Friday, October 08, 2010


Part of the new Private Healthcare Facilities and Services Act 1998, and accompanying Regulations ( 2006 ) mandates that doctors must attend to all emergencies brought to their clinic and no one in need of help should be turned away for whatever reason. We spend many hours meeting at Putrajaya, Ministry of Health to help define what is adequate "emergency help ". There were views expressed that required medical GP clinics to be furnished and staff like a " MASH " field hospital, able to perform all kinds of emergencies. We protested that this was ridiculous and that some have been influence too much by MASH and Chicago Hope, and Hollywood. We instead propose that all GPs should be able to resuscitate and help anyone collapsed. We also advised the MOH to go on a nationwide campaign to educate the public, so that our public have knowledge of CPR ( cardio-pulmonary resuscitation ) and less fear of it. To this, MOH finally agreed and we have gone of nationwide ( a few states ) to conduct talks and CPR courses for layperson, often in co-operation with the St John's Ambulance.
We advised the standard BLS ( Basic Life Support ) technique that is advocated by the British Resuscitation Council, basically 1. Identify the problem and call for help. 2. Maintain airway. 3. Cardiac compression of 30 compressions and one mouth-to-mouth breathe. 4. If an external defibrillator is available ( this is the program of St.John Ambulance, which we do not advocate ), to defibrillate. And to keep doing this until BP and Pulse returns or until professional help arrives. This is all standard in any emergency medical textbook.
I am very happy to note that studies have been done on out of hospital cardiac arrest and the technique have been simplified with some medical evidence to backup.
In the last 3 months, 3 studies have been published. Two studies were published in the July 29th issue of the NEJM ( New England Journal of Medicine ), and one in the Oct 6th issue of the Journal of the American Medical Association. Two of the studies were from USA ( one from Seattle, the resuscitation capital of the world, and the other from Pheonix, Arizona ). The third study was from Sweden. All three studies showed that, 1. It is important to have public education for out of hospital cardiac arrest, and that this increases survival. 2. That all that is needed is to compress the chest ( no need for mouth-to-mouth breathing ), to improve the chances.
In the study by Dr Bobrow of Pheonix, he prospectively studied 5,272 patients with out of hospital cardiac arrest, over a five year period. He followed the survivors till hospital discharge. He found that in Pheonix, after a program of public education, 2,900 of the 5,272 with out of hospital cardiac arrest, were not helped. Of these 5.2% survived till hospital discharge ( so you can survive without help, by the grace of God ). 666 patients had conventional CPR ( compression + mouth-to-mouth ) and 7.8% survive. 849 patients had only chest compression CPR, and 13.3% survive till hospital discharge. These numbers were basically similar to the other two studies in NEJM.
Now we have some fairly good medical evidence that if you see someone collapsed, first identify the problem. If he is no longer breathing and there is no pulse, call for help, and begin chest compression. And keep doing until help arrives. You could save 13.3% of collapse patients ( or 1 in 10 ).
Of course trying to help could have consequences, When we were discussing this emergency medicine regulations for GPs, we also advise the MOH that it must come with a " Good Samaritan " clause to protect the GP, or whoever Good Samaritan, who try to help. Otherwise, he may not get paid for his kindness, and yet end up having to defend himself ' herself from charges of causing hurt and even worse, the death of the patient.
We have along way to go, but if the Government is serious about 2020 and NEW with high income economy, and the status of a developed nation, all these things become important and necessary.

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