Thursday, November 26, 2009

Defibrillators for resuscitations - all talk and no action

It would seem that gyms and sporting facilities, and also parks, are not regulated in anyway with respect to the provision of resuscitative equipment. It's pretty much NATO - no action all talk only. Everybody wants to run CPR training cos they get money for course attendances, but when it comes to actually installing the equipment, it's pretty much dependent on organizationsto want to play ball.

The Singapore Heart Foundation just recently published lists of all the organizations and places where automated external defibrillators are installed. A consolidated list of places can be found here. My gym isn't on the list. Neither is the East Coast Park. Nor is the Prince George's Park Residence gym.

So there.

Maybe I can encourage you to speak to your gym, or sports facilities and pressure them to install appropriate resuscitative equipment. Perhaps you can also write in to National Parks and persuade them to be a bit more civic conscious and install appropriate resuscitative equipment in adequate quantities and in readily accessible locations. Their email is: NPARKS_MAILBOX@NPARKS.GOV.SGThis e-mail address is being protected from spambots. You need JavaScript enabled to view it

Wednesday, November 25, 2009

H1N1 vaccine toxicity?

The recent flurry of reports about side effects resulting from the recent H1N1 vaccines have caused many people to go into a flap.

The HSA reported a series of 27 cases, with one particularly problematic case of Sweet's Syndrome.

Canada reported high frequencies of unusual adverse reactions and some deaths, which resulted in cessation of the vaccinations, and withdrawal of the GSK vaccine.

Earlier China had reported 2 deaths, but evidence later discounted their relationship to the vaccine.

But actually, despite the fact that they are all H1N1 vaccines, they are all essentially different products. The China vaccine is China's own special product. The Singapore vaccine, I believe is pretty much the CSL version at the moment, while the Canadian vaccine is a GSK product manufactured in Canada.

It's interesting that the Canadian product is called Arepanrix and the Singapore GSK version is called Pandemrix. According to the GSK website, the difference is that Arepanrix is translucent and has particles..... Hmmmm...... poor manufacturing giving rise to allergies? We'll wait for the werdict.

Sudden death in the gym - adequate CPR support?

The recent fatal collapse of an NUS lecturer in the Prince George's Park Residences gym raised a number of concerns for me.

First of all is, whether there are adequate support for cardiopulmonary resuscitation to be done?

Although it was reported that CPR was started but was unsuccessful, I really question if proper CPR was at all possible. I can't imagine that there would be trained gym instructors at a hostel gym. Furthermore I really doubt if proper CPR equipment was available; don't even mention a defibrillator!

Which was a tragic shame....because in a young man with cardiac arrest, CPR/defibrillation could be life saving.

Which raised in my mind, a second question - how many gyms in Singapore are properly equipped for CPR? At the gym in the club I frequent, I discretely asked the instructor if there was any CPR equipment available. He stammered a bit and insisted there was. When I asked where, he stammered a bit more and said he didn't know.... perhaps it was out of order and sent for repairs. Then he said it was in the store room. Who had the key? That question really got him. I didn't want to embarass him further so I left it there. Bottom line was that even if there were CPR equipment it was not accessible in any way should an hapless auntie collapse from coronary insufficiency.

Then I thought a bit more..... what about at our parks? When I was at the East Coast Park the other weekend, I couldn't help marvelling at the thousands of weekend warriors who flock there every Sunday. If someone collapses, how does one do CPR? Does anyone know if there is a defibrillator anywhere? Why can't the park have well signposted CPR stations at regular intervals?


I wonder who is responsbile for ensuring there is adequate support for public cardiopulmonary resuscitation in Singapore? Or is everyone wishing someone else would do it?

Tuesday, November 24, 2009

Rising sea levels - what is the impact on Singapore's coastline?? #2

The WWF report's estimate of sea level change comes on the back of previous estimates from :

a] the IPCC (Intergovernmental Panel on Climate Change 4th Assessment Report) which predicted a range of possibilities based on various scenarios. The worst case scenario being 26-59 cm for the 21st century; and

b] a report by Siddall et al, Nature Geoscience 2, 571 - 575 (2009), projecting a rise of 7-82 cm rise in sea levels; and

c] a report by Grinsted et al,Climate Dynamics 2009, forecasting a meter rise in sea levels.

How will Singapore be affected?

It's hard to tell for sure since there is very little in terms of survey data out there. But I came across this cool website put up by some NUS students called 'Mapping Potential Sea Level Rise in Singapore' with some simulations and projections done using the 2001 IPCC Report.

The 2 figures below show projections based on an 82cm and 120cm increase in sea levels. For more info please go to their website.

Monday, November 23, 2009

Rising sea levels - what is the impact on Singapore's coastline??

The WWF recently released its Final Tipping Points Report, in which it suggested that the global warming was likely to increase beyond 2-3degC. Correspondingly by 2050 (which is not that far away) sea levels could well rise by more than 0.5m threatening many coastal cities.

"Global temperatures have already risen by at least 0.7 degrees Celsius. Global warming above 2-3 degrees in the second half of the century is likely unless strong extremely radical and determined efforts towards deep cuts in emissions are put in place before 2015.

The melting of the Greenland (GIS) and the West Antarctic Ice Shield (WAIS) could lead to a Tipping Point scenario, possibly a sea level rise of up to 0.5 meters by 2050. This is estimated to increase the value of assets at threat in all 136 global port mega-cities by around 25.000 billion USD.

On the North-eastern coast of the USA and due to a localized anomaly, the sea level could rise up to 0.65 meters, increasing the asset exposure from 1.350 to about 7.400 billion USD.

The gahment should tell us explicitly what they are doing to mitigate the effect of this rising sea level. If they have done any geographical surveys and modelling, they should let us know what the impact is on our coastlines, and the risks of flooding should sea levels rise by 0.5m.

We have a right to know.

NKF to dip into reserves

I wasn't quite sure what to make about the recent report about how the NKF suffered "one of its worst financial results in years". It ran into a deficit of some $900,000 and had to dip into its reserves.

I was tempted to feel sorry for it until I was reminded of the whopping size of its reserves. $270 million!!! This pretty much the same as when it ran into the TT Durai scandal in 2005. I couldn't help thinking that even if the charity couldn't ever do better than this recession year, and had to dip into into its reserves to the same degree for the next 100 years, there would still be a sizeable pile of cash in the bank.

By comparison, the Community Chest in 2007/8 raised $52 million and disbursed $49 million.
Annual Report 2007/2008

Saturday, November 21, 2009

Chemotherapy errors - medical device regulation

There are now two versions of the story:
a] Only one type of pump capable of being programmed for hourly or daily delivery rates. The mistake was in the programming.
b] Two similar looking pumps - one for hourly delivery and the other for daily delivery. The mistake was in the wrong pump being used.

I really have no way of establishing which of these stories are true. We'll wait for the BOI to release their findings....if they ever. But in both of these scenarios, the design of the pump is also important in minimizing the risks of operator error.

By the way, these pumps are actually regulated by the HSA as 'medical devices'. I wonder if they these design problems into consideration when they approve these pumps? Or just look at the brochures?

Friday, November 20, 2009

Cervical cancer and the Pap smear - another set of revised guidelines

Following upon the mammogram revisions, the American College of Obstetricians and Gynecologists have issued their own guideline revisions for the Pap smear in young girls. But not much debate here.

The timing of the revisions is pure coincidence, they say.

Mammogram madness - where is the objectivity?

A raging debate has emerged in the US over the recent release of the report by the U.S. Preventive Services Task Force (USPSTF) revising the recommendations for screening mammograms in women between 40-50 years of age. Stridently vocal critics of the report argue that this was part of some cost cutting measures, and that relaxation of these guidelines would lead to breast cancers not being detected early in these women and consequently more cancer deaths. The trouble with the arguments from these critics was that there was little to offer other than anecdotes.

The debate did focus my attention on how difficult it is to get truly objective information. I don't really know too much about who is right in this debate, but it did seem to me that at least the Task Force did try and base their findings on objective scrutiny of evidence. What disappointed me was that the major physician and oncology groups just lent their voices to the din by adding more and more anecdotes to support screening. Where is the objectivity? Where is this much touted 'evidence-based' medicine? (see NPR Report)

My question is, can we count on doctors to be objective in their recommendations? Can we even count on governmental reports to be objective given that governments themselves have become players themselves in this game of medical monopoly.

In a recent CNN report Alice Park writes: "If the brouhaha following a government advisory panel's recent change in breast-cancer-screening recommendations has proved anything, it is that even modern medicine does not rely on statistics, scientific facts and clinical outcomes alone."

How true. How sad. Oncology groups tend to gain by increasing hype and hysteria since they result in more screening, and more early treatment revenues.

This debate will not end soon. So far the Ministry of Health and Health Promotion Board have remained silent. How objective will they be, I wonder?

Wednesday, November 18, 2009

H1N1 mortality risks

So we get closer and closer to reality as the CDC revises its figures which suggest that the mortality for the dreaded H1N1 infection is somewhat less than the seasonal flu. Based on their figures we would be looking at a mortality rate of anywhere between 0.007-0.045% (average about 0.017%).

A recent report from the La Jolla Institute for Allergy and Immunology: "...the conservation of a large fraction of T-cell epitopes suggests that the severity of an S-OIV infection, as far as it is determined by susceptibility of the virus to immune attack, would not differ much from that of seasonal flu. These results are consistent with reports about disease incidence, severity, and mortality rates associated with human S-OIV (swine-origin H1N1 influenza virus)" further confirms its lack of threat.

How did we all get it so wrong? And what are we going to do with all those vaccines that nobody needs?

Doctor training smugness

There was a certain smugness in Dr Lim Suet Wun's (CEO of National Healthcare Group & Tan Tock Seng Hospital) blog about training doctors. He made reference to a recent survey among medical students,.... "recent feedback from 3rd, 4th and final year YLL medical students rated training at TTSH very highly." Indeed. He should be smug. TTSH has always been highly regarded for their consistent emphasis on training and mentoring.

What he didn't mention was which hospital was at the bottom of the survey.

We all know... but we but won't tell. (Hint:It isn't anything to do with Dukes as they have been credited with 'superior pedagogy')

Fermenting away in academia?

Spotted in a Straits Times report...about how the new university will add to the ferment in Singapore. Sigh.... such has become the quality of English practised by our journalists.

Tuesday, November 17, 2009

Chemotherapy errors - human factors design, management problems

So it appears that the problem is related to the fact that the two pumps looked identical.

" Mr Khaw laid the blame on the similarity in appearance of the two pumps which were mixed up, and said that he would be providing feedback to the manufacturers.
He said: ‘The pumps look almost exactly the same…This is very dangerous when there are two pieces of equipment and one is millilitre per hour, and one is millilitre per day – you are causing unnecessary risk to the users of this device.’
The key thing, he emphasised, is to learn from this incident and prevent similar mistakes from occurring. "

While it is right that the staff involved should bear some responsibility for being careless, Minister is right in not over apportioning blame on the hands that pulled the trigger.

A significant part of the responsibility should lie with the manufacturers, who were too dumb to design their pumps properly. Did they not consider the user in their design? Sadly it is too common to see engineers in their rush to get a working piece of equipment out into the market place, sacrifice all human factors considerations. It doesn't matter if the user gets into all kinds of problems, or have difficulties in getting the equipment to work properly. This is something I hope the new Singapore University of Technology and Design will address. It's not just a matter of getting an innovative product out into the market place, it is about getting a well designed product out. One that takes into considerations the needs of the user. This is called Human Factors Engineering.

Yet another part of the responsibility should be borne by the management. Did they not see this as an accident waiting to happen? Did it not seem clear to them that if you have two pieces of equipment looking exactly like each other, some one's going to make the mistake of using the wrong piece of equipment? Did they not do a risk assessment of the procedures they used in the chemotherapy unit? Even though the design of the equipment left a lot to be desired, they could just as easily have stuck on a strip of red tape distinguishing one from another. A simple solution that could have prevented this disaster. Just that nobody bothered.

Saturday, November 14, 2009

Chemotherapy errors.... what gives?

To the credit to the team involved they reacted pretty quickly and didn't try and sweep the error under the carpet. But what a horrendous error! It is no comfort to say that errors like this can happen, and can happen elsewhere as well...

The question is how can such a monumental error occur in a situation which should be regarded as nothing less than 100% error free. I am sure the hospital and the MOH are now scrambling with their Boards of Inquiries.

But I can tell how 2 people checking a procure can make an error.

There are simply 2 people looking at different things and not really checking with each other. I have seen it happen so many times in ward procedures, and you wonder what is the intention for the checking process. Clearly a checking process is instituted without understanding what the process is supposed to check. Take for example the checking on NRIC numbers.... Staff#1 reads of the case sheet while Staff#2 'checks' the number on the patient's bracelet. Sounds good. But wait..... if Staff#2 didn't get enough sleep and reads an 8 for a 3, even if you repeat the process 10 times, the same error will be reproduced. It is true that the chance of a nexus between a case sheet with an 8 meeting a bracelet with a 3 is very small, but when it does occur the error will not be detected. It's like trying to proof read your own report.

Likewise, in this case.

If Staff#1 reads the instructions and Staff#2 inputs the programme, and if Staff#2 makes the error of inputting hours instead of days, the error will be neither be detected nor prevented. The process only prevents errors caused by the same staff reading and inputting the error.

People who write such procedures need to rethink a bit more about what they are doing...