An armed assailant in our hospital: Are we prepared?

While armed assailant attacks are rare in the hospital setting, they pose a potential risk to healthcare staff, patients, visitors and the infrastructure. Singapore hospitals have well-developed disaster plans to respond to a mass casualty incident occurring outside the hospital. However, lack of an armed assailant incident response plan can significantly reduce the hospital's ability to appropriately respond to such an incident. The authors describe various strategies that can be adopted in the development of an armed assailant incident response plan. Regular staff training will increase staff resilience and capability to respond to a potential threat in the future. The aim of this article is to highlight the need for the emergency preparedness units of all hospitals to work together with various stakeholders to develop an armed assailant incident response plan. This will be of great benefit for keeping healthcare facilities safe, both for staff as well as for the community.

A multicenter prospective randomized study comparing the efficacy of escalating higher biphasic versus low biphasic energy defibrillations in patients presenting with cardiac arrest in the in-hospital environment.

BACKGROUND: Biphasic defibrillation has been practiced worldwide for >15 years. Yet, consensus does not exist on the best energy levels for optimal outcomes when used in patients with ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT). METHODS: This prospective, randomized, controlled trial of 235 adult cardiac arrest patients with VF/VT was conducted in the emergency and cardiology departments. One group received low-energy (LE) shocks at 150-150-150 J and the other escalating higher-energy (HE) shocks at 200-300-360 J. If return of spontaneous circulation (ROSC) was not achieved by the third shock, LE patients crossed over to the HE arm and HE patients continued at 360 J. Primary end point was ROSC. Secondary end points were 24-hour, 7-day, and 30-day survival. RESULTS: Both groups were comparable for age, sex, cardiac risk factors, and duration of collapse and VF/VT. Of the 118 patients randomized to the LE group, 48 crossed over to the HE protocol, 24 for persistent VF, and 24 for recurrent VF. First-shock termination rates for HE and LE patients were 66.67% and 64.41%, respectively (P=0.78, confidence interval: 0.65-1.89). First-shock ROSC rates were 25.64% and 29.66%, respectively (P=0.56, confidence interval: 0.46-1.45). The 24-hour, 7-day, and 30-day survival rates were 85.71%, 74.29%, and 62.86% for first-shock ROSC LE patients and 70.00%, 50.00%, and 46.67% for first-shock ROSC HE patients, respectively. Conversion rates for further shocks at 200 J and 300 J were low, but increased to 38.95% at 360 J. CONCLUSION: First-shock termination and ROSC rates were not significantly different between LE and HE biphasic defibrillation for cardiac arrest patients. Patients responded best at 150/200 J and at 360 J energy levels. For patients with VF/pulseless VT, consideration is needed to escalate quickly to HE shocks at 360 J if not successfully defibrillated with 150 or 200 J initially.

Emergency medicine as a specialty in Asia.

Aim: We aim to examine the similarities and differences in areas of EM development, workload, workforce, and capabilities and support in the Asia region. Emerging challenges faced by our EM community are also discussed. Methods: The National Societies for Emergency Medicine of Hong Kong, India, Japan, Malaysia, Philippines, Singapore, South Korea, Taiwan, Thailand and Turkey participated in the joint Japanese Association of Acute Medicine (JAAM) and Asian Conference of Emergency Medicine (ACEM) Special Symposium held in October 2013 at Tokyo, Japan. The findings are reviewed in this paper. Results: Emergency medicine (EM) has over the years evolved into a distinct and recognized medical discipline requiring a unique set of cognitive, administrative and technical skills for managing all types of patients with acute illness or injury. EM has contributed to healthcare by providing effective, safe, efficient and cost-effective patient care. Integrated systems have developed to allow continuity of emergency care from the community into emergency departments. Structured training curriculum for undergraduates, and specialty training programs for postgraduates are in place to equip trainees with the knowledge and skills required for the unique practice of EM. Conclusion: The practice of EM still varies among the Asian countries. However, as a region, we strive to continue in our efforts to develop the specialty and improve the delivery of EM.

Use of percussion as a screening tool in the diagnosis of occult hip fractures.

Traumatic hip pain is a common clinical problem in the emergency department. There is significant morbidity in discharging a patient with an undiagnosed undisplaced hip fracture. The auscultatory percussion technique is a useful method to risk stratify patients who present with traumatic hip pain and with normal radiographs. We sought to study the sensitivity and specificity of the auscultatory percussion technique in a prospective study.