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

To subscribe to our newsletter, please click
Facebook Facebook
Website Website
Email Email
Issue 017--Apr 2021

Hong Kong Society
for Emergency Medicine & Surgery
Message from the President...
The jobs of EM physicians and nurses are mentally taxing. Stress and pressure from the jobs lead to a state commonly known as “burnout”. Though this term is commonly mixed up with stress, they are not the more
From Editors...

In this issue we will bring to you the activities involved by the Sports Medicine Subcommittee of HKCEM, with a specific focus on Rugby Seven Medical Team. The updates of 2020 resuscitation guidelines will also be summarized in Advance in more 
Council News...                 
Induction program for EM trainees and EM Training Program for Chinese Medicine Practitioner were carried out in the first quarter this more
From Members
Members Area
The Sports Subcommittee of HKCEM takes an active role in supporting various sports events such as badminton, judo, tennis, lacrosse, tennis, and even cross harbour race. One of the most exciting events they take part in is the Hong Kong Sevens which has been held for more than forty years. The vice-chairman of Sports Subcommittee of HKCEM, Dr Chau Chi Wai will share with us his experience in the Rugby Seven Medical more 
Private EM Writes

The 'Cloth Street' used to be an area packed with shops selling fabrics. Yet with time, this traditional old area has been silently transformed into streets filled with modern coffee shops. Dr Cheung Chin Pang will lead us through this more

Nurse Corner
Resuscitation involving patients with infectious disease can pose significant risk to medical staff. This is especially important as new infectious diseases emerge every year. The APN of POH A&E Ms Chan Chiu Ying will talk about their training course on resuscitation and ventilator management in patients with highly pathogenic infectious more 
Advance in EM
The ACLS & PALS are regularly reviewed to keep up-to-date with any new evidence. The latest update in Oct 2020 have brought some specific changes as well. Dr  Cheung Koon Ho Ralph will summarize on more
Message from the President      Dr Ben Kuang-An WAN
Greetings to all members of HKSEMS.
We have withstood an unprecedented test by the COVID-19 pandemic since early 2020, when people were still excited in embarking on a new decade full of hope and vitality. The pandemic has not only led to profound negative effects, but also triggered an extraordinary global health response. The hallmark of this response is a global commitment to science and
solidarity. The rapid development of new vaccines against SARS-CoV-2 is an example. As it will take time to vaccinate every eligible individual (to achieve herd immunity), we must still comply with measures that have been keeping all of us safe. Social distancing, wearing face masks and practicing hand hygiene have proven to be simple yet effective measures to safeguard health amid the pandemic. 

The jobs of EM physicians and nurses are mentally taxing. Stress and pressure from the jobs lead to a state commonly known as “burnout”. Though this term is commonly mixed up with stress, they are not the same. Stress is normally a short-term matter, caused by certain situations that make people felt overwhelmed. Stress usually goes away once the triggering issues are settled. On the contrary, burnout is a long-lasting reaction to stress and exhaustion. When people experience burnout from their job, their morale and motivations are extremely low. Burnout not only negatively impacts on people’s work, but also negatively affects their fellow colleagues. Therefore, we need a healthy work-life balance. This avoids the building up of stress and burnout. We also encourage colleagues to reach out and support one another, especially in this era when people can easily feel isolated and helpless. Take a look at our surrounding and look for people in need. Outpourings of our kindness could help them through difficult times. It costs little, but may mean a lot.
The pandemic has reminded us to make our systems better prepared for the next inevitable pandemic. In 2021, COVID-19 will remain a hot topic globally. In the forthcoming ACEM 2021, “Global COVID-19 Challenges, and Asian Solutions” will be highlighted. We are pleased to announce that ACEM 2021 has been endorsed by the International Federation of Emergency Medicine (IFEM). We are confident that ACEM 2021 will be a platform for renowned experts to gather together and share their expertise on EM-related issues. 
Last but not the least, we would like to express our gratitude to members of our IT Subcommittee whose endeavours have led to a refreshing webpage of HKSEMS.
Though it is exhausting, we can get through the hardships together. We are confident that we will look back with admiration the way we have contributed, and got through this pandemic. Better days are just ahead. 
From Editors Editors in chief Dr Chor-man Lo, Dr Sam Siu-ming Yang

Dr Ho-yin Chan, Dr Wendy Cheng,
Dr Louis Chin-pang Cheung, Dr Kwun-bun Wong
Mr Chun Pong Leung

Sports injury is a common presentation to Accident & Emergency Department. As emergency physicians, we are well trained at dealing with various emergencies that arise from sports. We can provide first aid treatment to injuries ranging from trivial joint or muscle sprain, to severe trauma such as head or spinal insult. We are one of the most

appropriate specialties that can fulfill the role of pitch side team physician, overseeing the safety of athletes in sports activities. The Sports Subcommittee under HKCEM has been providing medical support for various sport events, including Badminton, Judo, Lacrosse, Tennis, Cross Harbor Race… etc. In this issue, we invited the past chairman of this subcommittee to share with us their previous valuable experience when providing medical support for Rugby Seven.
The ACLS (Advanced Cardiovascular Life Support) and PALS (Pediatric Advanced Life Support) courses provided by American Heart Association constitute important foundation in our resuscitation care. The content is regularly reviewed in order to keep up-to-date with any new evidence that has emerged. The latest updates in Oct 2020 have brought certain changes to these two courses. Let us check it out at the Advances in EM.
While doctors take up a leading role during resuscitation, nurses form the important bridging component that link up every part of the resuscitation process together. Resuscitation in the COVID-19 era requires modification and improvement to provide better protection to the medical team. Specific training courses have been developed to train nurses on resuscitation and ventilator circuit management at POH. We will briefly talk about this training course in the Nurses Corner.


Council News

Dear Members of HKSEMS,
Welcome to the 1st issue of 2021. Let us refresh the activities organized the Council in the last 3 months!!
Induction Program on Emergency Medicine co-organized by HAHO IEC and HKSEMS
This induction program, a conjoint function of Hospital Authority Head Office IEC (Infection, Emergency and Contingency) and HKSEMS, was held on 15 January 2021 as an online course via the ZOOM platform. This was a half-day program, aiming at offering newcomers (including Emergency Medicine Basic Trainee, Trainees from other specialties, and interns rotated to AED) the basic and practical knowledge for survival in the Emergency Department.
We would like to deliver our special thanks to HKCEM office staffs for helping us in the administrative work of the program.
The President of HKSEMS Dr. Ben Wan was delivering the lecture.
Mr. Andy Kung, Senior Manager in IEC, was sharing with the participants the role of A&E in Disaster Response
Emergency Medicine Training Program for Chinese Medicine Practitioners
HKSEMS has been conducting the Certificate Course for CMP in EM since 2015. The course was fully revamped in 2019 to help CMP to prepare for the opening of the Chinese Medicine Hospital. The course was successfully run online in January and February. Feedback from the participants were good, the next course will be run in Q1 of 2022.
Dr. Ben Wan was delivering a lecture on cardiovascular emergency.
Dr. Axel Siu was introducing the principle of Emergency Medicine to the Chinese Medicine Practitioners.
Upcoming Events

ACEM 2021
Save the date !!
HKSEMS will be the organizer for the 11th ACEM.
This will be the ASEM’s first ever virtual conference!
Although the conference will go virtual due to COVID-19, it will not be an obstacle for organizing a great conference to share and stay connected!
Further information will be released in Facebook, IG and Twitter soon!
Please stay tune and join us!!
The deadline for submission of abstract is 31July 2021. Don’t be late and grab the chance to win a prize!!
Members Area Dr. Chau Chi Wai
  Vice-chairman, Sports Medicine Subcommittee, HKCEM
Rugby Seven Medical Team

Rugby Seven is one of the major sports events in Hong Kong. I joined the medical team since 2007. I am happy to share our experience in this issue of newsletter.
Every year, we will recruit around 30 members to join the Medical Team, which includes doctors, nurses, physiotherapists and first-aiders. All of them are accredited level 2 or above in Pre-Hospital Immediate Care in Sport (PHICIS) hosted by England Rugby Football Union, organized in Hong Kong by HKCEM and Hong Kong Rugby Union (HKRU). We have team training before the event, to practise on spinal immobilization and CPR protocol.
We are split into three teams on the event days: Pitch Side Immediate Care Team, Medical Room Team and Head Injury Assessment (HIA) Team. Each team has its roles and responsibilities.
Pitch Side Immediate Care Team will stand-by at the pitch side to support the team medic. Usually, the team medic treats all the minor injuries. Our team is usually involved in more severe injuries like fracture-dislocation, suspected cervical spine injury and players who lose their consciousness. We try to reduce dislocation in the field, followed by immobilization. Moreover, we perform spinal immobilization, and retrieve the player with Scoop Stretcher. Work under 40000 spectators is a really stressful experience.
The Medical Room is a well-equipped clinic with minor OT and ultrasound machine. We have all kinds of drugs, including resuscitation drugs, dressing and suturing materials, ice packs, splints and sport tapes. On-site radiologists perform MSK ultrasound. Besides players, we also have medical consultation from VIPs and event officials. We have treated a drunk “Gorilla” before – A drunk spectator wearing gorilla costume who suffered from heat exhaustion. We have two stand-by ambulance from Hong Kong St John Ambulance. We also have support for X-ray, CT scan and MRI from private hospitals.
HIA Team stay at pitch side. The primary role is to identify any player suffering from concussion. They review instant video recording to recognize a concussion. If the player is suspected to have concussion, he will be removed from the pitch, and undergoes a concussion assessment at the Medical Room before he is allowed to return to play.
The three days of Rugby Seven are usually busy with many injuries and medical conditions. However, it is full of fun and unique experience. It is a “Shaolin Temple”(少林寺) for pitch side sports medicine, with the opportunity to manage hyper-acute sports injuries.  
Besides Rugby, the Sports Subcommittee of HKCEM has provided medical support for various sport events, including Badminton, Judo, Lacrosse, Tennis, Cross Harbor Race…etc. If you are interested in being our team member, please kindly contact the Subcommittee. 
Medical team
Busy medical room
Ultrasound at medical room 
Head injury assessment recording review
Pitch-side immediate care team
Private EM Writes 
Dr Cheung Chin Pang
  Honorary Treasurer, HKCEM
Deputy Director, Emergency Medicine Centre, Union Hospital

Nurse Corner Ms Chan Chiu Ying
  APN, A&E, Pok Oi Hospital
Training Workshop - “Resuscitation & Ventilator Circuit Management for Patient with Highly Pathogenic Infectious Disease” in POH A&E
As endorsed in COC-G(N) meeting, an e-learning course and Simulation training- “Resuscitation & Ventilator Circuit Management for Patient with Highly Pathogenic Infectious Disease” are
developed for training nursing staff in carrying out high-risk procedures for infectious patients. This e-learning course is mandatory for staff who will be deployed to high-risk area. Simulation training is highly recommended for staff deployed to high-risk area in order to prepare them for safe resuscitation of COVID-19 patients. It is essential for Accident & Emergency (A&E) nurses to strengthen their cardiopulmonary resuscitation (CPR) knowledge and skills in accordance with the best evidence-based practice in current pandemic. The below summarizes the objectives of the course.
  • To be familiar with specific infection control measures in CPR and endotracheal intubation for patients suspected or confirmed to have highly pathogenic infectious diseases.
  • To be familiar with the intubation procedure and aftercare of equipment for suspected infectious patients.
  • To be familiar with the management of accidental spillage of “infectious” respiratory fluids, and staff decontamination procedure.
  • To ensure all staff to be familiar with the steps of Don and Doff of PPE for airborne infection precaution.
  • To improve A&E teamwork and enhance communication among all A&E staff.
In order to prepare nursing staff to have safe resuscitation, strong teamwork, and to maintain staff’s competence in this COVID-19 era, Simulation training is highly recommended in our department. Target participants are all nursing staff working in A&E of Pok Oi hospital (POH).
Scenario-based simulation exercise is employed in our workshop. Communication skills, teamwork and problem-solving of participants during the management of simulated patients are assessed. Debriefing is conducted immediately afterwards to evaluate their strength and weakness.
Participant will receive feedback on their performance during debriefing. Through discussion, loops holes in their daily practice can be identified and the current evidence-based practice can be conveyed. In that way, participants can improve their professional competence, and ultimately, confidence.
As of 19 Mar 2021, a total of 10 resuscitation workshops were conducted. Several areas that need to be improved in daily practice were identified:
  • Inadequate closed loop communication among team members.
Immediate feedback was given to staff during debriefing and suggestions were shared to other colleagues.

In order to facilitate the resuscitation procedure for COVID-19 patients, several measures are suggested:
  • Review procedure and guideline on infection control periodically.
  • Provide annual refresher course on infection control training for all staff
Advance in EM  Dr Cheung Koon Ho, Ralph
  Consultant, A&E, Prince of Wales Hospital
Chairman, Resuscitation Subcommittee, HKCEM
Updates on 2020 Resuscitation Guidelines (American Heart Association)
Every five years, American Heart Association (AHA) will update the guidelines in resuscitation. The latest publications were in Circulation in October 20201, co-published in Resuscitation.
The majority of recommendations were based on level C evidence (68%), followed by level B (31%), and level A (1%). The evidence evaluation process was done by International Liaison Committee on Resuscitation (ILCOR).

I.  Adults
Regarding adult basic and advanced life support, it is recommended that laypersons should initiate cardiopulmonary resuscitation (CPR) for presumed cardiac arrest, because the risk of harm to patients is low, even if the patient is not in cardiac arrest.
Ventilation strategy is recommended to be 1 breath in every 6 seconds for respiratory arrest, with or without advanced airway. (Whereas in the 2015 guideline, there was a slight difference in ventilation rate with or without advanced airway).
 In refractory VF, routine use of double (dual) sequential defibrillation (DSD) is not recommended. DSD means the use of 2 defibrillators to deliver 2 overlapping shocks, or 2 rapid sequential shocks, in refractory VF. Only a few observational studies were related to DSD with regard to survival or neurological outcomes. Those individual studies were rated as low evidence, having serious risk of bias, and high degree of heterogeneity.
In cardiac arrest, it is reasonable to first attempt establishing intravenous (IV) access for drug administration. Intraosseous (IO) access may be considered if IV access is unsuccessful. The reason is that the IV route was associated with better clinical outcomes in various studies.
Regarding medication use, in shockable adult cardiac arrests (VF, pulseless VT), anti-arrhythmic choices are amiodarone or lignocaine. Give amiodarone 300mg bolus IV/IO in such cardiac arrests, after three shocks have been administered. Give a further bolus of amiodarone 150mg IV/IO after five shocks have been given. Alternatively, lignocaine 1-1.5mg/kg (or 100mg) IV/IO, may be used to replace the first dose of amiodarone. In such situation, an additional bolus of lignocaine 50mg can be given after five defibrillation attempts.2,4-5 Therefore, compared with the 2015 guideline, in shockable cardiac arrests, lignocaine is back again in the current guideline. Routine use of magnesium in shockable cardiac arrests is not recommended.2
In adult bradycardia accompanied by adverse signs, atropine dose is 1mg IV bolus. Repeat every 3-5 minutes, with a maximum of 3mg.4 (Whereas dose of atropine was recommended to be 0.5 mg in 2015 guideline). If atropine is ineffective, dopamine dose is 5-20 mcg/kg per minute for bradycardia4. (Whereas dose of dopamine was 2-20 mcg/kg per minute in the 2015 guideline).
In unstable tachycardia, cardioversion energy follows specific device recommended energy level.4 (Whereas there were specific energy recommendations for different tachycardia rhythms in the 2015 guideline).
It is recommended that cardiac arrest survivors should have multimodal rehabilitation assessment and treattment for physical, neurologic, cardiopulmonary, and cognitive impairments, before discharge from the hospital.
In post cardiac arrest patients, oxygen should be titrated to achieve SpO2 of 92%-98%. (Whereas in the 2015 guideline, oxygen titration was to achieve SpO2 of 94% or higher). Both hyperoxemia and hypoxemia during post-resuscitation critical care have been associated with worse outcomes. Hypoxemia may worsen brain and other organ injury, while hyperoxemia may lead to oxidative organ damage.
Figure 1: AHA chains of survival for adult in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA)
II. Pediatrics
For pediatrics, the recommended rescue breathing rate, or respiratory rate during CPR with an advanced airway, is 1 breath for every 2 to 3 seconds (20-30 breaths per minute). The breath rate is faster than the 2015 guideline. The reason for the change is that new data showed that higher ventilation rates are associated with improved ROSC and survival in pediatric IHCA.6
For intubation of infants and children, it is reasonable to choose cuffed endotracheal tubes. In previous guideline, both cuffed and uncuffed tubes are acceptable. The reason is that cuffed tubes may decrease the risk of aspiration, and safety of cuffed tubes had been supported.
For pediatric patients in any setting, it is reasonable to give an initial dose of adrenaline within 5 minutes from the start of chest compression. Earlier adrenaline administration increases the rates of ROSC, survival to admission, and survival to discharge.
In patients with septic shock, it is recommended that fluid should be given in 10ml/kg or 20ml/kg aliquots, with frequent reassessment. (Whereas in the 2015 guideline, fluid bolus was recommended as 20ml/kg). The reason for the change is that studies have shown that fluid overload can lead to increased morbidity. For septic shock unresponsive to fluids and requiring vasoactive support, it may be reasonable to consider stress dose corticosteroids.

For children with hypotensive hemorrhagic shock following trauma, it is reasonable to give blood products, when available, instead of crystalloid for ongoing volume resuscitation.
Figure 2: AHA Chains of Survival for paediatric IHCA and OHCA
In summary, although there are no drastic changes in the updated guidelines, there are some modifications and fine tunings involving different aspects of resuscitation care.
  1. Nolan JP, Maconochie I, Soar J, Olasveengen TM, Greif R, Wyckoff MH, et al. Executive summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(suppl 1):S2–S27.
  2. Soar, J., Berg, K. M., Andersen, L. W., Böttiger, B. W., Cacciola, S., Callaway, C. W., et al. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation156, A80–A119.
  3. Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, et al. Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. 
  4. Advanced Cardiovascular Life Support Provider manual. 2020 Edition. American Heart Association
  5. Perkins GD, Graesner JT, Semeraro F, Olasveengen T, Soar J, Lott C, et al. European Resuscitation Council Guideline Collaborators. European Resuscitation Council Guidelines 2021: Executive summary. Resuscitation. 2021 Apr;161:1-60
  6. Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL Jr, et al. Pediatric Basic and Advanced Life Support Collaborators. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S469-S523.  
Copyright © 2021 non-profit, All rights reserved.

Want to change how you receive these emails?
You can update your preferences or unsubscribe from this list

Email Marketing Powered by Mailchimp