Emergency Medicine Sum Lam Forest PWH Content Hospital AuthorityHospital Authority Structured Basic Surgical Training Program in Hospital AuthorityStructured.

Emergency Medicine

Sum Lam Forest

PWH

ContentContent

• Hospital AuthorityHospital Authority

• Structured Basic Surgical Training Program Structured Basic Surgical Training Program in Hospital Authorityin Hospital Authority

• Hong Kong College of Emergency MedicinHong Kong College of Emergency Medicinee

• StudyLightStudyLight

• QuestionsQuestions

Hospital AuthorityHospital Authority

www.ha.org.hkwww.ha.org.hk

HAHA

BackgroundBackground

BackgroundBackground

• The Hospital Authority is a statutory body The Hospital Authority is a statutory body established on 1 December 1990established on 1 December 1990

• under the Hospital Authority Ordinance to manage under the Hospital Authority Ordinance to manage all public hospitals in Hong Kongall public hospitals in Hong Kong

• It is an independent organization which is It is an independent organization which is accountable to the Government through the accountable to the Government through the Secretary for Health and Welfare, Secretary for Health and Welfare,

• who is responsible for the formulation of health who is responsible for the formulation of health policies and monitoring the performance of the policies and monitoring the performance of the Authority. Authority.

BackgroundBackground

• The Hospital Authority formally took over the manageThe Hospital Authority formally took over the management of all the 38 public hospitals and institutions, and tment of all the 38 public hospitals and institutions, and their 37,000 staff on 1 December 1991.heir 37,000 staff on 1 December 1991.

• It currently manages a Head Office, 44 public hospitals/It currently manages a Head Office, 44 public hospitals/institutions, and 49 specialist outpatient centres. institutions, and 49 specialist outpatient centres.

• At the end of 1997, the Authority managed a total of 26,At the end of 1997, the Authority managed a total of 26,400 hospital beds which represented 4.06 public hospita400 hospital beds which represented 4.06 public hospital beds per 1,000 population. It employs 48,452 full-time l beds per 1,000 population. It employs 48,452 full-time staff and operates under a recurrent budget of $26,022 staff and operates under a recurrent budget of $26,022 million in 1998/99 . million in 1998/99 .

BackgroundBackground

• The Authority is mainly responsible for delivering a The Authority is mainly responsible for delivering a comprehensive range of secondary and tertiary specialist comprehensive range of secondary and tertiary specialist care and medical rehabilitation through its network of care and medical rehabilitation through its network of health care facilities. health care facilities.

• The Authority also provides some primary medical services The Authority also provides some primary medical services in 10 primary care clinics providing 750,765 general in 10 primary care clinics providing 750,765 general outpatient attendances. outpatient attendances.

• In 1997, there were a total of 966,000 inpatient discharges, In 1997, there were a total of 966,000 inpatient discharges, 7,111,000 specialist outpatient attendances and 2,129,000 7,111,000 specialist outpatient attendances and 2,129,000 accident and emergency attendances representing an accident and emergency attendances representing an increase of 0.3%, 11.3% and 2.6% respectivelyincrease of 0.3%, 11.3% and 2.6% respectively

HAHA

MissionMission

MissionMission

• The Government's health care policy is The Government's health care policy is – to safeguard and promote the general public health of thto safeguard and promote the general public health of th

e community as a whole and e community as a whole and

– to ensure the provision of medical and health services fto ensure the provision of medical and health services for the people of Hong Kong,or the people of Hong Kong,

– including particularly that large section of the communiincluding particularly that large section of the community which relies on subsidised medical attention, so that ty which relies on subsidised medical attention, so that no one should be prevented through lack of means from no one should be prevented through lack of means from obtaining adequate medical attention.obtaining adequate medical attention.

MissionMission

• To meet the different needs of the To meet the different needs of the patientspatients for public for public hospital services, and to improve the hospital hospital services, and to improve the hospital environment for the benefit of the patients; environment for the benefit of the patients;

• To serve the To serve the publicpublic with care, dedication and with care, dedication and efficiency, and to encourage community participation efficiency, and to encourage community participation in the system, resulting in better care and more direct in the system, resulting in better care and more direct accountability to the public;accountability to the public;

• To provide rewarding, fair and challenging To provide rewarding, fair and challenging employment to all its employment to all its staffstaff, in an environment , in an environment conducive to attracting, motivating and retaining well-conducive to attracting, motivating and retaining well-qualified staff; qualified staff;

MissionMission

• To advise the To advise the GovernmentGovernment of the needs of the of the needs of the community for public hospital services and of the community for public hospital services and of the resources required to meet these needs, in order to resources required to meet these needs, in order to provide adequate, efficient and effective public provide adequate, efficient and effective public hospital services of the highest standards recognized hospital services of the highest standards recognized internationally within the resources obtainable; internationally within the resources obtainable;

• To collaborate with To collaborate with other agencies and bodiesother agencies and bodies in in the health care and related fields both locally and the health care and related fields both locally and overseas to provide the greatest benefit to the local overseas to provide the greatest benefit to the local community.community.

HAHA

Vision & StrategiesVision & Strategies

Vision & StrategiesVision & Strategies

• The Hospital Authority has established the fThe Hospital Authority has established the following corporate vision: ollowing corporate vision:

•   The Hospital Authority will collaborate witThe Hospital Authority will collaborate with other healthcare providers and carers in thh other healthcare providers and carers in the community to create a seamless healthcare community to create a seamless healthcare environment which will maximise healthce environment which will maximise healthcare benefits and meet community expectatioare benefits and meet community expectations.ns.

Vision & StrategiesVision & Strategies• Five Corporate Strategies: Five Corporate Strategies:

– Developing Developing Outcome-focused HealthcareOutcome-focused Healthcare to maximise health ben to maximise health benefits and meet community expectations efits and meet community expectations

– Creating Creating Seamless HealthcareSeamless Healthcare by restructuring and reorganising m by restructuring and reorganising medical services in collaboration with other providers and carers in thedical services in collaboration with other providers and carers in the community e community

– Involving the Involving the Community as Partners in HealtCommunity as Partners in Health in the decision-mh in the decision-making and caring process aking and caring process

– Cultivating Cultivating Organisation Transformation and DevelopmentOrganisation Transformation and Development thro through a multi-disciplinary team approach to holistic patient care and cugh a multi-disciplinary team approach to holistic patient care and continuous quality improvement ontinuous quality improvement

– Promoting Promoting Corporate Infrastructure Development and InnovatiCorporate Infrastructure Development and Innovationon to support service improvement to support service improvement

Vision & StrategiesVision & Strategies

• The annual planning process translates the corporaThe annual planning process translates the corporate vision and strategies of the Authority into specifte vision and strategies of the Authority into specific initiatives, which are then incorporated in the Aic initiatives, which are then incorporated in the Annual Plan as programmes, key result areas and tarnnual Plan as programmes, key result areas and targets to be achieved. gets to be achieved.

• The planning process is also broadly participative The planning process is also broadly participative with extensive input from healthcare professionals,with extensive input from healthcare professionals, Government policy directives and the community Government policy directives and the community to reflect different perspectives of health service pto reflect different perspectives of health service priorities. riorities.

HA- VisionHA- Vision

MottoMotto

HAHA

StructureStructure

StructureStructure

• Under the Hospital Authority Ordinance, the HospUnder the Hospital Authority Ordinance, the Hospital Authority is responsible for the following:ital Authority is responsible for the following:

• advising the Governement of the needs of the publadvising the Governement of the needs of the public for hospital services and of the resources requireic for hospital services and of the resources required to meet these needs managing and developing thd to meet these needs managing and developing the public hospital systeme public hospital system

• recommending to the Secretary for Health and Wrecommending to the Secretary for Health and Welfare appropriate policies on fees for the use of hoelfare appropriate policies on fees for the use of hospital services by the publicspital services by the public

StructureStructure

• establishing public hospitals promoting, assisting establishing public hospitals promoting, assisting and taking part in education and training of HA staand taking part in education and training of HA staff and research relating to hospital servicesff and research relating to hospital services

• To carry out this role effectively, the Hospital AutTo carry out this role effectively, the Hospital Authority Board has developed a functional committehority Board has developed a functional committee structure which allows it to make more efficient e structure which allows it to make more efficient use of Board members' time and expertise to focus use of Board members' time and expertise to focus more specifically on pertinent issues.more specifically on pertinent issues.

•   Organisation StructureOrganisation Structure• Committee StructureCommittee Structure

StructureStructure

• The Hospital Authority is of the view that in order The Hospital Authority is of the view that in order to serve the goal of improving the health of the to serve the goal of improving the health of the community community

• a health care systema health care system should consider the objectives should consider the objectives of:of:– equityequity, where patients can have access to appropriate , where patients can have access to appropriate

services regardless of financial means; services regardless of financial means; – efficiency efficiency in the use of resources; in the use of resources; – effectiveness effectiveness in the provision of quality care; and in the provision of quality care; and – choicechoice, where patients have a choice of service providers , where patients have a choice of service providers

at affordable cost. at affordable cost.

StructureStructure

• It is noted that sometimes these objectives It is noted that sometimes these objectives compete against each other, and health care compete against each other, and health care systems of different countries suggest that they systems of different countries suggest that they value some objectives above others. value some objectives above others.

• For example, in a public health care system For example, in a public health care system providing universal access, equity is very highly providing universal access, equity is very highly valued, but choice may be limited. Trade-offs valued, but choice may be limited. Trade-offs need to be made to enable the system to be need to be made to enable the system to be affordableaffordable to the community. to the community.

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Structured Structured Basic Surgical Training Basic Surgical Training

Program Program in the Hospital Authorityin the Hospital Authority

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Then Contract MO and Resident ColumnThen Contract MO and Resident Column

Then Annoucement & MessagesThen Annoucement & Messages

Then scroll downThen scroll down

BackgroundBackground

BackgroundBackground

• The Basic Surgical Training program involves The Basic Surgical Training program involves surgicallysurgically--relatedrelated clinical departments of clinical departments of – Surgery, Surgery, – ENT, ENT, – Orthopaedics & Traumatology, Orthopaedics & Traumatology, – Neurosurgery, Neurosurgery, – Cardiothoracic Surgery Cardiothoracic Surgery – and A&E and A&E – (not including Ophthalmology and Obstetrics and Gyna(not including Ophthalmology and Obstetrics and Gyna

ecology). ecology).

BackgroundBackground• These departments are currently providing training These departments are currently providing training

for nine specialties including for nine specialties including – General Surgery, General Surgery, – Cardiothoracic Surgery, Cardiothoracic Surgery, – Urology, Urology, – Paediatric Surgery, Paediatric Surgery, – Plastics Surgery, Plastics Surgery, – Neurosurgery, Neurosurgery, – Otorhinolaryngology, Otorhinolaryngology, – Emergency Medicine, Emergency Medicine, – and Orthopaedics & Traumatology. and Orthopaedics & Traumatology.

BackgroundBackground

• The program involving these nine The program involving these nine specialties are currently specialties are currently

• under the auspices of the Hong Kong under the auspices of the Hong Kong Intercollegiate Board of Surgical Colleges Intercollegiate Board of Surgical Colleges

• under the Hong Kong Academy of under the Hong Kong Academy of Medicine.Medicine.

Implementation of Implementation of the the

Basic Surgical Training Program Basic Surgical Training Program - - from July 2003 onwardsfrom July 2003 onwards

BST programBST program

• UUnder the new nder the new programprogram, basic specialist , basic specialist trainees trainees (BST) (BST) aspiring to pursue specialist aspiring to pursue specialist training in these nine specialties need to go training in these nine specialties need to go through a structured two-year Basic through a structured two-year Basic Surgical Training program Surgical Training program in a cluster in a cluster comprising at least four 6-month rotational comprising at least four 6-month rotational training unitstraining units. .

• They will not be attached to a particular They will not be attached to a particular department continuously until they enter department continuously until they enter their higher training their higher training at least at least 2 years later2 years later..

BST programBST program

• The structure of the typical rotational The structure of the typical rotational training program is composed of a training program is composed of a combination of modules of specialty combination of modules of specialty training as illustrated below:training as illustrated below:

6 months6 months 6 months6 months 6 mont6 monthshs

6 months6 months

OtorhinolarynOtorhinolaryngologygology

OrthopaedicOrthopaedics & s &

TraumatologTraumatologyy

General General SurgerySurgery

Emergency Emergency MedicineMedicine EmergenEmergen

cy cy MedicineMedicine

SurgeSurgeryry

Orthopaedics Orthopaedics & &

TraumatologyTraumatology

CardiothoraciCardiothoracic Surgeryc Surgery

UrologyUrology

Plastic Plastic SurgerySurgery

Paediatric SurPaediatric Surgerygery

NeurosurgeNeurosurgeryry

Selection ArrangementSelection Arrangement

SelectionSelection• Currently, surgically related departments in effect Currently, surgically related departments in effect

conduct their selection process in conjunction with conduct their selection process in conjunction with participating in central selection interviews to arrive at participating in central selection interviews to arrive at a priority list of candidates for their own departments. a priority list of candidates for their own departments.

• Under the new scheme, the new recruits may also be Under the new scheme, the new recruits may also be rotated to any surgically-related departments within a rotated to any surgically-related departments within a cluster during the course of their Basic Surgical cluster during the course of their Basic Surgical Training. Training.

• IIt is proposed that, starting from July 2003, tt is proposed that, starting from July 2003, the selectiohe selection arrangement is moving from a totally department-basen arrangement is moving from a totally department-based approach to a more program-based, cluster-coordinated approach to a more program-based, cluster-coordinated one. d one.

• To this end, aTo this end, a cluster-based selection mechanism will b cluster-based selection mechanism will be devisede devised by the by the respective clusters in due course. respective clusters in due course.

SelectionSelection

• Successful applicants Successful applicants in each Joint Recruitin each Joint Recruitment Exercise ment Exercise will be invited will be invited to indicate to indicate their their preferred training modules and preferred training modules and preliminary preliminary preferred specialty in which preferred specialty in which they aspire to pursue higher specialist they aspire to pursue higher specialist training in the future training in the future in order to facilitate in order to facilitate placements that best meet their training placements that best meet their training needsneeds

More…More…

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HKCEMHKCEM

www.hkcem.comwww.hkcem.com

Emergency MedicineEmergency Medicine

Emergency MedicineEmergency Medicine

• Emergency medicine is a discipline of Emergency medicine is a discipline of medicine that:medicine that:– Deals with the acute and life threatening aspect Deals with the acute and life threatening aspect

of medical careof medical care– Emphasize the recognition, evaluation, care and Emphasize the recognition, evaluation, care and

disposition of patient with acute illnesses and disposition of patient with acute illnesses and injuriesinjuries

Emergency PhysiciansEmergency Physicians

Emergency PhysiciansEmergency Physicians

• Who has the following characteristics:Who has the following characteristics:– Has undergone training and assessment in Has undergone training and assessment in

emergency medicineemergency medicine– Major part of practice is in emergency medicineMajor part of practice is in emergency medicine– Currently of good standing in the specialty of Currently of good standing in the specialty of

emergency medicine emergency medicine

Role of A&E service Role of A&E service in Hong Kongin Hong Kong

Role of A&E service in Hong KongRole of A&E service in Hong Kong

• To provide emergency life support for the To provide emergency life support for the critically ill patientscritically ill patients

• To direct patients to appropriate sources of To direct patients to appropriate sources of continuing carecontinuing care

• To provide disaster management when there To provide disaster management when there are massive casualties in the communityare massive casualties in the community

• To provide continuous accessible A&E To provide continuous accessible A&E services for the general public services for the general public

??? Abuse ?????? Abuse ???

? abuse? abuse

• Indeed more than 50% of the workload of the Indeed more than 50% of the workload of the emergency department is not of an urgent natureemergency department is not of an urgent nature

• Lay public will define what is an emergency to Lay public will define what is an emergency to him or herhim or her

• There are people who are genuinely alarmed by There are people who are genuinely alarmed by symptoms we as doctors believe to be trivialsymptoms we as doctors believe to be trivial

• Not our job to pass value judgmentNot our job to pass value judgment• We are there to relieve acute sufferingsWe are there to relieve acute sufferings• It is a fact of life that we have to live withIt is a fact of life that we have to live with

A&EA&E

A&EA&E

• Fifteen public hospitals under HAFifteen public hospitals under HA

• Mission: to provide a high standard of Mission: to provide a high standard of emergency care to those in the community emergency care to those in the community who perceive the need for or are in need of who perceive the need for or are in need of acute careacute care

A&E Information SystemA&E Information System

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TriageTriage

TriageTriage

• French word meaning 'to sort' or ' to choose'. French word meaning 'to sort' or ' to choose'. • Process of setting priorities for treatments for a Process of setting priorities for treatments for a

patient or a group of A&E patientspatient or a group of A&E patients• Exercise interventions in the early phase to Exercise interventions in the early phase to

prevent deterioration and deathprevent deterioration and death• Effective utilization of staff and resourcesEffective utilization of staff and resources• Improve patient flowImprove patient flow• Improve patient-staff relationship through greeting Improve patient-staff relationship through greeting

and communication and communication

5 categories5 categories

• Critical: a team of medical and nursing staff Critical: a team of medical and nursing staff without waitingwithout waiting

• emergentemergent• urgenturgent• semi-urgentsemi-urgent• non-urgent: treated in the order of their non-urgent: treated in the order of their

arrival and should expect a longer waiting arrival and should expect a longer waiting time time

Why A&E?Why A&E?

Why A&E?Why A&E?

• ChallengingChallenging

• LifestyleLifestyle

• New SpecialtyNew Specialty

ChallengingChallenging

• See a large number of patients with various See a large number of patients with various presentations in a short period of timepresentations in a short period of time

• New to doctor, past medical history often uNew to doctor, past medical history often unknownnknown

• Clinical >> Ix: H-stix, H-cue, blood gas & eClinical >> Ix: H-stix, H-cue, blood gas & electrolytes, ECG, CXRlectrolytes, ECG, CXR

ChallengingChallenging

• Risk Management / Stratification: Risk Management / Stratification: – high risk caseshigh risk cases– e.g. Child < 3 months old with any complaint, e.g. Child < 3 months old with any complaint,

subtle signs and symptomssubtle signs and symptoms– ask for current medication, drug allergy, ask for current medication, drug allergy,

pregnancy in female of reproductive age pregnancy in female of reproductive age

ChallengingChallenging

• Medico-legal disaster: Medico-legal disaster: – good communication skill - address the good communication skill - address the

concerns of the patients and relativeconcerns of the patients and relative– adequate clinical assessment - consider adequate clinical assessment - consider

potential serious conditionspotential serious conditions– careful documentation careful documentation

Why A&E?

• Challenging

• Lifestyle

• New Specialty

LifestyleLifestyle

• Shift workShift work

• With adequate rest, optimize our condition With adequate rest, optimize our condition for workfor work

• Efficient time management, fully utilize Efficient time management, fully utilize working hoursworking hours

• Adaptive, not affect performance Adaptive, not affect performance

New SpecialtyNew Specialty

• emerging, good prospectemerging, good prospect• Hong Kong College of Emergency Medicine Hong Kong College of Emergency Medicine

– Previously known as Hong Kong Society for EmergencPreviously known as Hong Kong Society for Emergency Medicine & Surgeryy Medicine & Surgery

– Formed in February 1996, newest among all colleges of Formed in February 1996, newest among all colleges of the Academythe Academy

– Admitted as the 15Admitted as the 15thth constituent specialist college of the constituent specialist college of the Hong Kong Academy of Medicine on 16Hong Kong Academy of Medicine on 16thth January 1997 January 1997

– President: Wong Tai WaiPresident: Wong Tai Wai– Council Members: Ong Kim lian …Council Members: Ong Kim lian …

www.hkam.org.hkwww.hkam.org.hk

Why me?Why me?

Why me?Why me?

• In view of:In view of:– the chaotic workload, the chaotic workload, – undifferentiated symptoms, undifferentiated symptoms, – completely new patients and completely new patients and – on the spot decision despite uncertainty is on the spot decision despite uncertainty is

requiredrequired

Why me?Why me?• I think I am suitable to be a Resident in AED:I think I am suitable to be a Resident in AED:

– Set prioritiesSet priorities– Organize activities flexiblyOrganize activities flexibly– Handle several cases at a time (multi-tasking)Handle several cases at a time (multi-tasking)– Adjust speed and style of evaluation and treatment to suit the particulaAdjust speed and style of evaluation and treatment to suit the particula

r presentation at handr presentation at hand– Good interpersonal communication skillsGood interpersonal communication skills– Clinical sense (acumen) for a focussed approach to clinical evaluationClinical sense (acumen) for a focussed approach to clinical evaluation– tolerate uncertaintytolerate uncertainty– Assess probability of serious pathologyAssess probability of serious pathology– Exposure to medicine, surgery, O&G and pediatrics during internship Exposure to medicine, surgery, O&G and pediatrics during internship

Training ProgramTraining Program

FHKAM ( Emergency Medicine)FHKAM ( Emergency Medicine)

Training ProgramTraining Program

• Basic Specialist TrainingBasic Specialist Training– Part I exams: MRCP, MRCS or PEEMPart I exams: MRCP, MRCS or PEEM– 1 year in an accredited A&E centre 1 year in an accredited A&E centre – plus 6 month elective to general surgery and 6 plus 6 month elective to general surgery and 6

months elective to internal medicinemonths elective to internal medicine– before eligible for attempting intermediate exabefore eligible for attempting intermediate exa

m of emergency medicine IEEMm of emergency medicine IEEM– alternative: MRCP, FRCS/MRCS or equivalent alternative: MRCP, FRCS/MRCS or equivalent

+ compulsory elective training + compulsory elective training

Training ProgramTraining Program

• Advanced Specialist TrainingAdvanced Specialist Training– At least 2 year training in an accredited A&E ceAt least 2 year training in an accredited A&E ce

ntre after IEEMntre after IEEM– Plus optional rotation terms making up to total Plus optional rotation terms making up to total

of 6 years prior to exit exam of 6 years prior to exit exam

Training ProgramTraining Program

• Part I of MRCP or MRCS or PEEMPart I of MRCP or MRCS or PEEM

• Then IEEM / MRCS Then IEEM / MRCS

• Then EEEMThen EEEM

Worry ?

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Everyone worries!Everyone worries!

• ConsultantConsultant• SMOSMO• Permanent MOPermanent MO• Contract MOContract MO• Resident with incrementResident with increment• Resident without incrementResident without increment• Temporary ResidentTemporary Resident• You ??You ??

The Serenity PrayerThe Serenity Prayer

The Serenity Prayer The Serenity Prayer

• GOD, grant me GOD, grant me

• the serenity to accept the things the serenity to accept the things

• I cannot changeI cannot change

• Courage to change the things Courage to change the things

• I canI can

• and the Wisdom to know the differenceand the Wisdom to know the difference• By Reinhold NeibuhrBy Reinhold Neibuhr

WorryWorry

• Matthew 6:34Matthew 6:34– ““So never So never worryworry about tomorrow, for tomorrow about tomorrow, for tomorrow

will will worryworry about itself. Each day has enough about itself. Each day has enough trouble of its own.”trouble of its own.”

• 1 Peter 5:71 Peter 5:7– ““Throw Throw ALLALL your your worryworry on him, because he on him, because he

cares for you.”cares for you.”

ForestForest

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