I refer to two articles on CodeBlue titled “Calling Code Blue For Emergency Care In Ministry of Health (MOH) Hospitals: Part 1 and Part 2” that are attributed to an anonymous emergency physician (EP).
The articles contain numerous misleading and inaccurate statements that I feel needs to be addressed to avoid misperceptions.
An EP in Malaysia undergoes four-year training and a further six months’ gazettement upon graduating. Every EP is a specialist who deals with emergency and urgent conditions across all disciplines.
For example, stabilising and handling heart attacks (cardiology), stroke (neurology), diabetes ketoacidosis (endocrinology), renal failure (nephrology), head trauma (neurosurgery), and bone fractures (orthopaedics), just to name a few.
They also handle aggression (psychiatry) and even social emergencies, such as rape and domestic violence. Leading, training, and updating the practice to the whole team in the department is the job of EPs.
To clarify, an EP wears both clinical and administrative hats. They are systems specialists who work out protocols or standard of practice to be adhered to by everyone in the team.
When wearing the clinical hat, an EP is involved in the resuscitation of cases (their core business), doing rounds on cases in red and yellow zones as well as observation ward, supervising the green and decontamination zones; performing critical procedures; receiving consultations from their own team as well as the incoming hospital team; authorising critical decisions like CT scans and ultrasound; handling ventilators and patient overcrowding; leading in mass casualty incidents; handling crises such as aggressions or situations like chemical, biological, radiological, nuclear and explosions.
Thus, in between doing the rounds, he or she can be in various zones to keep the department running. Thus, it is impossible to be an EP and “not see patients.”
When wearing the administrative hat, he or she must develop or oversee the implementation of protocols; ensure the team is updated with the latest management of emergency care; update the hospital’s disaster plan; attend hospital and intra-agency meetings; run quality improvement programmes; run audits; oversee the department’s and hospital’s key performance indicators; submit the department’s budget for consumables; get involved in research; organise mortality and morbidity meetings; manage complaints; and run emergency trainings for the team and the hospital.
EPs also have to plan and lead the medical standby for major sports events, international government events, and functions involving “Ketua Negara”, such as the King as well as the prime minister.
In wearing both these clinical and administrative hats, the percentage of involvement varies according to the ratio of EP and patients. If the department only has one EP, their administrative role is bigger, as the head has to keep the department running while being involved in resuscitation, taking consultations and others. It would require a team of EPs to ensure 24/7 clinical coverage.
Thus, the available number of EPs in a department will determine the balance of these two roles.
Emergency Medicine has progressed in Malaysia. The effects can be seen compared to when the specialty was not in existence. In the past, the Emergency Department was only a “traffic controller.” With not much done, patients were admitted with wrong diagnosis, no proper stabilisation, and wrong treatment given.
With EPs coming into the system, all these changed from the introduction of systematic triaging; introduction of red, yellow and green zones for critical, semi-critical and non-critical patients; having advanced resuscitation and procedures; as well as having point-of-care testing and technologies applied.
Furthermore, the Accident and Emergency (A&E) Department was rebranded to the Emergency and Trauma Department (ETD) – a name that better reflects our daily clinical core business, including handling trauma patients.
Addressing Misleading Points And Inaccuracies In Part 1
In Part 1, the author has claimed that there is “no science” in “triaging”, and at the same time looked down on the roles of Assistant Medical Officers (AMOs) in performing their duties.
AMOs are trained with primary and secondary triage as part of their six months’ gazettement process under Program Penempatan Wajib (PPW) in ETD.
During this programme, the new AMOs will be supervised by local perceptors (LP). i.e. senior AMOs, to handle daily clinical core businesses and undergo selected compulsory courses such as Basic Life Support (BLS) and the Malaysian Triage Category Course.
EPs oversee audits that are done on the triage process, including key performance indicators. Thus, there is adequate supervision of systems and performance improvements.
All teachings by EPs in any department’s medical education start with triage processes. There are numerous simulations and courses done by EPs to enhance their roles in triaging.
The article also strangely stated that “EPs do not see patients”. The author also stated that Emergency Departments are only run by medical officers (MOs), and not EPs.
The claims are unfathomable, as EPs are rostered for both clinical and administrative duties in the department. Their role is to lead and ensure the whole team runs properly, with all MOs, HOs, AMOs, and nurses.
EPs practice with a no-hierarchy philosophy, as they are supposed to seamlessly lead the staff. Saying that the department is only run by MOs would be akin to saying all medical and surgical wards, as well as clinics, are only run by MOs, and there are no roles for physicians or surgeons. That is totally incorrect.
The author also suggested that the Green Zone be abolished, and instead, Urgent Care Clinics be opened, which are manned by specialists from various departments.
Imagine having neurologists, endocrinologists, orthopaedics surgeons, surgeons, and other specialties working there to treat “urgent” patients. Imagine the cost implications as well as the time spent just to run this clinic.
No one will know what kind of illness patients will come with, as all are undifferentiated. Each discipline will work in their own silos and look at their own related problems, which is absurd and most impractical.
EPs exist to oversee every case using a holistic approach during emergency and urgent phases, which would save time and money.
The author also incorrectly claimed that those trained in “areas of interest” work on their own and do not do general emergency medicine.
In terms of EPs who have gone for training in areas of interest, it is the policy of Emergency Medicine and Trauma Service (EMTS) as well as the College of Emergency Physicians (CEP), that they are never to leave general emergency medicine.
Their training are aimed at acquiring higher skills in order to be taught to colleagues at the department they are placed in, as they practice emergency medicine. It is the core duty of an EP to see “undifferentiated” patients at “unscheduled times”, stabilise them, make diagnoses, initiate care, and manage them.
EPs exist to enrich the health care system and should not isolate themselves. With this system, they can bring the application of early advanced practices of resuscitation to the department, instead of taking days or even weeks to secure by appointment.
Nowadays, point-of-care echocardiograms and ultrasounds can be done within minutes. EPs will become the expert point of consultations for traumatology, toxicology, snakebites, paediatrics emergencies, CBRNE management, and more.
Advanced procedures like emergency regional anaesthesia, as well as resuscitative bronchoscopy can be performed by EPs, and this will benefit patients. EPs were also responsible in driving initiatives for many life, limb, or organ saving protocols and initial resuscitation concepts such as Damage Control Resuscitation Suites for major trauma, thrombolysis for myocardial infarct patients (STEMI Alert), stroke protocol (STROKE Alert), snake envenomation consultations, toxicology consultations, and more.
We have had international specialists coming to our centres in Malaysia to learn all these.
Addressing Misleading Points And Inaccuracies In Part 2
In Part 2, the author has suggested the solution that the triage counter be manned by one AMO, supervised by one Supervisor (a 1:1 ratio). Actually, the number of MOs should be reduced and each ED “unit” should only be run by one EP, one MO, and perhaps one HO.
How then can this unit can handle 200 to 300 patients per shift in a typical busy major hospital’s Emergency and Trauma Department? One case of resuscitation can last for an hour. Imagine how the other patients can be managed with such number of staff.
The author also suggested that observation wards should be run by hospital clinical administrators. This is an odd idea, as the observation wards are important place to handle brain trauma, abdominal pain that could be atypical appendicitis, atypical chest pain, and syncopal workouts that can turn out to be a heart attack and much more.
Many of these patients manifest symptoms clearer only upon further observation and reevaluation. There is medicolegal risk if this is not handled by clinicians. EPs would do ward rounds and supervise the team in the zone to avoid such consequences.
The author also claimed that by removing most MOs in ETD, the salary as a specialist can be increased as the MOs pay can be rechanneled to specialists. It is an absurd way of thinking on the method of getting a pay rise. Unfortunately, this seems quite self-centred and would not be fair for MOs.
All in all, it has been found that what has been stated in the writings run completely opposite to the services practised on the ground in ETDs in Malaysia. The suggestions given seem to be those that could not have come from an actual EP who practises emergency medicine.
Technically speaking, what was written does not tally with the thinking process of a genuine EP who deals with a daily overcrowded situation on the floor.
Moreover, the author has made claims that were self-incriminating, making it doubly hard to believe that the article was written by an actual EP. Even if it is written by one, the author only speaks for himself or herself and does not represent the real current practice of emergency medicine in Malaysia.
The author is a practising emergency physician who has experience working in many emergency and trauma departments in the Klang Valley, East Coast, and Borneo, and is now serving in a hospital in the southern region. CodeBlue is providing the author anonymity as civil servants are prohibited from writing to the press.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
