BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES
THE EMERGENCY ROOM
Medical Emergency vs Medical Urgency
Summary by Kiki
1. Medical Emergency – injury or illness that is sudden/ acute and poses an immediate threat on a person’s
life
Warning signs:
a. Difficulty breathing/
shortness of breath
b. Chest/ upper abdominal pain
or pressure
c. Fainting, sudden dizziness/
weakness
d. Changes in vision
e. Confusion/ changes in mental
status
f. Any sudden/ severe pain
g. Uncontrolled bleeding
h. Severe/ persistent vomiting
or diarrhea
i. Hematemesis/ hemoptysis
j. Suicidal feelings
k. Difficulty speaking
l. Unusual abdominal pain
In foreign literature, the most commonly encountered medical emergency in both primary care and child care
are asthma exacerbations.
2. Medical Urgency – not immediately life threatening but could become so if not resolved promptly
 May include: moderate fever; cough, colds or flu; bruises, abrasions and minor cuts; minor burns;
eye/ear/skin infections; sprains/strains; UTI; RTIs
Who provides emergency care? Family physicians 65% of the time in the US, probably higher in the Philippines
esp. in the provinces
The ER physician (Philippine context) should be: licensed MDs +/- residency training in emergency med
ER Setup –
1.
2.
3.
4.
Makati Medical Center - 1st to offer an emergency medicine training program
Manila Doctors
San Juan de Dios
PGH – first university hospital to offer an emergency training program
 ER is departmentalized: ACU/ PACU/ OBAS/ Ambu
Emergency referrals should contain: name, age, gender with a short history or clinical abstract and vital signs
"EFFECTS OF THE ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION
DUTY HOUR LIMITS ON SLEEP, WORK HOURS, AND SAFETY"
Summary by Dax
**Basically, the study has the PIOM:
P- pediatric resident physicians
I- work hour limits (accreditation of graduate meical education standards)
O- improvement of the rate of medication errors, resident depression, education ratings,
resident injuries
M- prospective cohort
**residents from 3 large pediatric training programs submitted daily reports of work hours, sleep, near-miss and
actual motor vehicle crashes, medical errors, and ratings of educational experience.
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES
**Results concluded that although fewer residents were burned out, rates of medication errors, depression,
injuries and educational ratings did not improve. and despite the scheduling changes, the total of hours of work
and sleep did not change after implementation of duty standards.
WHEN STAFF IS UNDERPAID: DEALING WITH THE INDIVIDUAL COPING STRATEGIES
OF HEALTH PERSONNEL Lenberghe Etal.
Summary By Len
Public Health Sector Workers have different coping strategies to respond to their inadequate salaries
The Coping Strategies of Underpaid Staff:

Public health workers are labeled as “unproductive, poorly motivated”

Widespread “demotivation” is due to unfair public salaries.

Previously the issues on how health workers cope has been considered politically incorrect to raise
explicitly.

Coping strategies by health professionals:

Predatory behaviors by public health sector clinicians include under the counter fees, forcing patients
to attend private consultations, sell drugs that are supposedly free.

Health system managers have fewer opportunities for predatory behavior so some use their position
for corruption or misappropriation.

Not all strategies are predatory, but they all play a role in how health services function.
Beyond predation: competition for time, brain drain and conflicts of interest

Why do some people decide to remain in public service when they can earn more in private practice?
Motivators include social responsibility, self-realization, access to medical technology, professional
satisfaction and prestige.

Individual income topping-up strategies allow professionals to achieve a standard of living that one
wants. Positive: helps them retain valuable expertise in public service.

Non-predatory coping strategies: moonlighting in private practice eat into their availability, limiting
access to care.

Low salaries paradoxically lead to high costs per unit of output.

Conflicts of interest

Not all negative, something positive is when they take an extra teaching job. It reinforces the contact of
trainees with realities of health services.

Countries attempt to retain health staff e.g. recruitment quotas, make sure far flung areas are well
represented. (like regionalization program)
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES

Brain drain is not only intercountry migration, there is also rural-urban migration.

Intercountry migration: overseas training is a highly prized opportunity to increase one market’s value.
Ways of addressing this e.g. World Bank has recommendations to tie access to professional education
to a commitment to practice a certain number of years in the country or reimburse cost of study when
they practice in an underserved area.

The problem: many of the best clinicians end up in private practice. The private practice that was
previously complementary becomes a matter of professional and social prestige.
Dealing with Coping Strategies
 Raising public sector to close the salary gap is unlikely to be enough to break vicious cycle.

In the average low-income country salaries need to increase the salaries up to 5x. This is impractical.
Doing this for all civil servants is unimaginable, doing it only to some groups is politically difficult.

A mere increase in salary would not automatically restore the sense of purpose required to make public
services function.

Prohibiting civil servants from complementing their income is unlikely to be successful. It will only
make the practice underground.
Deemed solutions:
 Holding an open discussion is a good idea. It minimizes feeling of unfairness among colleagues.

Introduction of systems of incentives coherent with social goals e.g. Financial compensation in deprived
areas may reinstate lost civil service values.

Improvement of working conditions, more than being a combination of adequate salary and decent
equipment, it means developing career prospects and training.

Value systems of the professionals: major determinant in the difference between providing good or bad
service to the public.
THE PRUDENT LAYPERSON DEFINITION OF AN EMERGENCY MEDICAL CONDITION
The American Journal of Emergency Medicine, Volume 20, Issue 1, Pages 10-13
J.Li, H.Galvin, S.Johnson (Am J Emerg Med 2002;20:10-13.
Summary by Avi
Study objectives: objectively define symptoms and signs commonly agreed on by prudent laypersons as emergency
medical conditions.
How was it done: survey of nonmedical laypersons after a comprehensive tabulation of symptom classifications
from the International Classification of Diseases (ICD-9) was done.
Data analysis: descriptive statistics, proportional calculations, and 95% confidence intervals.
Results:

Leading conditions deemed emergencies were loss of consciousness, seizure, no recognition of one side
of the body, paralysis, shock, gangrene, coughing blood, trouble breathing, chest pain, and choking.
Pain, except for renal colic or chest pain, was not considered an emergency.
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES

A minority of symptoms and signs (25/87, 29%) were considered emergency medical conditions by
more than half of nonmedical survey respondents.

No symptoms or signs specifically related to gynecologic disorders were considered emergencies.

Most symptoms and signs tabulated in the diagnostic coding manual, ICD-9, are not considered
emergency medical conditions by self-designated prudent laypersons. These include many conditions
that are commonly investigated and treated in the emergency department setting
Article 1
Title: The Early Effects of Code 405 Work rules on attitudes of orthopedic residents and attending surgeons
CODE 405: Restricts resident work to 80 hours per week.
Objectives:
1. evaluate attitudes of orthopedic residents and attending surgeons toward the code 405 and its effect on
perceived quality of residency training, quality of life and patient care.
2. quantify the effect of the work hour restrictions on the actual number of hours worked
Methods:
Questionnaires
Results:
Average weekly work hours decreased for PGY2 and PGY3, but increased for PGY4 residents
Residents felt they had increased time available for reading
Both attending surgeons and residents had negatively impacted their operating experience
Both agreed that their QOL improved
Conclusions:
Even if QOL of the residents and attendings improved, the study was not able to determine whether this offset the
perceived negative impact on education, continuity of care, and operative experience.
Article 2:
Title: Resident work-hour rules: a survey of residents’ and program directors’ opinion and attitudes
Population: 976 orthopedic residents (30% response rate) and 85 program directors (56% response rate)
A. Resident education
Junior residents perceived the work hour regulations as having a positive effect on education
All agreed that the QOL improved
B. Patient Care
Junior residents viewed the new regulations positively; senior residents and program directors disagreed
Conclusion: There is meaningful differences in attitudes and opinions of junior residents, senior residents and
program directors
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES
Article 3:
Title: Measuring the attitudes and impact of the eighty hour workweek rules on orthopedic surgery residents
Background:
Few studies detailing the attitudes of large numbers of residents in a particular surgical specialty toward the
new requirements
Methods:
Survey created by the Academic Advocacy Committee of the American Academy of Orthropedic Surgeons
(2004)
Population:
4207 Orthopedic residents at post graduate year 1 through year 6
Results:
Response rate: 13.2% (554 residents, 59 of whom did not specify their year level)
68% of 495 with known year level were at PGY4 or higher.
23% of all respondents thought the hours were appropriate
41% of all respondents thought the hours were too many
34% of all respondents thought the hours were insufficient
33% of all respondents worked more than the hours required since the new rules
Orthopedic trauma residents had the most difficulty adhering to the new rules
82% of respondents claimed that the program had to change schedules or hire more workers to adhere to the
new work rule; i.e. physician assistants, night-float systems, home-call assignments
Conclusion:
Mixed resident attitudes
New rules forced restructuring of programs
Junior residents favored the new rules more than did the senior residents
Residents reported an improved QOL, but the perception that the quality of training diminished still persists.
UNDERESTIMATION OF CASE SEVERITY BY EMERGENCY DEPARTMENT PATIENTS:
IMPLICATIONS FOR MANAGED CARE
Summary by Rovi
Objective: examine differences in symptom severity assessment by the emergency department patients and by the
emergency physicians
In short: They asked the patients to classify themselves with their symptoms as emergent (needed care within 1
hour), urgent (within 6 hours) or non-urgent; also the Emergency Physicians were asked to classify them
according to their presenting symptom. This was compared against the assessment of severity after the labs and all
the diagnostics.
Results:
-most patients rated themselves in the right category (emergent 44%, urgent 55%, non urgent 65%)
- 16% underrated themselves
- 28% overrated themselves
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES
*this study shows that self classification of case severity can be used as a rough guide to predict the chance
for need for admission (50% of self classified emergent, 25% of self classified urgent and 5% of self classified non
urgent were admitted)
* still, patients cannot accurately asses their true severity or urgency in a high percentage and are more
likely to assess themselves as being of a higher severity
(side note: this study was done because in some states, people had to call to the emergency room to say their
symptoms and were given a go signal if they would be accepted to the ER (if they didn't call previous to going, they
wont be entertained) and thus this study shows that this practice is unsafe for at least 5% of the population)
EMERGENCY MEDICAL CARE IN DEVELOPING COUNTRIES: IS IT WORTH IT?
[Short answer: Oo.]
Summary by Macky
INTRODUCTION
 Global health policy emphasis on multiple vertically oriented programs concentrated on maternal and child
health and control of communicable childhood diseases
 Vertical programs do not encourage the development of strong and efficient health care delivery systems
o Becomes most apparent during crises such as medical emergencies or incidents involving large numbers of
casualties
EMERGENCY MEDICAL CARE
 Purpose is to stabilize patients with life-threatening or limb-threatening injury or illness
 Focuses on provision of immediate or urgent medical interventions
 Two major components:
o Medical Decision-making
o Actions necessary to prevent needles death or disability
EMERGENCY MEDICAL CARE AND HEALTH SYSTEM PERFORMANCE
 Three fundamental functions of a health system:
o Improve the health of the population
o Respond to people’s expectations
 Leads to improved utilization and better outcomes
 Some expectations (based on various studies):
 Access to medical care for urgent or life-threatening conditions
 Use of primary health care centers more for emergency services than for preventive services
 Use of traditional home remedies for minor ailments but turn to primary care medical facilities for
acute complaints
 Better training of health center staff in the face of a medical emergency
 Provision of ambulances for emergencies
o Provide financial protection against costs of ill-health
 Forced to make a choice in case of an acute illness or injury: risk financial ruin or risk death or lifelong
disability?
 Prompt access to care during emergency essential regardless of whether the system gives financial
protection (i.e. prepayment options, government provision of health care, other insurance schemes)
CORE COMPONENTS OF EMERGENCY MEDICAL CARE
 Three components:
o Care in the community
o Care during transportation
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES

 Related to the question of access
o Care on arrival at the receiving health facility
Designed to overcome factors most commonly implicated in preventable mortality
o Delays in seeking care
o Access to a health facility
o Provision of adequate care at the facility
EMERGENCY MEDICAL CARE IN THE COMMUNITY
 Outcome of an acute illness or injury strongly influenced by early recognition of severity and need for medical
intervention
 Since most emergencies start at home, any system to promote early recognition of emergency conditions
should be based in the community
 Few data on ability of lay persons and community health workers to recognize life-threatening emergencies,
but reasonable to assume they can be trained to recognize severe blood loss, difficulty breathing, etc.
 Many benefits of pre-hospital emergency care could be realized by teaching community volunteers simple but
vital interventions (e.g. establishing and maintaining a patent airway, controlling external bleeding,
immobilizing fractures with local resources, etc.
EMERGENCY MEDICAL CARE AND TRANSPORTATION
 Absence of emergency medical transport is a common barrier to care
 May arise from several factors:
o Lack of appropriate vehicles
o Absence or inadequacy of roads
o Inability to pay for transport services
 Prevailing models of emergency medical transport in North America and Europe quite costly and impractical
for low-income countries
 May dictate utilization of wider range of options:
o Motorboats, canoes, bicycles with trailers, tricycles with platforms, tractors with trailers, reconditioned
vehicles, ox carts, etc.
EMERGENCY MEDICAL CARE AT FIRST-CONTACT AND REFERRAL FACILITIES:
 Facilities differ widely in respect of equipment, staff and resources; consequently, they possess varying
capacities to provide emergency care
 Some capacity to provide emergency care should be available at every level of a country’s health care system
 Health care facility’s capacity determined by:
o Human factors
 Number and mix of health care workers and level of training
o Structural factors
 Space, medications, supplies and specialized equipment
o Level of demand placed on facility by surrounding population may dictate what services are offered and are
available at short notice
 Initial triage and treatment are one of the weakest links in the system
CHALLENGES TO IMPLEMENTATION OF EMERGENCY MEDICAL CARE
 No successful models for systematically improving overall provision of emergency medical care in developing
countries
o But programs focused on emergency obstetric care and/or IMCI help
 Minimum standards of emergency medical care should be made clear, but it is not easy to define the emergency
services to which everyone should have access
 Supplement knowledge and skills of professional providers at community health centers
 Implement programs for teaching fundamentals of first aid to large numbers of volunteers
 Attention should be given to triage and emergency management training of physicians and other health care
professionals
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES



Doubts remain that investments in emergency medical care may divert resources from other preventive or
curative programs
Addition of emergency medical services to already overburdened facilities may overwhelm them
People may use emergency medical care system to bypass their community health centers and seek treatment
at higher levels of care
CONCLUSION
Health care in developing countries has not traditionally focused on emergency medical care. Although
health promotion and disease and injury prevention should be core values of any health system, many acute health
problems will continue to occur. The incorporation of a basic level of emergency medical care into health care
systems should have a significant impact on the well-being of populations
THE SHORT-STAY EMERGENCY OBSERVATION WARD IS HERE TO STAY
Fatimah Lateef, MBBS Venkataraman Anantharaman, MBBS
Summary by Micko
The traditional venue of management of most medical and surgical emergencies has been in an inpatient basis.
Patients can only be discharged after thorough evaluation and full treatment. The increasing cost of confinement
and hospital services becomes detrimental for both patient and hospital. This forces hospitals to manage
emergency cases in a more outpatient/ ambulatory basis.
The study is set in the Short-Stay Emergency Observation Ward (SSEOW) of the Singapore General Hospital (SGH).
It is a retrospective study done from July 1st to 31st December 1997; objectives were to assess volume,
characteristics and disposition of Emergency Department (ED) patients seen in the SSEOW.
The SSEOW is a 40-bed ward in the ER wherein the emergency physicians serve as gatekeepers. The site can serve
as a site for diagnostics, low and moderate level treatment as well as observation and monitoring of
intoxicated and psychiatry patients. SSEOW is similar to our ambulatory care unit.
RESULTS






Total of 114,586 Px seen in ED. 9,216 (7.9%) Px referred to SSEOW, 1,756 (1.5% of total ED Px) of these
patients eventually admitted for further inpatient care
If it weren’t for SSEOW, there would be an unnecessary 7460 admissions (9,216-1,756) from ED.
Patient disposition was based on triage classes. Priority I, II, III: emergent, urgent, non-urgent respectively.
Most cases were of Priority I and most subsequent admissions also came from this triage class, with an
admission rate of 63%. Admission rate for Classes II and III were 31.4% and 5.5% respectively.
Most patients were observed for 2-4 hours; however, admitted patients were those observed for 4-6 hours.
Alcoholics and psych patients had longest observation unit stay, (>7 hrs)
A majority of admitted patients had abdominal complaints: abdominal colic, non specific tenderness,
gastritis/ AGE and PUD. Patients presenting with abnormal serial ECGs were also almost always admitted.
Other common problems were viral/ bacterial URTI, fever, MPS, BA.
When looking at the disposition rates, 19.2% of SSEOW patients were admitted after a mean duration of
observation of 5.6 hours. Home against advice (HAA) patients were at 0.9%, most had AGE and minor head
trauma as chief complaints.
The advantages of an ambulatory/ observation unit in the ED are improved patient flow and effective decongestion
the flux of patients in the ED. There is also reduction of patient and hospital costs in unnecessary
confinements. On the part of the physician, the OU provides more time for honing clinical skills in diagnosing and
subsequent management. Disadvantages mainly revolve around longer and greater responsibility for the
emergency department physician. These can be easily overcome by an interdisciplinary approach and stronger
hospital procedure, protocol and policy.
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES
REAL-LIFE DRAMA IN THE EMERGENCY ROOM
An Apple A Day
By Tyrone M. Reyes, M.D.
Summary by Kuya Tots
Sometimes it is obvious that a trip to the nearest hospital ER is needed (ex. fall, seizure, unconsciousness)
At least 55% of ER visits are for minor medical problems or routine care and sometimes it is difficult to tell
whether an illness or injury requires an immediate trip to the ER.
People are advised to start by calling their personal physician, saying that they have an emergency, and briefly
describe the situation before they may be asked to come to the office or advised to go to the ER.
In one study by Kaiser Permanente in California
I. “ALWAYS AN EMERGENCY” CONDITIONS:
1. myocardial infraction
2. pneumonia
3. bowel obstruction
II. “OFTEN NOT AN EMERGENCY” CONDITIONS:
1. Chest wall pain (impossible to differentiate MI or heartburn without diagnostics)
2. Cough (might be 2o pneumonia or minor irritant inhalation)
3. Constipation (determining whether serious or a nuisance)
III. “ALWAYS URGENT” CONDITIONS:
1. Severe abdominal pain
May be 2o to appendicitis, bowel obstruction, perforation. Immediate Tx if with vomiting, swelling or tenderness of
abdomen, bloody diarrhea, severe constipation, fever or pain focused in one area.
2. Breathing difficulty
MI, pulmonary embolism, acute asthma, serious allergic reaction.
Trip to the ER is essential if with:
a) hx of heart or lung dx
b) chest pain
c) tachycardia
d) sweating
e) loud wheezing
f) dizziness or weakness
g) swollen tongue or throat
h) pale clammy skin
i) circumoral cyanosis.
3. Burns
1st degree burns (red painful skin) – rarely an emergency
2nd degree burn (cause blisters) – merit an ER trip if involving 5% or more of the body’s surface (roughly 4
handprints)
3rd degree burns – always emergencies – extend through all skin layers, look white or charred, involve muscle or
bone
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES
4. Chest pain
a. If with hx of CAD or angina, pt should seek help if pain begins during exercise and persists despite 10 minutes of
rest or under the tongue nitroglycerin, if it begins at rest, or if a familiar pattern of pain worsens.
b. Lung ailments, indigestion, muscle strain can also produce chest pain.
c. likely 2o to MI if with pressure, aching, tightness or crushing feeling in the middle of the chest, pain radiating
down an arm (usually the left), making the muscle feel weak or numb, chest pain spreading to the jaw, neck or
back; with lightheadedness, fainting, sweating, nausea or shortness of breath
5. Confusion and changes in consciousness
a. Sudden onset of confusion, loss of memory, alertness, or awareness (especially in older people).
b. May be 2o to stroke or some other serious medical problem if with altered mental status.
c. Dramatic declines that appear over hours or days are particularly worrisome.
6. Fractures
Most suspected fractures should be evaluated promptly at a hospital or clinic since a bone that is struck with
sufficient force may break apart damaging surrounding tissues, blood vessels, or nerves.
Exception – mildly fractured finger or toe (may be splinted by a family doctor)
7. Headaches
a. More appropriately handled in the doctor’s office than in the ER - even bad headaches are rarely emergencies
(ex. tension, migraine, sinus infection, toothache, poor posture, alcohol, stress or excitement. In rare cases persistent headaches are a symptom of a brain tumor or temporal arteritis (inflamed arteries in the skull).
b. True emergencies – meningitis, encephalitis, subarachnoid hemorrhage (bleeding inside the brain), headache
accompanied by unusual drowsiness or confusion, nausea and vomiting, loss of sensation or muscle strength, fever,
sensitivity to bright light, or abrupt onset of a headache or unprecedented severity.
8. Numbness or tingling
Occurs when the blood supply to a nerve is temporarily interrupted. Tingling signals the restoration of blood flow
to the area (ex. Carpal tunnel syndrome – this is no emergency)
Widespread numbness and tingling – may be 2o to stroke or transient ischemic attack (a precursor of stroke)
Immediate help needed – if one side of the body is affected, weak, hard to move, or immobile, vision is blurred or
distorted, with speech difficulty, or the sensation is accompanied by dizziness or confusion.
9. Rash
May be 2o to viral illnesses, or common reaction to certain foods, drugs, or environmental irritants in susceptible
people.
Most rashes can be treated at home.
2 types of rashes that require immediate treatment (because they can be signs of potentially life-threatening
illness):
1. purple spots on the skin and high temperature – may be 2o to meningitis especially if with headache, acute pain
when head is bent forward, sensitivity to bright lights, vomiting
2. hives (itchy, raised welts usually triggered by an allergy to food, drug, or an insect sting)
*constitute an emergency if they develop rapidly and cover a large area.
*progress to anaphylactic shock, a potentially lethal condition marked by dizziness, swelling of the tongue or
throat, wheezing, or difficulty of breathing.
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES
10. Vomiting
Unpleasant but sometimes valuable protective mechanism that rids the GI tract of poisons and contaminated food
Emergency:
1. If with blood or dark-colored material resembling coffee grounds (probably 2o to stomach or upper bowel
bleeding)
2. If accompanied by severe abdominal pain (may be 2o to an inflamed gall-bladder, appendicitis or bowel
obstruction or perforation)
3. If a head injury preceded the vomiting by several hours or days and headache or dizziness occurs
4. Vomiting persistent enough to cause dehydration especially in older persons
5. If accompanied by headache, fever, pain on bending the head forward, sensitivity to bright light, drowsiness or
confusion (may point to meningitis)
A POTENTIALLY LIFE-SAVING STRATEGY:
1. Carry a wallet-sized card listing significant illnesses, medications used, and names and phone numbers of
personal physicians.
2. Anyone with recent illness or a chronic condition should know the signs and symptoms of complications,
worsening health, and drug side effects. Ask physicians to explain warning signs to watch out for.
It would be a real tragedy if individual lives are lost or damaged because people stayed home when they should
have headed for the ER
THE REFERRAL SYSTEM PROJECT
(Dr. Pensigan, Dr. Caragay, and Dr. Ofrin)
Summary by Nano

aims to create a functional interrelationship between peripheral health services and the UP-PGH to
improve the selective referral of patients for diagnosis and treatment from the peripher to the Center and
vice-versa.
How can this help?
 maximize the use of limited resources in the delivery of quality care because patients are channeled to the
proper facility
 optimize various health facilities and provide more training opportunities for health care workers
Reason for not efficient referral system?
 lack of confidence by the community on health centers and lying-in clinics (on both facilities and
personnels)
 political environment may not be conducive for a referral system (lack of policies)
Search for Model Referral System
Four ARCS-commissioned studies on urban health system of Pasay City and its referral relationship with PGH:
1. Community Caring Mechanisms (Dr. Jaime Galvez-Tan, et.al)
 Communities can be tapped to support the referral network when they recognize their own “structure”
(trust groups which when trained can be a tool for community organizing) and thorugh cooperation
with them in the delivery of health care.
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES
2. Integrated Approach to Managing Childhood Illnesses for Physicians (Dr. Lulu Bravo, et.al)
 Use of clinical protocols in early detection and referral of diseases and continued training of physician
improve health care.
3. Pasay City – UP Manila – PGH Referral System Project (Dr. Ma. Sandra Tempogko, et.al)
 Integrated and community-supported referral system with referral forms, case definitions, monitoring,
and evaluation scheme is a must for a successful health care delivery.
4. Clinic-Based Training Program to Enhance Quality of Patient-Provider Interaction & Promote Patient
Education (Dr. Josefina Tuazon, et.al)
 If there is continued health education of the personnel, referral system is best supported.
Metro Manila – PGH Experience
Three layers (late 70s):
1. health centers – primary care (serves as triage, manages simple cases, refers difficult ones)
2. city, provincial & regional hospitals – secondary care
3. medical centers, teaching hospitals, & university hospitals – tertiary care
*change in administration in 1986 causes the referral system to die and “admit all” policy was implemented
* in 1999, referral system was reactivated
Proposed RP Model Referral System
When patient needs more than BHW – sent to health center (or private clinic)
▼
Gatekeeper (Fam/Com Med) – treats the patient or refer to appropriate level of care
▼
Patient can pass through an ambulatory health facility before any admissions (hospitals can refer back down for
further/follow up care)
▼
Lateral referrals are also present
Elements from the ARCS studies present on the proposed model:
 Necessity for well developed health human resources
 Built-in information subsystem where data are easily gathered, stored and retrieved
 Intensified facility development at all levels
 Presence of CPG and protocols
 Very compentent gatekeepers
 Trust groups and other community groups
 National policies encouraging the use of the referral system
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES
BALANCE OF FAMILY LIFE AND CAREER FOR WOMEN DOCTORS
Summary by Haidz
1. Characteristics and outcomes for women physicians who work reduced hours
- No difference except that reduced-hours physicians were more likely to be generalists, more likely to spend
more time in patient care than in research.
- Whether reduced-hours or full-time, women who worked their preferred number of hours reported better
job role quality and schedule fit, lower burnout , better marital role quality and higher life satisfaction.
2.
-
Dual-doctor marriages: the British experience
respondents rated their marriages high
major advantage:mutual understanding of all aspects of being a doctor
Major disadvantages:
-
o one partner's career must take precedence
o lack of time for other pursuits
sources of conflict
o
o
o
in laws
time husband was away from home
bringing work home
3. When doctors marry doctors: a survey exploring the professional and family lives of young
physicians
- more female physicians than male physicians were in dual-doctor marriages
- physicians in dual-doctor marriages (especially females) earned less money, less often felt that their career
took precedence over their spouse's career, and played a major role in child-rearing
- physicians in dual-doctor marriages achieved their goals for their children and their career as frequently as
other physicians
- major benefits of dual doctor marriages
o more frequent enjoyment from shared work interests
o higher family incomes
4. Family responsibilities and domestic activities of US women physicians
- women physicians spend less time on child care and substantially less time on housework than US women
- women physicians who do more domestic work (eg. Women who are married, widowed, have more
children, have lower personal incomes or have more highly-educated and higher-earning spouses) work
fewer hours outside the home and are on call less often
5. Pediatric generalists and subspecialists: determinants of career satisfaction
- there is a greater proportion of females in general and subspecialty pediatrics than in general internal
medicine and subspecialty internal medicine.
- general pediatricians have lower income, but higher levels of job, career and specialty satisfaction than
general internists
- pediatric specialists were more likely to work in academically-affiliated institutions, have lower incomes
and have less time for complete history and PE than subspecialty internists.
- general pediatricians worked the fewest hours (50/week), spent more time in the office instead of the
hospital, saw the least number of patients with complex medical/psychosocia l problems, and were the
least likely to suffer from burnout or job stress.
- pediatric specialists worked longer hours (59/week), saw more patients with complex problems, and were
more likely to suffer from burnout and job stress.
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES
6. The work lives of women physicians: results from the physician work life study
- female physicians were more likely to report satisfaction with their specialty and with patient and
colleague relationships
- female physicians saw the same number of patients, but a greater proportion of females and a greater
proportion of patients with complex psychosocial problems
- females needed more time to provide quality care for new patients or consultations
- females reported having less work control (eg. Volume of patient load, referrals, schedules) and earned less
- females were more likely to suffer from burnout, but the odds were lessened for women who had support
from colleagues, spouses and significant others.
AN EVIDENCE-BASED UPDATE ON NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
Summary by Tarobs
This study aims to address the following questions:
7. Are there clinically important differences in the efficacy and safety between the different NSAIDs?
8. If there are differences, which are the ones that are more effective and associated with fewer adverse
effects?
9. Which are the effective therapeutic approaches that could reduce the adverse effects of NSAIDs?
Oxford League Table
 constructed for analgesics in acute pain by giving each analgesic a number to grade its efficacy.
 NNT to provide at least 50% relief in over a 4-6 hour treatment period
 From this table, we can see that traditional NSAIDs (tNSAIDs) do extremely well in this single-dose
comparison and that they do differ in efficacy
 tNSAIDs such as ibuprofen, diclofenac and naproxen, and COX-2 inhibitors such as rofecoxib, valecoxib, and
lumiracoxib, top the league table.
 Limitations:
◦ A drug that is well suited to one pain setting may have a different effect or no effect at all in another
(because data are pooled from different studies which may involve pain of different regions of the body,
like tooth ache, headache, etc.)
◦ Small size of some trials used to combine the data.
Comparison of the Efficacy of NSAIDs with Other Analgesics
 Older clinical data suggested that acetaminophen is as effective as NSAIDs in many pain conditions.
◦ However, in the Oxford League Table, overall, NSAIDs are clearly more efficacious than acetaminophen
◦ Other studies show patient preference for NSAIDs
◦ Lee and colleagues: NSAIDs are statistically superior to acetaminophen in reducing osteoarthritis pain
◦ Zhang and colleagues: while acetaminophen was effective in relieving arthritis pain, NSAIDs were
significantly better in terms of pain relief, patient preference and clinical response
 However, acetaminophen has a safer profile than NSAIDs
◦ Acetaminophen's less risk for adverse gastrointestinal events than that of NSAIDs results in a benefitto-risk ratio that favored acetaminophen in certain pain conditions.
 Few analgesics, if any, are better than NSAIDs for acute pain
Effects of Formulation on the Analgesic Activity of NSAIDs
 The formulation of certain NSAIDs can have a profound effect on its efficacy.
◦ Examples:
▪ Ibuprofen lysin 400 mg produces faster onset and higher peak analgesia than a conventional tablet
of ibuprofen acid 400 mg in dental pain.
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES
▪



Solubilized liquigel ibuprofen 400 mg had more rapid onset than acetaminophen 1000 mg and had
a longer duration of action than either acetaminophen 1000 mg or ketoprofen 25 mg.
Generally, NSAIDs vary in time of onset and duration of analgesic effect.
◦ Longer half-life, the slower the onset of effect
◦ Higher dose has a faster onset, higher peak effect and longer duration
It is advantageous to start with a high dose of a short-life drug (like ibuprofen) and then adjust the dose
downward.
For management of chronic pain, administration of NSAIDs with long half-lives (like naproxen and the COX2i's) has clear advantages in allowing for once or twice-daily dosing.
Adverse Effects of NSAIDs
 NSAIDs are associated with a number of adverse effects.
◦ Alteraion in renal function
◦ Effects on blood pressure
◦ Hepatic injury
◦ Platelet inhibition
◦ Gastrointestinal (for tNSAIDs) and cardiovascular (COX-2i) adverse effects
Gastrointestinal Risk of tNSAIDs
 COX-1 is expressed in most tissues of the body and largely governs the homeostatic production of
arachidonic acid metabolites necessary to maintain physiologic integrity, including gastric cytoprotection
via PGI2 (prostacyclin)
 COX-2 is induced in response to inflammatory stimuli and is responsible for the enhanced production of
eicosanoid mediators for inflammation and pain.
 The ulcerogenic properties of tNSAIDs to a large extent relate to their capacity to inhibit COX-1 in the
gastric mucosa.
Relative Risks for Gastrointestinal Toxicity of the Different tNSAIDs
 In general, ibuprofen has the lowest risk among tNSAIDs, while diclofenac and naproxen have intermediate
risks, and piroxicam and ketorolac carry the greatest risk.
Therapeutic Approaches to Reduce Gastrointestinal Toxicity of tNSAIDs
 Gastrointestinal complications can be avoided by the use of non-tNSAID analgesics when possible (like
acetaminophen).
 Use the lowest effective dose of a tNSAID
 Anti-ulcer co-therapy
 COX-2 inhibitors can be used as an alternative analgesics
Use of Anti-Ulcer Co-Therapy
 Drugs that are used: PPI, prostaglandins, histamin H2-receptor blockers, antacids
 PPIs promote ulcer healing in patients with tNSAID-related gastric ulcers
◦ Prophylactic use of PPIs is considered appropriate by major treatment guidelines
◦ But, the protective effects of PPIs are confined solely to the gastric mucosa, where it specifically
suppresses acid secretion
 Efficacy of misoprostol is also supported
◦ However, due to its nonspecific MoA at the studied dose (800mcg/day), a significant proportion of
patients reported treatment-related adverse events (diarrhea) and discontinued the medication.
 To date, there is no definitive evidence that the concomitant administration of histamine H2-blockers or
antacids will either prevent the occurrence of GI effects or allow continuation of tNSAIDs when such
adverse reactions occur.
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES

Use of H2-blockers at standard doses appear to have little or no effect on the gastric lesions, as the benefit
seen in RCTs do not translate well in clinical use.
Use of COX-2i
 Use of COX-2i have reduced GI toxicity as compared to tNSAIDs
◦ by VIGOR, CLASS, TARGET, and SUCCESS-I trial
◦ The reduction of toxicity is equivalent of tNSAIDs+PPI therapy
◦ COX-2i improve the tolerability of anti-inflammatory therapy compared to tNSAIDs+PPI
Risk Factors for tNSAID-Induced GI Adverse Events
 Age >65 years old
 Hx of previous PUD
 Corticosteroid intake
 Anticoagulant usage
 Use of aspirin
 Long-term use
◦ In the over-the-counter formulation, tNSAID use is generally advised not to exceed 3 days for fever and
10 days for analgesia
◦ Short-term use (5-10 days) of over-the-counter tNSAIDs has been shown in several studies to be
extremely safe and well-tolerated.
Cardiovascular Risks of NSAIDs
 The problem of inhibiting only the COX-2 is that metabolism imbalances may occur, resulting in an
overproduction of harmful byproducts that may damage the arterial wall and induce arterial blood clotting.
◦ When COX-2 is inhibited, less PGI2 (less vasodilatory and antiaggregatory effects) and more
leukotriene B4 and thromboxane A2 (opposite of PGI2).
◦ Rofecoxib has 80x inhibitory effects to COX-2 than COX-1, while celecoxib has only 9x.
▪ Greater shift in the PGI2/TXA2 balance of rofecoxib
▪ > cardiovascular adverse events.
◦ Evidence from several large scale RCTs and epidemiologic studies of structurally distinct COX-2i has
indicated that such compounds elevate the risk of MI and stroke
▪ Reason for withdrawal of rofecoxib and valdecoxib in the worldwide market
▪ The risk of COX-2i differs to some degree between individuals, across agents, is dose-related, and
varies with the duration of therapy.
◦ Some studies suggested that celecoxib and lumiracoxib may have a slightly better safety profile than
the other COX-2i
▪ Because the benefits seem to outweigh potential cardiovascular risks, these have remained in the
market
▪ SUCCESS-I trial found no increased cardiovascular risks of celecoxib compared to either diclofenac
and naproxen
▪ TARGET trial – no inc. risk for lumiracoxib
◦ No placebo-controlled RCTs to show that this is a class effect for ALL NSAIDs
▪ Some observational studies suggest that some tNSAIDs may increase MI (ex. Diclofenac), but still
inconclusive.
◦ Overall, COX-2i as a group have a small bu absolute risk of cardiovascular adverse effects.
▪ COX-2i are contraindicated in patients with a history of ischemic heart disease, stroke, or
congestive heart failure and in patients who have undergone CABG (bypass)
BLOCK 8 CLASS 2011 AMBU ARTICLES SUMMARIES
▪
One should not forget that an inadequate long-term control of cardiovascular risk factors such as
HPN, dyslipidemia, DM, smoking and weight excess is more deleterious than COX-2i use.
Drug Interaction of NSAIDs
 Aspirin and NSAIDs – key concern
◦ low dose aspirin reduces its cardioprotective benefits and increase GI risk when used together with
certain NSAIDs (such as ibuprofen).
◦ Ibuprofen prevents the irreversible platelet inhibition induced by aspirin
 In contrast, sustained exposure to diclofenac, rofecoxib or acetaminophen did not influence the effects of
aspirin on platelet function.
 Another study on the effect of ibuprofen in aspirin-treated health adult volunteers showed no clinically
meaningful loss of cardioprotection – adds to confusion.
 The gastroprotective benefits of COX-2i is partially or, in some patients, totally lost if aspirin is used for
cardiovascular prophylaxis
 Recent evidence suggests that GI benefits may also be lost in patients who receive warfarin together with
NSAIDs
 Concurrent use of NSAIDs and corticosteroid may also increase GI risk
Alternative Analgesics
 Acetaminophen should be used as the first-line alternative in view of its efficacy and safety
 Opioids and tramadol may also be used when NSAIDs are unsuitable.
 Combining analgesics (ex. Acetaminophen 1g + codeine 60 mg) results in increase in efficacy than when
each used alone.
 Nitric oxide releasing NSAIDs are a new class of anti-inflammatory agents under approval
◦ Studies suggest that NO-NSAIDs inhibit COX-1 and COX-2 with less adverse effects on GI tract, as well as
reduce systemic blood presure
 There is lack of evidence for any difference in analgesic efficacy of NSAIDs given by different routes
◦ IM and rectal routes were more likely to have specific local adverse effects
◦ IV route = increase risk for postoperative bleeding.
◦ Parenteral route has = risk in GI as oral route
◦ Only exception – topical
◦ ORAL ROUTE SHOULD BE USED WHENEVER POSSIBLE
Current recommendations for the Use of NSAIDs
 When COX-2i and tNSAIDs are to be used for the management of individual patients, they should be
prescribed with the LOWEST EFFECTIVE DOSE and for the SHORTEST DURATION
 They should NOT be prescribed to HIGH RISK PATIENTS:
◦ Hx of ischemic heart disease, strok, congestive heart failure, pt recently undergone CABG
 All prescription-strength NSAIDs will now display “black box” label warnings for the potential risk of
cardiovascular and GI adverse effects
 Tx with tNSAIDs alone in patients aged <65 years old with no GI risk factors is considered appropriate, and
use of PPI or COX-2i is considered unnecessary
 Px with previous GI event and in those w/ concomitant aspirin, steroids, or warfarin use should receive
either tNSAID+PPI, or a COX-2i
 Use of COX-2i+PPI is appropriate only in px with very high risk (those with previous GI event who are
taking aspirin, and those who are taking aspirin+steroids or aspirin+warfarin)
Important Figures Attached Separately in the e-mail:
1. Oxford League Table
2. Algorithm for NSAID Pain Management