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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
How do I get started?
Review the current literature: Pubmed/Medline Cochrane database Embase Google scholar Textbooks
How do I get started?
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?
How do I get started?
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
How do I get started?
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
How do I get started?
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___________________________________________________
How do I get started?
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
How do I get started?
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
How do I get started?
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).
How do I get started?
Step 4:
Build a relationship with a research mentor
How do I get started?
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?
How do I get started?
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
How do I get started?
Step 7:
Research career pathways?
• Clinician-Scientist
• Academic Emergency Medicine
• Scientist-Clinician