JILID 7 BIL 3 DECEMBER 2005
JILID 7 BIL 3 DECEMBER 2005
Newsletter of the Malaysian Society of Anaesthesiologists and the College of Anaesthesiologists,
Academy of Medicine of Malaysia
Editor: Dr Rafidah Atan
Academy of Medicine of Malaysia
19 Jalan Folly Barat, 50480 Kuala Lumpur, Malaysia
Tel: 603-2093 0100, 2093 0200 Fax: 603-2093 0900
Editor: Dr Rafidah Atan
The Passing of Dato' Dr K Inbasegaran
On 8 November, Dato' Dr K Inbasegaran passed away after a three and half year battle with cancer of the prostate. With his death, Malaysia has lost one of its most illustrious clinicians whose contribution to anaesthesia was unparalleled. Dato' Inba was the p resident of Malaysian Society of Anaesthesiologists (MSA) for two terms (1995 1997 and 2001 2003) and the president of the College of Anaesthesiologists (1997 1999). He was also the head of the anaesthetic department, Hospital Kuala Lumpur and advisor to the Ministry of Health from 1992 to 2003. His contribution to MSA was immense. Under his stewardship for over a decade, he had organised a series of highly successful regional conferences and thus provided MSA with a strong financial foundation. The Society's purchase of a RM 1.8 million shop lot ten days after his death was a poignant reminder of the toils and labour of Dato' Inba and his team in the early days of MSA.
Dato' Inba was instrumental in introducing the guidelines on 'Minimum Monitoring Standards During Anaesthesia'. By setting mandatory requirements, the anaesthetic professional bodies provided the much needed impetus for the government and private hospitals to upgrade their anaesthetic monitoring in the operating theatres. To this day, the guideline remains a landmark document and has continued to influence the way we practise anaesthesia in Malaysia. Dato' Inba was a champion in quality improvement and clinical governance. Under his guidance, the 'Peri-Operative Mortality Review' (POMR) became one of the most successful quality improvement activities of the Ministry of Health. His achievement in POMR was remarkable as he was able to gain the confidence and support of the surgeons in pursuing what was essentially a surgical audit exercise.
On a personal note, I have lost my mentor and a good friend. Our friendship spanned over twenty years and it started when I worked with him as a registrar. In the ensuing years, he had provided me guidance and advice especially in matters pertaining to the Ministry of Health. During his last two years working in HKL, he continued to actively participate in the department's CME activities. He continued to read vastly and would send us articles from journals on a regular basis in spite of his illness. I particularly cherish the many afternoon teas that we spent together at the hospital cafeteria reminiscing the good old days and musing on the little things that enriched one's life.
As a tribute to Dato' Inba and in recognition of his contributions to anaesthesia and MSA in particular, the Executive Committee has recommended that the MSA Award for the best free paper presentation be named the K Inbasegaran Award.
Investment in Property
My colleagues and I in the Executive Committee would like to thank members especially those who were present at the Extraordinary General Meeting on 30 November for their approval of the purchase of the shop lot at 16, Jalan 21/35, Damansara Utama, Petaling Jaya. The decision to invest in a shop lot was made five years ago when Dato' Inba was the Acting President of MSA. The next president, Prof Y K Chan, saw it through the AGM and the current Executive Committee took the final step to purchase the shop lot after an exhaustive search which lasted more than eight months. The Executive Committee is convinced that we have made a sound decision which will not only help the Society to grow financially and but also generate regular income to support the increasing continuing professional development activities. The purchase of the shop lot in Damansara Utama was a major event and will be remembered as an important milestone in the history of MSA.
16th Asean Congress of Anaesthesiologists, 2009 in Malaysia!
There is yet another piece of good news. During the last board meeting of the Confederation of Asean Societies of Anaesthesiologists (CASA) at Hanoi, we were successful in our bid to host the 16t h Asean Congress of Anaesthesiologists in 2009. Members will recall that the last ACA was hosted in 1999 in Kuala Lumpur and except for the 11th Asian Australasian Congress of Anaesthesiologists in 2002, we have not held any major regional meetings since. The hosting of the 16th ACA is a timely event and is an opportunity for us to showcase our organisational skills and hospitality. The current Executive Committee, as well as the subsequent committees, will start early preparation to ensure that the 16th ACA will be a resounding success.
Adoption of ICT to Reduce Expenditure and Enhance E-learning
The Executive Committee at its last meeting decided that notices for CME activities will be hosted at the Society's website and e-mailed to members. The Society will no longer send out hard copies of announcement for CME activities. It will however, continue to do so for important events e.g. call letter for AGM and delivery of the Berita. The cost of sending mails to more than five hundred members has increased considerably over the years (about RM 500 per announcement) and with more CME activities being planned in the pipeline, the Executive Committee has decided that this would help in reducing cost. I urge members to ensure that e-mail addresses registered at the MOPS site (www.msa-mops.org.my) are current as they will be used for bulk e-mailing.
We have enhanced the content of the MSA website (www.msa.net.my) by having a 'members only' section. Under the section, members will be able to view video recording of the plenary lectures given by renowned intensivists during the 3rd National Intensive Care Conference at the Sunway Pyramid Convention Centre in September this year. This privilege is only awarded to members and to access the section, the same user name and password for MOPS should be used. Many more video recordings are being planned for the section and we hope to make e-learning a prominent feature of our website.
Accreditation of Hospitals by ANZCA
Representatives of the Australian and New Zealand College of Anaesthetists visited five hospitals in Malaysia recognised for their fellowship training programme from 1317 October. In spite of some areas of deficiencies identified in the respective hospitals, the surveyors recommended that the five hospitals i.e. Hospital UKM, UMMC, HKL, IJN and Hospital P. Pinang continue to be recognised for a varying period of two to four years. Accreditation of our local hospitals by ANZCA is recognition of the high standards of anaesthetic practice in Malaysia and is something for all to be proud of. Through the ANZCA programme, we continue to maintain a strong link with our Australian anaesthetic colleagues. The ANZCA fellowship programme serves as a useful benchmark for our local Master's programme and a spring board for subspecialty training. We congratulate the five hospitals for having achieved this prestigious status and we hope many more hospitals will join this rank in the near future!
As the year 2005 draws to an end and we usher in a new year, I wish you happiness and a fulfilling year.
Ng S H
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I am shocked by the announcement by the Malaysian Society of Anaesthesiologists (MSA) in the "Berita Anestesiologi" (August 2005) to stop the subscription to the UMMC online library facility. Personally, I would be utterly disgusted and disappointed if the Society goes ahead with the plan to "do away with it". I plead the Society; please do not stop the facility!
Ever since I received my login username and password for accessing the Maintenance of Professional Standards (MOPS) earlier this year, I have been a regular user of the online library. It is heaven-sent. It has been my only access to the wealth of knowledge and literatures in the worldwide web. Since the demise of the Telehealth system, access to Medline, Ovid or other databases is difficult to come by for those working and staying outside the Klang Valley. We do not have the privilege of being near to two of the largest universities in Malaysia where access to the world of wisdom is unlimited. The online library is a portal for me to unlock the treasure trove of literatures and journals for research (which I enjoy doing!) and professional update.
I champion the Society's commendable effort to make the wealth of knowledge accessible to all MSA members and encourage continuous professional development in medicine, in general and anaesthesiology, in particular. Although the Society has to "pay exorbitant sum annually", consider it money well-spent because wisdom is priceless!
The reasons for poor usage of the online library are that many MSA members are either not aware of such access, or they just do not bother. Lack of publicity is another probable explanation. However, if it were to be widely publicised, the limited access would be overwhelmed and inundated. God forbid there might be those who would be irresponsibly or forgetfully logged on continuously to the site that others be denied access. It is believably possible in this day and age of unlimited broadband connection.
I would like to congratulate the Editor for bringing new ideas to the Berita Anestesiologi, such as the contest. "Ask what you can do for the Society" was Prof Chan Yoo Kuen's call for the New Year resolution earlier in January 2005. Here I would like to do my part for the Society by making a few suggestions for the MSA bulletin. Articles could include notes on didactic topics like physiology, pharmacology, etc, or journal review/summary on anaesthetic and intensive care management updates, for the benefit of postgraduate trainees and the rest of us! MSA members should be encouraged to participate and make contributions to the newsletter like case reports on management of rare/unusual cases, practical tips, poems, quotes or even cartoons to liven up our day! I am sure there are individuals in our midst who would love to participate and contribute but do not know how. This could be used as a channel to flaunt your hidden talents. I hope with the addition of relevant and interesting articles, the Berita Anestesiologi would be a sought after newsletter and this will encourage membership from the trainees.
I believe all anaesthesiologists should become MSA members and all doctors in Malaysia (15300 serving in the country up to end of last year) should become MMA members to denote unity and solidarity in the fraternity. The usual excuses of expensive membership fees and I-am-benefiting-anyway attitude should not arise as these are lame excuses. All professionals should join and support their fraternity to voice and protect their own rights. Examples of such associations are the NUTP for teachers and the MNA/MNU for nurses. There will be a fraction saying that doctors should not be forced to join an association against their own free will. I too believe in the freedom of choice, but we have to see the big picture. Another means is to get other doctors' association to be affiliated to MMA. My views may be far-fetched but just imagine the impact and what we can achieve if all of us doctors unite under one umbrella body, the MMA. To protect our rights and to ensure our voices are heeded, this is the path that we must all take.
Dr Norezalee Ahmad
Department of Anaesthesiology & Intensive Care,
Hospital Sultanah Aminah, Johor Bahru, Johor
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by Dr Norezalee Ahmad
Xin-chao (hello) colleagues,
Vietnam has successfully hosted the 14th ASEAN Congress of Anaesthesiologists in Hanoi from the 23 to 25 November 2005. Despite concerns regarding the Avian influenza, the Congress was well attended by delegates and speakers from all over the world including the very famous and distinguished Ronald Miller. Our Vietnamese colleagues did a great job considering the fact that it was the first ever international medical conference held in Hanoi. They deserve to be applauded for their tireless effort, indefatigable spirit and warm hospitality. Bravo!
"Narrowing the Gaps in Anaesthesia" was aptly chosen as the theme. Huge gaps in quality of care currently exist between the developed and developing countries in the world, and even within countries in the ASEAN region itself. The schedule was filled with a wide range of topics, delivered by regional and international speakers alike, in an effort to bridge the gaps of knowledge and experience in anaesthesia and to bring the ASEAN communities closer together.
There are currently many exciting innovations and new advances around the corner in the field of anaesthesia and intensive care. In transfusion medicine, in a lecture by the renowned Ronald D Miller, is the exciting prospect of the use of recombinant activated factor VII (rVIIa) as "rescue therapy" for transfusion-related coagulopathy. Recent advances in obstetric anaesthesia, in a lecture given by Professor Stephen Gatt, highlighted the renaissance of spinal anaesthesia with intrathecal opioids for postoperative pain relief in caesarean sections, the renewed interest on intravenous PCA remifentanil as an alternative pain relief in labour and the question of vasopressor choice to treat spinal related hypotension. The controversy of crystalloid versus colloid for fluid resuscitation was excellently explained by Prof Brown. The SAFE (Saline versus Albumin Fluid Evaluation) study published in 2004 was heralded as a landmark study that addressed the question of safety of albumin use in critically ill patients. With regard to the use of neuromuscular blocking agents (Prof Duvalstein), the search for an alternative agent to suxamethonium may have ended with the discovery of cyclodextrines which can antagonize very rapidly the effects of rocuronium and possibly other nondepolarising muscle relaxants as well. Skeptics, however, may choose to believe suxamethonium is here to stay for many years to come. Prof Dohlmans lecture on peripheral nerve blocks was also noteworthy in advocating the use of peripheral nerve stimulator for safety and the use of light sedation during the procedure to enhance patient comfort. Techniques of peripheral nerve blocks were also explicitly described and tips to ensure success included.
In the intensive care section, it appears that indications for the use of muscle relaxants should nowadays be limited to severe cases of acute respiratory distress syndrome, intracranial hypertension and spasms in tetanus and that when all other means are ineffective. The update on septic shock (Prof Gropper) to me was mainly a recap of the recent "Surviving Sepsis Campaign", highlighting on early goaldirected resuscitation, low dose steroids, tight glucose control and the use of recombinant human activated protein C in the sickest patients.
Educational programs aside, the Hanoi experience was unforgettable in many other ways. Arriving at Noibai International Airport, I was pleasantly surprised by the crisp cool autumn breeze. The journey from the airport to the hotel was hair-raising to say the least. The traffic was in havoc as though no rules applied. The constant honking of Vietnamese drivers and motorcyclists would certainly drive any Malaysian driver nuts. It appears that the continuous honking was more of a way to announce ones presence rather than an expression of anger, as would be their context of use in Malaysia. I was surprised to be told that the accident rate in the city centre in Hanoi is very low, probably due to the fact that the motorcyclists ride very slowly. In fact, as a whole, the pace in Hanoi is indeed rather slow (Dr Ng Siew Hian can certainly profess to this!). Even crossing the road was a new experience. The journey from my hotel to the venue involved crossing the road five times, which meant putting my life on the line five times! The trick in crossing in Hanoi is not to hesitate. J-walking is the name of the game.
Hanoi is a shopping haven for some especially the gals. Hang Gai Road seems to be the favourite shopping destination for tourists. I have to confess to some shopping myself. Where else can you get a real reproduction in oil painting of "The Sunflower" by van Gogh for RM160? The Vietnamese traditional dress, the "ao dai" is available everywhere for less than RM50. One can even tailor-made an "ao dai" within 24 hours. Aesthetically, the ao dai is certainly a sweet and charming dress.
The social events arranged were entertaining and rather amusing. The opening ceremony was dominated by endless speeches from almost every VIP. The food, thankfully, was excellent. The closing ceremony was held at the West Lake Water Park in the suburb of Hanoi. Although said to be a popular tourist spot, it was too dark to appreciate the scenery. Muslim delegates had the worse deal that night as the 'halal' food was ordinary to say the least. By the by, I also never knew that it was traditional for delegates from each ASEAN country to perform during the ASEAN Congress Night. The Malaysian delegates had to put together a fashion parade impromptu. The stars of the parade were our couple anaesthetists (Dr Azim & Dr Rafidah) donning the traditional "baju melayu and songkok" and "baju kebarung", respectively. Yours truly didn't do too badly himself. Luckily, I brought my "batik" shirt! The highlight of my night was having my photograph taken with Prof Ronald Miller.
The only major disappointment with the whole trip was that I could not join the trip to Halong Bay, a beautiful UNESCO world heritage site. This may be an excuse for me to return to Vietnam someday.
Finally, I was glad I decided to come to Hanoi despite the so-called health risks. Otherwise, I would not have met Prof Roger Eltringham, the Vice President of WFSA, who works at Gloucestershire Royal Hospital where I did my surgical housemanship in 1994. In all, the ASEAN Congress is truly a venue to renew acquaintances, meet new ones and narrow the gaps.
Chao (good bye).
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A team from the Australian New Zealand College of Anaesthetists visited five hospitals in our country to revalidate their suitability to continue to provide training for the ANZCA fellowship. The visitors were Dr Wally Thompson, Dr Kate Leslie, Dr Diana Khursandi and Dr Leona Wilson. They visited Hospital Kuala Lumpur, Hospital Universiti Kebangsaan, Hospital Pulau Pinang, Institut Jantung Negara and University Malaya Medical Centre from the 13 to 17 October, 2005.
The College of Anaesthesiologists hosted a dinner in the Sri Thai Restaurant on the 13 October for these visitors. This was attended by the Council of the College together with the local ANZCA regional committee. There was exchange of ideas about training and ways to improve the delivery of anaesthetic care. As a token of appreciation to the visitors for their invaluable advice during the visit, the College presented ANZCA with a volume of the History of Medicine that was just released by the Academy of Medicine.
Dr Diana Khursandi, in addition, stayed back to give a talk during the MSA CME meeting held at Hospital Kuala Lumpur, which was very well received.
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by C Y Lee
Associate Professor and Consultant Anaesthesiologist,
Department of Anaesthesiology & Intensive Care, Faculty of Medicine, Universiti Kebangsaan Malaysia
Kuala Lumpur, Malaysia
The first book, Manual of Anaesthesia for Medical Officers, was prepared some nine years earlier in 1996. Over the years, new developments, drugs and anaesthetic techniques have modified our present day anaesthetic practice, and it has become imperative that the book should be revised and updated. But what started off as merely "rearranging and updating facts in the book" became a major undertaking of sorts, because there is just no end to the details that can and should be included here.
From the feedback received, the appeal of the first book was largely attributable to its simplicity and practicality. It was raw and somewhat flawed, as seen through the eyes of a young specialist fresh from exams. While retaining the practical aspects in this book, more facts are included because it is felt that with more background knowledge available, it would help the reader to understand not just what to do and how to do it, but also the reasons behind the steps taken in our anaesthetic management. Anaesthesiologists are certainly not technicians but perioperative physicians and essential members of the medical team in optimal patient care .
New chapters have been added but the basic structure of the book remains divided into 5 sections:
The book is now available in the major bookstores in Malaysia, including MPH, UM Coop Medical, Syarikat Kamal, and Unipress. The list price for the book is RM79.80. There are dealers for McGraw-Hill outside the Klang Valley who carry this title in their bookstores. The publisher is also promoting this book overseas ASEAN countries, Australia, UK and US. I hope that this book will be informative and beneficial to all.
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16 October 2005
Hospital Kuala Lumpur, Kuala Lumpur
by Dr Ng L Y & Dr Thohiroh Abd Razak
In conjunction with the National Anaesthesia Day, the Department of Anaesthesia and Intensive Care, HKL conducted an exhibition held at the Foyer of Hospital Kuala Lumpur.
"Winds Of Change" was chosen as the main theme, which described the development of anaesthesia from the past till the present. The exhibition also had a second theme which was "Your Safety Is Our Priority" referring to our dedication at ensuring patient safety in anaesthesia.
Despite having limited time to prepare for the exhibition, the team managed to come up with an interesting and informative display. A few days before the exhibition, three banners were hung around strategic locations in HKL to inform the public regarding the event. An announcement was also made through the HKL website and posters were hung along main corridors.
The exhibition consisted mainly of a display of photos and explanation notes. However, the team also re-enacted some real life scenarios pertaining to both anaesthesia and intensive care situations. These ingenious plays involved our medical assistants (MAs), doctors and two mannequins.
One scenario demonstrated mask holding techniques followed by anaesthesia of the mannequin. This did a good job at catching the attention of members of the public! The other scenario, also using a mannequin, involved the intensive care setting.
The set-up was geared towards educating the public regarding the importance of close monitoring of patients and the use of life-support apparatus in the intensive care unit.
A section of the display was dedicated to the history of anaesthesia. Intubation apparatus and ventilators of the past and present were included in this aspect of the exhibition.
An opportuninty was also taken to provide information regarding the services off e red by our department including the wide area of coverage involved. In general, the areas depicted included the General OT, the Urology OT, the Neuro surgical OT, the Paediatric OT, the Maternity OT, the Accident and Emergency OT, the General ICU, the Neuro surgical ICU, the Urology ICU, the Paediatric ICU, the remote anaesthesia locations of radiotherapy, ECT, angiogram and burns and the Anaesthesia Clinic.
As a whole the exhibition received very encouraging responses from the members of the staff and public. Most were made aware of the important role of the Department of Anaesthesia and Intensive Care in ensuring patient's safety in the preoperative, intraoperative and postoperative period as well as the importance of intensive care.
The pro-active and committed team members certainly made the exhibition a resounding success. Thank you!
Hospital Melaka, Melaka
by Datin Dr V Sivasakthi
We had a moderate scale celebration in commemoration of Hari Anaestesia 2005 in Hospital Melaka. We displayed posters in the foyer of Hospital Melaka from October 14 to October 21. These posters displayed the scope of the anaesthetic services provided by the Department to the public.
We were happy to discover that the visitors had a number of questions regarding our services. There was a lot of interest generated on whether we could teach CPR to the public on a regular schedule. In summary, we felt that we had achieved our objective of providing information to the public with regards to our services.
Hospital Selayang, Selangor
by Dr Hanapi Mohd Tahir
The National Anaesthesia Day was celebrated in Hospital Selayang from 17 to 18 October 2005. An exhibition was held at the foyer of the Specialist's Clinic to ensure a good audience. In addition to the posters and video presentations of various anaesthetic activities, a mock operation theatre was also displayed. A quiz about patient-related issues in anaesthesia was also held daily. Judging from the overwhelming response from the public, the latter event must have been the most successful section of the exhibition. Even if the participants were only interested in the prize, they would have learnt something about anaesthesia and their rights as patients by going through all the flyers, posters and video for answers!
The encouraging response from the public was also apparent from the many questions directed to the medical staff who were manning the exhibition. Some were surprised to realise that such sophisticated technologies and highly trained professional staff exist in a public hospital! We will surely hold this event again next year.
Hospital University Kebangsaan Malaysia, Kuala Lumpur
by Assoc Prof Norsidah Abdul Manap
Hospital Universiti Kebangsaan Malaysia also joined in the celebration of Anaesthesia Day 2005. The Department of Anaesthesiology and Intensive Care put up a small exhibition in the main foyer from 17 to 20 October 2005. The posters and pictures depicted various anaesthetic techniques and services, fro m general anaesthesia, regional anaesthesia, intensive care management to labour pain management.
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by Dr Suresh Anselm Rao
The aim of the examination for the European Diploma in Intensive Care Medicine is to promote quality standards in education and training for Intensive Care Medicine in Europe and elsewhere.
The EDIC examination consists of two parts. The Part I examination which consists of 100 multiple choice questions is held during the yearly Annual Scientific Meeting of the European Society of Intensive Care Medicine in Europe (ESICM). Questions are drawn from the entire spectrum of intensive care medicine, including basic medical sciences, pathophysiology of relevant diseases, interpretation of diagnostic data, therapeutics / toxicology, ethics and all aspects of clinical practice. The Part II examination is a clinical/oral examination and is taken at the end of specialist training in intensive care medicine. This examination is usually held at a major hospital in Europe.
The Part II of the above examination was held for the first time in Malaysia on 10 September 2005 at Selayang Hospital in conjunction with the National Conference on Intensive Care, which was held at the Sunway Lagoon Convention Centre. This was the first time the examination was held in a country out of Europe.
The examination was jointly organised by the Intensive Care Section of the Malaysian Society of Anaesthesiologists and the Anaesthetic Subspecialisation Committee of the Ministry of Health. The aim of having the examination in Malaysia is to encourage anesthesiologists to specialise and gain certification in the field of Intensive Care Medicine and also to save the cost and expenditure of taking the examination by enabling candidates to sit for the exam locally. However, one should note that only candidates who have undergone at least two years of training at accredited ICUs locally or overseas are eligible to sit for the examination.
The Department of Anaesthesia and Intensive Care of Selayang Hospital coordinated the first Part II EDIC examination in Malaysia successfully. The two examiners were Dr Julian Bion, the President of the ESICM and Professor Gracie Ong from University Malaya Medical Centre. There was one candidate for the examination and she was successful in getting through the examination.
With the success in conducting the above examination in Malaysia and the favourable feedback received from the Examination Committee of the EDIC, Malaysia will continue to be hosting the Part II examination in the next few years to come. In fact, barring any last minute changes, the Part II clinical examination in 2006 has been fixed on 23 August and the venue will be the General ICU of Hospital Kuala Lumpur.
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|THEME:||Towards A New Horizon in Anaesthesia of the 21st Century|
|DATE:||17 19 March 2006|
|VENUE:||Malacca International Trade Centre (MITC) Melaka, Malaysia|
Message from Organising Chairperson
It is that time of the year again when anaesthesiologists across the nation lay down their laryngoscopes, put up their hair and get together for their annual meet. This year, the historical city of Malacca has been chosen to host this esteemed group as they gather to discuss topics of importance in anaesthesiology and yes, to gripe over the woes of work to each other.
As a prelude to the conference, a one-day comprehensive workshop addressing fundamental and advanced airway management principles will be held on 16 March 2006. This event is to be presided over by the illustrious Prof C Y Wang.
All work and no play certainly makes an anaesthesiologist extremely cranky as all of us can certainly attest to so a variety of social events have been set up for the participants of the conference.
The yearly awards for the Young Investigator's Award and the MSA Award will be presented during the course of this conference. To prove that ageism is obsolete, there is no age limit for hopeful entrants and all anaesthesiology trainee MOs are invited to present papers on any topic in Anaesthesiology and Intensive Care. If eternal glory in the field of anaesthesiology is not prize enough, cash prizes are also being given as an incentive.
Datin Dr V Sivasakthi
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by Dr Norezalee Ahmad
I have always wanted to become an anaesthetist ever since my undergraduate anaesthesiology posting during medical school years. I found it a very challenging medical field, intellectually and practically. Apart from escaping the dreary follow up clinics, it is a medical discipline where I can put knowledge and wisdom into practice, literally! Throughout almost a decade of experience in anaesthesiology, I have always tried to find new challenges every now and then to keep me motivated and get my "adrenaline rush". When I thought I have seen it all, I found a new challenge: off-pump coronary artery bypass surgery or aptly known as OPCAB.
Off-pump coronary bypass surgery is an old technique, performed first in St Petersburg in 1964, but was soon outshone by the development of cardiopulmonary bypass (CPB). Some centers have been performing OPCAB since 1980s. The development of off pump coronary bypass surgery started off with MIDCAB (minimally invasive coronary artery bypass) which consists of anastomosing the left internal mammary artery to the left anterior descending coronary artery through a small anterior left thoracotomy. This technique is now obsolete. Another technique, which involves a standard median sternotomy, gives access to all coronary vessels allowing multivessel grafting without CPB. The latter technique has enjoyed recent resurgence in interest and popularity worldwide with advances in sophisticated stabilising devices and exposure techniques to facilitate beating heart surgery and a growing awareness of the morbidity attributable to CPB.
A team comprised a Chief Cardiac Surgeon (Mr Shuichiro Takanashi), an anaesthetist (Dr Masayuki Nakagawa) and several company representatives from Japan visited Hospital Sultanah Aminah Johor Bahru for a workshop on OPCAB. I happened to be posted in cardiothoracic at that time. Although it was not the first time OPCAB was performed in HSAJB, it was my first! Up to that time, anaesthesia is "hours of boredom, moments of terror". With OPCAB, on the contrary, anaesthesia is "hours of terror, moments of peril". Initially I was petrified with this expectation.
The anaesthetic management during off-pump cardiac surgery is certainly an interesting challenge. This is one surgery where effective communication and team work between the anaesthetist and surgeon are crucial, as well as complete trust of one another. The interaction between the Mr Takanashi, (the cardiac surgeon) and Dr Nakagawa, (the anaesthetist) was fascinating. They were so in tune with each other. Instructions were given and carried out effectively as if they communicated through brain waves! In one incident, during the dreaded circumflex artery grafting, the patient was haemodynamically unstable with severe hypotension and even momentary cardiac standstill. If it were not for Mr Takanashi who was operating, the patient would have been converted to cardiopulmonary bypass. During the frenetic episode, however, Mr Takanashi was so cool, calm and collected, entrusting the haemodynamic management fully to the anaesthetist, that he continued to finish off the distal grafting and naively gave the heart a quick massage resulting in an immediate recovery. Now that all the vasopressors and inotropic agent has entered the circulation, we were faced with the reverse effects of tachycardia and hypertension requiring vasodilators and β blockade.
Indeed one of the central roles of anaesthetist in OPCAB surgery is the management of haemodynamic instability during heart enucleation especially during posterior and lateral wall grafting. An anaesthetist's knowledge of physiology and pharmacology is really put to the test and applied time and time again during the "hours of terror". One useful tip shared by Dr Nakagawa, on maintaining haemodynamic stability, was instilling vasopressor (either phenylephrine or noradrenaline) using a paediatric microdrip chamber (60 drops/ml) instead of intermittent boluses using vasopressor prepared in a syringe. In fact, in his practice he uses two of such paediatric microdrip chambers to maintain stable haemodynamics; one for vasopressor (he prefers noradrenaline for its a and mild β effects) and the other for glyceryl trinitrate. Undeniably, the use of vasopressor in a microdrip burette allowed the haemodynamics to be maintained in the straight and narrow range (SBP 80100 mmHg and PAP 2040 mmHg).
Advances in surgical techniques have presented us with endless possibilities. The developments involving cardiopulmonary bypass machine such as the mini-bypass system will certainly revolutionise coronary artery surgery. Furthermore, the advent of robotic surgery has given us another alternative- RAVE-CAB (robotic-assisted voice-activated endoscopic coronary artery bypass). I for one believe that OPCAB is the future of coronary artery bypass surgery. As anaesthetist the management of OPCAB is certainly an interesting challenge in which my knowledge of physiology and pharmacology learned during the Primary M. Med examination is really put to the test. This is where one could separate the men from the boys.
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Displayed is the ECG tracing of a 23 year-old lady who was scheduled for tonsillectomy.
This contest is opened to all medical officers who are MSA members. Please e-mail your answers together with your full name and address (work or home) to firstname.lastname@example.org. The closing date will be the 31 January 2006 . Snail mails can be sent to Academy of Medicine of Malaysia, 19 Jalan Folly Barat, 50480 Kuala Lumpur. The first correct answer will receive free registration to attend the coming ASM meeting in Malacca on 1719 March 2006. Winners will be notified by e-mail.
Results of the Previous Contest
We would like to congratulate Dr Ng Lip Yang from Hospital Kuala Lumpur who was the winner of the previous contest. He received free registration to attend the National Congress on Intensive Care that was held earlier in September this year.
The answers (and some added information) for the previous contest were:
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The Malaysian Society of Anaesthesiologists would like to congratulate the following candidates (in alphabetical order) for passing the recent masters examinations. Well done folks!!
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by Prof Chan Yoo Kuen
It is with much sadness that we announce the passing away of Dato' Dr Inbasegaran, a much beloved Malaysian anaesthesiologist who died prematurely after a long illness. Dato' Dr Inbasegaran was born on 26 May 1947 and was a top all round student in his younger days. He did medicine in the University of Malaya where he graduated as a doctor in 1972. He was appointed as a medical officer and subsequently registrar in the Department of Anaesthesia in Penang where he began his illustrious career in the discipline of Anaesthesiology under his mentor, the late Dr M K Subrahmanyan.
He went on from there to rapidly pass his Part 1 of the FFARACS. He continued his anaesthestic rotation in Alor Setar General Hospital in 1977 where his interest in intensive care was kindled. In 1979 he passed his Final FFARACS and was gazetted as a specialist in anesthesia in 1980.
Realising his great potential and capability, the government rotated him through nearly all the states in the country for the next 12 years where he did a lot to set up intensive care facilities in the state general hospitals and improved the anaesthetic services remarkably. The pinnacle of his career was when he was appointed as the Head of the Department of Anaesthesia and Intensive Care in Hospital Kuala Lumpur and chief anaesthesiologist in the country in 1992.
In his capacity as the Head of the Department of Anaesthesia and Intensive Care in Hospital Kuala Lumpur, he spearheaded many changes that changed the landscape of anaesthesia not only in Hospital Kuala Lumpur but throughout the whole country. He brought focus on perioperative deaths and was the chairperson of the Perioperative Mortality Review committee since 1992. He helped initiate many programmes to reduce mortality in this aspect of care. He was instrumental in mobilizing efforts to streamline credentialing and accreditation of anaesthetic and intensive care services in hospitals in the country. He was also heavily involved in the reviewing and evaluation of drug usage in the country. Being very conscious of safety in the provision of anaesthesia, he was instrumental in initiating the review of maternal deaths, especially anaesthetic related ones, and further pushed the Ministry of Health to revamp, upgrade and modernize equipment used for anaesthesia and intensive care in public hospitals in the country. To enhance the improvement of anaesthetic and intensive care, he pushed for rational distribution of manpower and consolidated the discipline with subspeciality development. He was also heavily involved in training programmes in the discipline and was the chairman of the subspeciality training committee in the Ministry of Health until 2003. He was also the advisor to the Ministry on medico-legal issues pertaining to anaesthesia. He still found time in his busy schedule to be the chairperson of the Medical Advisory Board of Hospital Kuala Lumpur and was for sometime the chairperson of the operating theatre executive committee.
During his tenure in Hospital Kuala Lumpur, he was appointed to be examiner for the final examination of the M Med (Anaesthesia) for University Kebangsaan Malaysia and University of Malaya and examiner for the Post-Basic Nursing Examinations in Intensive Care. He chaired various committees that produced landmark documents for safety standards in anaesthesia and recovery and safety standards in minimal monitoring. He was a reviewer for the Medical Journal of Malaysia and a member of the editorial board of the Asean Journal of Anaesthesiologists, a journal that was mooted by him when he was the President of the Malaysian Society of Anaesthesiologists.
The Malaysian Society of Anaesthesiologists was honoured to have him as its president on two occasions. During his tenure as president of the MSA as well as the president of the College of Anaesthesiologists, Academy of Medicine of Malaysia, he streamlined many of the activities in the Society and the College. He was heavily involved in arranging for national and international meetings in anaesthesia in the country. His involvement in society work in anaesthesia also extended as far as the World Federation of Societies of Anaesthesiologists where he was a member of the Statues and Bye Laws Committee.
Dato' Dr Inbasegaran contributed to the field of anesthesia in a way that few can equal. His academic interests spanned from quality assurance in anaesthesia and intensive care, medical audit and acute pain management to regional anaesthesia. In each of these aspects that he was involved in, he published extensively and all had appeared in journals of international standing.
Dato' Dr Inbasegaran was a much sought after speaker in the national and international arena. He had been a speaker not only at symposia but also at plenary sessions. He had the remarkable ability to put his thoughts across very clearly.
Although he suffered a setback in his health towards the end, he still contributed positively to the discipline of anaethesiology and intensive care. For all his positive contributions, he received numerous awards from various states as well as from the Federal Government. The most prestigious award had been the DPMP from the State of Perlis which carried the title, Dato'.
On 8 November, 2005, the Malaysian anaesthetic community mourned the loss of a great friend and true leader in our midst. Not only did he change the facade of anaesthesia and intensive care in the country and allowed the discipline to become one of the most respectable and sought after disciplines in terms of training, he did it with grace and in a remarkably short time. For this man who had blessed us with so much in terms of legacy, may we get the Malaysian anaesthetic community to reflect for a moment, memories of good times they have had with him and to request the Almighty to bless his soul and support his family through this very trying period.
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9 11 September 2005
Sunway Pyramid Convention Centre, Petaling Jaya, Malaysia
by Dr Nor' Azim Mohd Yunos
The overwhelming response to our 3r d successive NCIC sealed its standing as an established annual scientific meeting for Malaysian intensive care clinicians. A total of 910 delegates attended the conference, making it the largest turn out since the first edition back in 2003. A similarly warm response was received from the trade industry with more than 60 trade booths displayed, exhibiting the latest intensive care related products in the market.
The Opening Ceremony, graced by the presence of YB Deputy Minister of Health, saw the conferment of MSA Honorary Membership to Dato' Dr K Inbasegaran. The citation read by Dr Sylvian Das was a fitting tribute to this very distinguished member of the MSA. We are now thankful that we were able to express our appreciation of all his contributions while he was still alive.
The scientific program, which formed the core of the conference, had generated keen participation from the delegates. Under the theme 'Intensive Care in Trauma', various new findings and approaches in intensive care medicine were presented and discussed. The Organising Committee also received a lot of positive feedback regarding the scientific sessions, indicating genuine interests in the topics selected. This encouraging enthusiasm on the Intensive Care Medicine speciality was further reflected by the bigger number of participation in the Free Papers Session this year.
Fresh from the success of the 3r d NCIC, the organizing committee is now back to the drawing board planning for the 4th NCIC. Look out for our First Announcement!
Intensive Care Section,
|In conjunction with
Ministry of Health Malaysia
(Anaesthetic and Intensive
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