EmergencyMedicine Research

Emergency Medicine Research :

How do I get started?A/Prof Marcus Ong

Consultant, Senior Medical Scientist& Director of Research

Department of Emergency MedicineSingapore General HospitalAdjunct Associate Professor

Duke-NUS Graduate Medical SchoolOffice of Research

How do I get started?

Step 1:

Ask questions about your everyday practice


Review the current literature: Pubmed/Medline Cochrane database Embase Google scholar Textbooks


Step 1a:

Frame the question in a way that the answer can be measured:

• Is HAT better than T&S for scalp lacerations in terms of better wound healing, lower infection and lower wound breakdown?


Step 1b:

Choose an appropriate study design:

• RCT

• Pseudorandomised clinical trial

• Cohort study

• Case-control study

• Observational/descriptive type

Patients meeting entry criteria

Explain and give patient information sheet to patient

Get written consent from patient

Randomisation

Hair apposition technique with tissue glue Standard Toilet and Suture with injection localanaesthesia and prolene sutures

Fill up study forms. Instructions given regarding no hair washing for 2 days. Instructions regarding removalof stitches for T&S group on 7th post-op day

Wound review on 7th post-op day and removal of stitches if appropriate

Wound healed, study forms completed and patientdischarged

Wound not healed. Patient to be managed asrequired and reviewed again on 14th post-op day


Step 1c:

Choose appropriate statistical tests:• Frequencies, mean, sd, se• Chi Square test/ Fisher’s exact test• T test• Correlation• Multivariate analysis, Logistic regression• Survival analysis

Results

Table 1: Characteristics of patients

HAT SuturingNo. (%)(n=96)

No. (%)(n=93)

Age Mean (SD) Median (range)

32.7 (22.5)30 (2, 90)

32.0 (19.0)30 (1, 79)

Sex Male Female

66 (68.8)30 (31.3)

74 (79.6)19 (20.4)

Race Chinese 62 (64.6) 61 (65.6) Malay 8 (8.3) 6 (6.5) Indian 20 (20.8) 16 (17.2) Others 5 (5.2) 10 (10.8)

Results

Complications by treatment

HAT(n=95)

Suturing(n=93)

Effect size (95% CI) p value

Infection 1.1% 1.1% 0% (-3.0%, 3.0%) 1.00

Scarring 6.3% 20.4% -14.2% (-23.8%, -4.6%) 0.004

Bleeding 0% 1.1% -1.1% (-3.2%, 1.0%) 0.492

Wound breakdown 0% 4.3% -4.3% (-8.5%, -0.1%) 0.057

Any complication(infection, scarring,bleeding or woundbreakdown)

7.4% 21.5% -14.1% (-24.1%, -4.3%) 0.005


Step 1d:

Design and execute your data collection

• Case record form

• Survey

• Computer based data collection

• Case notes review

• Warning: Clinicians hate form filling!

Patient information (Study no_______) Name________________________________________________HRN__________________________Age___________Sex 1)M 2)FRace 1)Chinese

Patient’s sticker2)Malay3)Indian

4)Others ,State_________________

Attending Doctor____________________Scalp injury (circle where appropriate)

Multiple wounds 0)n 1)ySite 1) frontal 2)occipital 3)temporal 4)parietal 5)vertexLength ___________(Use longest wound only)Wound 1)Linear 2)complicatedState 1)Clean 2)mild contamination 3)moderate contamination 4)severe contaminationUnderlying fracture 1)y 0)nProven intracranial injury 1)y 0)nBleeding 1)none 2)mild 3)moderate 4)severeTime to treatment__________

Medical history steroids1)y 0)n DM 1)y 0)n Immunocompromise 1)y 0)nOthers________________________Technique used 1)hair apposition 2)T&SUnable to score pain 1)y 0)nProcedure painful? VISUAL SCALE: 0 1 2 3 4 5 6 7 8 9 10 NO PAIN UNBEARABLE PAINAdhesive used 1)Dermabond 2)Histoacryl glueHair shaved 1)y 0)nAntibiotics 1)y 0)nDuration of procedure______________Problems encountered___________________________________________________


Step 1e:

Analyse, present and write up your data:

• DIY vs consult a statistician

• Get feedback from your presentation

• The art of manuscript writing

Reader’s Digest 2003


Step 2:

Develop basic research skills

• Biostatistics/Epidemiology

• Clinical Trials Design

• Good Clinical Practices (GCP) courses

• Bioethics courses

• Medical writing courses

University of Ottawa EM Research Fellowship

incorporating MSc in Epidemiology

(2 years)

Dept of Emergency MedicineDept of Emergency Medicine/VCURES /VCURES

VCU Health SystemVCU Health SystemResearch FellowshipResearch Fellowship

Incorporates Phd (3 years) or Incorporates Phd (3 years) or Masters of Public Health (1.5 years)Masters of Public Health (1.5 years)

Dept of Epidemiology and Community HealthDept of Epidemiology and Community HealthVirginia Commonwealth UniversityVirginia Commonwealth University


Step 3:

Grow in your research experience and interest

• Start with accessible data sources

• Common clinical conditions

• Develop your research question

Spontaneous Pneumothorax Outcome Study (SPOT Phase 1) : A

2 yr Review

Ong, MEH, Chan YH, Kee TYS, Chew HC, Koh MSY. Spontaneous Pneumothorax

Outcome Study (SPOT phase I): a 2-year review.

European Journal of Emergency Medicine. April 2004, 11(2):89-94

Spontaneous Pneumothorax Outcome Trial II (SPOT II)

•A randomised controlled trial comparing needle aspiration and mini-chest tube (20-24F) insertion with Heimlich valve attachment in the treatment of primary spontaneous pneumothorax (PSP).


Step 4:

Build a relationship with a research mentor


Step 5:

Develop your collaborations, research funding and portfolio

CARE Study• Cardiac Arrest and Resuscitation Epidemiology in Singapore: A Pre-hospital Study

• Largest and most comprehensive OHCA study to date

• Prospective, Observational study

• Multi-center, covers whole of Singapore

CARE Study

•Period of study:

•CARE I: 1 Oct 2001 to 30 Apr 2002

•CARE II: 1 Oct 2002 to 14 Oct 2004

•CARE III: Ongoing

•CARE IV: In planning

•Number of Cases Recruited: >28, 000

‘Public access defibrillation in Singapore: where should automated

external defibrillators (AEDs) be placed? (PADS Phase I)’

CARE Study– Ong EHM, Chan YH, Anantharaman V, Lau ST, Lim SH, Seldrup J.

Cardiac Arrest and Resuscitation Epidemiology in Singapore (CARE I study). Prehospital Emergency Care 2003; 7: 427-433

– Ong ME, Chan YH, Srither DE, Lim YH. Asian Medical Staff Attitudes Towards Witnessed Resuscitation; Resuscitation; Jan 2004;60(1):45-50

– Ong MEH, . Chan YH, Ang HY, Lim SH, Tan KL. Resuscitation of out-of-hospital cardiac arrest by Asian primary health care physicians. Resuscitation 2005, 65:191-195

– Ong MEH, Chan YH, Anantharaman V. Improved response times with motorcycle based Fast Response Paramedics. SGH Proceedings 2003; 12(3): 114-119

– Ong MEH, Chan YH, Yap YH, Ang HY. Intravenous access by paramedics in out-of-hospital cardiac arrest. Singapore Nursing Journal Apr 2003; 30 (2): 38-41

– Ong MEH, Chan YH, Ang HY, Yap YH. Public attitudes to Emergency Medical Services (EMS) in Singapore: EMS day 2002. Singapore Med J 2004; 45(9): 419-422

Funding sources• Government research funding

• Hospital funds

• Charity funding: Singapore Heart Foundation, Cancer Society

• Commercially funded (Drugs, devices)

• Military/Security

• Investors/ Business start ups

Funding sources

• Capital items

• Manpower

• Expendables

• Protected time?


Step 6:

Finding research ‘niches’

• EM related

• Emerging technologies

• Inter-disciplinary collaborations

• International collaborations

Early Defibrillation

“ Controlled Therapeutic Hypothermia Post-Cardiac Arrest Compared to

Standard Intensive Care Unit Therapy Marcus EH Ong, MD, FRCS (A&E),

MPH

Department of Emergency Medicine, Virginia Commonwealth University

(VCU) Health SystemMary Ann Peberdy MD, FACC

Department of Medicine and Emergency Medicine, VCU Health System

Renata Sampson, RN, MSN, BC, CPHQ

Department of Performance Improvement, VCU Health System

Joseph P. Ornato MD, FACP, FACC, FACEP

Department of Emergency Medicine, VCU Health System

SGH Center for Resuscitation Science and Emergency Medicine

ResearchMulti-disciplinary approach :

oStatisticians/Epidemiologists

oBiomedical Engineering

oMedical /Surgical/ Other disciplines

oPara-medical disciplines: pharmacists, sociologists, public health. Psychology

oBasic sciences

> $1 million in funding from NMRC, Singhealth Foundation, CTERU, commercial companies and Singapore Armed Forces etc.

SGH Center for Resuscitation Science and Emergency Medicine

Research5 full time researchers :

2 Research Co-ordinators (nurse/paramedic, psychologist

2 Research Engineers (Biomedical Engineering)

1 Research Assistant (IT)

Resuscitation Research at SGH

o Measurement of Prehospital Heart Rate Variability as a Predictor of Hospital Outcomes

o A Prospective Observational Study of Heart Rate Variability in Trauma Patients

o Real-Time Measurement of Prehospital Heart Rate Variability as a Clinical Predictor of Hospital Outcomes in Acutely Ill Patients (Phase II)

o Wireless Remote Detection of Heart Beat & Respiratory Rate o Wearable, Wireless Vital Signs Monitoring Devices in Critically Ill

patientso Respiratory and Ventilation Characteristics in an Animal Model of Load

Distributing Band Chest Compressiono Preadmission Intravenous Vasopressin, adrenaline Outcome Trial

Measurement of Prehospital Heart Rate Variability as a Predictor of

Hospital Outcomes

Measurement of Prehospital Heart Rate Variability as a Clinical Predictor of Hospital

Outcomes in Acutely Ill Patients

Pavitra Padmanabhan, Zhiping Lin, Marcus Eng Hock Ong,

Wee Ser and Guang-Bin Huang.

Automatic Extraction of HRV Sequences From Noisy ECG

Data For Reliable Analysis And Telediagnosis. In print.

Proceedings of the Third IASTED International

Conference on Telehealth

Wang Su Ho (265-317 AD) A Treatise on Qualities of the Pulse, “If the pattern of the heart beat becomes as regular as the tapping of a woodpecker or the dripping of rain from the roof, the patient will be dead in four days.”

Noise reduction & QRS detection

Noise reduction

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QRS detection

Wireless Remote Detection of Heart Beat &

Respiratory Rate

Portable Body Cooling System for Prehospital Management of

Patients with Heat Stroke

MEH Ong , Department of Emergency Medicine, Singapore General Hospital

A/Prof Francis E.H. Tay, National University of SingaporeDepartment of Mechanical Engineering

CRM modulePower

CondenserCompressor

Fan

Temperature sensor

Heat pipe inlet

Heat pipe inletIce inside

HAM module

Blanket

Heat pipe

Heat pipe outlet

Buckle

Blanket and heat pipe module

Inner ear temperature

sensor

Electrodes for ECG measurement

Skin surface temperature sensor Schematic view of

Body Cooling Unit and wireless vital signs monitoring system


Step 7:

Research career pathways?

• Clinician-Scientist

• Academic Emergency Medicine

• Scientist-Clinician

EmergencyMedicine Research

Health & Medicine

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