- Email: [email protected]
Emergency medicine in China: current situation and its future development
Correspondence
2075
from TIA, magnetic resonance imaging is the modality of choice, thereby permitting timely initiation of specific treatments both for ischemic stroke and for TIA, respectively. Oscar M.P. Jolobe MB, ChB, DPhil Manchester Medical Society Manchester M13 9PL E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2012.07.009
References [1] Panagos PD. Transient ischemic attack(TIA): the initial diagnostic and therapeutic dilemma. Am J Emerg Med 2012;30:794-9. [2] Smith EE, Foranow GC, Reeves MJ, Cox M, Olson DM, Hernandez AF, et al. Outcomes in mild or rapidly improving stroke not treated with intravenous recombinant tissue-type plasminogen activator. Findings from Get With The Guidelines-Stroke. Stroke 2011;42:3110-5. [3] Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet 2007;369:193-298. [4] Fiebach JB, Schellinger PD, Gass A, Kucinski T, Siebler M, Villringer A, et al. Stroke magnetic resonance imaging is accurate in hyperacute intracerebral haemorrhage a multicentre study on the validity of stroke imaging. Stroke 2004;35:502-7.
Implications of early and accurate imaging for suspected transient ischemic attack To the Editor, With the advancements of acute stroke systems of care and stroke teams, there has been an increasing demand for the development of better diagnostics and therapies in the identification and treatment of both ischemic and hemorrhagic stroke patients presenting to the emergency department (ED). Although the progress for treating acute ischemic and hemorrhagic stroke has been slow, the advancements in imaging techniques have been substantial. Traditionally, a simple computed tomographic (CT) scan has been used to differentiate an ischemic from a hemorrhagic stroke, but the inherent physiologic limitations of this “static” imaging technique are now apparent. A number of new and improved magnetic resonance (MR) and CT techniques are not available in the ED that allow a more sensitive and specific demonstration of acute ischemia, vascular occlusion, viable penumbra, and hemorrhage. For example, MR diffusion-weighted imaging is the most sensitive and specific technique to demonstrating early infarction and can be combined with MR perfusion to differentiate viable from nonviable hypoperfused tissue. Magnetic resonance angiography can demonstrate vascular occlusion, and the gradient-recalled echo sequence can detect and exclude subtle intracerebral hemorrhage [1-6].
This combination of MR sequences can be performed in 10 to 15 minutes and offer much more information than the standard noncontrast CT scan. I agree with the writer that “MRI is the imaging modality of choice…for both ischemic stroke and TIA” and is very useful to help distinguish between ischemic and hemorrhagic stroke. Yet, because of the general lack of proximity to existing EDs and the absence of acute stroke MR imaging protocols in many centers, both which may lead to increased door-to-needle times, acceptance within the United States is not widespread. The demand for more accurate and timely diagnostic tools combined with better therapies for acute ischemic stroke, hemorrhagic stroke, and transient ischemic attack will ultimately lead to a wider acceptance of this superior imaging modality. Peter D. Panagos MD Department of Emergency Medicine Washington University St Louis, MO, 63110 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2012.07.012
References [1] Fiebach JB, Schellinger PD, Jansen O, Meyer M, Wilde P, Bender J, et al. CT and diffusion-weighted MR imaging in randomized order: diffusion-weighted imaging results in higher accuracy and lower interrater variability in the diagnosis of hyperacute ischemic stroke. Stroke 2002;33:2206-10. [2] Schaefer PW, Ozsunar Y, He J, Hamberg LM, Hunter GJ, Sorensen AG, et al. Assessing tissue viability with MR diffusion and perfusion imaging. AJNR Am J Neuroradiol 2003;24:436-43. [3] Hjort N, Butcher K, Davis SM, Kidwell CS, Koroshetz WJ, Röther J, et al. Magnetic resonance imaging criteria for thrombolysis in acute cerebral infarct. Stroke 2005;36:388-97. [4] Kidwell CS, Chalela JA, Saver JL, Starkman S, Hill MD, Demchuk AM, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA 2004;292:1823-30. [5] Schellinger PD, Jansen O, Fiebach JB, Pohlers O, Ryssel H, Heiland S, et al. Feasibility and practicality of MR imaging of stroke in the management of hyperacute cerebral ischemia. AJNR Am J Neuroradiol 2000;21:1184-9. [6] AHA Scientific Statement. Recommendations for Imaging of Acute Ischemic Stroke. A Scientific Statement From the American Heart Association. Latchaw RE, Alberts MJ, Lev, MD, et al., on behalf of the American Heart Association Council on Cardiovascular Radiology and Intervention, Stroke Council, and the Interdisciplinary Council on Peripheral Vascular Disease. Stroke 2009;40:3646-78.
Emergency medicine in China: current situation and its future development To the Editor, In mainland China, formal emergency departments (EDs) were not established until the mid 1980s [1]. Numerous
2076 problems in the field of emergency medicine became apparent, which will be discussed in this article. There are too many patients leading to overcrowding of ED beds, especially in the tertiary hospitals. For example, in our hospital, which is one of the largest and wellrenowned hospitals in China, patient attendance per day in total has risen from 146 in year 2000 to 269 in year 2007, and patients with severe illness attending the ED has been increased from 114 per month in year 2000 to 235 in year 2007. The daily patient intake in total in our ED has risen to 400, whereas the number of severely ill patients attending ED has reached 300 per month. On the other hand, this overcrowding is exacerbated by the long length of patient stay in the ED [2]. Many of the patients will stay in the ED more than 3 days, which is in breach of the Ministry of Health 2009 Guidelines [3]. According to the guidelines, ED patients who cannot be discharged are required to be admitted to the wards within 72 hours, so enough beds in the ED can be maintained for the next lot of new emergency patients. Since the 2009 guidelines, because of increased patient attendances to ED, the number of patients that breached the 72-hour waiting time limit has risen substantially. The reason for the crowding is supposed as follows: (1) There is a lack of primary care system in China therefore patients are allowed to refer themselves to any hospital. However, in tertiary hospitals such as ours, there are huge waiting lists for appointments at outpatient clinics. The patients become frustrated at the long waiting times at outpatients and then decide to attend ED to be seen more quickly. (2) In China, most patients, especially the farmers, have to pay directly by themselves for medical care. To save money, some patients wait a long time until their chronic conditions to build up and worsen. This leads to some patients developing complex diagnoses and diseases involving multiple systems, which can be difficult to be admitted to the specialist wards (ie, should the complex patient be accepted onto the internal medicine ward or to the general surgical ward?). This dilemma leaves the patient waiting for prolonged periods on an ED bed. The aforementioned reasons have led to huge numbers of the emergency patients exceeding bed capacity in not only ED but also in the entire hospital [4]. Because of the above phenomenon, many tertiary hospitals have expanded their ED and set up their own ED intensive care units to tackle the overcrowding. So in addition to emergency medicine, the Chinese emergency physician needs to have good knowledge in allied specialties, such as critical care and respiratory medicine [5]. The Ministry of Health 2009 Guidelines formally recommended that all tertiary hospitals should have its own ED intensive care unit [3]. This has led to the phenomenon whereby the ED has become “a hospital within a hospital.”
Correspondence This problem is complex and can only be tackled in the following multiple ways. 1. The introduction of an established primary care service to prevent patients self-referring to the tertiary hospitals. 2. Implementing a national junior doctor training programme in all specialities involving rotations in a mixture of different-sized hospitals, hence ensuring a national standard of care in all hospitals thereby eliminating patients' perceived difference in the quality of physician's training in bigger vs smaller local hospitals. 3. Expand the provision of local district general hospitals so that patients would want to go to their nearest hospital as opposed to travelling all the way to big cities, such as Beijing. 4. Only patients with emergency medicine problems should be admitted into the ED. Other patients ideally should not be admitted into the ED but if admitted they should be exempt from being counted in the 72-hour waiting limit. Poor working environment leads to physicians leaving the specialty. Emergency medicine has a substantial drop-out rate. For example, there were 6 physicians who left our department during the year 2008 to 2010: Two senior staff for private practice, 3 decided to retrain in other specialties, and the remaining doctor left the medical profession entirely. Factors cited for leaving the specialty included low income, few holidays, no opportunity to subspecialize, huge workload, and long working day with antisocial hours leading to fatigue especially as one gets older. Physicians' salaries in China can vary greatly; however, compared with other professions, they are generally quite low with starting salaries of US$100 per month in the rural hospitals [6]. Pull factors for leaving the specialty as mentioned by our former coworkers include high remuneration in private practice/ pharmaceutical industry and better worklife balance in other fields. Jiang [7] thought the reasons for leaving emergency medicine are huge work burden, low income, high risk of litigation, and the feeling of “often being criticized while rarely being praised by patients and/or hospital management.” The problem is a difficult one that affects ED physicians throughout the world. We propose the following solutions: 1. Raising the salary of ED physicians. 2. Introducing flexible training for physicians with young children. 3. Having a working time directive to limit the maximum number of working hours per week. 4. Establishing emergency medicine as an independent specialty from other disciplines may improve its autonomy and prestige and help stabilize the workforce.
Correspondence
2077
In conclusion, emergency medicine of China is still in its infancy. The above problems should be tackled to raise the standards of our specialty and provide a stable workforce with independent physicians. A national-level junior doctor training programme can provide a steady supply of ED-trained physicians, hence providing a busy but not overburdened department. Because emergency medicine has attracted greater attention from the Ministry of Health and the public than ever before, we look forward to improvements in the quality of emergency medicine in China, in the years to come. Yi Li MD Emergency Department Peking Union Medical College Hospital Dongchen District Beijing, People's Republic of China 100730 Shigong Guo MRCS Department of Orthopaedics Wexham Park Hospital Wexham Park, Slough Berkshire, SL2 4HL, UK Shengyong Xu MD Zhong Wang MD Emergency Department Peking Union Medical College Hospital Dongchen District Beijing, People's Republic of China
Xuezhong Yu MD Emergency Department Peking Union Medical College Hospital Dongchen District Beijing, People's Republic of China E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2012.07.011
References [1] Jiang Jian. China emergency, yesterday, today and tomorrow. Lingnan Emerg Med Mag 2006;11:81-3 [in Chinese]. [2] Zhang Tao, Wang Mingxiao, Zhang Bin. Current situation of China emergency medicine and the develop trends. Chin Charcoal Ind Med Mag 2009;12:295 [in Chinese]. [3] China Ministry of Health. No.50 Guidelines - the development and administration of emergency department. (2009-06-10). http://www. moh.gov.cn/publicfiles/business/htmlfiles/mohbgt/s9509/200906/ 41146.htm [in Chinese]. [4] Xu Tengda, Ma Sui, Yu Xuezhong. The research of emergency department crowding. Chinese J Emerg Med 2008;17:1221-4 [in Chinese]. [5] Yu Xuezhong, Liu Jihai, Wang Zhong. Residency training in emergency medicine: an arduous and constant challenge. Acta Acad Med Sci 2008;30:128-30 [in Chinese]. [6] Zhang Tao, Wang Mingxiao, Zhang Bin. The develop trends of emergency department in hospitals in China. West Med 2009;21:678 [in Chinese]. [7] Alli Robbie. Emergency medicine in China 2000 (part 1). Chinese Crit Care Med 2001;13:3-4 [in Chinese].
2075
from TIA, magnetic resonance imaging is the modality of choice, thereby permitting timely initiation of specific treatments both for ischemic stroke and for TIA, respectively. Oscar M.P. Jolobe MB, ChB, DPhil Manchester Medical Society Manchester M13 9PL E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2012.07.009
References [1] Panagos PD. Transient ischemic attack(TIA): the initial diagnostic and therapeutic dilemma. Am J Emerg Med 2012;30:794-9. [2] Smith EE, Foranow GC, Reeves MJ, Cox M, Olson DM, Hernandez AF, et al. Outcomes in mild or rapidly improving stroke not treated with intravenous recombinant tissue-type plasminogen activator. Findings from Get With The Guidelines-Stroke. Stroke 2011;42:3110-5. [3] Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet 2007;369:193-298. [4] Fiebach JB, Schellinger PD, Gass A, Kucinski T, Siebler M, Villringer A, et al. Stroke magnetic resonance imaging is accurate in hyperacute intracerebral haemorrhage a multicentre study on the validity of stroke imaging. Stroke 2004;35:502-7.
Implications of early and accurate imaging for suspected transient ischemic attack To the Editor, With the advancements of acute stroke systems of care and stroke teams, there has been an increasing demand for the development of better diagnostics and therapies in the identification and treatment of both ischemic and hemorrhagic stroke patients presenting to the emergency department (ED). Although the progress for treating acute ischemic and hemorrhagic stroke has been slow, the advancements in imaging techniques have been substantial. Traditionally, a simple computed tomographic (CT) scan has been used to differentiate an ischemic from a hemorrhagic stroke, but the inherent physiologic limitations of this “static” imaging technique are now apparent. A number of new and improved magnetic resonance (MR) and CT techniques are not available in the ED that allow a more sensitive and specific demonstration of acute ischemia, vascular occlusion, viable penumbra, and hemorrhage. For example, MR diffusion-weighted imaging is the most sensitive and specific technique to demonstrating early infarction and can be combined with MR perfusion to differentiate viable from nonviable hypoperfused tissue. Magnetic resonance angiography can demonstrate vascular occlusion, and the gradient-recalled echo sequence can detect and exclude subtle intracerebral hemorrhage [1-6].
This combination of MR sequences can be performed in 10 to 15 minutes and offer much more information than the standard noncontrast CT scan. I agree with the writer that “MRI is the imaging modality of choice…for both ischemic stroke and TIA” and is very useful to help distinguish between ischemic and hemorrhagic stroke. Yet, because of the general lack of proximity to existing EDs and the absence of acute stroke MR imaging protocols in many centers, both which may lead to increased door-to-needle times, acceptance within the United States is not widespread. The demand for more accurate and timely diagnostic tools combined with better therapies for acute ischemic stroke, hemorrhagic stroke, and transient ischemic attack will ultimately lead to a wider acceptance of this superior imaging modality. Peter D. Panagos MD Department of Emergency Medicine Washington University St Louis, MO, 63110 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2012.07.012
References [1] Fiebach JB, Schellinger PD, Jansen O, Meyer M, Wilde P, Bender J, et al. CT and diffusion-weighted MR imaging in randomized order: diffusion-weighted imaging results in higher accuracy and lower interrater variability in the diagnosis of hyperacute ischemic stroke. Stroke 2002;33:2206-10. [2] Schaefer PW, Ozsunar Y, He J, Hamberg LM, Hunter GJ, Sorensen AG, et al. Assessing tissue viability with MR diffusion and perfusion imaging. AJNR Am J Neuroradiol 2003;24:436-43. [3] Hjort N, Butcher K, Davis SM, Kidwell CS, Koroshetz WJ, Röther J, et al. Magnetic resonance imaging criteria for thrombolysis in acute cerebral infarct. Stroke 2005;36:388-97. [4] Kidwell CS, Chalela JA, Saver JL, Starkman S, Hill MD, Demchuk AM, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA 2004;292:1823-30. [5] Schellinger PD, Jansen O, Fiebach JB, Pohlers O, Ryssel H, Heiland S, et al. Feasibility and practicality of MR imaging of stroke in the management of hyperacute cerebral ischemia. AJNR Am J Neuroradiol 2000;21:1184-9. [6] AHA Scientific Statement. Recommendations for Imaging of Acute Ischemic Stroke. A Scientific Statement From the American Heart Association. Latchaw RE, Alberts MJ, Lev, MD, et al., on behalf of the American Heart Association Council on Cardiovascular Radiology and Intervention, Stroke Council, and the Interdisciplinary Council on Peripheral Vascular Disease. Stroke 2009;40:3646-78.
Emergency medicine in China: current situation and its future development To the Editor, In mainland China, formal emergency departments (EDs) were not established until the mid 1980s [1]. Numerous
2076 problems in the field of emergency medicine became apparent, which will be discussed in this article. There are too many patients leading to overcrowding of ED beds, especially in the tertiary hospitals. For example, in our hospital, which is one of the largest and wellrenowned hospitals in China, patient attendance per day in total has risen from 146 in year 2000 to 269 in year 2007, and patients with severe illness attending the ED has been increased from 114 per month in year 2000 to 235 in year 2007. The daily patient intake in total in our ED has risen to 400, whereas the number of severely ill patients attending ED has reached 300 per month. On the other hand, this overcrowding is exacerbated by the long length of patient stay in the ED [2]. Many of the patients will stay in the ED more than 3 days, which is in breach of the Ministry of Health 2009 Guidelines [3]. According to the guidelines, ED patients who cannot be discharged are required to be admitted to the wards within 72 hours, so enough beds in the ED can be maintained for the next lot of new emergency patients. Since the 2009 guidelines, because of increased patient attendances to ED, the number of patients that breached the 72-hour waiting time limit has risen substantially. The reason for the crowding is supposed as follows: (1) There is a lack of primary care system in China therefore patients are allowed to refer themselves to any hospital. However, in tertiary hospitals such as ours, there are huge waiting lists for appointments at outpatient clinics. The patients become frustrated at the long waiting times at outpatients and then decide to attend ED to be seen more quickly. (2) In China, most patients, especially the farmers, have to pay directly by themselves for medical care. To save money, some patients wait a long time until their chronic conditions to build up and worsen. This leads to some patients developing complex diagnoses and diseases involving multiple systems, which can be difficult to be admitted to the specialist wards (ie, should the complex patient be accepted onto the internal medicine ward or to the general surgical ward?). This dilemma leaves the patient waiting for prolonged periods on an ED bed. The aforementioned reasons have led to huge numbers of the emergency patients exceeding bed capacity in not only ED but also in the entire hospital [4]. Because of the above phenomenon, many tertiary hospitals have expanded their ED and set up their own ED intensive care units to tackle the overcrowding. So in addition to emergency medicine, the Chinese emergency physician needs to have good knowledge in allied specialties, such as critical care and respiratory medicine [5]. The Ministry of Health 2009 Guidelines formally recommended that all tertiary hospitals should have its own ED intensive care unit [3]. This has led to the phenomenon whereby the ED has become “a hospital within a hospital.”
Correspondence This problem is complex and can only be tackled in the following multiple ways. 1. The introduction of an established primary care service to prevent patients self-referring to the tertiary hospitals. 2. Implementing a national junior doctor training programme in all specialities involving rotations in a mixture of different-sized hospitals, hence ensuring a national standard of care in all hospitals thereby eliminating patients' perceived difference in the quality of physician's training in bigger vs smaller local hospitals. 3. Expand the provision of local district general hospitals so that patients would want to go to their nearest hospital as opposed to travelling all the way to big cities, such as Beijing. 4. Only patients with emergency medicine problems should be admitted into the ED. Other patients ideally should not be admitted into the ED but if admitted they should be exempt from being counted in the 72-hour waiting limit. Poor working environment leads to physicians leaving the specialty. Emergency medicine has a substantial drop-out rate. For example, there were 6 physicians who left our department during the year 2008 to 2010: Two senior staff for private practice, 3 decided to retrain in other specialties, and the remaining doctor left the medical profession entirely. Factors cited for leaving the specialty included low income, few holidays, no opportunity to subspecialize, huge workload, and long working day with antisocial hours leading to fatigue especially as one gets older. Physicians' salaries in China can vary greatly; however, compared with other professions, they are generally quite low with starting salaries of US$100 per month in the rural hospitals [6]. Pull factors for leaving the specialty as mentioned by our former coworkers include high remuneration in private practice/ pharmaceutical industry and better worklife balance in other fields. Jiang [7] thought the reasons for leaving emergency medicine are huge work burden, low income, high risk of litigation, and the feeling of “often being criticized while rarely being praised by patients and/or hospital management.” The problem is a difficult one that affects ED physicians throughout the world. We propose the following solutions: 1. Raising the salary of ED physicians. 2. Introducing flexible training for physicians with young children. 3. Having a working time directive to limit the maximum number of working hours per week. 4. Establishing emergency medicine as an independent specialty from other disciplines may improve its autonomy and prestige and help stabilize the workforce.
Correspondence
2077
In conclusion, emergency medicine of China is still in its infancy. The above problems should be tackled to raise the standards of our specialty and provide a stable workforce with independent physicians. A national-level junior doctor training programme can provide a steady supply of ED-trained physicians, hence providing a busy but not overburdened department. Because emergency medicine has attracted greater attention from the Ministry of Health and the public than ever before, we look forward to improvements in the quality of emergency medicine in China, in the years to come. Yi Li MD Emergency Department Peking Union Medical College Hospital Dongchen District Beijing, People's Republic of China 100730 Shigong Guo MRCS Department of Orthopaedics Wexham Park Hospital Wexham Park, Slough Berkshire, SL2 4HL, UK Shengyong Xu MD Zhong Wang MD Emergency Department Peking Union Medical College Hospital Dongchen District Beijing, People's Republic of China
Xuezhong Yu MD Emergency Department Peking Union Medical College Hospital Dongchen District Beijing, People's Republic of China E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2012.07.011
References [1] Jiang Jian. China emergency, yesterday, today and tomorrow. Lingnan Emerg Med Mag 2006;11:81-3 [in Chinese]. [2] Zhang Tao, Wang Mingxiao, Zhang Bin. Current situation of China emergency medicine and the develop trends. Chin Charcoal Ind Med Mag 2009;12:295 [in Chinese]. [3] China Ministry of Health. No.50 Guidelines - the development and administration of emergency department. (2009-06-10). http://www. moh.gov.cn/publicfiles/business/htmlfiles/mohbgt/s9509/200906/ 41146.htm [in Chinese]. [4] Xu Tengda, Ma Sui, Yu Xuezhong. The research of emergency department crowding. Chinese J Emerg Med 2008;17:1221-4 [in Chinese]. [5] Yu Xuezhong, Liu Jihai, Wang Zhong. Residency training in emergency medicine: an arduous and constant challenge. Acta Acad Med Sci 2008;30:128-30 [in Chinese]. [6] Zhang Tao, Wang Mingxiao, Zhang Bin. The develop trends of emergency department in hospitals in China. West Med 2009;21:678 [in Chinese]. [7] Alli Robbie. Emergency medicine in China 2000 (part 1). Chinese Crit Care Med 2001;13:3-4 [in Chinese].