual respect towards each other. Dr Ludwig TSOI will elaborate on inter-professional relationship in the Message from the President.

Several subcommittees have been established in the past one to two years under HKCEM. Dr Cing Hon LAI, Chairman of Emergency Medicine Extended Care (EMEC) Subcommittee of HKCEM, will talk on this newly established subcommittee.

Hope you will take a rest and enjoy this issue of our Newsletter!

Council News

Dear Members,

Here comes the 3^rd issue of HKSEMS Newsletter in 2018.
Let’s walk through the activities that have been conducted in the last 3 months!

Induction Program on Emergency Medicine July 2018

This induction program, a conjoint function of the Hospital Authority Head Office IEC (Infection, Emergency and Contingency) and HKSEMS, was held on 10 July 2018 in Tang Shiu Kin A&E Training Centre. This is a half day program, aiming to offer new comers basic and practical knowledge for survival in the Emergency Department. A new session hosted by EM Trainee Network of HKCEM started after the lectures, which included A&E experience sharing by their chairman and vice-chairman, followed by lunch session.

The President of HKSEMS, Dr. Ludwig Tsoi spoke in the first session.

Winners of the Q&A session, the prize was a book written by Dr. Tsoi.

Dr. Chan Yiu Cheung from UCH spoke on Pediatric Emergencies.

Committee members from Young Fellow Chapter & EM Trainee Network (HKCEM)

Chairlady and Vice-chairman from EM Trainee Network shared their experience with the new comers

Lunch session

Training of Guangzhou primary health care staffs by HK St. John Ambulance Brigade & HKSEMS

HKSESM liaised with HK St. John Ambulance Brigade to provide BLS training for the primary care physicians and nurses in Guangzhou on 24 July 2018. Three instructors from St. John, together with Dr. CS Leung & Dr. Wendy Cheng from HKSEMS, jointly conducted the training.

Teaching BLS and the use of AED.

Miss Po from St. John was in charge of the airway management station

From left to right: Dr. Wendy Cheng, Miss Eva Lee, Dr. Leung Chin San

Group photo with the local faculty

Library talk- First Aid for Elderly

Dr. Wan Kuang-an represented HKSEMS and delivered a talk on the topic “長者基礎急救技巧 / Fundamental First Aid Techniques for Elderly” on 1 September 2018 in Chai Wan Library. Practical knowledge on Patient Assessment, Recovery Position and Basic Life Support was promulgated.

Dr. Wan and a volunteer demonstrated the correct way of using AED.

DR. Wan explained the importance of “Chain of Survival”

The next talk will be on 1 December 2018 by Dr. Cheung Lap Woon in Cheung Chau Public Library

Civil Aid Service (CAS) Mountain Search and Rescue (MSaR) Team Mountain Rescue Basic Trauma Life Support (Provider) Course

In order to promote knowledge and provide training on pre-hospital basic trauma life support and wilderness related emergencies, HKSEMS ran a series of 4 identical classes for the CAS MSaR members. Each class consisted of 18 hours, including lectures, skill training and practical sessions, followed by written and practical assessment.

Dr Ho Hiu Fai teaching the class about patient transfer

Dr Chau Chi Wai teaching the class on taking care of the wounded patient

Dr Ho Man Kam introducing the laryngeal mask airway

Dr. Chan Kam Hoi (left), course coordinator from CAS, with Dr. Wendy Cheng (HKSEMS)

Dr Willis Kwok introducing the pelvic binder

Dr Wong Tai Wai giving a talk in the class

The group photo of the class and the facilitators

Condemn violence in ED

In response to an incident of workplace violence in which an Emergency Physician was physically assaulted by a patient suspected of substance abuse, HKCEM (Hong Kong College of Emergency Medicine) and HKSEMS published a Joint Statement: “Condemn violence in Emergency Department”, on 13 August 2018 (see below):

Medical Tips
Abnormalities in the ECG Measurements

Heart Rate
Bradycardia is defined as a resting heart rate of below 60 bpm and tachycardia is defined as heart rate of above 100 bpm.

PR Interval

measured from beginning of P to beginning of QRS in the frontal plane –
Normal: 0.12 - 0.20s
Short PR: < 0.12s

WPW (Wolff-Parkinson-White) Syndrome: An accessory pathway that connects the atrium to the ventricle which allows early activation of the ventricles, resulting in a delta wave and a short PR interval.
LGL (Lown-Ganong-Levine): The presence of an AV nodal bypass track which connects the atrium to the His bundle. This allows early activation of the ventricles without a delta wave.
Ectopic atrial rhythms which originates near the AV node allows a short PR interval because of shorter time to arrive at the AV node than sinus node.

Prolonged PR: > 0.20s

First degree AV block- constantly prolonged PR interval
Second degree AV block- PR interval may be increasingly prolonged until non-conducted P waves occur (Type I or Wenkebach) or fixed PR interval with some non-conducted P waves at regular intervals (type II or Mobitz)
Third degree AV block. P waves and QRS complexes are dissociated.

QRS Duration
Prolonged QRS Duration is defined as QRS duration ≥ 0.12s, causes include:
-Complete RBBB or LBBB
-Nonspecific IVCD
-Ectopic rhythms originating in the ventricles (e.g., ventricular tachycardia, pacemaker rhythm)

QT Interval

measured from beginning of QRS to end of T wave in the frontal plane
The QT interval is inversely proportional to heart rate:
The QT interval shortens at faster heart rates and lengthens at slower heart rates
The corrected QT interval (QTc) estimates the QT interval at a standard heart rate of 60 bpm.
An abnormally prolonged QTc(>500ms) is associated with an increased risk of ventricular arrhythmias, especially Torsades de Pointes.
Causes of LQTS include the following:

-Drugs (many antiarrhythmics, tricyclics, phenothiazines, and others)
-Electrolyte abnormalities ( hypokalemia, hypocalcemia, hypomagnesaemia)
-central nervous system disease (especially subarachnoid hemorrhage, stroke, trauma)
-Hereditary LQTS (e.g., Romano-Ward Syndrome)
-Coronary Heart Disease (some post-MI patients)

Congenital short QT syndrome(<350ms) has been found to be associated with an increased risk of paroxysmal atrial and ventricular fibrillation and sudden cardiac death.

Leisure Corner

The Emergency Medicine Extended Care (EMEC) Subcommittee Dr Cing Hon LAI

The Emergency Medicine Extended Care (EMEC) Subcommittee of HKCEM was established in January 2017, with the support from Dr. Ho Hui Fai and Dr. Axel Siu (the immediate past and present presidents of HKCEM). Sixteen Members are representatives from different A&E centres, who are the key persons to review and enhance the Emergency Medicine Ward (EMW) services.

Fourteen out of 17 A&E centres are currently providing certain form of EM in-patient services. However, there had been no academic group or body to promote it’s development and enhance the services. Therefore, one of the important missions of our subcommittee is to provide a platform to share the expertise and experience across different hospitals. Inter-hospital grand rounds are organized half-yearly, to provide an opportunity for different centres to present their service models and management protocols.

Clinical management of EMW patients requires a specific set of clinical skills and knowledge, which is different from what we acquired through conventional training in Emergency Medicine. The mission of EMEC is to fill in the knowledge gap by organizing training and workshops for our fellows and trainees in future.

Apart from local activities, we also plan to network and liaise with international organizations such as Observation Medicine Section of American College of Emergency Physicians (ACEP). We have attended the Observation Medicine Conference organized by ACEP last year. In the current year, we have just visited the A&E and EMW of Conde S. Januário Hospital in Macau. It was an enjoyable and fruitful experience and we have learnt a great deal from our Macau colleagues, especially on the management of critical cases in EMW.

Visit to EMW of Conde S. Januário Hospital in Macau.

EMW Grand Round with Dr. Ho Hiu Fai as our guest speaker.

Upcoming Events and Conferences

Dinner Seminar on 6th Nov 2018

Seats are limited, please secure your place as soon as possible!!
Registration method: Miss Sonia Suen (sonia@hkcem.org.hk or +85228718874)
Fee: free of charge
Deadline of registration: 23 October 2018

The 2018 AGM of the HKSEMS

The 2018 AGM of the HKSEMS will be held on 26th October 2018 at 6:00pm in the Function Room 1&2 , 2/F, Hong Kong Academy of Medicine Jockey Club Building, 99 Wong Chuk Hang Road, Hong Kong.

Asian Conference on Emergency Medicine (ACEM) 2021

HKSEMS will be hosting ACEM in 2021. Please mark your calendar!

Facebook

Website