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Issue 014--Jul 2020

Hong Kong Society
for Emergency Medicine & Surgery
Message from the President...
With the pandemic of covid 19, healthcare workers are met with the dilemma of saving a great number of patients with scarce resources. Dr Wan will elaborate on the ethical dilemma thus more
From Editors...
With new members joining our editorial board, we are pleased to have new columns in our more 
Council News...                 
Despite the threat of COVID 19, a number of our activities were still able to proceed as scheduled. Our honorary society secretary, Wendy will lead us the through the activities in the past 3 more
From Members
Members Area
The threat of COVID-19 has much effect on our activities, which includes our EM training. We are honored to have President of HKCEM, Dr Axel Siu to elaborate how the COVID-19 pandemic affects the current CPR more 
Private EM Writes

Burnout and physician wellness are important topics yet they are seldom touched upon. Deputy Medical Director of Union Hospital & Vice-President of HKCEM, Dr Clara Wu will introduce to us on more

Nurse Corner
Since the onset of local COVID 19 infection, the occupancy of negative pressure rooms at A&E has reached a very high rate. Drills for contingency plan involving negative pressure room/AIIR room faulty functions were carried out.  Mr Leung Chun Pong, President of HKENA, share with us his experience from the more 
Advance in EM
With the increasing popularity of e-cigarettes, it is expected chronic excessive use will cause hazard to health. EVALI, a new type of lung injury associated with e-cigarette use, is gaining people's more
Message from the President      Dr Ben Kuang-An WAN

It has been half a year since the first case of COVID-19 was reported in Hong Kong. In response to the COVID-19 pandemic and the stringent control measures, many economic and social activities in the community have been disrupted and activities of HKSEMS are no exception. However, our preparatory work for Asian Conference on Emergency Medicine 2021 is ongoing. Council meetings have been continued so that our operations are not disrupted, and we are prepared to deal with any urgent business. 

Despite the devastating effects of COVID-19, we do learn something from the COVID-19 pandemic.
For community, importance of pandemic preparedness and response, such as public health preventive measures, border control, medical surveillance system and resilience of healthcare system, is emphasized again. Many Hong Kong citizens still have recurring flashbacks to the SARS pandemic and are willing to adopt measures such as hand hygiene, social distancing and universal masking early to curb the transmission. These measures have been shown again to be highly effective to keep the number of reported cases low. People harness technology to overcome the challenge of social distancing and travel restrictions. Online meeting software is gaining popularity to connect people in business world, healthcare settings and academic trainings etc. How technology and innovations will enhance our emergency medical care will be an interesting topic worth further pursuing.
For frontline EM healthcare professionals, the stress experienced is enormous as the COVID-19 pandemic is related to a novel infectious agent without specific therapy and vaccine. We have learnt how to adjust our lifestyle to protect ourselves and beloved families, and keep resilient to strive through the pandemic.
For physicians, medical ethics is another interesting aspect in the context of pandemic. The COVID-19 pandemic led to a large number of severely ill patients within a short period of time in some countries. The needs far outstripped the resources available (such as access to hospitals, ventilators, vaccines, PPE and medications), creating logistic, medical and ethical challenges.
More than 2000 years ago, Hippocrates introduced the concept of medicine as a profession and that physicians place the best interests of their patients above their own interests. Ethical principles, such as beneficence, non-maleficence, autonomy and justice, are the core values that physicians embrace during their clinical practice.
Modern healthcare leads to multifaceted ethical dilemmas, especially when no consensus has been developed for an unprecedented situation, such as the pandemic related to novel infectious agents. Despite the physicians’ duties to provide ensuring fair and equitable care, a more social approach to the resource distribution is required to preserve the functioning of society during the pandemic. Distributive justice has to be exercised for resource allocation, even though tragic choices may have to be made. 
Generally speaking, 3 key principles may be considered when deciding the priority for scarce resources:
1)      Equality - Each patient’s interests should be equal unless good reasons exist to justify the differential resource allocation (for example vaccines among high-risk populations, ventilators among patients with similar chance of survival).
2)      Best outcome - The allocation of resources is justified according to their capacity to do the most good and to save the most lives (for example, ventilators to those with certain favorable prognostic indicators for the most benefit).
3)      Prioritize the worst off – This refers to the principle that resources should be prioritized to those having greatest medical needs or those at highest risk (for example, PPE for healthcare professionals working in hot zones, vaccines for those at highest risk of infection and mortality)
Each pandemic is unique. While the libertarian approach (i.e. resource distribution according to market principles) is undesirable during a pandemic, there may exists no single approach to exercise full distributive justice during pandemic. For example utilitarianism, which refers to the policies of resource allocation aiming at maximal anticipated benefits for the majority, may be tempered by the ethical principles of non-maleficence and respect for persons. Multiple principles may be concurrently valid depending on the characteristics of the pandemic, and the crux is on how to strike the balance. However, no matter what decisions will be, patient characteristics such as race, ethnicity, ability or gender should not be determining factors. 
At the time of writing, there is resurgence of local COVID-19 cases. Restrictions previously lifted have to be imposed again. Until specific countermeasures for the COVID-19 are ready, we still have to stay vigilant to stop community transmission. Stay resilient, stay safe and we shall overcome the difficult times. 

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

Welcome to the new issue of HKSEMS newsletter!
We are happy to introduce a new look of our newsletter. Thanks to the joining of news members in our editorial board, we have new columns in the newsletter so as to make our newsletter more interesting than ever.  

The “Members Area” allows our members or council members to submit any EM related articles for sharing with other members. We welcome any of our members to share with us any interesting EM related topics, be it academic or non-academic. You can submit your article to Selected articles will be published in the column.   
While most of the EM service is provided by public-funded A&E, Private EM service is gaining more attention in recent years. The column, “Private EM Writes” allows private EM doctors to share with us their works and thoughts.
EM nurses form an important partner with EM physician in every part of EM care. “Nurses Corner” let members gain more understanding of the work and life as an EM nurse.
“Advance in EM” will touch on new hot topics about EM. We will explore important new developments on EM such as new disease, new clinical evidence, new guidelines, or even new technology on EM, and bring this to our members in a concise format.
Hope you all enjoy this new issue of newsletter.


Council News

Dear Members of the HKSEMS,
Welcome to the 2nd issue in 2020. Let’s refresh the activities organized by the council in these 3 months!!
EM module for School of Chinese Medicine in HKBU
HKSEMS is actively involved in different types of education programs, in addition to the courses for the public and health care professions, we also target to the teaching of students in the School of Chinese Medicine of HKBU. This program composed of lectures in a weekly basis for two months plus a half-day course for BLS in TSK AETC. We used to conduct the class in person,

Due to COVID-19, we temporarily switched to teach online using ZOOM which is a great challenge to us. The course had been completed successfully with good feedback from the students.
Level One Mountaineering Certificate Course (co-organized with HKCEM)
This course compromised of half day theory plus 2 days of hiking session has been completed. All of the 10 participants were granted the certificate!
We planned to conduct level two Mountaineering Certificate course in the coming year. Please stay tuned for our update! Let’s share the joy with the participants!
Day one:  Yau Tong-> Devil’s Peak-> Black Hill->Mau Wu Shan
Day two: Tai Koo->Hong Pak Country Trail-> Sir Cecil’s Ride
Training program in trail running 2020 (cojoint with HKCEM sports team (postponed)
The Trail running course 2019 (basic course) had been completed with a success, the intermediate class has been planned to start after the Chinese New year but was postponed due to the COVID-19 pandemics.
We plan to start the class in late Autumn! Please register
Please stay tuned for our update!!
Upcoming activities

ACEM 2021
Save the date !!
HKSEMS will be the organizer for the 11th ACEM.
We are looking forward to meeting you at the conference!!
Members Area Dr Siu Yuet Chung, Axel
  President, Hong Kong College of Emergency Medicine

CPR Training during COVID-19 Pandemic
COVID-19 has swept the whole world since the 2020 bell rang. It significantly influenced our health care system in a way that we need to sacrifice some of those non-urgent services in order to meet the rapid growing demand for diagnosis confirmation, disease management and subsequent contact tracing.
Besides the impact on the patient services, staff safety was also a great concern. Cardiopulmonary resuscitation (CPR) was the essential core skills for emergency physicians and nurses to rescue the patient’s life. However, CPR was also considered as one of the Aerosol Generating Procedures (AGP) which may result in considerable risk in transmission of the SARS-CoV-2. Therefore, we need to strike for the balance between the efficiency of resuscitation and the potential risk to the health care provider in provision of this life-saving procedure.
American Heart Association has announced the new interim guidelines on Basic and Advanced Life Support in Adults, Children and Neonates with suspected or confirmed COVID 19 on 9 April 2020. The major changes in the approach of resuscitation was to initiate intervention such that the infection risk to health care providers will be minimized, including early DON PPE and early use of endotracheal intubation to reduce the risk of aerosol generation. In a low resource setting, one may need to consider the necessity to initiate resuscitation if the chance of survival was futile. Modification was also proposed in the management of out-of-hospital cardiac arrest by layperson. Though hand-only CPR was advocated as before, the safety of the rescuer was further accomplished by putting the face mask or even just a piece of clothes over the patient’s mouth.
Infection control issue is not only restricted to real-life resuscitation, but also concerning about the training. The HKSAR government has advocated social distancing and avoidance of any possible gathering. However, regular training is essential to maintain the knowledge and skills to provide high standard of resuscitation. It is impossible to withhold all these trainings until the end of the pandemic. Instead, measures could be initiated in order to provide a safe environment for CPR training. Routine temperature checking before class should be implemented. Students are also advised not to attend class if they have fever or symptoms of upper respiratory tract infection. If there was history of travel overseas within 14 days, they should be refrained from attending the class. Adequate spacing should be allocated in between students during lecture and skills practice. If feasible, students should be assigned to use a designated manikin only. Mouth-to-mouth or Mouth-to-mask rescue breathing practice is suspended in order to reduce the risk of droplets production. All the equipment used should be thorough disinfected before they are ready for the next class.
Although all these measures appeared to be inconvenient to both the organizer and the students, a vigilant approach on CPR training should be adopted in this critical time to minimize the potential infection risk so that all sorts of CPR training can be continued for skill and knowledge preservation. Once the war against COVID-19 is over, we will be able to return to our usual training practice.
Private EM Writes 
Dr Wu Wing Yee, Clara
  Vice-President of Hong Kong College of Emergency Medicine
Deputy Medical Director & Director of Emergency Medicine Centre 
Union Hospital 
Wellness in Emergency Physicians
A dual track system of healthcare is in place in Hong Kong, in which healthcare services are jointly provided by the public and private sector. Among various specialty services, Emergency Medicine service is grossly under-developed in the private sector until 2008 after the first private Emergency Medicine Centre at Union Hospital was set up. Subsequently, more private Emergency Department/ Urgent Care Centre have commenced their service.
As in many developed countries, healthcare demand in Hong Kong is expected to rise due to the longevity of the population. Alongside with the associated increase of healthcare demand, the evolving complexity and scope of work in Emergency Department have posed remarkable challenges and stress to the Emergency Physicians (EP) in both public and private sector.
According to Estry-Behar et al’s study, burnout was highly prevalent in EPs and 51.5% of them reported burnout as measured by the Copenhagen Burnout Inventory [1]. Besides, EPs are found to be suffering from higher level of burnout and stress than other specialties within the medical profession [2].
Despite burnout was commonly reported in literature, most EPs found that they had a high level of career satisfaction and considered their work meaningful [3]. Job satisfaction in EPs was highly related to a positive job culture characterized by friendliness among colleagues [4]. The importance of peer support is obvious and it is no doubt that building up supportive social networks can serve as a buffer against the isolating effects of chronic stress.
Hong Kong Society for Emergency Medicine and Surgery (HKSEMS) has long been actively organizing different activities and training to connect members. Working in partnership with HKSEMS, 3 chapters namely Woman Fellows’ Chapter, Young Fellows’ Chapter and Private Emergency Physicians’ Chapter have been set up under the Hong Kong College of Emergency Medicine (HKCEM).  In addition to educational programmes, various kinds of social activities are arranged by these chapters to encourage the participation of EPs & trainees from different institutions to stay connected.
The epidemic of COVID-19 has highlighted the adverse impact of social isolation which has created a lot of stress in society. The same phenomenon also occurs in our profession. Therefore it is important for us to stay connected with fellow EM colleagues and to have mutual sharing of both joy and problems. Showing friendliness to our colleagues is the best way to demonstrate our peer support.
By promoting wellness in ourselves, I believe that we will have more satisfying careers, live healthier lives, take better care of our patients and possibly even improve patient outcomes. So, let us work together to build a healthy and supportive environment to our fellow colleagues. Hope to see you all in the upcoming activities organized by the HKSEMS and HKCEM very soon.
  1. Estryn-Behar M, Doppia MA, Guetarni K, Fry C, Machet G, Pelloux P, et al. Emergency physicians accumulate more stress factors than other physicians results from the French SESMAT study. Emerg Med J 2011; 28:397–410.
  2. Lepnurm R, Lockhart WS, Keegan D. A measure of daily distress in practising medicine. Can J Psychiatry 2009; 54:170–180.
  3. Cydulka RK, Korte R. Career satisfaction in emergency medicine: the ABEM Longitudinal Study of Emergency Physicians. Ann Emerg Med 2008; 51:714–722.
  4. Lin BY, Wan TT, Hsu CP, Hung FR, Juan CW, Lin CC. Relationships of hospital-based emergency department culture to work satisfaction and intent to leave of emergency physicians and nurses. Health Serv Manage Res 2012; 25:68–77.
Nurse Corner Mr Leung Chun Pong
  President, Hong Kong Emergency Nurse Association
Emergency Preparedness – Negative Pressure Room Failure Drill

 The pandemic of COVID 19 caused much pressure to healthcare service. The crisis not only affected our daily life but also disrupted the global economy.

In response to the pandemic, Hospital Authority activated the “Emergency” level of preparedness on 25 Jan 2020.  All isolation facilities in the territory were activated.
Ever since the SARS period in 2003, most isolation equipment/facilities were on standby mode without being actually recruited into active use, which meant a sixteen- year period without being put on stress test. To meet the sudden surge of demand for service, the isolation facilities would need to operate 24 hours a day, 7 days a week. It was not unexpected that some equipment would not work properly and malfunction would be inevitable.

While we always hope for the best, we need to prepare for the worst. Together with Hospital Q&S division, Isolation Wards, Facility Management Department and ICU (isolation cubicle), we organized a Negative Pressure Room/AIIR Failure Drill to test our contingency plan.

In the drill, there was one suspected COVID 19 patient attending our A&E and put in negative pressure room A. The negative pressure system in room A was then found to have malfunctioned. Nurse IC would then need to remind related staffs to put on appropriate PPE and relocate the patient to another negative pressure room. However, it was eventually found out that all negative pressure rooms in A&E were out of order and we needed to admit the patient to isolation ward.

The scenario for the isolation ward was similar to A&E. With one AIIR failure at the beginning, it was later found out that all AIIR in the ward was broken down as well. The isolation ward needed to evacuate all patients to another ward.

The drill ran smoothly and made sure that our contingency plan can work properly. From the drill, we learnt two management issues:

 The first issue is need of communication with all staffs who will be on duty, particularly all APNs/Senior nurses. We assigned one APN to have dual role as being on-duty and drill in-charge, which simulated the real-life situation as the nurse in-charge need to manage the clinical situation as well as deal with emergency. However, the assigned APN fell sick that day and was unable to join the drill. Another nurse in-charge therefore needed to take up her role. The nurse in-charge was stressed because she was not adequately briefed before and therefore there was inadequate preparation. In view of this, we expressed our understanding to her anxiety and appreciated her effort. To show our appreciation of the team work contributed by all colleagues, we prepared tea buffet after the drill. From this we learnt that we need to engage all stakeholders in the briefing of the drill and prepare plan B with second/third IC to take up leader role if needed so that there is a better expectation of colleagues.  

The second issue is viewing challenge as an opportunity.A hospital-wide drill is commonly seen as a stress to the front-line staff. Yet, we can always turn the stress to an opportunity to learn, which was fully illustrated in this drill.  
The negative pressure rooms in our department has been in use for more than 15 years and they may not able to meet the current infection control standard. The negative pressure rooms are equipped with exhaust fan failure alarm but without pressure differentiate sensors. This means we can know whether the exhaust fan is running but whether the negative pressure in the room can meet the standard (-2.5) is not monitored. Due to space and financial constraint, our pressure differentiate sensors installment was not put at first priority list in our facilities improvement work. We invited cluster infection control officer (ICO) to participate in the drill. He provided his valuable input and we expressed our concern on lack of pressures differentiate sensors installation. Our ICO supported this suggestion and recorded the post-drill debriefing minute for further follow-up.

  We need to look every matter from different views so that we can understand the whole picture.
Advance in EM  Dr Kwun-bun Wong   
  Associate Consultant, Prince of Wales Hospital


What is e-cigarette and current trend?
Electronic cigarettes (e-cigarettes) are battery-operated devices that heat a solution (called e-liquid) usually containing nicotine, propylene glycol, glycerin, flavorings, and other additives, producing a vapor (which is actually an aerosol) that the user inhales.
“Vaping” is the process of inhaling an aerosol that is created by heating a liquid or wax.

E-cigarette use has surged in popularity worldwide, particularly among young people. In United State, high school students reported having used e-cigarettes jumped from 2% to 16% from 2011 to 2015(1). In 2017, 3.5% of the respondents had ever used e-cigarettes, over one-third of respondents (37.4%) who had tried e-cigarettes were aged 15-29(2). E-cigarettes are marketed as healthy and trendy products, which pander to the curiosity of teenagers.

Is it legal to smoke e-cigarette in Hong Kong?
Cigarette smoking (including e-cigarette) is banned in no smoking areas (include all indoor area such as school campus, public parks and beaches) under the Smoking (Public Health) Ordinance (Chapter 371, Laws of Hong Kong). Under the pharmacy and Poison Ordinance (Chapter 138, Laws of Hong Kong), nicotine is a Part I poison. E-cigarette containing nicotine is regarded as pharmaceutical product and must be registered with the Pharmacy and Poisons Board before sale and distribution. Possession or sale of unregistered pharmaceutical product, and the possession or sale without authority of Part I poison, are both offences. Each offence shall be liable on conviction to maximum penalty of $ 100,000 fine and 2 years’ imprisonment.

What is EVALI?
E-cigarette, or vaping, product use-associated lung injury (EVALI) was first recognized in summer of 2019. As of February 18, 2020, a total of 2,807 has been reported and causing 68 deaths in the United States. (3).  EVALI appears to be a form of acute lung injury with pathologic findings of acute fibrinous pneumonitis, diffuse alveolar damage, or organizing pneumonia.
The clinical features include respiratory symptoms such as nonproductive cough, pleuritic chest pain, and shortness of breath. Systemic signs and symptoms might include tachycardia, fever, chills, and fatigue. Gastrointestinal symptoms, which have preceded respiratory symptoms in some cases, include nausea, vomiting, abdominal pain, and diarrhea(4).

What is the culprit?
National and state data from patient reports and product sample testing showed tetrahydrocannabinol (THC) in e-cigarette. Vitamin E acetate is strongly linked to the EVALI outbreak. Vitamin E acetate was identified in bronchoalveolar lavage fluid obtained from 48 of 51 case patients (94%)(5) Vitamin E acetate might be used as an additive in the production of e-cigarette, or vaping, products; it also can be used as a thickening agent in THC products (6)
The diagnosis of EVALI is mainly clinical and by ruling out other diagnose. Criteria used as a case definition for EVALI include the followings: (7)
  • Use of an e-cigarette or related product (eg. “vaping” or “dabbing”) in the previous 90 days
  • Lung opacities on chest radiograph or computed tomography (CT)
  • Exclusion of lung infection based on negative influenza polymerase chain reaction (PCR) or rapid test (unless out of season), viral respiratory panel, and, as clinically indicated, urine antigen tests for Legionella and Streptococcus pneumoniae, blood cultures, sputum culture (if producing sputum), bronchoalveolar lavage (if performed), and testing for HIV-related opportunistic infections 
  • Absence of a likely alternative diagnosis (e.g. cardiac, neoplastic, rheumatologic)
The treatment of EVALI is mainly supportive care with the use of antibiotics and systemic glucocorticoids. In a case series of 98 patients, 95% of the patients were hospitalized, 26% underwent intubation and mechanical ventilation(4). Long-term outcomes and subsequent use of vaping-related products have not been reported in survivors.
The total number of EVALI showed a peak in September 2019, and a gradual, but persistent decline due to increased public awareness of the risk associated with THC-containing e-cigarette, or vaping, product use as a result of the rapid public health response and removal of vitamin E acetate from some products.

The use of electronic cigarettes has become increasingly popular over the past decade, particularly in the adolescent and young adult population, often exposing users to harmful chemicals. There was an association between the use of cannabis and vaping in the case of EVALI. There is no case of EVALI in Hong Kong yet. However, we should be highly vigilant about it.
  1. Barrington-Trimis JLLeventhal AMAdolescentsuse of “pod mod” e-cigarettesurgent concernsN Engl J Med2018;379(12):1099–1102.
  2. Derek YT CHEUNG, MP WANG, SY HO et al, TH LAM Report on Tobacco Control Policy-related Survey 2017
  4. Layden JE, Ghinai I, Pray I et al Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Final Report. N Engl J Med. 2020;382(10):903. Epub 2019 Sep 6
  5. Blount BC, Karwowski MP, Shields PG et al Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI. N Engl J Med. 2020 Feb 20;382(8):697-705
  6. Blount BC, Karwowski MP, Morel-Espinosa M et al Evaluation of Bronchoalveolar Lavage Fluid from Patients in an Outbreak of E-cigarette, or Vaping, Product Use-Associated Lung Injury - 10 States, August-October 2019.
  7. Schier JG, Meiman JG, Layden J, et al. Severe Pulmonary Disease Associated with Electronic-Cigarette-Product Use - Interim Guidance. MMWR Morb Mortal Wkly Rep 2019; 68:787.
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