This is not particularly common; but is very often missed. When missed, the potential for medicolegal action is high, and often very difficult to defend. So, listen up.
TON refers to injury to the optic nerve as a result of trauma; which may be direct (often a result of orbital fractures and bone ends that sever the nerve) or indirect (usually as a result of blunt force applied on the orbit or malar eminences - a high force impact over the eye or on the cheek). Nobody can really know for sure why the Optic N gets injured indirectly; shear force injuring the axons, or local swelling of the nerve at that area resulting in secondary injury. But regardless, TON must be considered in every patient with local injury over the eye and / or cheek; especially if associated with blunt head injury.
Which is why TON is easily missed. The main symptom is blurring of vision in that eye; not something the patient will readily complain of when their face is smashed, or their eyes are so swollen that they cannot open it to see. Worse still, if it is associated with blunt head injury and a low GCS. It is NOT easily identified on fundoscopic examination in the initial 24 hours, and the main suspicion will come from a Relative Afferent Pupillary Defect (RAPD) detected by the swinging torchlight test. (YouTube) This is often not done in the ED, for many reasons (none of which will convince the Judge in a medical negligence suit). Therefore, this is commonly missed; and the patient will only notice persistent vision blurring or loss after days to weeks; when nothing can be done.
So what can be done, if TON is diagnosed ? Actually, nothing much. In many patients, the visual loss is temporary and will recover to some extent. Surgical decompression was used for some time in some countries, but very little evidence can support its efficacy (probably unless structural defects that require decompressing can be demonstrated). For some time, the use of high dose steroids (esp Methyl Prednisolone) was promoted as the wonder drug, to be given early for better outcomes. Most recent trials have not found conclusive evidence to support this either.
So what then is the issue, you may ask ? If there is no real treatment, why sue the doctor for missing it in the first place ? The Courts do not work that way, my friend. As long as there is a "potential" for recovery, and that "potential" was not made available to the patient because the diagnosis was missed, it is negligence. Not really how medicine works, but that's why they are lawyers and not doctors.
How then to stay safe ie how to keep the lawyers at bay ? Examine the eye carefully in every patient with injury around the eye and cheek; esp if they have head injury as well. Check for the RAPD. Check for pupillary response. DOCUMENT IT. If you are unable to check (swollen, uncooperative, priority to head injury etc), make sure you refer to the Ophthalmology team for a complete eye examination. And write that down it.
Much, much better than having to appear in inquiry and inquiry after inquiry and then in courts. Stay safe.
In a few days time, I will hand over the helmship of the ED which I have had the opportunity and privilege to lead for (almost) the last 9 years. This has been in planning for more than a year, and careful steps have been done over the last year to make it happen in the best way possible. And now that the time is really near, and most of the tasks are already done, I am honestly feeling rather happy.
I will not stop working here; in fact my role will remain even more clinical and at the same time, more planning and oversight as I continue, for a while, the newer tasks that I have assumed. I look forward to this new role with quite a bit of excitement, a little bit like a boy with a new toy.
Now, it is customary to do several things when you leave. And, if you know me at all, you will know that I rebel at anything customary. So I will NOT do the following
I will not leave a long list of unrealized targets for my successor. It is tough enough to do the job; no need the additional burden of what I could not achieve myself
Similarly I will not assume great wisdom and give lots of advice. Most advice is, well, unwarranted and merely reflects unattained goals of the advisor. No sireeee. I am no wiser than everybody else.
I will also NOT assume that the days under my helm was any better than the days to come. The future is always brighter, the younger are always better. A really useful quote comes to mind (Thanks Bro!) "Every new generation outperforms the previous one, despite every prediction that it will fail". To the young, it is your world, your time and your day.
I will also NOT apologize for being rude, for stepping on toes, for making someone else feel hurt nor for doing what needs to be done. I performed my role as best as I could, using the force of my conscience to guide me. I will not have done any differently otherwise as I have not let my conscience down.
I must however thank several people.
My family has been the support structure on which I have built everything else. That foundation has held strong despite the demands placed upon it. I am nothing without this.
My "comrade-in-arms" (you know who you are) have been my pillars; you have held back my impatience, reasoned with my folly, and argued with my delusions; that wisdom, experience and knowledge that I have, is no less a credit to me as it is to you.
So this last post of 2011 is just to say that. Nothing special really, but very special too, to me.
This change is ultimately just a start of a new morning in a new year. A year and a future that I really look forward to.
And on the last night, of the last day of the year, it is appropriate just to say "Thank You, and Good Night"
In a few days time, I will hand over the helmship of the ED which I have had the opportunity and privilege to lead for (almost) the last 9 years. This has been in planning for more than a year, and careful steps have been done over the last year to make it happen in the best way possible. And now that the time is really near, and most of the tasks are already done, I am honestly feeling rather happy.
I will not stop working here; in fact my role will remain even more clinical and at the same time, more planning and oversight as I continue, for a while, the newer tasks that I have assumed. I look forward to this new role with quite a bit of excitement, a little bit like a boy with a new toy.
Now, it is customary to do several things when you leave. And, if you know me at all, you will know that I rebel at anything customary. So I will NOT do the following
I will not leave a long list of unrealized targets for my successor. It is tough enough to do the job; no need the additional burden of what I could not achieve myself
Similarly I will not assume great wisdom and give lots of advice. Most advice is, well, unwarranted and merely reflects unattained goals of the advisor. No sireeee. I am no wiser than everybody else.
I will also NOT assume that the days under my helm was any better than the days to come. The future is always brighter, the younger are always better. A really useful quote comes to mind (Thanks Bro!) "Every new generation outperforms the previous one, despite every prediction that it will fail". To the young, it is your world, your time and your day.
I will also NOT apologize for being rude, for stepping on toes, for making someone else feel hurt nor for doing what needs to be done. I performed my role as best as I could, using the force of my conscience to guide me. I will not have done any differently otherwise as I have not let my conscience down.
I must however thank several people.
My family has been the support structure on which I have built everything else. That foundation has held strong despite the demands placed upon it. I am nothing without this.
My "comrade-in-arms" (you know who you are) have been my pillars; you have held back my impatience, reasoned with my folly, and argued with my delusions; that wisdom, experience and knowledge that I have, is no less a credit to me as it is to you.
So this last post of 2011 is just to say that. Nothing special really, but very special too, to me.
This change is ultimately just a start of a new morning in a new year. A year and a future that I really look forward to.
And on the last night, of the last day of the year, it is appropriate just to say "Thank You, and Good Night"
There is this hospital in a political area (which means that its MP was once a VVIP somebody). A district hospital similar to almost every other, with one significant exception; that it is just about a thousand times more likely to receive complaints from its patients than any other.
Wait half hour to see doctor, some Minister calls you up. Cannot get medical report extra early, the PM's department calls you up. The gardener of the politician sprains his foot, you get called up to wait for his arrival at the ED. Someone comes with a cough and cold to the ED; try diverting that fellow to the nearest health clinic, and you will probably get asked your name and receive the "Don't you know who my relative is ?" thinly veiled threat.
As such, the Emergency Department in this hospital now runs on a manic mode; everything needs to done fast; fast fast fast. Never mind properly, just fast will do. And everybody, just about everybody is seen at the ED. No diverting patients away to the Klinik Kesihatan just down the road.
So now this ED sees 70% of its workload in NON-emergencies. The standard cough and running nose patient will come to the ED and insist on being attended to in good time. A real emergency case will still be attended to immediately, but soon after the initial resuscitation is done, most of the team will have to go attend to the non-emergencies, so that they will not have to answer to complaints !
And when any referral to another specialist hospital needs to be done, the ambulance must send them, even though it is not a critical nor urgent referral. Because the ambulance must, or else ..... Sometimes, true emergencies cannot be sent immediately because all the ambulances are out sending these non-urgent referrals to other hospitals !
It is just a ridiculous situation; a freak result of our complaint culture; and the wielding of political influence on daily life. It is the madness of me, me, me.
In the politics of today, it is ME, ME, ME. We have forgotten that we have but one cake; and pushing for more for ME will mean less for everyone else. Who is everyone else ? Our very own community. So the madness of ME kills our own community.
This madness is seen everywhere. Another example. At the end of every year, every ED runs a community circumcision program; conducted in sterile operating room environments with sterile equipment and the highest standards, it is done FREE. All that is needed is to make an appointment in advance. Great, right ? Not so great, it seems for politicians. They, instead, want to do hundreds of circumcisions in the open, in community halls, in villages; because it is more "meriah" and they can have kenduris and political events together with it. They will then insist that we provide the staff for it, and the equipment for it. They will not listen to our concerns about sterility; nor to our concerns about having to perfunctorily clean equipment between patients instead of full sterilization; nor to our laments about higher risks of infections. No, these are not excuses they want to hear. Say it, and they will then demand your name and threaten to inform the Minister or Deputy or whoever other politician's name they feel like using on that day. Just madness.
Just pure madness ....
There is this hospital in a political area (which means that its MP was once a VVIP somebody). A district hospital similar to almost every other, with one significant exception; that it is just about a thousand times more likely to receive complaints from its patients than any other.
Wait half hour to see doctor, some Minister calls you up. Cannot get medical report extra early, the PM's department calls you up. The gardener of the politician sprains his foot, you get called up to wait for his arrival at the ED. Someone comes with a cough and cold to the ED; try diverting that fellow to the nearest health clinic, and you will probably get asked your name and receive the "Don't you know who my relative is ?" thinly veiled threat.
As such, the Emergency Department in this hospital now runs on a manic mode; everything needs to done fast; fast fast fast. Never mind properly, just fast will do. And everybody, just about everybody is seen at the ED. No diverting patients away to the Klinik Kesihatan just down the road.
So now this ED sees 70% of its workload in NON-emergencies. The standard cough and running nose patient will come to the ED and insist on being attended to in good time. A real emergency case will still be attended to immediately, but soon after the initial resuscitation is done, most of the team will have to go attend to the non-emergencies, so that they will not have to answer to complaints !
And when any referral to another specialist hospital needs to be done, the ambulance must send them, even though it is not a critical nor urgent referral. Because the ambulance must, or else ..... Sometimes, true emergencies cannot be sent immediately because all the ambulances are out sending these non-urgent referrals to other hospitals !
It is just a ridiculous situation; a freak result of our complaint culture; and the wielding of political influence on daily life. It is the madness of me, me, me.
In the politics of today, it is ME, ME, ME. We have forgotten that we have but one cake; and pushing for more for ME will mean less for everyone else. Who is everyone else ? Our very own community. So the madness of ME kills our own community.
This madness is seen everywhere. Another example. At the end of every year, every ED runs a community circumcision program; conducted in sterile operating room environments with sterile equipment and the highest standards, it is done FREE. All that is needed is to make an appointment in advance. Great, right ? Not so great, it seems for politicians. They, instead, want to do hundreds of circumcisions in the open, in community halls, in villages; because it is more "meriah" and they can have kenduris and political events together with it. They will then insist that we provide the staff for it, and the equipment for it. They will not listen to our concerns about sterility; nor to our concerns about having to perfunctorily clean equipment between patients instead of full sterilization; nor to our laments about higher risks of infections. No, these are not excuses they want to hear. Say it, and they will then demand your name and threaten to inform the Minister or Deputy or whoever other politician's name they feel like using on that day. Just madness.
Just pure madness ....
In just a few days time, we will hold the second edition of the National Pre-Hospital Care Competition awarding the Tuan Gurcharan Singh Challenge Trophy. This time, it will be more difficult and much more challenging, aimed at raising the standards of paramedics to an even higher level. This second edition, coupled with a Pre-Hospital Care seminar, will bring together more than 12 teams from around the country representing different ambulance service providers, and more than 200 paramedics either as competitors, observers or seminar participants. It should be a good one, a true Battle of Paramedics !
You may ask, why compete ? I believe that anyone and everyone that lays claim to some sort of professional standard must have deep within them some yearning to know where they stand; how they compare to the rest; where their abilities lie; what their deficiencies are; and are they really as good as they think they are. Competition is the only way for us all to know this; in a fair and clear manner.
But competition is not merely an exercise in comparison; it encourages a spirit of continual improvement, the reality of self-reflection and a desire to go beyond what we already are. Competitions makes winners of all who participate.
So what can we then say about those who shirk away from competition ? Those who do not take part for reasons unimaginable and immaterial ? Maybe they are just not interested in continual improvement, or maybe self-reflection will conjure an unflattering result. Maybe they just cannot handle the thought that the young may be better than the old. Maybe they are just too comfortable where they now are.
Or maybe I am just too old school. Maybe competition is outdated; together with fairplay, challenging oneself and each other, maybe it is just not part of today's world. Maybe I am just an old fart sour grapes.
Old school or not, to me, competition is about life itself. Life needs us to compete, in order to survive. Life needs us to improve, in order to survive. The adversities and challenges that life throws to us makes us better in the long run. The kite needs the resistance of the wind to fly higher. Competition just creates those similar challenges in simulation; an artificial wind for us to test our wings.
The Tuan Gurcharan Singh competition will have its winners and its losers. On the whole, everyone will end up a winner; ambulance teams will have improved, paramedics will have learnt and practiced more. Friendships will be made; information shared, ideas created. Not least of all, the real winners will be the next patients in their ambulances, who would have benefited from this unique effort at improving our paramedics and the care that they provide.
See you all there.
In just a few days time, we will hold the second edition of the National Pre-Hospital Care Competition awarding the Tuan Gurcharan Singh Challenge Trophy. This time, it will be more difficult and much more challenging, aimed at raising the standards of paramedics to an even higher level. This second edition, coupled with a Pre-Hospital Care seminar, will bring together more than 12 teams from around the country representing different ambulance service providers, and more than 200 paramedics either as competitors, observers or seminar participants. It should be a good one, a true Battle of Paramedics !
You may ask, why compete ? I believe that anyone and everyone that lays claim to some sort of professional standard must have deep within them some yearning to know where they stand; how they compare to the rest; where their abilities lie; what their deficiencies are; and are they really as good as they think they are. Competition is the only way for us all to know this; in a fair and clear manner.
But competition is not merely an exercise in comparison; it encourages a spirit of continual improvement, the reality of self-reflection and a desire to go beyond what we already are. Competitions makes winners of all who participate.
So what can we then say about those who shirk away from competition ? Those who do not take part for reasons unimaginable and immaterial ? Maybe they are just not interested in continual improvement, or maybe self-reflection will conjure an unflattering result. Maybe they just cannot handle the thought that the young may be better than the old. Maybe they are just too comfortable where they now are.
Or maybe I am just too old school. Maybe competition is outdated; together with fairplay, challenging oneself and each other, maybe it is just not part of today's world. Maybe I am just an old fart sour grapes.
Old school or not, to me, competition is about life itself. Life needs us to compete, in order to survive. Life needs us to improve, in order to survive. The adversities and challenges that life throws to us makes us better in the long run. The kite needs the resistance of the wind to fly higher. Competition just creates those similar challenges in simulation; an artificial wind for us to test our wings.
The Tuan Gurcharan Singh competition will have its winners and its losers. On the whole, everyone will end up a winner; ambulance teams will have improved, paramedics will have learnt and practiced more. Friendships will be made; information shared, ideas created. Not least of all, the real winners will be the next patients in their ambulances, who would have benefited from this unique effort at improving our paramedics and the care that they provide.
See you all there.
Exanthems - Greek "exanthema" meaning 'breaking out' refers to widespread rashes often occurring in children and associated with fever. There were originally 6 classical or original childhood exanthems; and they were numbered in 1905 as follows: - First disease - refers to measles (rubeola) which was described aeons ago
- Second disease - refers to scarlet fever which was differentiated from measles in the 17th century
- Third disease - refers to german measles (rubella) which was described in 1881
- Fourth disease - refers to Filatov or Dukes disease which was described by Dr Clement Duke in 1900; but it has not been widely accepted as an independent entity since.
- Fifth disease - refers to Erythema Infectiosum which was initially described in 1896 and later renamed as the fifth disease in 1905; currently the only one that retains the original numbered nomenclature
- Sixth disease - refers to roseola infantum (exanthem subitum) which was the last of the original list.
Later on, most of the diseases reverted to their original names except for Erythema Infectiosum which is still commonly called Fifth disease today. [sometimes mistakenly accredited to Dr Fifth!!]
It is often quite difficult to manage children with febrile exanthems. Firstly it is often difficult to describe the lesion. Secondly, some lesions are more obvious in more obscure areas. More often than not, it is associated with significant parental anxiety and doctor anxiety as well. This is justifiable because hidden in the mysteries of the rashed lurk potential life threatening conditions hidden amongst the common diseases of children.
This diagrammatic flow chart is an excellent way of approaching the child with exanthems. This is adapted from the Royal Children's Hospital in Melbourne.
I thought it would be interesting to review some of the more common rashes that we may come across at the ED. Part One will be the common, probably less dangerous exanthems. Rash with clear fluid filled lesions 
Varicella (chickenpox) - initially papules then vesicles appearing like little drops of water on skin, which rapidly turns into pustules and crusts; often occurs in crops of varying types; starting from the face and scalp, then spreading to trunk and to extremities. Fever initially high, then becomes low grade. Be careful of dyspnoea / breathlessness which may indicate VZ Pneumonitis. 
Impetigo - probably the most common skin infection in children, caused by Strep or Staph. Varied presentations, often itchy. One or a few blisters which are easily broken leaving a red raw-looking base, that may crust up. Lymphadenopathy in draining lymphatics. Treat with anti-bacterial cream in mild cases, oral antibiotics in severe cases. MRSA related is becoming more common.
Papular Rash LesionsUrticaria - aka Hives, Nettle Rash (no nettle in Malaysia; but the same itchy lesions seen with contact to some plants). Highly itchy papular lesions, appears suddenly especially with a triggering incident, and often resolves spontaneously after a day or two. [for the unfortunate few, it can turn to chronic urticaria lasting months, often with an unfruitful search for the triggering cause]. A cool bath / shower help relieve some of the itchiness; so do anti-histamines (but try to avoid this). I've never given steroids, but it is written in the recommendations for severe situations.
Molluscum Contagiosum - viral infection; develops 2 weeks odd after infection; lasts for about 2 - 3 months then disappears. Often disappears on its own after 12 - 18 months. This is the one skin rash that is often treated with home remedies like garlic, etc etc.
Measles - used to be the most common viral exanthem; but very rare nowadays due to the high rates of immunizations in children. Outbreaks still occur amongst immigrant populations. It is a highly infectious disease with symptoms appearing about 10 days after droplet or fomite contact; often with fever, runny nose and sore red eyes; followed quickly by the development of a rash. Koplik's spots ? Wish I actually saw more of them.
--- End of Part One ---
Exanthems - Greek "exanthema" meaning 'breaking out' refers to widespread rashes often occurring in children and associated with fever. There were originally 6 classical or original childhood exanthems; and they were numbered in 1905 as follows: - First disease - refers to measles (rubeola) which was described aeons ago
- Second disease - refers to scarlet fever which was differentiated from measles in the 17th century
- Third disease - refers to german measles (rubella) which was described in 1881
- Fourth disease - refers to Filatov or Dukes disease which was described by Dr Clement Duke in 1900; but it has not been widely accepted as an independent entity since.
- Fifth disease - refers to Erythema Infectiosum which was initially described in 1896 and later renamed as the fifth disease in 1905; currently the only one that retains the original numbered nomenclature
- Sixth disease - refers to roseola infantum (exanthem subitum) which was the last of the original list.
Later on, most of the diseases reverted to their original names except for Erythema Infectiosum which is still commonly called Fifth disease today. [sometimes mistakenly accredited to Dr Fifth!!]It is often quite difficult to manage children with febrile exanthems. Firstly it is often difficult to describe the lesion. Secondly, some lesions are more obvious in more obscure areas. More often than not, it is associated with significant parental anxiety and doctor anxiety as well. This is justifiable because hidden in the mysteries of the rashed lurk potential life threatening conditions hidden amongst the common diseases of children.
This diagrammatic flow chart is an excellent way of approaching the child with exanthems. This is adapted from the Royal Children's Hospital in Melbourne.
I thought it would be interesting to review some of the more common rashes that we may come across at the ED. Part One will be the common, probably less dangerous exanthems. Rash with clear fluid filled lesions Varicella (chickenpox) - initially papules then vesicles appearing like little drops of water on skin, which rapidly turns into pustules and crusts; often occurs in crops of varying types; starting from the face and scalp, then spreading to trunk and to extremities. Fever initially high, then becomes low grade. Be careful of dyspnoea / breathlessness which may indicate VZ Pneumonitis. Impetigo - probably the most common skin infection in children, caused by Strep or Staph. Varied presentations, often itchy. One or a few blisters which are easily broken leaving a red raw-looking base, that may crust up. Lymphadenopathy in draining lymphatics. Treat with anti-bacterial cream in mild cases, oral antibiotics in severe cases. MRSA related is becoming more common.
Papular Rash LesionsUrticaria - aka Hives, Nettle Rash (no nettle in Malaysia; but the same itchy lesions seen with contact to some plants). Highly itchy papular lesions, appears suddenly especially with a triggering incident, and often resolves spontaneously after a day or two. [for the unfortunate few, it can turn to chronic urticaria lasting months, often with an unfruitful search for the triggering cause]. A cool bath / shower help relieve some of the itchiness; so do anti-histamines (but try to avoid this). I've never given steroids, but it is written in the recommendations for severe situations.
Molluscum Contagiosum - viral infection; develops 2 weeks odd after infection; lasts for about 2 - 3 months then disappears. Often disappears on its own after 12 - 18 months. This is the one skin rash that is often treated with home remedies like garlic, etc etc.
Measles - used to be the most common viral exanthem; but very rare nowadays due to the high rates of immunizations in children. Outbreaks still occur amongst immigrant populations. It is a highly infectious disease with symptoms appearing about 10 days after droplet or fomite contact; often with fever, runny nose and sore red eyes; followed quickly by the development of a rash. Koplik's spots ? Wish I actually saw more of them.
--- End of Part One ---
I'm kinda passionate about our country - in many ways, I feel that we have gone down the wrong path for many years, and this accounts for many of the ills that we face today. I am passionate because I feel we can be so much better; if only ....
That is why I write so much about Malaysia in this blog. Writing to create awareness, to stimulate thought, to initiate greater community activism and above all, writing to invoke a response, regardless of whether you agree with me, or not.
But in typical Malaysia style, we keep quiet, we let things be. We don't bother to take a stand, and make our stand known. We leave things as "No Comments". Surely this is not the Malaysian of the future, passively waiting as the future sweeps us away, into whichever direction it want.
So, this is what I'll do. These are the links to several articles from before. Let me know what you think, agree or not. Let me know what your stand is - it is your right to have a stand of your own. Just let me know.
The Utter Insignificance of Here and NowA country with the richest and most powerful ...To my friends who now live somewhere elseLost generations in MalaysiaAttitude, Mindset and the Inertia of Change History Teaches Us DifferentFootball, the Game of Life Oh America
Let me know.
I'm kinda passionate about our country - in many ways, I feel that we have gone down the wrong path for many years, and this accounts for many of the ills that we face today. I am passionate because I feel we can be so much better; if only ....
That is why I write so much about Malaysia in this blog. Writing to create awareness, to stimulate thought, to initiate greater community activism and above all, writing to invoke a response, regardless of whether you agree with me, or not.
But in typical Malaysia style, we keep quiet, we let things be. We don't bother to take a stand, and make our stand known. We leave things as "No Comments". Surely this is not the Malaysian of the future, passively waiting as the future sweeps us away, into whichever direction it want.
So, this is what I'll do. These are the links to several articles from before. Let me know what you think, agree or not. Let me know what your stand is - it is your right to have a stand of your own. Just let me know.
The Utter Insignificance of Here and NowA country with the richest and most powerful ...To my friends who now live somewhere elseLost generations in MalaysiaAttitude, Mindset and the Inertia of Change History Teaches Us DifferentFootball, the Game of Life Oh America
Let me know.
A beautiful song for a soulful day ...
A beautiful song for a soulful day ...
As an emergency physician, you see terrible things. People, injured in all kinds of trauma incidents and accidents. Sometimes, the incident is the same, or the accident occurred in similar circumstances. In one, the injured patient would have suffered little, apart from wounds, abrasions and a bruised ego; and somehow in the other, the injured would be struggling between life and death; with no hope of recovery, of really ever being the same anymore.
There is really no way to explain that well; maybe it just wasn't their time yet. More likely, the ones that escaped with minor injuries were just damn lucky.
Every day, we will see these patients, injured, bleeding and in pain, brought in to the ED. Registered with different names, and different faces, but almost always, with the same story to tell. Knocked down by another vehicle. Avoiding something and crashed. Pedestrian run over by another vehicle. Cyclist ran off the road and crashed. Same story day in, day out. Why do some live while others die ? Why do some recover, whilst others suffer, incapacitated then die ?
We really don't know. Not their time yet ? Maybe. Just damn lucky ? Probably. But we do know this. The most common injured person, BY FAR, is the motorcyclist! The number of injured motorcyclists just overwhelms all other injuries that we see. And interestingly, the another common injury are the pedestrians hit by motorcyclists !! So, it would be safe to say that motorcyclists are a danger to themselves, and to others too.
But how do you tell this to your friends and family members who want to use their bikes on our roads ? How do you tell them that every day you see many others, in situations similar to that they are in, injured and maimed on our roads ?
Start mentioning injury and death, and quickly you get shushhhed and "Soi ! Soi !" [very much akin to washing your mouth out with soap, by western standards]. Start talking about how much more safe cars are, and you are met with a louder explanation about the "convenience" and "economy" of using bikes in our world. Persist with the topic and you get branded an old-fart who doesn't understand the joys of wind in your hair and the rumble between your thighs.
So, I do this. I nag generally everyone about the dangers of using the motorcycle on our roads. I nag and nag every chance I get. But if ever one of my friends or family ever get in an accident, I go straight to the point. Sell the bike !! My argument is this; if God wanted you to stop using the bike, He would give you a small accident and minor injuries. So, the accident was a warning. Just take it as a message from God. Sell the bloody bike. [Ooops .... sorry God.]
The problem starts becoming personal for the me is when they don't listen. Because, my greatest fear, my absolute worst nightmare, is that one day, God decides that enough is enough; and time's up. Before I can succeed in my argument, God takes the whole point away.
I have come to realize that the people on two wheels are really no better than smokers.
Smokers, for their own fulfillment, are not bothered about the risk their second hand smoke causes to their family, their children, their unborn child. They are not bothered about their reduced life span, about their worsening health and the ultimate need for their family to support them through their illness. They don't think about the suffering that their family goes through, when they are sick and when they die. They just think of the fulfillment from the next puff of smoke.
People on two wheels, for their own fulfillment of convenience, for the fun of wind in their hair and rumbling between their thighs, risk the very same thing. Their injury or their dying makes their family suffer as much, maybe even more. The thought of being incapacitated, and needing full time nursing care never crosses their minds. The possibility that everything could be taken away in that split second of carelessness from anyone on the road never seems near enough to consider. They just think of the selfish fulfillment of convenience.
Now, I do not mean people who cannot afford other modes of transport. I really don't. Many people in our community just cannot afford a car, new or old. Their only way is a bike. That's okay. They have no choice. Ask any one of them; they all wish that if they had the money, they would happily exchange their bikes for an old car. No, I do not mean them. My wish for them would be to achieve their dream.
But most people I know are not like that. They have a car. But they just prefer to use their bike. They are, in my mind, selfish and inconsiderate. No better than a smoker, risking themselves, their future and risking their family's future.
And don't even talk to me about bikers and smokers ....
As an emergency physician, you see terrible things. People, injured in all kinds of trauma incidents and accidents. Sometimes, the incident is the same, or the accident occurred in similar circumstances. In one, the injured patient would have suffered little, apart from wounds, abrasions and a bruised ego; and somehow in the other, the injured would be struggling between life and death; with no hope of recovery, of really ever being the same anymore.
There is really no way to explain that well; maybe it just wasn't their time yet. More likely, the ones that escaped with minor injuries were just damn lucky.
Every day, we will see these patients, injured, bleeding and in pain, brought in to the ED. Registered with different names, and different faces, but almost always, with the same story to tell. Knocked down by another vehicle. Avoiding something and crashed. Pedestrian run over by another vehicle. Cyclist ran off the road and crashed. Same story day in, day out. Why do some live while others die ? Why do some recover, whilst others suffer, incapacitated then die ?
We really don't know. Not their time yet ? Maybe. Just damn lucky ? Probably. But we do know this. The most common injured person, BY FAR, is the motorcyclist! The number of injured motorcyclists just overwhelms all other injuries that we see. And interestingly, the another common injury are the pedestrians hit by motorcyclists !! So, it would be safe to say that motorcyclists are a danger to themselves, and to others too.
But how do you tell this to your friends and family members who want to use their bikes on our roads ? How do you tell them that every day you see many others, in situations similar to that they are in, injured and maimed on our roads ?
Start mentioning injury and death, and quickly you get shushhhed and "Soi ! Soi !" [very much akin to washing your mouth out with soap, by western standards]. Start talking about how much more safe cars are, and you are met with a louder explanation about the "convenience" and "economy" of using bikes in our world. Persist with the topic and you get branded an old-fart who doesn't understand the joys of wind in your hair and the rumble between your thighs.
So, I do this. I nag generally everyone about the dangers of using the motorcycle on our roads. I nag and nag every chance I get. But if ever one of my friends or family ever get in an accident, I go straight to the point. Sell the bike !! My argument is this; if God wanted you to stop using the bike, He would give you a small accident and minor injuries. So, the accident was a warning. Just take it as a message from God. Sell the bloody bike. [Ooops .... sorry God.]
The problem starts becoming personal for the me is when they don't listen. Because, my greatest fear, my absolute worst nightmare, is that one day, God decides that enough is enough; and time's up. Before I can succeed in my argument, God takes the whole point away.
I have come to realize that the people on two wheels are really no better than smokers.
Smokers, for their own fulfillment, are not bothered about the risk their second hand smoke causes to their family, their children, their unborn child. They are not bothered about their reduced life span, about their worsening health and the ultimate need for their family to support them through their illness. They don't think about the suffering that their family goes through, when they are sick and when they die. They just think of the fulfillment from the next puff of smoke.
People on two wheels, for their own fulfillment of convenience, for the fun of wind in their hair and rumbling between their thighs, risk the very same thing. Their injury or their dying makes their family suffer as much, maybe even more. The thought of being incapacitated, and needing full time nursing care never crosses their minds. The possibility that everything could be taken away in that split second of carelessness from anyone on the road never seems near enough to consider. They just think of the selfish fulfillment of convenience.
Now, I do not mean people who cannot afford other modes of transport. I really don't. Many people in our community just cannot afford a car, new or old. Their only way is a bike. That's okay. They have no choice. Ask any one of them; they all wish that if they had the money, they would happily exchange their bikes for an old car. No, I do not mean them. My wish for them would be to achieve their dream.
But most people I know are not like that. They have a car. But they just prefer to use their bike. They are, in my mind, selfish and inconsiderate. No better than a smoker, risking themselves, their future and risking their family's future.
And don't even talk to me about bikers and smokers ....
Dr William Haddon Jr. Widely considered the father of modern injury epidemiology. I have been meaning to write this post for YEARS. Twice every year, after the Ops Sikap, I always get just soooo pissed off with the authorities. They seem just so helpless to do anything about our terrible road traffic accident death rates. Unfortunately, our authorities are not the experts; instetad they seem to only have a one-track mind; a single shot pistol; the only trick up their sleeve. Year in, year out, we are treated to the police, then the Minister or somebody lamenting about speeding, dangerous and inconsiderate drivers. In adverts, these drivers are always protrayed as the evil looking fellow, with dastardly schemes coming out of their every pore. And each year we are treated to police reports about how many saman they issued and the ever-increasing, how many deaths occurred.
Their single point is this. Our high numbers of road traffic accidents and deaths is due to DRIVERS faults and bad attitudes ie. you and me. We are the culprits if we are involved in an accident ! That is their single point. That seems to be the only job of the police at the moment. Determine who is wrong, so that the saman can ensue. And, that is why their main tool, their only tool to reduce the death rate is to saman us, and that is also why when they fail to reduce the death rate, the only excuse is the belligerent attitude of Malaysian drivers.
I challenge this point.
And I have two simple tools to tell you why. First tool, simple calculation. Every year, for at least the past 10 years, we have reported more than 5,500 deaths on our roads. Divided by 365, this averages out to just over 15 deaths per day, every day. So when the daily Ops Sikap reports comes out stating that similar figure, most Malaysians just tsk-tsk-tsk it thinking that it is an increased figure due to the higher traffic during those times. NOT TRUE. Essentially, we have the same death rate every day of the every year, for at least the last 10 years. To put it into context, the wars in Iraq and Afghanistan have resulted in 45,231 deaths of US, coalition, Iraqi and Afghan soldiers in the last 10 years. More than 50,000 deaths have occurred on Malaysian roads in that same time frame.
It is inconceivable that so many deaths are merely due to belligerent drivers with bad attitude. It is improbable that just trying to change attitudes of drivers by saman during Ops Sikap will change this number. This problem goes far beyond a single simple solution.
To me, the first attitudes that need to be changed are those of the authorities. Stop the blame game. Instead, look for the steps that can be reasonably done. And the best way to approach this problem is to use the second tool. The Haddon's Matrix was developed as a tool to consider the various aspects of injury prevention. Usually reported as a 4 x 3 table, it considers factors of the host, the agent or vehicle, the physical environment and the social environment, that can be reversed or addressed.
This would be a good way to start. And since ambulance crashes are in the news lately, I have done up a simplistic Haddon's Matrix analysis for road traffic accidents involving ambulances. Hmmmm, you may have to click to further enlarge.
To me, the best first step is this. Ensure that EVERY ambulance crash, and EVERY road traffic accident that has resulted in major trauma and / or death, has a Haddon's Matrix analysis done, and reported publicly to the stakeholders and authorities.
Only then, ONLY then, can we possibly hope to make a dent in this terrible war, on our roads.
Dr William Haddon Jr. Widely considered the father of modern injury epidemiology. I have been meaning to write this post for YEARS. Twice every year, after the Ops Sikap, I always get just soooo pissed off with the authorities. They seem just so helpless to do anything about our terrible road traffic accident death rates. Unfortunately, our authorities are not the experts; instetad they seem to only have a one-track mind; a single shot pistol; the only trick up their sleeve. Year in, year out, we are treated to the police, then the Minister or somebody lamenting about speeding, dangerous and inconsiderate drivers. In adverts, these drivers are always protrayed as the evil looking fellow, with dastardly schemes coming out of their every pore. And each year we are treated to police reports about how many saman they issued and the ever-increasing, how many deaths occurred.
Their single point is this. Our high numbers of road traffic accidents and deaths is due to DRIVERS faults and bad attitudes ie. you and me. We are the culprits if we are involved in an accident ! That is their single point. That seems to be the only job of the police at the moment. Determine who is wrong, so that the saman can ensue. And, that is why their main tool, their only tool to reduce the death rate is to saman us, and that is also why when they fail to reduce the death rate, the only excuse is the belligerent attitude of Malaysian drivers.
I challenge this point.
And I have two simple tools to tell you why. First tool, simple calculation. Every year, for at least the past 10 years, we have reported more than 5,500 deaths on our roads. Divided by 365, this averages out to just over 15 deaths per day, every day. So when the daily Ops Sikap reports comes out stating that similar figure, most Malaysians just tsk-tsk-tsk it thinking that it is an increased figure due to the higher traffic during those times. NOT TRUE. Essentially, we have the same death rate every day of the every year, for at least the last 10 years. To put it into context, the wars in Iraq and Afghanistan have resulted in 45,231 deaths of US, coalition, Iraqi and Afghan soldiers in the last 10 years. More than 50,000 deaths have occurred on Malaysian roads in that same time frame.
It is inconceivable that so many deaths are merely due to belligerent drivers with bad attitude. It is improbable that just trying to change attitudes of drivers by saman during Ops Sikap will change this number. This problem goes far beyond a single simple solution.
To me, the first attitudes that need to be changed are those of the authorities. Stop the blame game. Instead, look for the steps that can be reasonably done. And the best way to approach this problem is to use the second tool. The Haddon's Matrix was developed as a tool to consider the various aspects of injury prevention. Usually reported as a 4 x 3 table, it considers factors of the host, the agent or vehicle, the physical environment and the social environment, that can be reversed or addressed.
This would be a good way to start. And since ambulance crashes are in the news lately, I have done up a simplistic Haddon's Matrix analysis for road traffic accidents involving ambulances. Hmmmm, you may have to click to further enlarge.
To me, the best first step is this. Ensure that EVERY ambulance crash, and EVERY road traffic accident that has resulted in major trauma and / or death, has a Haddon's Matrix analysis done, and reported publicly to the stakeholders and authorities.
Only then, ONLY then, can we possibly hope to make a dent in this terrible war, on our roads.
First and foremost, I salute you!
Second and even more importantly, you must remember that your primary duty is to go home safely every shift of every day; and that includes your entire crew. And patient. Safety is key.
Now, let me fill you in about why safety is key. Driving the ambulance is DANGEROUS. Somebody's got to do it, and I would like to think that you, being that somebody, would do it with eyes wide open. Ambulances are about 10 times more likely to get involved in an accident compared with other road vehicles, especially when they are running "HOT" on lights and siren. In addition, they are also much more likely to cause accidents, both to other vehicles as they try to get out of the way, and to pedestrians who may run out to look and get hit in all that confusion. So, keeping to safe practices when driving the ambulance is key to ensuring you and your crew go home safely; and that you don't cause an injury to someone else along the way. This is called "due regard for the safety of others" and in my mind, it is the single most important characteristic of an ambulance driver!
OK a good and safe ambulance design would be a good place to start - in Malaysia, I would recommend you take a look at the St John Ambulance in Penang. Their newer ambulances are really well-designed and have many of the essential features for safety. Note the position of LED lights and siren speakers on their ambulances. My only input would be that I wished their seats at the back had the better 5-point harnesses instead of the 3-point one, and I have always wished that ambulances install canvas cargo nets to allow for better emergency grips for paramedics on board.
Next step, use the safety stuff. Seat belts at all times. No exceptions. Drive carefully and conscientiously. Do not rush. Lights and Sirens only on Priority Calls ie. unconscious, breathless, chest pain, seizures, active bleeding, major trauma, road traffic accidents, collapsed patient. It is really pointless to rush for every case. Just imagine rushing for a call from a patient too weak to drive to hospital after persistent vomiting for the last two days; and getting involved in an accident. The matter looks even worse when most current evidence tells us that Lights and Siren priority ambulance calls only save a few minutes in earlier response time. Is that really worth the 10 times higher risk for a non-urgent call ?
How then to use Lights and Siren ? This is our recommendation for our ambulance service. Lights at all times when responding to an emergency call and when there is a patient in the ambulance. Lights increase visibility of the ambulance, allowing other vehicles to give way in a more controlled manner. Lights should blink to attract attention, and there should not be too many nor too bright, or else the "camouflaging effect" blinds the driver of other vehicles. Lights on.Sirens, however, should be reserved for responding to Priority Calls and on the return journey to hospital, only when the critical situation of the patient mandates it. The priority of the call decides the use of siren on the way there; the condition of the patient decides on the way back. I would give greater consideration to the safety of the patient and crew in the ambulance, and the medic's ability to provide care in the ambulance; than to save the few minutes of travel time to the hospital.
Sirens have always been a source of debate between ambulance people. Most evidence note that drivers can only clearly identify the siren when the ambulance is about 25 - 40 feet away! So generally speaking, an ambulance driver can never be sure if the driver of another vehicle can see them or hear them. Or even know which direction they are coming from. And how far away they are. Drivers either simply can't hear the sirens (because they have their radios on full blast, they have selective hearing or they are just plain deaf) or even if they can hear the siren, they cannot identify where it is coming from (sound bounces off buildings and other vehicles, confusing drivers). So, do not assume your siren gets through to everyone on the road.
Most newer ambulances nowadays have at least 3 basic siren modes; a wail, yelp and hi-lo mode. Many systems can add another siren over and above these 3; either a priority or rumbler or air-horn.The US systems tend to favour the Wail whereas the European systems have traditionally used the Hi-Lo modes. I would suggest using the Wail in wide-open areas on longer distance transfers; and the Hi-Lo on more urban roads as the basic mode. In more urgent cases, many ambulances like to use the Yelp because of its higher tone change rate suggesting a greater urgency. In higher traffic areas, use of the additional mode, or a change in mode is useful to impel drivers to let you through. It is important to change the mode when approaching an intersection; the change making more drivers aware of your approach; and then changing back after the intersection. It is also very important, that if there are more than one emergency vehicle in the area, to use a different siren mode than the other vehicle, so that everyone is aware that there are more than one emergency vehicle around (wash-out effect). But really, try to avoid changing the siren mode too much, okay ? Hands on the steering !!What about road rules ? This part is simple. ALL road rules apply ! Lights and Siren are essentially requests for right of way, not assumed right of way. So stop at RED and move when allowed by other traffic. Slow down at all junctions, even if the lights are Green. [the confused driver opposite you may think that you are behind them, and run the red light to give way - this is the most common reason why ambulances get whacked by on-coming vehicles even when they are on the Green light]. When on a larger road or on the highway, the ambulance stays on the fast lane (other vehicles move to give way) - no swerving between lanes, and please none of that Schumacher-like overtaking maneuvers. Other good habits to observe - Never speed in residential areas. Don't ask for police escorts and try not to use bike ambulance escorts (it is too dangerous). Read my post on escorts. Don't ask family members to follow the ambulance. They are worried, they are stressed, they can't see anything and they want to follow the ambulance as closely as possible. That is a recipe for a high-speed backender crash. Just tell them which hospital you are bringing their loved one to. If you are stuck in heavy traffic and there is just no immediate possibility to move, turn off your sirens [keep your lights on!]. The drivers around you will appreciate it; and will try their best to give way once the traffic moves again. Go easy on the air-horn; give people a chance to move, without shocking them into an accident.Lastly, when arriving on a road side scene, park after the collision, so that you can load your patient and move off. If you are the only emergency vehicle on scene, then park in a "fend-off" position to protect your crew and the patient. Always get someone to step out of the ambulance and guide you if you are reversing the ambulance. ALWAYS. Your ambulance reverse sensors are worth shit!And finally, most accidents are NOT the fault of the emergency ambulance driver. In fact, worldwide, ambulance drivers report significant frustration at all the difficulties they have dealing with traffic, trying to get to the scene as quickly as possible. Whilst it is important to have a safe ambulance (so that accidents do not result in injury or death), and it is important to have safe practices (to reduce the incidence of accidents in the first place), it is absolutely essential that the public be EDUCATED about what to do when you note lights and sirens of emergency vehicles. Did we ever learn this under the Undang-undang Jalanraya ? And did our driving school ever teach us this ? Were we ever tested on this during the on-the-road sessions ? No ?? no wonder we are now in this situation. This is my simple suggestion for public education on "What to do when You note Lights and Sirens of Emergency Vehicles". Slow down, not speed up. Keep your hands on your steering wheel and your eyes on the road in front of you, and in the mirrors. Try to identify where the emergency ambulance is coming from. After you have done that, try to slow down and give way. Any change in lanes at this point must be indicated with your indicator lights. After the ambulance has passed, show your intention with your indicator lights again. Never tail-gate the ambulance. Never intentionally block the ambulance. Always try to give way. Assuming that ambulances are abusing their siren just to get out of a traffic jam is a no-win situation; not giving way in these situations earns you bad bad karma.That's it. I wish you all a safe shift, and a safe journey home.
Read some other stuff on emergency ambulances here and here and here.
First and foremost, I salute you!
Second and even more importantly, you must remember that your primary duty is to go home safely every shift of every day; and that includes your entire crew. And patient. Safety is key.
Now, let me fill you in about why safety is key. Driving the ambulance is DANGEROUS. Somebody's got to do it, and I would like to think that you, being that somebody, would do it with eyes wide open. Ambulances are about 10 times more likely to get involved in an accident compared with other road vehicles, especially when they are running "HOT" on lights and siren. In addition, they are also much more likely to cause accidents, both to other vehicles as they try to get out of the way, and to pedestrians who may run out to look and get hit in all that confusion. So, keeping to safe practices when driving the ambulance is key to ensuring you and your crew go home safely; and that you don't cause an injury to someone else along the way. This is called "due regard for the safety of others" and in my mind, it is the single most important characteristic of an ambulance driver!
OK a good and safe ambulance design would be a good place to start - in Malaysia, I would recommend you take a look at the St John Ambulance in Penang. Their newer ambulances are really well-designed and have many of the essential features for safety. Note the position of LED lights and siren speakers on their ambulances. My only input would be that I wished their seats at the back had the better 5-point harnesses instead of the 3-point one, and I have always wished that ambulances install canvas cargo nets to allow for better emergency grips for paramedics on board.
Next step, use the safety stuff. Seat belts at all times. No exceptions. Drive carefully and conscientiously. Do not rush. Lights and Sirens only on Priority Calls ie. unconscious, breathless, chest pain, seizures, active bleeding, major trauma, road traffic accidents, collapsed patient. It is really pointless to rush for every case. Just imagine rushing for a call from a patient too weak to drive to hospital after persistent vomiting for the last two days; and getting involved in an accident. The matter looks even worse when most current evidence tells us that Lights and Siren priority ambulance calls only save a few minutes in earlier response time. Is that really worth the 10 times higher risk for a non-urgent call ?
How then to use Lights and Siren ? This is our recommendation for our ambulance service. Lights at all times when responding to an emergency call and when there is a patient in the ambulance. Lights increase visibility of the ambulance, allowing other vehicles to give way in a more controlled manner. Lights should blink to attract attention, and there should not be too many nor too bright, or else the "camouflaging effect" blinds the driver of other vehicles. Lights on.Sirens, however, should be reserved for responding to Priority Calls and on the return journey to hospital, only when the critical situation of the patient mandates it. The priority of the call decides the use of siren on the way there; the condition of the patient decides on the way back. I would give greater consideration to the safety of the patient and crew in the ambulance, and the medic's ability to provide care in the ambulance; than to save the few minutes of travel time to the hospital.
Sirens have always been a source of debate between ambulance people. Most evidence note that drivers can only clearly identify the siren when the ambulance is about 25 - 40 feet away! So generally speaking, an ambulance driver can never be sure if the driver of another vehicle can see them or hear them. Or even know which direction they are coming from. And how far away they are. Drivers either simply can't hear the sirens (because they have their radios on full blast, they have selective hearing or they are just plain deaf) or even if they can hear the siren, they cannot identify where it is coming from (sound bounces off buildings and other vehicles, confusing drivers). So, do not assume your siren gets through to everyone on the road.
Most newer ambulances nowadays have at least 3 basic siren modes; a wail, yelp and hi-lo mode. Many systems can add another siren over and above these 3; either a priority or rumbler or air-horn.The US systems tend to favour the Wail whereas the European systems have traditionally used the Hi-Lo modes. I would suggest using the Wail in wide-open areas on longer distance transfers; and the Hi-Lo on more urban roads as the basic mode. In more urgent cases, many ambulances like to use the Yelp because of its higher tone change rate suggesting a greater urgency. In higher traffic areas, use of the additional mode, or a change in mode is useful to impel drivers to let you through. It is important to change the mode when approaching an intersection; the change making more drivers aware of your approach; and then changing back after the intersection. It is also very important, that if there are more than one emergency vehicle in the area, to use a different siren mode than the other vehicle, so that everyone is aware that there are more than one emergency vehicle around (wash-out effect). But really, try to avoid changing the siren mode too much, okay ? Hands on the steering !!What about road rules ? This part is simple. ALL road rules apply ! Lights and Siren are essentially requests for right of way, not assumed right of way. So stop at RED and move when allowed by other traffic. Slow down at all junctions, even if the lights are Green. [the confused driver opposite you may think that you are behind them, and run the red light to give way - this is the most common reason why ambulances get whacked by on-coming vehicles even when they are on the Green light]. When on a larger road or on the highway, the ambulance stays on the fast lane (other vehicles move to give way) - no swerving between lanes, and please none of that Schumacher-like overtaking maneuvers. Other good habits to observe - Never speed in residential areas. Don't ask for police escorts and try not to use bike ambulance escorts (it is too dangerous). Read my post on escorts. Don't ask family members to follow the ambulance. They are worried, they are stressed, they can't see anything and they want to follow the ambulance as closely as possible. That is a recipe for a high-speed backender crash. Just tell them which hospital you are bringing their loved one to. If you are stuck in heavy traffic and there is just no immediate possibility to move, turn off your sirens [keep your lights on!]. The drivers around you will appreciate it; and will try their best to give way once the traffic moves again. Go easy on the air-horn; give people a chance to move, without shocking them into an accident.Lastly, when arriving on a road side scene, park after the collision, so that you can load your patient and move off. If you are the only emergency vehicle on scene, then park in a "fend-off" position to protect your crew and the patient. Always get someone to step out of the ambulance and guide you if you are reversing the ambulance. ALWAYS. Your ambulance reverse sensors are worth shit!And finally, most accidents are NOT the fault of the emergency ambulance driver. In fact, worldwide, ambulance drivers report significant frustration at all the difficulties they have dealing with traffic, trying to get to the scene as quickly as possible. Whilst it is important to have a safe ambulance (so that accidents do not result in injury or death), and it is important to have safe practices (to reduce the incidence of accidents in the first place), it is absolutely essential that the public be EDUCATED about what to do when you note lights and sirens of emergency vehicles. Did we ever learn this under the Undang-undang Jalanraya ? And did our driving school ever teach us this ? Were we ever tested on this during the on-the-road sessions ? No ?? no wonder we are now in this situation. This is my simple suggestion for public education on "What to do when You note Lights and Sirens of Emergency Vehicles". Slow down, not speed up. Keep your hands on your steering wheel and your eyes on the road in front of you, and in the mirrors. Try to identify where the emergency ambulance is coming from. After you have done that, try to slow down and give way. Any change in lanes at this point must be indicated with your indicator lights. After the ambulance has passed, show your intention with your indicator lights again. Never tail-gate the ambulance. Never intentionally block the ambulance. Always try to give way. Assuming that ambulances are abusing their siren just to get out of a traffic jam is a no-win situation; not giving way in these situations earns you bad bad karma.That's it. I wish you all a safe shift, and a safe journey home.
Read some other stuff on emergency ambulances here and here and here.
Hypertensive Emergencies - severely raised blood pressures with evidence of acute end-organ damage. Usually treated with IV drugs to bring down the BP aggressively.
Hypertensive Urgencies - severely raised blood pressures with NO evidence of acute end-organ damage. Often treated with oral drugs to control the BP slowly.
Hypertensive Not-So-Urgencies : Raised blood pressures in asymptomatic patients that everybody seems to want to refer to the Emergency Department !!!
You know the story. 45 year old patient had blood pressure checked. It was sky-high. Re-checked and re-checked. Still high. Refer the ED immediately, with some scare story about "if you don't go now, you may get a stroke or heart attack" [which makes the patient's BP go even higher!] The patient then practically runs to the nearest ED.
So you get this patient, who is somewhat anxious, but otherwise, asymptomatic; and with a high blood pressure. What should you do ?
Well, measure the blood pressure again. If there is agreement with the first reading, that's it. If the second reading does not correlate with the first, do the third reading after adjusting cuff and position etc etc. Then, take the average of the two lowest readings as the blood pressure recorded.
Still high. What to do next ? I would search for end-organ damage. A fundoscopic examination to look for papilloedema (but really more to look for haemorrhages and vessel wall changes characteristic of hypertensive retinopathy), blood for renal function and a Urine examination for microscopic proteinuria. An ECG would be great.
Nothing remarkable comes back. Now what ? I would like to consider if it is due to a secondary cause eg. phaeo, thyrotoxicosis, renal artery stenosis, renal diseases, etc etc. Which needs to be considered if the patient is young (< 40 years) and does not have a family history suggestive of young-onset hypertension. If this is so, probably some discussion with the Internal Med people as to how they would like to investigate for this. Sometimes, it is done as an in-patient, other times as out-patient.
So, your asymptomatic 45 year old patient is still here. By now, you would have put the patient in observation, and repeated readings would have indicated that the BP is still high. Do we need to bring it down urgently ? I would argue against the idea. Not unless the BP is persistently above 180 / 120 mm Hg. [absolutely no evidence for those figures]. Giving the patient Captopril or Nifedipine or Metoprolol now would not help; well, maybe will bring down the doctor's BP a bit. So, then what ?
Well, start them on anti-hypertensives. According to the nice British people at NICE (NHS National Institute of Health and Clinical Excellence), who have just released the NICE Clinical Guideline 127 on Management of Primary Hypertension in Adults (August 2011), we should be starting them off with an ACE or "low-cost" ARB.
In essence, Guideline 127 says the following:- If BP > 135 / 85 and target organ damage or diabetes or renal damage or high cardiovascular risk, start anti-hypertensives.
- If BP > 150 / 95, start anti-hypertensives.
- If age < 55 years, start with ACE or low cost ARB.
- If age > 55 years, start with a CCB.
- If CCB is not suitable (due to intolerance, oedema, heart failure) use a thiazide-like diuretic (preferably Chlorthalidone or Indapamide). In Malaysia, available preparations are Apo-Chlorthalidone and Natrilix SR.
- If the first line drugs don't work well enough, combine them ie ACE / ARB with CCB / Thiazide-like diuretics.
Wowwweeeee. Whatever happened to all the older evidence supporting the beta-blockers and thiazide diuretics ? I think for reasons of cost and tradition [and pretty significant previous evidence] many hypertensive patients are still on beta-blockers. In view of the high reported cases of cough with ACE in our population, I wonder if this guideline can be used at all. Furthermore, I can't think of a "low-cost" ARB; well, at least nothing as low cost as the current beta-blockers.
Anyways, our 45 year old asymptomatic should therefore be started off on an ACE (once-daily), with some aggressive talking-to about lifestyle changes (exercise, sodium control, relaxation, weight loss, stop smoking and no more watching English football! ~wink~) A discharge from the ED with a followup within a week with the GP and a repeat renal function test.
So where do the beta-blockers come into the picture ? According to them, only if the younger hypertensive patient has an intolerance to both ACE and ARBs; or in women of "child-bearing potential". Sheesh. I really really don't know how to ask this. "uhhhh are you still doing it? uhhh you know, it ..... IT ??" This is a reasonable concern though, because both ACE and ARBs have evidence to show harm to foetus in the first few weeks of pregnancy.
So, the final word on the not-so-urgent hypertensive patient ? OK-laaa keep on sending them to us; we'll sort it out. Just don't scare them too much before that ....
Whewwwww !!
Hypertensive Emergencies - severely raised blood pressures with evidence of acute end-organ damage. Usually treated with IV drugs to bring down the BP aggressively.
Hypertensive Urgencies - severely raised blood pressures with NO evidence of acute end-organ damage. Often treated with oral drugs to control the BP slowly.
Hypertensive Not-So-Urgencies : Raised blood pressures in asymptomatic patients that everybody seems to want to refer to the Emergency Department !!!
You know the story. 45 year old patient had blood pressure checked. It was sky-high. Re-checked and re-checked. Still high. Refer the ED immediately, with some scare story about "if you don't go now, you may get a stroke or heart attack" [which makes the patient's BP go even higher!] The patient then practically runs to the nearest ED.
So you get this patient, who is somewhat anxious, but otherwise, asymptomatic; and with a high blood pressure. What should you do ?
Well, measure the blood pressure again. If there is agreement with the first reading, that's it. If the second reading does not correlate with the first, do the third reading after adjusting cuff and position etc etc. Then, take the average of the two lowest readings as the blood pressure recorded.
Still high. What to do next ? I would search for end-organ damage. A fundoscopic examination to look for papilloedema (but really more to look for haemorrhages and vessel wall changes characteristic of hypertensive retinopathy), blood for renal function and a Urine examination for microscopic proteinuria. An ECG would be great.
Nothing remarkable comes back. Now what ? I would like to consider if it is due to a secondary cause eg. phaeo, thyrotoxicosis, renal artery stenosis, renal diseases, etc etc. Which needs to be considered if the patient is young (< 40 years) and does not have a family history suggestive of young-onset hypertension. If this is so, probably some discussion with the Internal Med people as to how they would like to investigate for this. Sometimes, it is done as an in-patient, other times as out-patient.
So, your asymptomatic 45 year old patient is still here. By now, you would have put the patient in observation, and repeated readings would have indicated that the BP is still high. Do we need to bring it down urgently ? I would argue against the idea. Not unless the BP is persistently above 180 / 120 mm Hg. [absolutely no evidence for those figures]. Giving the patient Captopril or Nifedipine or Metoprolol now would not help; well, maybe will bring down the doctor's BP a bit. So, then what ?
Well, start them on anti-hypertensives. According to the nice British people at NICE (NHS National Institute of Health and Clinical Excellence), who have just released the NICE Clinical Guideline 127 on Management of Primary Hypertension in Adults (August 2011), we should be starting them off with an ACE or "low-cost" ARB.
In essence, Guideline 127 says the following:- If BP > 135 / 85 and target organ damage or diabetes or renal damage or high cardiovascular risk, start anti-hypertensives.
- If BP > 150 / 95, start anti-hypertensives.
- If age < 55 years, start with ACE or low cost ARB.
- If age > 55 years, start with a CCB.
- If CCB is not suitable (due to intolerance, oedema, heart failure) use a thiazide-like diuretic (preferably Chlorthalidone or Indapamide). In Malaysia, available preparations are Apo-Chlorthalidone and Natrilix SR.
- If the first line drugs don't work well enough, combine them ie ACE / ARB with CCB / Thiazide-like diuretics.
Wowwweeeee. Whatever happened to all the older evidence supporting the beta-blockers and thiazide diuretics ? I think for reasons of cost and tradition [and pretty significant previous evidence] many hypertensive patients are still on beta-blockers. In view of the high reported cases of cough with ACE in our population, I wonder if this guideline can be used at all. Furthermore, I can't think of a "low-cost" ARB; well, at least nothing as low cost as the current beta-blockers.
Anyways, our 45 year old asymptomatic should therefore be started off on an ACE (once-daily), with some aggressive talking-to about lifestyle changes (exercise, sodium control, relaxation, weight loss, stop smoking and no more watching English football! ~wink~) A discharge from the ED with a followup within a week with the GP and a repeat renal function test.
So where do the beta-blockers come into the picture ? According to them, only if the younger hypertensive patient has an intolerance to both ACE and ARBs; or in women of "child-bearing potential". Sheesh. I really really don't know how to ask this. "uhhhh are you still doing it? uhhh you know, it ..... IT ??" This is a reasonable concern though, because both ACE and ARBs have evidence to show harm to foetus in the first few weeks of pregnancy.
So, the final word on the not-so-urgent hypertensive patient ? OK-laaa keep on sending them to us; we'll sort it out. Just don't scare them too much before that ....
Whewwwww !!
I'm SORRY I've acted too busy to really listen ...
I'm SORRY I've acted too busy to really listen ...
Scenario: Patient with a sore throat, goes to see a doctor. Doctor takes out tongue depressor and torchlight (because that is what they have been taught to do) and patient sticks out tongue and says Ahhhh (because that is what they have also been taught to do). But what is it that the doctor is looking for ? And why is it more important that the doctor feels around the neck rather than listen to the chest ?Streptococcus were first categorized based on their ability to haemolyze RBCs on blood agar. Alpha-haemolytic meaning partial haemolysis, beta-haemolytic meaning complete haemolysis (which would lead to a clear patch surrounding the sample on blood agar). It was later on, with the Lancefield classification, that the various groups (A to G) came about. Historically, Group A Strep led to significant morbidity and mortality; but after the antibiotics became commonplace, these infections now cause much fewer deaths - but their adverse impact persists, especially if they are not diagnosed.
The Group A Beta-Haemolytic Streptococcus (GABHS) were the group of Strep most associated with severe infections and sequelae. They would cause "suppurative infections" ie pus-causing, in most tissues from sore throats to pneumonia, ear infections to CNS abscesses, skin impetigo to necrotizing fasciitis. In addition, this GABHS could cause two main non-suppurative sequelae; ie acute rheumatic fever (ARF) and its dreaded complication of rheumatic heart disease, and acute glomerulonephritis (AGN) and renal failure. The marked impact was that it tended to affect a population of between 5 years and 15 years old; most of them starting off with a "simple" sore throat.
Imagine that. A sore throat that would, in 2 - 4 weeks time, lead to heart disease or kidney disease that may kill the child or leave long-standing complications. Worse, it was all treatable with antibiotics in the first place.
Then why not treat all sore throats with antibiotics in the first place ? Why take the risk of the sore throat turning out to be GABHS ?
The main problem was that the vast majority of sore throats (90% in adults, 70% in children) were idiopathic (no confirmed cause) or viral in origin and not GABHS. Even if it was a bacteria causing the sore throat, only between 10 - 30% were due to GABHS. Treating all with antibiotics was just not reasonable.
How could we guess better then ? One of the strategies was the use of diagnostic criteria; the most common one used was the Modified Centor Score and Clinical Decision Rule.
The idea was that 4 main symptoms and signs were suggestive of GABHS ie sudden onset of high fever and a sore throat, swollen and tender anterior cervical lymph nodes (that's what your doc is feeling for), enlarged red and suppurative tonsils, and an absence of cough (which would have indicated either a viral problem or a problem lower in the respiratory tract). And if the patient had other symptoms like coryza (runny, congested nose), conjunctivitis (reddish, tearing eyes) or diarrhoea, it would have indicated a viral problem (which wasn't a problem at all!) The real problem was that it wasn't very accurate; and many clinicians were more inclined to do either throat swab and cultures (which would take a day or two, at least) or the rapid antigen detection test (RADT). In our context, we have neither. So it is the Modified Centor, or nothing.
I would play it this way. A score of 3 or more would earn a course of antibiotics. And I am biased toward tonsillar exudates; so I am even more likely to prescribe antibiotics whenever I see red exudative tonsils.
Treat or don't treat, GABHS pharyngitis would self-resolve within a few days. The argument to treat was to prevent those suppurative and especially the non-suppurative complications. And probably no harm to speed up symptom relief (we all want to be known as "good docs", right ?) So, initiating antibiotics reduces the duration of symptoms by 16 hours, and the NNT (number needed to treat) for symptoms relief at 72 hours is 4 (which means every 4th patient gets full symptom relief at 72 hours - not very impressive, huh?)Which antibiotics ? The general recommendation is Penicillin V 250 mg 3 times per day for 10 days (adults 500 mg tds 10 days); but I don't even know I can prescribe Penn-V. So the most common alternative is Amoxicillin in pretty standard dosing for 10 days. For 10 days, okay ? For those with penicillin allergies (real or imagined), Erythromicin 10 days or Cephalexin 10 days. And for those who just cannot take meds for 10 days, the only alternative is Azithromycin (for 5 days) or IM Benzathine Penicillin single dose (which I'm told makes your butt hurt for more than 10 days!)
And really, they need someone to look at them again after a week, so write that referral letter.
On a personal note, you just need one of your patients that you have sent home, to come again in a couple of weeks with Acute GlomeruloNephritis, to fully regret and REMEMBER to look for GABHS; I've had mine, and I hope this article may prevent you from having yours.
Scenario: Patient with a sore throat, goes to see a doctor. Doctor takes out tongue depressor and torchlight (because that is what they have been taught to do) and patient sticks out tongue and says Ahhhh (because that is what they have also been taught to do). But what is it that the doctor is looking for ? And why is it more important that the doctor feels around the neck rather than listen to the chest ?Streptococcus were first categorized based on their ability to haemolyze RBCs on blood agar. Alpha-haemolytic meaning partial haemolysis, beta-haemolytic meaning complete haemolysis (which would lead to a clear patch surrounding the sample on blood agar). It was later on, with the Lancefield classification, that the various groups (A to G) came about. Historically, Group A Strep led to significant morbidity and mortality; but after the antibiotics became commonplace, these infections now cause much fewer deaths - but their adverse impact persists, especially if they are not diagnosed.
The Group A Beta-Haemolytic Streptococcus (GABHS) were the group of Strep most associated with severe infections and sequelae. They would cause "suppurative infections" ie pus-causing, in most tissues from sore throats to pneumonia, ear infections to CNS abscesses, skin impetigo to necrotizing fasciitis. In addition, this GABHS could cause two main non-suppurative sequelae; ie acute rheumatic fever (ARF) and its dreaded complication of rheumatic heart disease, and acute glomerulonephritis (AGN) and renal failure. The marked impact was that it tended to affect a population of between 5 years and 15 years old; most of them starting off with a "simple" sore throat.
Imagine that. A sore throat that would, in 2 - 4 weeks time, lead to heart disease or kidney disease that may kill the child or leave long-standing complications. Worse, it was all treatable with antibiotics in the first place.
Then why not treat all sore throats with antibiotics in the first place ? Why take the risk of the sore throat turning out to be GABHS ?
The main problem was that the vast majority of sore throats (90% in adults, 70% in children) were idiopathic (no confirmed cause) or viral in origin and not GABHS. Even if it was a bacteria causing the sore throat, only between 10 - 30% were due to GABHS. Treating all with antibiotics was just not reasonable.
How could we guess better then ? One of the strategies was the use of diagnostic criteria; the most common one used was the Modified Centor Score and Clinical Decision Rule.
The idea was that 4 main symptoms and signs were suggestive of GABHS ie sudden onset of high fever and a sore throat, swollen and tender anterior cervical lymph nodes (that's what your doc is feeling for), enlarged red and suppurative tonsils, and an absence of cough (which would have indicated either a viral problem or a problem lower in the respiratory tract). And if the patient had other symptoms like coryza (runny, congested nose), conjunctivitis (reddish, tearing eyes) or diarrhoea, it would have indicated a viral problem (which wasn't a problem at all!) The real problem was that it wasn't very accurate; and many clinicians were more inclined to do either throat swab and cultures (which would take a day or two, at least) or the rapid antigen detection test (RADT). In our context, we have neither. So it is the Modified Centor, or nothing.
I would play it this way. A score of 3 or more would earn a course of antibiotics. And I am biased toward tonsillar exudates; so I am even more likely to prescribe antibiotics whenever I see red exudative tonsils.
Treat or don't treat, GABHS pharyngitis would self-resolve within a few days. The argument to treat was to prevent those suppurative and especially the non-suppurative complications. And probably no harm to speed up symptom relief (we all want to be known as "good docs", right ?) So, initiating antibiotics reduces the duration of symptoms by 16 hours, and the NNT (number needed to treat) for symptoms relief at 72 hours is 4 (which means every 4th patient gets full symptom relief at 72 hours - not very impressive, huh?)Which antibiotics ? The general recommendation is Penicillin V 250 mg 3 times per day for 10 days (adults 500 mg tds 10 days); but I don't even know I can prescribe Penn-V. So the most common alternative is Amoxicillin in pretty standard dosing for 10 days. For 10 days, okay ? For those with penicillin allergies (real or imagined), Erythromicin 10 days or Cephalexin 10 days. And for those who just cannot take meds for 10 days, the only alternative is Azithromycin (for 5 days) or IM Benzathine Penicillin single dose (which I'm told makes your butt hurt for more than 10 days!)
And really, they need someone to look at them again after a week, so write that referral letter.
On a personal note, you just need one of your patients that you have sent home, to come again in a couple of weeks with Acute GlomeruloNephritis, to fully regret and REMEMBER to look for GABHS; I've had mine, and I hope this article may prevent you from having yours.
I have the dark in me, a void
that seems to take away all feeling
leaving emptiness that just aches;
and wants to pull me away into its world
away from this one of grief
This one of unbearable unbearable loss
It will get better, I can feel again
you say I can ?
you say it will ?
I don't know it still
But do tell me again tomorrow
This loss will always be, but I will continue on,
this pain may yet stumble me, but I must still soldier on,
the thoughts shall still crash through, and I will endure,
Life will move on, even if I resist, I will live on.
You say I can, you say it will,
I still don't know it now,
But please, tell me again tomorrow.
Dedicated to Friends, struggling bravely through adversity.
I have often been asked "What is the future of the Emergency Physician?" and "Why should I specialize in Emergency Medicine?". Many years ago, my enthusiasm was often met with quite a bit of skepticism. But things have changed.
If anything, Emergency Medicine is going places. Its scope of practice is changing at a pace not seen in any other specialty, creating new areas of specialty and interest, and really pushing the boundaries of acute care beyond even acute care itself.
In the recent ACEM conference, we heard varied references to the many roles of the Emergency Physician. At different times and in different situations, the EP was a :-
'resuscitationist' - all things critical care and resuscitation;
'proceduralist' - managing many of the common procedures done, even in the wards; simply because in a few years time, many would have had too little exposure to these procedures to do them well;
'diagnostician' - in most EDs in more developed systems, acute presentations are diagnosed completely before a more complete "packaged" is handed over to other teams. This must surely be one of our main aims as we develop EM here; and I think it will only be limited by our ability to perform the necessary testing, and our willpower and confidence to walk this path;
'hospitalist' - in smaller hospitals, the EP takes a greater role in the management of in-patients, both by virtue of their greater all-round experience, and probably because they are the only senior doctor around during off-peak hours.
'researcher' - it was just a few years ago, when the community was still lamenting the difficulty of getting good research done from the ED; but wowweee, in these few years, ED research have affected practices and standards not only in Emergency Medicine, but in other fields as well.
'teacher' - if anything, this has been, to my mind, the single greatest leap for Emergency Physicians in the last few years; the involvement of EPs in academia, in the training of students, nurses, allied health staff, residents and specialists in various fields.
This was definitely not the situation a short while ago. Honestly, just a few years ago, EM was very much like a child. We had childish notions. We wanted attention. "Here, here, look at me. I can do this, I can do that. See, see. Look at me!" A bit of a noisy, hyperactive kid. Lovable though [i'm biased!] because all we wanted to do, was to help; to do a part that we knew we could do, that would make a difference. But it was difficult convincing the 'adults' at the time [ie the other specialties] and especially the 'older grandparents' [ie. internal medicine, general surgery] that this noisy little fellow could actually amount to something, much less help make a difference.
But that noisy little fellow grew up; and began to make a difference. No more the ignored child, we are now often part of the adult specialties. Part of the team. A player like any other. But in some ways, this isn't necessarily a good thing either; we can too easily become "just another specialty"; just another unremarkable adult. For it was in our child-like enterprising unchallenged mind, that we managed to achieve so much; and it would be sad to lose that spirit.
So now as adults, we must still strive to make the difference; performing a part that we know we can do, to make that difference. We must learn to work within the team of adults. We must learn to communicate as adults, collaborate with adults, win and lose as adults. We must learn that life is not always a win, never fair and mostly learning to ride the ups and downs. So the EP must now be, in addition to those roles above, the communicator and collaborator.
We should learn to LISTEN to what other specialties are trying to say and understanding what they are trying to do; and we are inclined to do this well; for who else can get a history and working diagnosis from that delusional patient who is ranting away.
We should learn to TALK to say what we want without emotion, without the child-like anxiety to be understood. And we are similarly inclined to do this well too; for who else can convince the receiving teams to take our patients when we have not figured out their diagnosis yet?
And we should learn to collaborate with others, to work as a team. And here is where we shine. For we, from the first day that we stepped into the ED, have always worked in a team environment; and we have never known me, my, mine type of self-centered specialty medicine that is so prevalent in other fields.
What I have NOT heard thus far, is how GOOD we EPs think we are. That I have not heard. Because I think we all believe that we are nothing special. Difficult airway ? Nope ain't difficult; you can do it, with a few tools. Ultrasound ? Not tough, just follow these few views. Everybody can do what we do, as long as they want to. We are nothing great.
But make no mistake. What we can do, is nothing short of remarkable.
