'Who you gonna call?' A qualitative study of psychiatrists accessing mental health services.

OBJECTIVE: To identify motivation, capabilities and opportunities that enable psychiatrists and registrars to seek help for mental health problems and to inform design of interventions. METHOD: Data collected in qualitative semi-structured interviews were analysed using a framework approach with the COM-B model of behaviour as a theoretical frame. RESULTS: Accounts of the eight participants show help-seeking to be a complex process requiring cognitive and emotional capability to recognise a problem or goal, acceptance of vulnerability, and facilitated by access to professional networks. Help-seeking was enabled by openness about mental health problems in workplace culture. CONCLUSIONS: Interventions to enable help-seeking should focus on normalising the experience of mental health problems among doctors and challenge the notion that difficulties represent characterological flaws. Greater understanding of the mandatory reporting requirements is also required.

"Fighting for the Last Gasp"-Severe Borderline Personality Disorder and Posttraumatic Stress Disorder, Chronic Deliberate Ingestion of Foreign Bodies, and Palliative Struggles in Intensive Care.

Repeated deliberate ingestion of foreign bodies can have tragic long-term consequences. We report the case of a young woman with borderline personality disorder and chronic posttraumatic stress disorder, whose chronic repeated ingestion of razor blades and batteries eventually resulted in severe medical complications. We focus on the involvement of the consultation-liaison psychiatry team as part of her multidisciplinary care, predominantly in the intensive care environment. Her care posed extensive challenges due to the retraumatizing effects of the intensive care environment and the measures required to provide life-sustaining care when the young woman was emotionally dysregulated. Strategies used to address team dynamics and "compassion fatigue" are discussed, including some pertinent relevant literature that was used as educational material for staff to develop a better understanding of the confronting and apparently self-defeating antitherapeutic behavior she frequently displayed. The consultation-liaison psychiatry team has a significant role to play in such situations, carefully balancing patient advocacy roles while simultaneously supporting staff who may be vicariously traumatized by the substantial emotional challenges of providing care in these circumstances.

Stepping forward: challenges and pathways to building a vibrant research culture through the Scholarly Project.

OBJECTIVES: The Scholarly Project is a relevant task to support building a culture of research in psychiatry across Australia and New Zealand. However, there are several impediments to trainees' confident completion of this project. The authors review recent literature on the challenges voiced by trainees, as well as solutions posed by clinician-researchers and medical educators. Relevant strategies are highlighted, and several practical solutions to support the completion of the Scholarly Project are proposed. CONCLUSIONS: There are several pathways available to alleviate barriers to trainees' timely commencement and completion of the Scholarly Project, including enhancing research capacity within services, familiarity with the requirements, access to supervisors and additional support for trainees.

Validation of the new Vancouver Chest Pain Rule in Asian chest pain patients presenting at the emergency department.

OBJECTIVES: The new Vancouver Chest Pain (VCP) Rule recommends early discharge for chest pain patients who are at low risk of developing acute coronary syndrome (ACS), and thus can be discharged within 2 hours of arrival at the emergency department (ED). This study aimed to assess the performance of the new VCP Rule for Asian patients presenting with chest pain at the ED. METHODS: This prospective cohort study involved patients attended to at the ED of a large urban centre. Patients of at least 25 years old, presenting with stable chest pain and a non-diagnostic ECG, and with no history of active coronary artery disease were included in the study. The main outcome measures were cardiac events, angioplasty, or coronary artery bypass within 30 days of enrolment. RESULTS: The study included 1690 patients from 27 August 2000 to 1 May 2002, with 661 patients fulfilling the VCP criteria. Of those for early discharge, 24 had cardiac events and 13 had angioplasty or bypass at 30 days, compared to 91 and 41, respectively, for those unsuitable for discharge. This gave the rule a sensitivity of 78.1% for cardiac events, including angioplasty and bypass. Specificity was 41.0%, and negative predictive value (NPV) was 94.4%. CONCLUSION: We found the new VCP Rule to have moderate sensitivity and poor specificity for adverse cardiac events in our population. With an NPV of less than 100%, this means that a small proportion of patients sent home with early discharge would still have adverse cardiac events.

Reducing ambulance response times using geospatial-time analysis of ambulance deployment.

OBJECTIVES: This study aimed to determine if a deployment strategy based on geospatial-time analysis is able to reduce ambulance response times for out-of-hospital cardiac arrests (OOHCA) in an urban emergency medical services (EMS) system. METHODS: An observational prospective study examining geographic locations of all OOHCA in Singapore was conducted. Locations of cardiac arrests were spot-mapped using a geographic information system (GIS). A progressive strategy of satellite ambulance deployment was implemented, increasing ambulance bases from 17 to 32 locations. Variation in ambulance deployment according to demand, based on time of day, was also implemented. The total number of ambulances and crews remained constant over the study period. The main outcome measure was ambulance response times. RESULTS: From October 1, 2001, to October 14, 2004, a total of 2,428 OOHCA patients were enrolled into the study. Mean ± SD age for arrests was 60.6 ± 19.3 years with 68.0% male. The overall return of spontaneous circulation (ROSC) rate was 17.2% and survival to discharge rate was 1.6%. Response time decreased significantly as the number of fire stations/fire posts increased (Pearson χ(2) = 108.70, df = 48, p < 0.001). Response times for OOHCA decreased from a monthly median of 10.1 minutes at the beginning to 7.1 minutes at the end of the study. Similarly, the proportion of cases with response times < 8 minutes increased from 22.3% to 47.3% and < 11 minutes from 57.6% to 77.5% at the end of the study. CONCLUSIONS: A simple, relatively low-cost ambulance deployment strategy was associated with significantly reduced response times for OOHCA. Geospatial-time analysis can be a useful tool for EMS providers.

Temporal variation of out-of-hospital cardiac arrests in an equatorial climate.

OBJECTIVE: We aimed to determine whether there is a seasonal variation of out-of-hospital cardiac arrests (OHCA) in an equatorial climate, which does not experience seasonal environmental change. METHODS: We conducted an observational prospective study looking at the occurrence of OHCA in Singapore. Included were all patients with OHCA presented to Emergency Departments across the country. We examined the monthly, daily, and hourly number of cases over a three-year period. Data was analyzed using analysis of variance (ANOVA). RESULTS: From October, 1st 2001 to October, 14th 2004, 2428 patients were enrolled in the study. Mean age for cardiac arrests was 60.6 years with 68.0% male. Ethnic distribution was 69.5% Chinese, 15.0% Malay, 11.0% Indian, and 4.4% Others. There was no significant seasonal variation (spring/summer/fall/winter) of events (ANOVA P = 0.71), monthly variation (P = 0.88) or yearly variation (P = 0.26). We did find weekly peaks on Mondays and a circadian pattern with daily peaks from 9-10 am. CONCLUSIONS: We did not find any discernable seasonal pattern of cardiac arrests. This contrasts with findings from temperate countries and suggests a climatic influence on cardiac arrest occurrence. We also found that sudden cardiac arrests follow a circadian pattern.

Geographic-time distribution of ambulance calls in Singapore: utility of geographic information system in ambulance deployment (CARE 3).

INTRODUCTION: Pre-hospital ambulance calls are not random events, but occur in patterns and trends that are related to movement patterns of people, as well as the geographical epidemiology of the population. This study describes the geographic-time epidemiology of ambulance calls in a large urban city and conducts a time demand analysis. This will facilitate a Systems Status Plan for the deployment of ambulances based on the most cost effective deployment strategy. MATERIALS AND METHODS: An observational prospective study looking at the geographic-time epidemiology of all ambulance calls in Singapore. Locations of ambulance calls were spot mapped using Geographic Information Systems (GIS) technology. Ambulance response times were mapped and a demand analysis conducted by postal districts. RESULTS: Between 1 January 2006 and 31 May 2006, 31,896 patients were enrolled into the study. Mean age of patients was 51.6 years (S.D. 23.0) with 60.0% male. Race distribution was 62.5% Chinese, 19.4% Malay, 12.9% Indian and 5.2% others. Trauma consisted 31.2% of calls and medical 68.8%. 9.7% of cases were priority 1 (most severe) and 70.1% priority 2 (moderate severity). Mean call receipt to arrival at scene was 8.0 min (S.D. 4.8). Call volumes in the day were almost twice those at night, with the most calls on Mondays. We found a definite geographical distribution pattern with heavier call volumes in the suburban town centres in the Eastern and Southern part of the country. We characterised the top 35 districts with the highest call volumes by time periods, which will form the basis for ambulance deployment plans. CONCLUSION: We found a definite geographical distribution pattern of ambulance calls. This study demonstrates the utility of GIS with despatch demand analysis and has implications for maximising the effectiveness of ambulance deployment.

Comparison of chest compression only and standard cardiopulmonary resuscitation for out-of-hospital cardiac arrest in Singapore.

OBJECTIVE: Chest compression only cardiopulmonary resuscitation (CC-CPR) without ventilation has been proposed as an alternative to standard cardiopulmonary resuscitation (CPR) for bystanders. However, there has been controversy regarding the relative effectiveness of both of these techniques. We aim to compare the outcomes of cardiac arrest patients in the cardiac arrest and resuscitation epidemiology study who either received CC-CPR, standard CPR or no bystander CPR. METHODS: This prospective cohort study involved all out-of-hospital cardiac arrest (OHCA) patients attended to by emergency medical service (EMS) providers in a large urban centre. The data analyses were conducted secondarily on these collected data. The technique of bystander CPR was reported by paramedics who arrived at the scene. RESULTS: From 1 October 2001 to 14 October 2004, 2428 patients were enrolled into the study. Of these, 255 were EMS-witnessed arrests and were excluded. 1695 cases did not receive any bystander CPR, 287 had standard CPR and 154 CC-CPR. Patient characteristics were similar in both the standard and CC-CPR groups except for a higher incidence of residential arrests and previous heart disease sufferers in the CC-CPR group. Patients who received standard CPR (odds ratio (OR) 5.4, 95% confidence interval (CI) 2.1-14.0) or CC-CPR (OR 5.0, 95% CI 1.5-16.4) were more likely to survive to discharge than those who had no bystander CPR. There was no significant difference in survival to discharge between those who received CC-CPR and standard CPR (OR 0.9, 95% CI 0.3-3.1). CONCLUSION: We found that patients were more likely to survive with any form of bystander CPR than without. This emphasises the importance of chest compressions for OHCA patients, whether with or without ventilation.

Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: randomised controlled trial.

OBJECTIVE: To investigate whether antenatal breast feeding education alone or postnatal lactation support alone improves rates of exclusive breast feeding compared with routine hospital care. DESIGN: Randomised controlled trial. SETTING: A tertiary hospital in Singapore. PARTICIPANTS: 450 women with uncomplicated pregnancies. MAIN OUTCOME MEASURES: Primary outcomes were rates of exclusive breast feeding at discharge from hospital and two weeks, six weeks, three months, and six months after delivery. Secondary outcomes were rates of any breast feeding. RESULTS: Compared with women who received routine care, women in the postnatal support group were more likely to breastfeed exclusively at two weeks (relative risk 1.82, 95% confidence interval 1.14 to 2.90), six weeks (1.85, 1.11 to 3.09), three months (1.87, 1.03 to 3.41), and six months (2.12, 1.03 to 4.37) postnatally. Women receiving antenatal education were more likely to breast feed exclusively at six weeks (1.73, 1.04 to 2.90), three months (1.92, 1.07 to 3.48), and six months (2.16, 1.05 to 4.43) postnatally. The numbers needed to treat to achieve one woman exclusively breast feeding at six months were 11 (6 to 80) for postnatal support and 10 (6 to 60) for antenatal education. Women who received postnatal support were more likely to exclusively or predominantly breast feed two weeks after delivery compared with women who received antenatal education (1.53, 1.01 to 2.31). The rate of any breastfeeding six weeks after delivery was also higher in the postnatal support group compared with women who received routine care (1.16, 1.02 to 1.31). CONCLUSIONS: Antenatal breast feeding education and postnatal lactation support, as single interventions based in hospital both significantly improve rates of exclusive breast feeding up to six months after delivery. Postnatal support was marginally more effective than antenatal education. TRIAL REGISTRATION: Clinical Trials NCT00270920 [ClinicalTrials.gov].

Comparison of termination-of-resuscitation guidelines for out-of-hospital cardiac arrest in Singapore EMS.

CONTEXT: Termination of resuscitation (TOR) in the field for out-of-hospital cardiac arrest (OHCA) can reduce unnecessary transport to hospital and increase availability of resources for other patients. OBJECTIVES: To compare the performance of three TOR guidelines for Basic Life Support-Defibrillator (BLS-D) providers when applied to cardiac arrest patients in the Cardiac Arrest and Resuscitation Epidemiology (CARE) study. DESIGN: This prospective cohort study involved all OHCA patients attended by BLS-D providers in a large urban center. The data analyses were conducted secondarily on these prospectively collected data. Three TOR guidelines proposed by Marsden et al. [BMJ 1995;311:49-51], Petrie [CJEM 2001;3:186-92] and Verbeek et al. [Acad Emerg Med 2002;9:671-8] were applied to show the relationship between the guidelines and actual survival. RESULTS: From 1 October 2001 to 14 October 2004, 2269 patients were enrolled into the study. Thirty-two (1.4%) survived to hospital discharge. For the 3 TOR guidelines, sensitivity was 93.8% (95%CI=79.9-98.3) (Petrie), 81.3% (95%CI=64.7-91.1) (Verbeek) and 90.6% (95%CI=75.8-96.8) (Marsden). Negative predictive value was 99.7% (95%CI=99.0-100.0) (Petrie), 99.6% (95%CI=99.2-99.8) (Verbeek) and 99.8% (95%CI=99.4-99.9) (Marsden). Application of these guidelines would have resulted in transport of 68.4% (Petrie), 31.3% (Verbeek) and 36.1% (Marsden) of cases. The Petrie guidelines would have recommended TOR in two patients who eventually survived. Similarly TOR was recommended in six patients for Verbeek and three patients for Marsden who eventually survived. CONCLUSION: We found all three TOR guidelines to have high sensitivity and negative predictive value. However the specificity and transport rates varied greatly. Application of any TOR guidelines may be affected by local EMS and population factors which should be considered in any policy decision.

Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest.

STUDY OBJECTIVE: The benefit of epinephrine in cardiac arrest is controversial and has not been conclusively shown in any human clinical study. We seek to assess the effect of introducing intravenous epinephrine on the survival outcomes of out-of-hospital cardiac arrest patients in an emergency medical services (EMS) system that previously did not use intravenous medications. METHODS: This observational, prospective, before-after clinical study constitutes phase II of the Cardiac Arrest and Resuscitation Epidemiology project. Included were all patients who are older than 8 years, with nontraumatic out-of-hospital cardiac arrest conveyed by the national emergency ambulance service. The comparison between the 2 intervention groups for survival to discharge was made with logistic regression and expressed in terms of the odds ratio (OR) and the corresponding 95% confidence interval (CI). RESULTS: From October 1, 2002, to October 14, 2004, 1,296 patients were enrolled into the study, with 615 in the pre-epinephrine and 681 in the epinephrine phase. Demographic and EMS characteristics were similar in both groups. Forty-four percent of patients received intravenous epinephrine in the epinephrine phase. There was no significant difference in survival to discharge (pre-epinephrine 1.0%; epinephrine 1.6%; OR 1.7 [95% CI 0.6 to 4.5]; adjusted for rhythm OR 2.0 [95% CI 0.7 to 5.5]); return of circulation (pre-epinephrine 17.9%; epinephrine 15.7%; OR 0.9 [95% CI 0.6 to 1.2]), or survival to admission (pre-epinephrine 7.5%; epinephrine 7.5%; OR 1.0 [95% CI 0.7 to 1.5]). There was a minimal increase in scene time in the epinephrine phase (10.3 minutes versus 10.7 minutes; 95% CI of difference 0.02 to 0.94 minutes). CONCLUSION: We were unable to establish a significant survival benefit with the introduction of intravenous epinephrine to an EMS system. More research is needed to determine the effectiveness of drugs such as epinephrine in resuscitation.