Featured Doctors of the Month

Transcription

1 Featured Doctors of the Month Dr Rakhee Yash Pal MBBS, MRCS-ED, MMED, FAMS Emergency Medicine Department National University Hospital Jan- Mar 2018 There have been many challenges and adaptations; the fast-paced, time-pressured ED environment, limited timely access to community resources, ethical and medicolegal considerations. However, the change in ED culture and mindset in embracing the care of the dying has been heartening. It is not a matter of doing everything possible or doing nothing, but doing what is reasonable and right. And what is right for the dying patient is what respects their values, prioritises comfort and dignity, and brings consolation and meaning to those who will be left behind. An age-old saying stays relevant to Emergency Medicine as to any other; To cure sometimes, to relieve often, but to comfort always! Dr Rakhee Yash Pal completed her speciality training in Emergency Medicine in Singapore and has been working in the National University Hospital since She serves as the Emergency Department Palliative Care Director. Her sub-speciality interests are in trauma resuscitation and the novel field of palliative and end-of-life care in the emergency department. The EDEN (Emergency Department End-of-Life NUH) Project Is Emergency Medicine just about aggressive resuscitation and saving lives? It entails a lot more than that. The reality is that we see many patients with severe end-stage chronic disease, terminal cancer and even acute catastrophic illness, where the resuscitative approach is often neither appropriate, nor even desired by patients and families. This is where we advocate an aggressive palliative approach in emergency medicine. Data has shown that in the National University Hospital, 25% of all deaths occur in the Emergency Department (ED), averaging one death a day. An additional 12% died within 24 hours of admission from ED to the inpatient wards. This indicates that the ED manages large numbers of death and dying patients. It is therefore imperative that we acknowledge the need for quality end-of-life (EOL) care provision at ED. In 2014, a team of doctors and nurses set up a workgroup to meet the needs of ED patients at their end of life. The EDEN Project entailed the establishment of specific guidelines and clinical workflows for EOL provision at the ED. We identify patients that are at the end-of-life (EOL) early at the ED, conduct goals of care discussions, and aid EOL decisionmaking. The clinical management focus shifts to comfort care and alleviating symptoms of breathlessness and pain. Dignified care of the dying patient is a priority. Families are given special visitation privileges and the privacy of a Quiet Room. We continually aim to equip our ED staff with knowledge, skills and resources to provide a good standard of palliative care. The pioneer members of the EMD Palliative Workgroup: (left to right) APN Geraldine Baird, Dr Lee Sock Koon, Dr Rakhee YP, Dr Jane Philips, Dr Alina Tan, Dr Peng Li Lee, NM Uma Chandra, Ms Janet Seak Dr Daniel Chor MBBS, MCEM, MMed (Emergency Medicine) Associate Emergency Medicine Department National University Hospital Dr Daniel Chor recently completed his specialty training in Emergency Medicine in July He was also the Chief Resident of the NUH Emergency Medicine Residency in 2014 and a participant in the Singapore Chief Resident Program in His clinical and research interests are in observational medicine, patient safety and end-of-life care in the emergency department.

2 Enhancing patient safety and optimising care in the Emergency Department The Emergency Department at NUH sees approximately 120,000 patients a year. With the high volume of patients, together with the chaotic environment and regular turn-over of medical officers and residents, it is easy to compromise on patient safety to cope with the patient numbers. To reduce the incidence of patient safety incidents and to enhance patient care, various initiatives have been introduced in the department. These include: introduction of needle-less blood transfer devices, teambased patient management involving nurses, clinician safety huddles between shifts to bring up any immediate safety events, regular safety team meetings to work towards reducing safety incidents and two monthly safety bulletins to highlight recurrent issues. Through these initiatives, we hope to promote a culture of safety that can be carried by our medical officers / residents to the other departments that they may rotate to in future. In terms of improving patient care, systematic audits of stroke and acute myocardial infarction (AMI) related management are also performed. Regular cross-departmental meetings are held to enhance work flows and cooperation between the various stake holders. These have resulted in consistent and low Door-to-Balloon (for Percutaneous Coronary Intervention within ninety minutes for patients presenting with AMI) and Door-to-Needle (for thrombolysis within 60 minutes for patients presenting with ischaemic strokes) times. Given the importance of timely interventions for these conditions, this inter-disciplinary work will continue to impact on patient outcomes for years to come. In the News Picture 1: EMD Trauma Team assembled in response to a pre-hospital trauma activation With tertiary-level hospital Emergency Medicine Departments (EMD) - like the one the National University Hospital (NUH) - being staffed 24/7 by specialist board-certified EPs and all relevant trauma-related specialties being in house - Trauma surgery, orthopedics, neurosurgery, paediatric surgery, Ob-Gyn, interventional radiology among others we are uniquely equipped to manage the immediate, and subsequent downstream care, of all manner of complex trauma cases. Our hardware includes dedicated trauma resuscitation bays, portable x-ray machines, rapid infusers, intraosseous vascular access systems and an indepartment CT scanner. Epidemiology: Major trauma has traditionally been viewed as a disease of the young. With ageing populations in developed societies, the major population involved in major trauma is becoming more elderly as well. Trauma Care at the Emergency Medicine Department Introduction: Modern day trauma care needs to be understood as a continuum: beginning with safe retrieval and optimal interventions by paramedics in the field; diagnosis, resuscitation by the EMD. If needed, surgical intervention by trauma surgeons; intensive care support; recovery with physiotherapy and occupational therapy in the wards; long term physical rehabilitation and psychological support services. All the pieces must synergise to ensure the best outcome for the patient. NUH EMD overview: The role of the Emergency Medicine Physician (EP) in the care of trauma patients has undergone a significant change since the earlier days of the specialty. Fig 1: NUH Trauma Registry Data for 2015 The data from the NUH Trauma Registry (2015) indicates that though the 65 demographic comprises 12% of all adult-emd cases, almost 43% of these patients get admitted. In comparison, the overall admission rate for the years old demographic is much lower at 13% (1). Accidents, violence & poisonings remain the foremost conditions for hospitalisation in Singapore (2).

3 The tier 3 trauma patient: The significant majority (up to 98%) of patients seen at healthcare facilities across Singapore for trauma related presentations, comprise tier 3 patients. Patients with this lower acuity of trauma are routinely seen in the primary care settings and subsequently get referred to EMDs for various manner of further management, or interventions. Joint dislocations are routinely reduced in the EMD. Adequate levels of analgesia and sedation are administered using procedural sedation as per departmental protocols. Inhalational anesthetic agents like Entonox, and nerve blocks are used for the reduction of selected joint dislocations. To optimise care delivery and meet patient expectations, it is advisable that primary healthcare professionals are well versed in the capabilities of the centre that the patient is being referred to. This part of the article attempts to elaborate upon some of NUH EMD s capabilities for the management of the tier 3 trauma patient. Orthopaedic injuries: The emergency department at NUH manages a significant number of orthopedic injuries. These include sprains (ligamentous injuries), strains (muscle injuries), simple lacerations, joint dislocations and minimally displaced fractures. The majority of these injuries are seen, diagnosed and discharged from the EMD. Closed fractures of the distal forearm are a particularly frequent presentation to the EMD. The majority of these patients undergo reduction of the fractures under intravenous regional anesthesia by the Bier s block. Post reduction x-rays ensure acceptable reductions and the patients are discharged with short arm back slabs and outpatient orthopaedic follow up. Picture 3: Simulated patient undergoing reduction of a right shoulder dislocation in the EMD. Demonstrating use of patient administered Entonox inhalation for pain relief Picture 2: Simulated patient undergoing reduction of a distal radius fracture in the EMD under regional anesthesia (Bier s block), using an automatic tourniquet system Observation unit: The department has an 18 bedded Extended Diagnosis and Treatment Unit (EDTU). The patients admitted to the unit are managed as per specific protocols. Patients presenting with history of trauma and assessed to be requiring prolonged observation are admitted under two protocols: head injury protocol & blunt chest trauma protocols. Patients considered for EDTU admission include: Minor head injury: 1. Head injury with history of LOC> 10 min or transient amnesia. 2. Persistent nausea and vomiting after minor HI despite treatment. 3. Uncomplicated, non-depressed closed skull fracture. 4. No reliable caregiver at home. 5. Patient on anticoagulants. Blunt chest trauma: 1. Significant blunt chest trauma with no evidence of underlying organ injury. 2. Normal vital parameters. 3. Normal/non-significant injuries on CXR. 4. Normal screening hematological & biochemical labs.

4 In summary, besides being equipped and staffed to manage the entire spectrum of trauma including special groups. The EMD at NUH evaluates and manages a significant number of walk-in trauma patients. To optimize care delivery and patient expectations, it is key that primary healthcare professionals are well versed in the capabilities of the centre that the patient is being referred to. References: 1) Trauma Registry (NUH) data ) MOH Singapore Health Facts Top 10 Conditions of Hospitalisation ( ) The author wishes to acknowledge the tireless efforts of the Team EMD in striving every day to provide world-class care to all our patients. Special thanks to Ms Chin Sock Teng, Senior Clinical Research Coordinator, National University Health System, Singapore. Photos courtesy: Picture 1: (Left to right): Dr Nikhil Joy, Dr Tay Wei Ling, Dr Ian Mathews, SSN Marinel Duclayan Obejas, SN Yu Jialin, SSN Jessica Santyh Anak Silon. Picture 2: SSN Loh Xie Hui Dave, SSN Toh Shi Yun Kelly. Picture 3: SSN Eunice Ubaldo, SSN Loh Xie Hui Dave. Article by: Dr Kanwar Sudhir Lather To simulate trauma realistically, we obtained assistance from the Centre of Healthcare Simulation, NUS to train members of the team on how to moulage various wounds and the necessary moulaging equipment. Feedback and post-program tests demonstrated that the training program was very helpful and greatly appreciated by the Timorese doctors. During the trips, we also ran mobile clinics in villages treating presentations like sprains, anaemia and various skin conditions. After a medical consult, the patients were given medication, advice, referrals or taught simple physiotherapy depending on the condition. Frequently, a dental specialist from NUH Oral-maxillary Surgery Department will come alongside to treat dental conditions and perform extractions. Preventive medicine sessions on tooth brushing with the village children were also conducted with free toothbrush and toothpaste distributed after the sessions. As NUH EMD has a strong culture of excellence in clinical practice and medical education, the program allows us to leverage on our strengths to contribute to a need in Timor-Leste as part of our hospital s corporate social responsibility efforts. We are thankful for the support of the hospital leadership and we look forward to more opportunities for us to extend our education work to serve people in need. Article by: Dr Derek Heng Jiun Yi A Volunteering Heart Empowering the Healthcare Workers of Timor-Leste In 2011, Care Channels International- Timor-Leste (CCI-TL), an NGO (nongovernment organisation) working with the villages in Timor-Leste, approached the National University Hospital (NUH) Emergency Medicine Department (EMD) to collaborate in a medical education project. At that time, there were a large number of young doctors coming back to Timor- Leste after a seven-year medical undergraduate program in Cuba. The Timorese doctors were sent to Cuba for training as there were only 47 doctors and no medical school in Timor-Leste after the Indonesians withdrew in As the Cuban program was mostly lecture-based, there was a great need for more hands-on training and assistance in practical application, leading to the development of this training program. These topics were taught by an inter-professional team from NUH EMD comprising nurses, residents and specialists. Doctors from other disciplines joined the team frequently and taught modules on paediatric emergencies, dermatology and O&G. We also held practical sessions on suturing, hand-washing and even bought a simulator to allow the doctors and mid-wives to have more practice with obstetric emergencies like breech delivery and post-partum haemorrhage. Training in Timor-Leste Passion Beyond Duty Saving Starfish Saving Souls Why does your project title sound so familiar? I thought to myself as I was invited by Dr. Loon Seng Chee (Ophthalmology, NUH) to help out with his overseas community involvement programme. Then it struck me it was a page out of The Star Thrower by Loren Eiseley where one attempts to change the world for the better, one step at a time. Saving Starfish Saving Souls is a self-funded initiative by Dr Loon. He and his team (mostly assembled from NUH and SNEC) travel to impoverished regions around Asia to perform cataract and pterygium removal surgery, giving the gift of sight back to the people. GP Liaison Centre 1E, Kent Ridge Road, NUHS Tower Block, Level 6, Singapore

5 August 2017 saw the team partner with Cambodia International Sight Foundation(CISF), a local non-governmental organization (NGO) led by H.E Sean Ngu (also the Cambodian Secretary of State) to perform over 50 operations over a period of 5 days in Preah Ang Duong Hospital, Phnom Phen. With only 38 ophthalmologists serving a population of 15 million, there is a pressing need for others to fill in the gap. Despite my lack of ophthalmology training, I was able to contribute in my own way by being the overall administrative coordinator (or the Chief Minion as Dr. Loon would call it). Amongst other responsibilities, I was required to troubleshoot any problems may arise during the course of the mission (which can you imagine happens quite frequently!) While it certainly was not easy being in a foreign land away from the creature comforts of home, each smile from the patients and their family members post-op made it all worthwhile. Truly, no one has ever become poor by giving. Sisters Joann Pang, Tan Cheng Hong with Dr Nyo Yoke Lin with the local translators Article by: Dr Dennis Chia Honorary Associate Team Saving Starfish Saving Souls celebrating National Day over lunch Upcoming CME Event. Dr Ng Bang Teen, our Anesthesiologist carrying a post op patient to the recovery room 20 Jan Date Topic Venue Management of Dementia & Diabetes 27 Jan Advances in Modern Hernia Management: From Open to Roboticassisted Repair NUHS Tower Block Auditorium 1E Kent Ridge Road Hotel Jen Tanglin Singapore 1A Cuscaden Rd, Malacca 2 & Penang, Level 2A 27 Jan Practical Tips in Sports Medicine for the General Practitioner NUH Sports Centre Dr Lee Chin Piaw performing cataract surgery For more information and registration, you may contact the GP Liaison Centre at gp@nuhs.edu.sg Registration & lunch will start at 1.00 pm For more information and registration, you may contact the GP Liaison Centre at gp@nuhs.edu.sg