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HKSEMS eNewsletter Issue 008
2019 Jan

香港急症醫學會

Hong Kong Society
for Emergency Medicine & Surgery

The HKCEM, HKSEMS, HKENA and HKCEN jointly issued a statement to condemn the ongoing workplace violence at emergency department. Please click here for the statement

The president of HKSEMS, Dr Ludwig Tsoi will talk about " Public Health and Emergency Medicine". Please click here for further reading.

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 !

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

Message from the President Dr Ludwig Chun-Hing TSOI

Public Health and Emergency Medicine

Introduction
Public health concerns the broad-brush maneuvers that could alter the health of the general population at large, e.g. anti-smoking campaign to reduce the risk of coronary heart disease. The campaign may involve lobbying the government for raising the tariff on tobacco products and

legislation on the packaging of cigarettes. Whereas emergency medicine (EM) is characterized by the acute and life-threatening aspect of medical care, with emphasis on recognition, evaluation, care and disposition of patients with acute illnesses and injures. Therefore, the layperson may consider public health and EM as totally unrelated. However, this is not true.

Interplay between the two disciplines
In an article published by WHO1, it was already recognized that EM “functions as a cornerstone for secondary disease prevention and is one of the many tools for implementing primary disease prevention programmes”. The direction of development of EM is said to be “horizontal integration”, in contrast to traditional system-based specialties where the emphasis is on “vertical expansion”. The discipline of EM care nowadays dives into multiple disciplines, ranging from pre-hospital to end-of-life care, clinical toxicology to POCUS, field medicine to critical care, Paediatric to Geriatric emergencies, so on and so forth. Having said that, EM is still developing in other areas. Disease or injury prevention is one of those.

Traditional view on EM
The practice of EM has conveniently been divided into four main areas: clinical, teaching, research and administration. Disease prevention does not seem to belong to any one of these. However, due to the very nature that emergency care touches upon the lives of many people, it opens up a door to reach the public through investing in and changing the mindset of accident and emergency (A&E) department. In Hong Kong, the annual attendance of public A&E departments exceeds 2 million. Just imagine the magnitude of impact we could bring to the patients and their families if this encounter could be utilized as an opportunistic intervention.

Possible opportunities
With the continuous development of EM, it has now come to a time that the EM academicians and the institutes responsible for the training of EM physicians should start to instill an element of public health into the training of EM curriculum. We have been good at secondary disease prevention, e.g. treating and referring hypertensive patients to general outpatient clinics. WHO suggested EM to play a role in primary disease prevention, which local A&E departments have been doing for some years, e.g. vaccination of tetanus toxoid, post-exposure prophylaxis for rabies, hepatitis B and HIV. In recent years, A&E departments are also providing crisis intervention for substance abuse, emotional disturbance and violence. From the big-data point of view, EM can generate huge quantity of data to assist the formulation of public health policy. EM also has a potential to enroll patients into clinical trials, especially those studies that have a public health aspect (e.g. smoking, exercise, etc). Traditionally, heart attack, acute stroke and sepsis patients will have many research topics related to the acute treatment, and the management of these conditions is time-critical. These time-sensitive diseases could also form a source of research, as A&E is the interface between the public and the hospital. The concentration of different case-mix also makes A&E an ideal site for training, not just for EM specialists, but also for family physicians and community health-providers, who may need to provide emergency care in the community from time to time. The District Health Centre proposed by the FHB recently should also consider sending their staff to A&E department for training and rotation. Lastly, disaster response is one area that is quite new in Hong Kong. At present, the training of disaster preparedness and response is shouldered by Community Medicine and EM. Definitely in the future development of disaster medicine, a lot of work has to be done at the population level, and EM physicians must play a pivotal role in it.

Dr Ludwig TSOI
31 Jan 2019

Reference
1. Philip Anderson, Roberta Petrino, Pinchas Halpern, & Judith Tintinalli. The globalization of emergency medicine and its importance for public health. Bulletin of the World Health Organization, October 2006, 84 (10)

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

The atmosphere in the Accident and Emergency (A&E) Departments of Hong Kong (HK) has been increasingly tense over the years. The number of patients attending our A&E Departments has been on a slow but steady rise. Moreover, we have an aging population with increased life expectancy (HK has

been the city with the longest life expectancy since 2016). This in turn leads to increasing complexity of medical problems encountered in the A&E Departments due to multiple comorbidities and polypharmacy. On the other hand, understaffing and heightened expectation from the general public further exaggerates the problem.

If the quality of care is to be safeguarded, it goes without saying that longer waiting time will ensue, given that the manpower and other resources remain just the same as our good old days. Lengthened waiting time occurs both during pre-consultation and post-consultation (admission block). Many a times, staffs in the A&E Departments encounter discontent from patients (and their relatives and friends) as a result of these. We have to settle the conflict despite our already busy work. It can be easily imagined that Workplace Violence is not uncommon in our local A&E Departments. Violence is not only limited to physical assault, but also verbal abuse which is another form of violence that can cast considerable harmful effects to our staffs. Both physical and verbal violence cause severe mental stress to our clinical staffs and undermine their morale. This may even carry negative influence onto their personal life.

Workplace Violence in local A&E is not something new. Our past President, Dr CH Chung had written an article “Emergency department violence: a local scene” in the Hong Kong Journal of Emergency Medicine in 2003 (HKJEM Vol. 10(1) Jan 2003). HKSEMS has posted two Position Statements strongly condemning Workplace Violence in the A&E Department. The statement issued on 13 August 2018 was jointly issued with HKCEM when the victim was an A&E doctor. In response to a violent incident against an A&E nurse just a couple of weeks ago, another statement was issued jointly with HKCEM, HKCEN and HKENA. We aimed to increase the public awareness of the importance of providing a safe working environment for our clinical staffs. While the general public should be educated about the zero tolerance of workplace violence, it is hoped that more resources can be injected into the frontline service of A&E Departments to improve the manpower and alleviate the long waiting time.

Coming back to this issue of Newsletter, our President will write on the inter-relationship between Emergency Medicine and Public Health.

Meanwhile, we shall have a dinner gathering on 21^st February. Dr. James Winearls, an intensivist from Gold Coast University Hospital of Australia, will give a talk on “Thromboelastometry (TEM) Guided Therapy on Trauma Coagulopathy”.

Wishing you all a fruitful and prosperous Chinese New Year !

Council News

Dear Members,

Here comes the 4^th issue of HKSEMS newsletter in 2018.
Let’s walk through the activities that have been conducted in the last 3 months!

Annual General Meeting (AGM)

Our AGM was held on 26^th October 2018 after the annual scientific meeting (SSEM). 26 members attended the meeting. Our president reported the activities we have held in the year 2017-2018 and the plan for the coming year. HKSEMS, a charitable organization to be, will continue to serve the public and increase their awareness on health. Various programs with primary and secondary schools are now under construction to emphasize the importance of CPR to save life. Details will be released later and all of you are welcomed to join us!!

A photo taken with our past presidents and Councilors.

Therom Fisher Dinner Seminar: Procalcitonin Guided Therapy Consensus and Controversies cum Dinner in Holiday Inn Hotel (TST)

Professor Pierre Hausfater, expert in the development of diagnostic and prognostic biomarkers, presented to us the topic on Procalcitonin and its use in the management of sepsis patient in the Emergency Department. After this inspiring and informative presentation, we enjoyed dinner together and was having a very memorable and fruitful evening!!

Council meeting before the Seminar.

Introducing Professor Hausfater to the floor by our president Dr. Ludwig Tsoi.

Key Messages from Professor Hausfater.

Welcome new members

We welcome the following doctors to join our family!!

Dr. Yeung Hoi Yee (QMH)
Dr. Lee Fook Kay (CMC)
Dr. Lam Han Gang (QEH)

Joint statement against violence in ED

The HKCEM, HKSEMS, HKENA and HKCEN jointly issued a statement to condemn the ongoing workplace violence at emerency department.

Medical Tips

ECG Axis Determination

The axis of the ECG is the direction of the overall electrical activity of the heart. It is determined mainly through examining the QRS wave of the limb leads(I, aVF, II). The figure below illustrates the standard ECG leads and their relationship to the cardiac axis.

The normal QRS axis should be between -30 ̊ and +90 ̊. Left axis deviation(LAD) occurs when the QRS vector falls between -30 ̊ and -90 ̊ . Right axis deviation(RAD) occurs when the QRS axis is between +90 ̊ and +180 ̊. Indeterminate (or Northwest, NW) axis refers to the QRS axis being between +/- 180 ̊ and -90 ̊.

Normal QRS Axis
If the QRS complex is predominantly positive in both lead I and lead aVF, then the axis fall into the quadrant of 0 to 90 ̊, which is normal..

Left Axis Deviation
If the QRS is predominantly positive in I and negative in lead aVF, then the axis is between 0 ̊ and -90 ̊. To further distinguish normal from left axis deviation in this setting, we need to assess QRS at lead II. If QRS at lead II is predominantly negative, then the axis is between -30 ̊ to -90 ̊, and left axis deviation is present. If the QRS complex in lead II is predominantly positive, then the axis is between -30 ̊ to 0 ̊, and the QRS axis is normal.
The causes of left axis deviation include: normal variant, left anterior fascicular block,
left ventricular hypertrophy, left bundle branch block etc.

Right Axis Deviation
If the QRS is predominantly negative in lead I and positive in lead aVF, then the axis is between +90 ̊ to 180 ̊ and it is considered right axis deviation. The causes of right axis deviation include normal variant, right bundle branch block, right ventricular hypertrophy, left posterior fascicular block etc.

Indeterminate Axis
If the QRS is predominantly negative in lead I and lead aVF, then the axis is indeterminate or “northwestern axis.” This finding is uncommon and usually from ventricular rhythms and can also occur in paced rhythms and certain congenital heart diseases.

Upcoming Events and Conferences

Dinner Symposium on 21st Feb 2019

HKSEMS Dinner Symposium will be held on Feb 21, 2019. Dr. James Winearls, an intensivist from Gold Coast University Hospital in Australia, will present an innovative topic on Thromboelastometry (TEM) Guided Therapy on Trauma Coagulopathy, followed by dinner gathering in Sheraton Hotel (TST). Due to enthusiastic response, seats are all full now!! Educational dinner symposium will be held regularly for our members, please keep track of our website and email notice!!

The Shenzhen-Hong Kong Emergency Medicine Conference 2019

The Shenzhen-Hong Kong Emergency Medicine Conference 2019 will be held in Shenzhen 北大深圳醫院 from 25/5/2019- 26/5/2019. There will be 1 plenary and 8 scientific tracts involving 61 speakers covering various innovative topics and updates in Emergency Medicine, it is a really precious chance to join and exchange ideas with our Mainland counterparts!! Please mark your calendar!
Details will be announced later!

Asian Conference on Emergency Medicine (ACEM) 2021

The 11^th ACEM organized by HKSEMS will be held on 17^th to 19^th December 2021. Please save the date, and see you on this big day!!

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