The first 5 years since trauma center designation in the Hong Kong Special Administrative Region, People's Republic of China.

BACKGROUND: In 1994, the Hong Kong Special Administrative Region (HKSAR) introduced plans to implement a trauma system based on the recommendations outlined by Professor Donald Trunkey in his report to the local Hospital Authority. Five government-subsidized public hospitals were subsequently designated as trauma centers in 2003. This article reviews the initial experience in these five centers. METHODS: Prospective trauma registries from January 2004 to December 2008 were reviewed. Primary clinical outcome measures were hospital mortality. The Trauma and Injury Severity Score methodology was used for benchmarking with the Major Trauma Outcome Study (MTOS) database. RESULTS: The majority (83.3%) of the 10,462 patients suffered from blunt trauma. Severe injury, defined as Injury Severity Score>15, occurred in 29.7% of patients. The leading causes of trauma were motor vehicle collisions and falls, with crude hospital mortality rates of 6.9% and 10.7%, respectively. The M-statistic was 0.95, indicating comparable case-mix with the MTOS. The worst outcome occurred in the first year. Significant improvement was seen in patients with penetrating injuries. By 2008, these patients had significantly higher survival rates than expected (Z-statistic=0.85). Although the overall mortality rates for blunt trauma were higher than expected, the difference was no longer statistically significant from the second year onward. CONCLUSIONS: The case-mix of trauma patients in the HKSAR is comparable with that of the MTOS. A young trauma system relatively unburdened by dissimilar reimbursement and patient access issues may achieve significant improvement and satisfactory patient outcomes. Our findings may serve as a useful benchmark for HK and other Southeast Asian cities and trauma systems to establish local coefficients for future evaluations.

Is public access defibrillation needed in Hong Kong?

The survival rate for non-traumatic out-of-hospital cardiac arrest in Hong Kong is low (1.25%-1.6%). Despite the reduced time interval between call receipt and first defibrillatory shock to 11.12 minutes during the past decade, the time interval between collapse/recognition and first defibrillatory shock, at 14.25 minutes, is too long. Studies of out-of-hospital cardiac arrest performed in Hong Kong were reviewed to ascertain whether a public access defibrillation programme can improve survival in Hong Kong. Three delays were found in the traditional response by emergency medical service, namely in the collapse/recognise-to-call receipt, call receipt-to-vehicle stops, and vehicle stops-to-first defibrillatory shock time intervals. The first delay is related to public education, while the second and third delays are intrinsic to a dispatched response. A public access defibrillation programme employing responders at scenes of cardiac arrests can eliminate the collapse/recognise-to-call receipt and call receipt-to-vehicle stops time intervals before defibrillation. Possible sites of public access defibrillation could include the airport and other immigration points, which have a high volume of people passing through, with projected figures for out-of-hospital cardiac arrest at these sites supporting this consideration. For successful implementation of public access defibrillation, a comprehensive educational programme and coordination with the emergency medical service are required.

A returned traveller with persistent fever due to murine typhus.

Murine (endemic) typhus is a notifiable disease in Hong Kong, but its diagnosis can be difficult. We report a case of murine typhus in a middle-aged man who presented with persistent fever, headache, and skin rash 2 weeks after returning from a visit to China. The diagnosis of murine typhus requires a high index of suspicion for a febrile patient with a history of potential exposure to the disease vector (rat flea) in an endemic area. The importance of early recognition lies in the potential for early therapeutic intervention, leading to decreases in morbidity and duration of stay in hospital.

Sonographic features of xanthogranulomatous pyelonephritis.

PURPOSE: The purpose of this study was to describe the various sonographic features of xanthogranulomatous pyelonephritis (XGP). METHODS: We retrospectively reviewed the CT, sonographic, and medical records of patients diagnosed with XGP from January 1981 to December 1998. Twenty-seven patients for whom XGP was histopathologically confirmed were included in the study. There were 12 men and 15 women, with an age range of 21-86 years (mean, 57 years). All patients had undergone sonography of the kidneys. The renal size, shape, and outline were recorded. The presence of perinephric fluid accumulation, of obstructive uropathy, or of internal echoes in the dilated collecting system and the echotexture of the renal parenchyma were documented. RESULTS: We categorized the XGP into 4 groups on the basis of the sonographic features: (1) diffuse hydronephrotic, 12 patients (44%); (2) diffuse parenchymal, 9 patients (33%); (3) diffuse contracted, 4 patients (15%); and (4) segmental or focal, 2 patients (7%). A localized perinephric fluid collection was present in 4 patients (15%). The preoperative sonographic diagnoses were pyonephrosis (n = 14, 52%), renal pelvic tumor with possible associated infection (n = 5, 19%), renal parenchymal mass (n = 2, 7%), hydronephrosis (n = 2, 7%), and chronic pyelonephritis with renal atrophy (n = 4, 15%). XGP was considered a possible diagnosis in only 11 patients (41%). CONCLUSIONS: XGP has no specific sonographic features but is suggested by parenchymal thinning and hydronephrosis, sonographic signs of chronic obstructive uropathy caused by stones; echoes in the dilated collecting system; and a perinephric fluid collection. CT, needle biopsy, or both are recommended to further evaluate and confirm sonographically suspected XGP.

Out-of-hospital cardiac arrest in Hong Kong.

OBJECTIVES: To evaluate the effectiveness of the local emergency medical services system in resuscitation of out-of-hospital cardiac arrest and identify areas for improvement. METHODS: This was a prospective descriptive study of adults with nontraumatic out-of-hospital cardiac arrest treated in the three accident & emergency departments that serve the whole of Hong Kong Island from March 15, 1999, to October 15, 1999. Patient characteristics, circumstances of cardiac arrest, final outcomes, and response times of the ambulance service were recorded according to the Utstein style. RESULTS: Three hundred twenty patients were included. There was male predominance, and the mean age was 71.5 years. The majority of cardiac arrests occurred at patients' homes. In 57.5% of cases the arrest was not witnessed. The bystander cardiopulmonary resuscitation (CPR) rate was 15.6%. The most common electrocardiographic (ECG) rhythm at scene was asystole. Ventricular fibrillation or pulseless ventricular tachycardia constituted 14.1%. The average call to dispatch interval was 1.04 minutes. The average call to CPR interval was 9.82 minutes. The average total prehospital interval was 27.55 minutes. The overall immediate survival rate was 14.1% and the rate of survival to hospital discharge was 1.25%. CONCLUSION: The prognosis of out-of-hospital cardiac arrest in Hong Kong was dismal. Every link in the chain of survival has to be improved.

Multidisciplinary team interaction: summary and Action Plan.

INTRODUCTION: Multidisciplinary team interaction has become a commonplace phrase in the discussion of disaster response. Theme 6 explored multidisciplinary team interactions and attempted to identify some of the key issues and possible solutions to the seemingly intractable problems inherent in this endeavour. METHODS: Details of the methods used are provided in the introductory paper. The Cochairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. The Cochairs then presided over a workshop that resulted in the generation of a set of Action Plans that then were reported to the collective group of all delegates. RESULTS: Main points developed during the presentations and discussion included: (1) promotion of multidisciplinary collaboration, (2) standardization, (3) the Incident Command System, (4) professionalism, (5) regional disparities, and (6) psychosocial impact. DISCUSSION: Action plans recommended: (1) a standardized template for Needs Assessment be developed, implemented, and applied using collaboration with international organizations, focusing on needs and criteria appropriate to each type of event, and (2) team needs assessments be recognized for local responses and for determination of when international assistance may be required, for planning a command system, and for evaluating the psychosocial impact. CONCLUSIONS: There is a clear need for the development of standardized methods for the assessment of needs, development and implementation of a command structure, and for appreciation of regional differences and the psychosocial impact of all interventions.

Prehospital care in Hong Kong.

A quick and efficient prehospital emergency response depends on immediate ambulance dispatch, patient assessment, triage, and transport to hospital. During 1999, the Ambulance Command of the Hong Kong Fire Services Department responded to 484,923 calls, which corresponds to 1329 calls each day. Cooperation between the Fire Services Department and the Hospital Authority exists at the levels of professional training of emergency medical personnel, quality assurance, and a coordinated disaster response. In response to the incident at the Hong Kong International Airport in the summer of 1999, when an aircraft overturned during landing, the pre-set quota system was implemented to send patients to designated accident and emergency departments. Furthermore, the 'first crew at the scene' model has been adopted, whereby the command is established and triage process started by the first ambulance crew members to reach the scene. The development of emergency protocols should be accompanied by good field-to-hospital and interhospital communication, the upgrading of decision-making skills, a good monitoring and auditing structure, and commitment to training and skills maintenance.