Evelyn Wong

Road traffic accident mortality in Singapore

The aim of this study was to identify factors that contribute to road traffic accident mortality and the patterns of injuries sustained by these victims, with a view to identifying areas for future intervention. All road traffic accident deaths that occurred in Singapore over a period of 1 year were reviewed. A total of 226 deaths occurred: 82.3% of the victims were male. The median age was 31 years. Blood alcohol was detected in 42 (18.7%) victims. In general, head (86.7%), followed by thoracic (67.7%) and abdominal (31.4%) injuries, were the most common injuries. Severe lower extremity trauma was most common among pedestrians and pedal cyclists (20.6% and 11.0%, respectively). The mean Injury Severity Score was 38.7. The relative risk of mortality between motorcyclists and motorcar drivers was 18.8:1. Suggestions for future prevention and intervention include stricter enforcement of speed limits, more severe penalties for drunk driving, helmet use among pedal cyclists, and the introduction of pre-hospital advanced airway management.

The difficult airway in the emergency department

BackgroundThe patient with difficult airways is a common challenge for emergency physicians.AimsOur goal was to study the reasons for difficult airways in the emergency department.MethodsWe performed a prospective observational study of patients requiring advanced airway management from 1 January 2000 to 31 December 2006.ResultsThere were 2,343 patients who received advanced airway management of which 93 (4.0%) were deemed difficult. The main diagnoses were cardiac arrest (28), trauma (27) and congestive heart failure (10). The main reasons for the difficult airways were attributed to an anterior larynx (38, 40.9%), neck immobility (22, 23.7%) as well as the presence of secretions and blood (14, 15.1%). The mean number of attempts at intubation was 3.6 versus 1.2 for all cases. The mortality rate of 40.5% among patients with difficult airways was not different from that of all patients who had airway management (41%). There were seven (0.3%) failed airways. Anaesthetists performed 21 (22.6%) of the rescue airways while surgeons performed 5 (5.4%). Of the rescue strategies performed, 24 were through the use of the bougie, 3 by cricothyroidotomy, 4 by tracheostomy, 6 with the GlideScope and 3 with the laryngeal mask airway. The rest the airways were secured by tracheal intubation using the laryngoscope.ConclusionsEmergency physicians manage most of the difficult airways successfully (68.8%). However, the success rate can be further improved through the more frequent use of the bougie or other rescue device. A possible suggestion would be for the emergency physician to use the bougie after the second or third attempt at direct orotracheal intubation.

A randomized controlled trial comparing minichest tube and needle aspiration in outpatient management of primary spontaneous pneumothorax

OBJECTIVES The aim of this study was to compare outcomes and complications associated with needle aspiration (NA) and minichest tube (MCT) insertion with Heimlich valve attachment in the treatment of primary spontaneous pneumothorax at an emergency department (ED). METHODS Patients presenting with primary spontaneous pneumothorax were randomized to NA or MCT. They had repeat chest x-rays immediately after the procedure and 6 hours later. Patients who underwent NA were discharged if repeat x-rays showed less than 10% pneumothorax. Those who had MCT were discharged if repeat x-rays did not show worsening of pneumothorax. They were reviewed at the outpatient clinic within 3 days. The primary outcomes of interest were failure rate and admission rate. The secondary outcomes were complication rate, pain and satisfaction scores, length of hospital stay, and rate of full recovery during outpatient follow-up. RESULTS There were 48 patients whose mean age was 25 years. We found no difference in failure rate between the groups, except that there were more MCT (24%) than NA patients (4%) with complete expansion at first review (difference, -0.20; 95% confidence interval, -0.38 to -0.01). Thirty-five percent of NA group and 20% of MCT group needed another procedure at the ED. Fifty-two percent of NA patients and 28% of MCT patients were admitted from the ED to the inpatient ward. Nine percent and 12%, respectively, of patients who had NA and MCT were admitted from the review clinic. Both groups of patients had equivalent pain scores, satisfaction scores, and complication rates. CONCLUSION Both MCT and NA allowed safe management of primary spontaneous pneumothorax in the outpatient setting.

Addressing the needs of colorectal cancer survivors: current strategies and future directions

Colorectal cancer (CRC) is one of the three topmost common cancers in men and the second most common cancer in women worldwide. With current advances in the medical and surgical treatment of CRC, care has slowly transformed to curative treatment. With these advances, CRC survivors are increasing in numbers and these patients have a unique range of medical, physical and psychological needs that require regular follow-up. In 2006, the Institute of Medicine recommended that cancer survivors who are completing primary treatment receive a survivorship care plan. There are many different programs of different complexity that are implemented for CRC survivors. This review outlines the needs of CRC survivors, the current surveillance techniques used in the continuing care of patients with CRC after curative treatment and the evidence behind these strategies.

The effect of severe acute respiratory syndrome (SARS) on emergency airway management

Summary From early March 2003 to late May 2003, severe acute respiratory syndrome (SARS) was detected in Singapore. The increase in workload and new infection control procedures were thought to affect resuscitation and airway management. Our aim was to study the effects of wearing of personal protective equipment (PPE) and powered air-purifying respirator (PAPR) and the restriction in the number of resuscitation personnel on airway management during the SARS crisis. Data was collected prospectively through an ongoing emergency airway registry. The data was divided into three periods: (1) before PPE was instituted from 1 November 2002 to 31 March 2003; (2) during SARS (when PPE use was mandatory) from 1 April to 31 July 2003; (3) post-SARs (when PPE use was non-mandatory but encouraged) from 1 August to 31 March 2004. There was no change in patient demographics during the three periods. There were significant increases in the proportion of resuscitation cases and airway interventions during the SARS period compared to the pre-SARS period. The resident medical officer intubation rate decreased from 45.1% pre-SARS to 35.2% during SARS and 17.7% post-SARS. The complication rates were 10.5%, 9.9% and 9.4% in periods 1–3, respectively. Restriction in the number of healthcare staff attending to each patient may have influenced the departments decision to allow only the most confident or experienced personnel to manage the airway. The exposure of junior medical officers in emergency airway management during SARS and the immediate post-SARS period was decreased. This trend should be monitored further and intervention may be necessary should it continue to decline.