If you have problem reading this email, you can cilck this LINK
or you can access our facebook or website from the links below.

To subscribe to our newsletter, please click HERE

Facebook

Website

Issue 015--Oct 2020

香港急症醫學會

Hong Kong Society
for Emergency Medicine & Surgery

Message from the President...

Despite the dropping of local coronavirus transmission, much work still has to be done to prevent the resurgence before the vaccine is launched. So, stay vigilant!.....read more

From Editors...

Our topics in the coming issue include introduction of St John Hospital at Cheung Chau, the experience sharing at the Universal Community Testing Program and the introduction of hiking trail by private EM fellows.....read more

Council News...

Several activities such as the Induction Program for Emergency Medicine, HK-Taiwan Young Fellows/Trainees Exchange Forum and Multi-specialty Medical Mega Conference were converted from physical to online activities...read more

From Members

Members Area

Cheung Chau is famous for the Bun Festival and its delicious street food. Yet not many people know that there is a hospital on this island. Dr Ronnie Lo, the Associated Consultant at St John Hospital at Cheung Chau will introduce to us the smallest A&E, and probably the smallest public hospital in Hong Kong....read more

Private EM Writes

Practicing social distancing turns many social gatherings from indoor to outdoor activities. The chairman of Private Emergency Physician Chapter, Dr Cheung Chin Pang, Louis will share with us a hiking trail for us to meet with friends in the coming autumn...read more

Nurse Corner

Due to the third wave of COVID 19 surge, the Universal Community Testing Program was launched to identify hidden virus carriers. Nurse consultant of NWTC AEDs, Mr William Chan will share with us his experience working at the screening station....read more

Advance in EM

The occurrence of refractory ventricular fibrillation is not uncommon. The evidence for the optimal treatment of this condition is still controversial and worth discussion. Our editor, Dr Wong Kwun Bun will discuss the use of dual external defibrillation in this condition...read more

Message from the President Dr Ben Kuang-An WAN

Eight months have passed since the occurrence of first local COVID-19 case. Despite the dropping of local coronavirus transmission, much work still has to be done to prevent the resurgence before the vaccine is launched. So, stay vigilant!

In the face of adversity, we shall not back down, but rather continue to move forward together as a team. The Joint statement with the

Hong Kong College of Emergency Medicine - Accident & Emergency Department Services in COVID-19 pandemic was released to address the influx of asymptomatic patients requesting tests for COVID-19 in A&E departments. We have made the “classroom” a safe space for our members and those who joined our training courses. We adopted distance learning and conducted the Induction Course with Zoom. We will continue exploring the feasibility of distance learning or blended learning in our upcoming courses.

My special thanks to the devoted team of Publication subcommittee, which has addressed the need of our members from different disciplines by providing new, diverse contents in a new layout of our newsletter. Positive feedbacks are received. Members are welcome to submit articles to share the life and experience with others in the circle of EM. Social media is a powerful platform to reach audience in this fast-paced world. To strengthen the connection with our members, IT subcommittee is newly formed with a team of dedicated, energetic young EM physicians. Change is constant around the society. Our younger generation is incredibly adaptive to the surrounding, and grows up with technology so they would be the first to understand the power of technology and how it could help push the boundaries of Emergency Medicine Specialty.

Last but not the least, the Annual General Meeting (AGM) of HKSEMS will be held on 24th October 2020. As a universal effort to curb COVID-19, precautionary measures will be exercised in the AGM to safeguard the health of participants. Important events of HKSEMS will be reviewed. Your attendance and suggestions on our development will be highly appreciated.

From Editors	Editors in chief	Dr Chor-man Lo, Dr Sam Siu-ming Yang
	Editors	Dr Ho-yin Chan, Dr Wendy Cheng, Dr Louis Chin-pang Cheung, Dr Kwun-bun Wong Mr Chun Pong Leung

We have been combating against SARS-CoV-2 virus for almost nine months. In these nine months we have been through three waves of surge of infection. The third wave of COVID 19 infection has put the isolation facilities of public hospitals at the verge of overloading. This led to the building of a makeshift isolation hospital at AsianWorld Expo Exhibition Centre in order to cater for those with mild

symptoms. Apart from that, the government also launched Universal Community Testing Program to identify those hidden virus carriers. Numerous medical staff were recruited into delivering the screening tests throughout Hong Kong. In the nurse corner, Mr William Chan will share with us his experience working in the screening station

The pandemic affects much of our daily life. Practicing social distancing turns many social gatherings from indoor to outdoor activities. The chairman of Private Emergency Physician Chapter, Dr Cheung Chin Pang will share with us a hiking trail for us to meet with friends in the coming autumn.

Apart from hiking at country parks, many of us resort into visiting outlying islands. Most Hong Kong people probably have ever visited Cheung Chau for Bun Festival and tasted the delicious street food. But probably not many people know that there is a hospital at Cheung Chau and even fewer people know that there is an A&E in that hospital. We have invited Dr Ronnie Lo, the Associated Consultant at St John Hospital at Cheung Chau to introduce to us the smallest A&E, and probably the smallest public hospital in Hong Kong.

Travelling for international conference is also difficult in the era of COVID 19 pandemic. The 5th HK-Taiwan young fellows/Trainees exchange forum was successfully held on 1^st Sept 2020 in the Taiwan Society of Emergency Medicine annual conference. The forum was held through video-conferencing this year due to the pandemic. Instead of purely academic discussion on Emergency Medicine, this forum allows doctors from two localities to share their experience on non-academic aspects of emergency medicine. The topics discussed in this forum were Emergency Physicians’ Key to Financial Freedom and Artificial Intelligence in Emergency Medicine. It is hoped that the young doctors can better their medical career through widening their field of view in medicine.

Council News

Dear Members of HKSEMS,

Welcome to the 3rd issue in 2020. Let’s refresh the activities organized by the Council in these 3 months!!

Induction program on Emergency Medicine July 2020

This induction program, a conjoint function of HKSEMS and Hospital Authority Head Office IEC (Infection, Emergency and Contingency) was held on 17 July (class A) and 24 July (class B) 2020. Class A was held physically in Tang Shiu Kin A&E Training Centre, while Class B was held in the format of an online course due to the 3^rd wave of COVID-19 infection. This is a half day program, aiming to offer new comers (including Emergency Medicine Basic Trainee, Trainees from other specialties and interns rotated to AED) the basic and practical knowledge for survival in the Emergency Department. This was the first time that we run the course with ZOOM!

The Taiwan Society of Emergency Medicine Annual Conference ( 31^st Aug -1^st Sept 2020)

The Greater China Office (HKSEMS/ HKCEM) and the Young Fellow Chapter (HKCEM) take part in this exchange program annually.

A session of exchange forum 2020港台急診住院醫師交流論壇 (trainee exchange forum) was scheduled and reserved for us on 1/9/2020 08:30 in the format of online video conference. Dr. Axel Siu and Dr. Ben Wan were invited as the chairman of the session, taking part in panel discussion with 黃集仁醫師 and李景行醫師. Real time video recording was uploaded to the EMRN: Emergency Medicine Residents Network in Facebook.

Multi-specialty Medical Mega Conference (MMMC) 2020

The MMMC is an annual conference supported by 60 co-organizing medical societies. The MMMC 2000 was once scheduled to be held in April 2020 in Cordis, Hong Kong, but it was postponed to 12^th-13^th Sep 2020, changed from physical conference to Virtual. It was an event of diversity and inclusivity comprising of 31 scientific sessions with 150 speakers and chairpersons.

Being one of the co-organizers, HKSEMS collaborated with the following 4 societies to conduct 4 tracks.

-The Hong Kong Society of Rheumatology
-The Hong Kong Geriatrics Society
-The Hong Kong Society of Critical Care Medicine
-The Hong Kong Institute of Allergy

Here is a snap shot capturing the speakers and chairpersons in one of the tracts.

Training program in trail running 2020 (co-joint with HKCEM sports team (postponed)

The Trail running course 2019 (basic course) had been completed with success. The intermediate class was planned to start after the Chinese New year, but was postponed due to the COVID-19 pandemic.
We plan to start the class in 2020 Q4! Please register

Please stay tuned for our update!!

Upcoming activities

HKSEMS AGM 2020 on 24^th October 2020

AGM of HKSEMS will be held on 24^th October 2020 in HKAM Building. Please refer to the attached AGM notice for further information. If you are not available to attend in person, please sign proxy form and return to the secretariat.
Please come and join the AGM, as far as possible!

Scientific Symposium on Emergency Medicine (SSEM) 2020

SSEM 2020 organized by HKCEM, and supported by HKSEMS, HKCEN and HKENA will be held virtually on 24^th October 2020.

This year, with the theme of “New Frontier of Paediatric Emergency Medicine: Collaboration and Synergy”, the symposium features inspirational plenary sessions and multi-disciplinary tracks of presentations.

Please save the date and register at https://ssem.hk !

ACEM 2021

Save the date !!
HKSEMS will be the organizer for the 11th ACEM.
We are looking forward to meeting you at the conference!!

Members Area	Dr. Ronnie Lo
	Associate Consultant St. John Hospital

Introduction to St. John Hospital

Cheung Chau is a popular outlying island to visit especially during the weekends and holidays. However, some may not even know there is a hospital in Cheung Chau that provides 24 hours emergency services. St. John Hospital (SJH) is located in Tung Wan of Cheung Chau near Tung Wan Beach, which is around

7 minutes walk from the Cheung Chau Pier. The Hospital provides primary, emergency and community health services. It is under the Hong Kong East Cluster of the Hospital Authority. It consists of a 24-hour Accident and Emergency Department (AED), medical wards, day medical centre and General Out-patient clinic (GOPC), all led by doctors of emergency medicine backgrounds. There are altogether seven doctors in total, including the Deputy Hospital Chief Executive (DHCE), two Associate Consultants (AC) and four non-specialists. Other services include: Physiotherapy, Occupational Therapy, Pharmacy, X rays, Community Nursing and Chaplaincy. Additional services are provided by the Department of Health include: Chest Clinic, Dental Clinic, Maternal and Child Health Clinic and Methadone Clinic.

Apart from the DHCE, all doctors share the duty roster consists of three types of duties, namely D (day, from 9 to 5), A (a.m., from 9 to 1) and L (long, meaning 24 hours from 9 to 9 of next morning), which is very different from the urban AEDs which only consist of A (a.m.), P (p.m.) and N (night). Each doctor either covers the GOPC duty, or the AED duty (which also include medical ward rounds and day medical centre consultations). During the day time (half day on Saturday), two doctors are on duty in the GOPC and only one doctor in the AED. For after hours, only one doctor runs the AED and covers any medical ward emergencies. The L duty doctor may have either GOPC duty during the day time together with AED duty during after hours, or whole 24 hours AED duty.

Working in St. John Hospital is very different from working in urban hospital in many aspects. First we do not just concentrate on the emergency services, but we cover the medical wards, day medical centre and the GOPC. We have to look after patients with chronic illness and terminal illness, which can be challenging for doctors of emergency medical background. We have to understand more on the primary health settings. Compared to the urban GOPCs, we are more selective on referring patients to the AEDs.

Second, the support is very limited. There is no emergency laboratory. Routine blood tests are only limited to weekday mornings, and the results are only available in the evening, and therefore only useful in the GOPC and ward settings. X rays are only available till 5 p.m. No CT scan is available. Point-of care-testings (POCT) are available in terms of ECG, bedside ultrasound, I-stat (for electrolytes, hemoglobin and acid-base), hemostix, and bedside troponin. These are the only tools doctors can rely on in additional to clinical approach. Doctors need to become “back to the basics” and as clinical knowledge and skills play a more important role. Pharmacy is only available till 5 p.m. Smart drug cabinet has recently been introduced to facilitate after hours AED drug dispensary. As there is no other clinical specialties available, patients attend the AED who are considered requiring specialty care will be transferred to the urban hospitals, by means of CASEVAC (by helicopter or police launch) or ferry. Urgency of CASEVAC is graded A+, A and B depending on the patient’s clinical condition. The usual destinations of urban hospital AEDs are Pamela Youde Nethersole Easterna Hospital (PYNEH), Queen Mary Hospital (QMH) and Rutonjee Hospital (RH). The choice of transferal is protocol driven. Our medical wards may cater cases which are either manageable by the capacity of emergency doctors, such as mild congestive heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), cellulitis, glycemic abnormalities, gastroenteritis with dehydration, acute retention of urine (AROU), just to name a few; or for supportive or palliative intent, such as terminal cancers, multiple co-morbidities, and those declined urban hospital transferal. Doctors become more familiar with the transport medicine. However, doctor cannot afford to escort the patient to urban hospital as there is only one doctor in the AED. Limited hours of escort service is provided by the Government Flying Service (GFS), after these hours escort is provided by nurses. Stand-by orders by doctor may be required during escort. Further, as there is only one doctor covering the whole hospital during the after-hours, no on-site support is available. Senior opinion can only be given over the phone. Doctors have to be proficient in working independently. Last but not least, the case load is relatively low around 30 cases a day (can be more during Sundays and public holidays). Apart from day time, in which ward round and day ward consultations are included, the working environment is otherwise quite relaxed with free time usually available during the afternoon and evening. Usually there are only a few attendances after midnight and some sleep is usually possible. However, resuscitation cases do occur although it is far less than urban AEDs. Despite the relaxing environment at most of the time, you are still required to perform when you come across serious business.

I have been working in quite a few AEDs in my careers and I become in love with this place. How you like this place depends on what sort of lifestyle you are seeking. Working is more free and relaxing. Staff bonding is close. Island residents are easy going. Working in St. John Hospital may give you an unique experience.

Private EM Writes	Dr Cheung Chin Pang, Louis
	Chairman of Private Fellows' Chapter, HKCEM Deputy Director of Emergency Medicine Centre Union Hospital

［隱藏於煩囂都市中的寧靜小徑］

秋天將至，大家開始想到郊外舒展一下身心，時間長的遠足未必能配合大家作息時間表，今次介紹這一條路線，可以讓大家消磨一個早上。

1.此路線起點在金鐘山頂纜車總站旁邊

2. 沿這段路往上走，先會到達堅尼地道，橫過堅尼地道（請小心兩端來回車輛），繼續沿梯級往上行。

之後會經過麥當勞道，繼續往上走，會到達馬己仙峽道。橫過馬己仙峽道然後到了蒲魯賢徑的，請沿著這條車路繼續往上走。沿途可以看到中區自然徑的路牌，大家會發覺郊區原來隱藏在中環深處。

3. 沿蒲魯賢徑走了一小段之後，會有一段分叉路，請大家轉左往上走，左邊這條路叫高化利徑，之後便接上梅道。到了梅道，請不要走進地利根德里的車路，也不要走上地利根德里旁的樓梯，應該繼續向東行。再行前少少有一個電話亭，電話亭旁邊的小路叫漆咸徑，我們需要沿着漆咸徑繼續往上走。

4.漆咸徑的開端有一個小公廁，大家可以先洗個面或者方便一下。

5. 漆咸徑也有一些分叉路，沿着路牌走就沒有錯

6. 繼續往上走，小路開始收窄，但全是水泥石屎路，亦有濃密樹陰遮擋，行起來應該不是太辛苦，相信沒有什麼難度。

7. 沿途可以看到維港的石屎森林的風光。

8. 上了差不多到了漆咸徑的頂點

9. 漆咸徑的頂點連接白加道，離開漆咸徑繼續往右方行，步行不久便會見到域多利醫院 Victoria Hospital 的石碑。這建築物曾經是兒童及婦女醫院，現在已變成政府官員宿舍。

10. 建築物旁邊有一條小路叫作醫院徑，此路可以通往施勳道，是其中一條往山頂的道路，但這次我們繼續沿着白加道往前走。因為白加道中後段可以看到維港兩岸壯觀的景色，很多名車廣告也在這個位置拍攝。

11. 白加道的盡頭是一個歷史悠久的山頂纜車站，這個車站早在1888年已經建成，最初命名為種植道車站，因為白加道在1898年之後才建成。因著這個車站的古舊的外表及位置關係，很多遊人喜歡在這裏打卡。

12. 過了白加道纜車站，繼續往前行很快我們便進入舊山頂道，慢慢步行10多分鐘便會到達山頂凌霄閣纜車總站。到了終點，大家可以吃個飯然後坐纜車回到金鐘，如時間尚早意猶未盡，可以選擇從其他路徑落山，例如經薄扶林水塘道往薄扶林道一帶。

後記：由金鐘出發全程大約需要一至兩小時，視乎步速，有部份路段已鋪了防滑鋼沙，但仍要留意天雨或潮濕時地面較為濕滑，小心跌倒受傷。泊車貼士，最接近起步點的停車場在金鐘花園道三號的商業大廈停車場。

Nurse Corner	*Mr Chan Yuk Wing, William*
	Nurse Consultant(Emergency Care), NTWC AEDs

We are emergency nurses; we fight the virus in the community.

The coronavirus COVID-19 pandemic is the defining global health crisis of our time and the greatest challenge we have faced since World War Two.

One of the anti-epidemic measures was 14-day Universal Community Testing (UCT) Program. The UCT aims to better gauge

the COVID-19 infection situation in Hong Kong and find asymptomatic infectious cases as early as possible to make early identification, early isolation and early treatment, in order to cut the virus transmission chain in the community.

The 14-day Universal Community Testing Programme concluded successfully with about 1.8 million people were screened for Covid-19 from 1 September to 14 September 2020, resulting in 42 cases being identified.
A group of emergency nurses from the Accident & Emergency Department, Tuen Mun Hospital and Tin Siu Wai Hospital participated the UCT program under the collaboration with the Hong Kong Academy of Nursing. We were assigned to work in Tai Hing Sports Centre, Tuen Mun, N.T.

On the first day of operation, it was found that some PPEs, equipment, and consumables were not adequate. The daily workflow was fine-tuned, and consumables were adequate after liaising with the site supervisor of UCT. The later days were smooth and uneventful till the end.

We received thanks and appreciations from citizens regarding our professional and quality services to them. We were encouraged that the Chair & Chief Executive (CE) of Hospital Authority as well as Professor Sophia Chan Siu-chee, JP Secretary for Food and Health visited our nurses in Tai Hing Sports Centre. They expressed their sincere gratitudes to nurses for their professionalism, dedication, high quality and efficient services to the public.

Although the epidemic situation in Hong Kong has been slightly controlled, there are still asymptomatic COVID-19 cases in the community. We should stay vigilant and work together to fight the virus.

Our nursing team

Close up, cheers.

Daily operation in the UCT centre

Appreciation of HA Chairman Mr Henry Fan & CE Dr Tony Ko & to our colleagues

Appreciation from Professor Sophia CHAN, JP, Secretary for Food and Health

Advance in EM	Dr Kwun-bun Wong
	Associate Consultant, Prince of Wales Hospital

Dual external defibrillation (DED)

Background
High quality cardiopulmonary resuscitation and early defibrillation are the key elements to improve survival among victims with shockable rhythms. Refractory Ventricular Fibrillation (RVF) is a

complication of cardiac arrest and is commonly defined as ventricular fibrillation that does not respond to three or more defibrillation attempts. (1) In patients with refractory ventricular fibrillation, an increased number of defibrillation attempts is associated with worse outcomes. (2). Dual external defibrillation (DED) is considered as an off-label use in this group of patient.

What is dual external defibrillation?
Double external defibrillation (DED) involves the use of a second defibrillator providing an additional shock in a sequential (DESD) or simultaneous manner. It was first described in human in a case series in 1994 (3). Five patients of 2,990 consecutive patients were successfully resuscitated using the double sequential shocks after failure of the standard defibrillation in routine electrophysiologic studies. The proposed theory included increasing energy dose, alternative energy vector by change of pad position, changes in impedance threshold based on the delivery of two sequential shocks and timing between sequential defibrillations lowering the impedance threshold. (4) Several case reports (5-7) have shown success with excellent neurologic outcomes in terminating RVF using dual defibrillation after failure of traditional Advance Cardiac Life Support (ACLS) measures. One Hong Kong case was reported for successful return of spontaneous circulation (ROSC) and Survival-to-Admission (STA) by using dual defibrillation in OHCA(8).

What is the current evidence?
A retrospective study was conducted in 2016, 12 out of 2428 patients were treated with double sequential external defibrillation, nine patients were converted out of ventricular fibrillation, three patients survived to hospital discharge, and two patients (2/12, 17%) were discharged with Cerebral Performance Category scores of 1 (good cerebral performance) (9).
Observational studies conducted in Canada of 252 patients (10) and 45 patients in England London (11) did not find any clear benefit of DED use by EMS in the treatment of RVF. A systematic review and meta-analysis about DESD did not show effect on survival to hospital discharge (OR 0.69, 95% CI: 0.30, 1.60), event survival (OR 0.98, CI: 0.59, 1.62) or ROSC (OR 0.86, 95% CI: 0.49-1.48) (12)
A clinical randomized study about DED was conducted in Sept 2019 and will be completed in 2022. (13) The preliminary data demonstrated that this treatment is feasible. ROSC was slightly higher in DSD group (40%) vs standard group (25%) although it is not statistically significant.

Potential harm
There was a case report that the use of dual-dose cardioversion was associated with external defibrillator damage. (14). There is a risk of damaging both defibrillators if the pads are touching each other.

Conclusion
DED is a highly variable intervention and there are still many unknown factors which continue to cause debate and controversy. DED may increase the chance of ROSC. However, whether that translates into patient oriented benefit (survival with neurologic function) is unclear. There are other ways to improve the success of defibrillation such as earlier defibrillation, adequate defibrillation paddle and compression pressure, defibrillation during expiration phase. Use of DED can be considered for treating RVF if failed standard ACLS management.

Reference:

Sakai T, et al. Incidence and outcomes of out-of hospital cardiac arrest with shock-resistant ventricular fibrillation: data from a large population-based cohort. Resuscitation. 2010
Manabu Hasegawa, Takeru Abe, Takashi Nagata et al. The number of prehospital defibrillation shocks and 1-month survival in patients with out-of-hospital cardiac arrest Scand J Trauma Resusc Emerg Med. 2015; 23: 34.
Hoch, DH, Batsford, WP, Greenberg, SM. Double sequential external shocks for refractory ventricular fibrillation. J Am Coll Cardiol 1994; 23(5): 1141–1145.
Ramzy M, Hughes PG. Double Defibrillation. StatPearls, 2019 Jun 28; www.ncbi.nlm.nih.gov/books/NBK544231
Bell C.R. Szulewski A. Brooks S.C. Make it two: a case report of dual sequential external defibrillation. Canadian Journal of Emergency Medicine. 2017; : 1-6
Boehm K.M. Keyes D.C. Mader L.E. Moccia J.M. First report of survival in refractory ventricular fibrillation after dual-axis defibrillation and esmolol administration. Western Journal of Emergency Medicine. 2016; 17: 762
Cabañas J.G. Myers J.B. Williams J.G. De Maio V.J. Bachman M.W. Double sequential external defibrillation in out-of-hospital refractory ventricular fibrillation: a report of ten cases. Prehosp Emerg Care. 2015; 19: 126-130
Lau, SK; Yau, MY ; Wong, YT et al. Right time, right place, and right direction: First reported use of dual simultaneous external defibrillation in Hong Kong [online]. Hong Kong Journal of Emergency Medicine, Vol. 26, No. 1, Jan 2019: 61-64.
Cortez E, Krebs W, Davis J, et al . Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest. Resuscitation. 2016 Nov;108:82-86
Cheskes S, Wudwud A, Turner L, et al. The impact of double sequential external defibrillation on termination of refractory ventricular fibrillation during out-of-hospital cardiac arrest. Resuscitation. 2019;139:275-281.
Emmerson AC, Whitbread M, Fothergill RT. Double sequential defibrillation therapy for out-of-hospital cardiac arrests: The London experience. Resuscitation. 2017; 117:97-101.
Delorenzo A, Nehme Z, Yates J, Bernard S, Smith K. Double sequential external defibrillation for refractory ventricular fibrillation out-of-hospital cardiac arrest: A systematic review and meta-analysis. Resuscitation 135 (2019) 124-129.
Cheskes S, Dorian P, Feldman M, et al. Double Sequential External Defibrillation for Refractory Ventricular Fibrillation: The DOSE VF Pilot Randomized Controlled Trial. Resuscitation. 2020
Gerstein NS, McLean R, Stecker EC, Schulman PM. External Defibrillator Damage Associated With Attempted Synchronized Dual-Dose Cardioversion. Annals of EM. 2018;71:109-112.