JILID 12 BIL 1 JANUARY 2010
JILID 12 BIL 1 JANUARY 2010
Newsletter of the Malaysian Society of Anaesthesiologists and the College of Anaesthesiologists,
Academy of Medicine of Malaysia
G-1, Medical Academies of Malaysia
210 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
TEL (603) 4023 4700, 4025 4700, 4025 3700
FAX (603) 4023 8100
EDITORS Dr Shireen Jayan
Dr Julina Santhi Johami
G-1, Medical Academies of Malaysia
G-1, Medical Academies of Malaysia
210 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
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To all my anaesthetic colleagues and friends, welcome to 2010 and may all our plans and resolutions come to life! It is about ten years now since the turn of the century, with the hue and cry about Y2K, and it seems just like yesterday.
After recently coming back from the Haj with another inspiring fulflling experience, I am hopeful and optimistic of what the future holds. Let’s start small, and see what MSA is up to.
National Specialist Register (NSR) and our Specialty 'Anaesthesiology and Critical Care'
We have received news from the Anaesthesiology Specialty Subcommittee that the NSR has agreed to reissue certifcates that have not included ‘Critical Care’ as a specialty but in due time. This is because of the heavy workload they are experiencing. In the meantime be prepared to exchange the old certifcate for the new as we are allowed to have only one. Almost 300 specialist anaesthetists have registered in our specialty, so please join in and submit your applications soon. The forms and detailed information is at www.nsr.org.my.
National Anaesthesia Day
Our yearly 16th October National Anaesthesia Day celebration was taken to greater heights this year. Dato’ Dr Subrahmanyan Balan and his team from Hospital Sultanah Aminah Johor Bahru arranged the successful Mt Kinabalu climb as you can see in our website at www.msa.net.my. I must also thank the Anaesthesia Departments in Hospital Melaka, Hospital Sultan Ismail Johor Bahru, Hospital Tuanku Bainun Ipoh, Hospital Tuanku Jaafar Seremban, UKMMC and UMMC for their participation. Their reports are in this issue of Berita Anestesiologi.
This multi-centre celebration requires a little effort from each of us but it can promote friendship and togetherness amongst anaesthesiologists. For those departments which have yet to join us, you can do so in October 2010. The MSA is willing to subsidize as one of the objectives of the Society is to coordinate the activities as well as promote co-operation and friendship amongst anaesthesiologists. Those with bright ideas, or better still those willing to take on the challenge, to make this celebration a more consolidated project to propel our image to the fore, kindly step forward! I will also await the day the private sector joins in our celebration. Many a time, we hold the occasion in conjunction with another event organized by the hospital, so it is really not much to ask.
CPD & Education
I wonder what it will be like if we do not regularly and frequently organize or collaborate CPD programs for our anaesthetic fraternity. It may make no difference to some who can afford to travel abroad to international conferences or others who depend on company sponsored talks and seminars. Nevertheless, I honestly believe many anaesthesiologists and anaesthetic trainees beneft from MSA’s effort in spreading the CPD programs to various states, and at various levels from small talks to huge congresses. Since our last issue of Berita Anestesiologi, we have had ‘Updates’ in IJN, Ipoh Hospital and HKL, Examiners Dinner Talk in UMMC, Fluid Balance Talk in KL and Kuching, and a Neuromuscular Meeting in Langkawi. Were you a part of any of these? Notifcation is sent via the e-mailing list and the website so do keep an eye out for more.
Annual Scientifc Meeting 2010
Our next big date to block on the calendar is 23rd to 25th April 2010 as we will hold our yearly ASM/ AGM at the Zon Regency Hotel, Johor Bahru.Dato’ Dr Subrahmanyan Balan and his organizing committee welcome us all to the southern end of the peninsular with open arms with the theme ‘Taking Anaesthesiology to Greater Heights’. This is the frst time our ASM is moving way down south (we have gone way up north to Langkawi so follow us, span the country and enjoy our cuti-cuti Malaysia! The bonus this time is the nearby border!
The scientifc committee headed by Prof Dr Marzida Mansor has lined up an incredible range of scientifc topics and speakers, with three plenaries and eight symposia. The four workshops to be held on 22nd April are Airway (Adult and Paediatric), TIVA, Critical Care Ultrasound and Regional Anaesthesia (in HSAJB). Of course, our AGM is also a highlight and not to be missed.
We have the MSA and Young Investigator awards for oral presentations worth RM3000 each. There will also be awards for the three best poster presentations in the sum of RM1000, RM500 and RM300. Please be reminded that the abstract deadline is on the 10th March 2010. So let’s get busy and register early.
K Inbasegaran Research Fund
Applications are slow to come in for this fund, but we have a successful candidate recently who will be awarded a sum of RM8000. The rules and regulations are on our website, so feel free to browse and then apply.
13th Asian Australasian Congress of Anaesthesiologists (AACA)
This congress is scheduled for 1st-5th June 2010 in Fukuoka, Japan. It is held once every two years and MSA will offer limited sponsorship to members who will be presenting papers (according to regulations as on the website) to a maximum of RM5000 each. The abstract deadline is on 1st Feb 2010 and applications for MSA sponsorship must be submitted by 15th March 2010.
Moving of MSA Secretariat
The MSA Secretariat (which is sharing the Secretariat of the Academy of Medicine of Malaysia) will be shifting to the new Academies Building situated at G-1 Medical Academies of Malaysia, 210 Jalan Tun Razak, 50400 Kuala Lumpur with effect from 1stJanuary 2010. Their telephone numbers are 03 4023 4700, 03 4025 4700, 03 4025 3700 and the fax number is 03 4023 8100. There is however, no change in the email address (firstname.lastname@example.org or email@example.com).
We are trying very hard to improve our website. I must thank Dr Shahridan and the webmaster for the change in design and their readiness and willingness to make updates whenever we have the material. That is our main problem, actually – getting articles, updates and write-ups...
Robert Half says ‘Persistence is what makes the impossible possible, the possible likely, and the likely defnite.’ That’s probably the reason I’m again requesting and appealing for your contribution. Just browse our website, see what we need and chip in for what you think will be useful for our fraternity.
Since our next Berita Anestesiologi will only be out in three months time, the MSA exco and I would like to wish everyone ‘Happy 2010 & Gong Xi Fa Cai’!
Assoc Prof Datin Dr Norsidah Abdul Manap
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Seasons Greetings and Happy New Year to all! May 2010 be a good year for all of us! I hope everyone has made their new year resolutions and plans for the year so that we will be able to improve ourselves and work towards achieving our goals in our career and in life...
Membership of the College
In my last message in the Berita, I started off by calling for more anaesthesiologists to join the College. Alas, the call has fallen on deaf ears. In the last three months, we have only had about ten applicants to join the College, all of which we have approved.
I have not given up – perhaps there is some confusion regarding the College and the Society. Several anaesthesiologists I spoke to thought they were already members of the College! I would like to clarify that there are TWO DIFFERENT organisations – the Malaysian Society of Anaesthesiologists (MSA) and the College of Anaesthesiologists, Academy of Medicine Malaysia.
And you need to join each of them separately – you have to fll in the membership forms, pay the membership fees and wait for approval of your membership for EACH of the organisations. Previously, College membership was only open to specialists who had published or presented scientifc papers but now any specialist anaesthesiologist can apply to join the College, whether you have publications/presentations or not. Non-specialists can join as associate members (previously this was not allowed).
Regarding the membership fees for the two organisations, they are also a little different, as tabulated below:
|Annual fee||Life membership||Exempted|
Once you are a member of the College of Anaesthetists, you are allowed to put the letters “AMM” after your name (together with MBBS, M Med, FANZCA, FRCA, etc). When you have been a member of the College for more than ten years, you are eligible to apply to become a FELLOW of the College. For this you will need to have some publications and presentations, and the College will recommend to the Academy of Medicine to accept you as a fellow. Once you are conferred the Fellowship, you can change the letters after your name to “FAMM”. So you see, there are some advantages of joining the College!
So I would like to make another appeal to all anaesthesiologists, and trainees to take this opportunity to to join the College of Anaesthesiologists. Please go to the Academy of Medicine website www.acadmed.org.my, and click on Membership form to download the document, which lists all the requirements. You have to submit a hard copy of the form (signed) together with the necessary documents including your basic and postgraduate medical degrees.
In the last issue of Berita, I explained at length about the College’s Special Interest Groups (SIGs) and asked members to indicate which SIG they are interested in. Guess what? I had no response at all. So, I plan to send out emails to all College members asking you to indicate which SIG(s) you would like to join – I hope to get a better response this time!
Before I end on the topic of membership, I would also like to remind all existing College members to pay their membership dues. If you cannot be bothered to pay the fees annually, please consider paying the life membership fees and we won’t bother you again for fees for the rest of your life! We will be sending out reminders for 2010 payment soon, and will include information on how many years you are in arrears for those who have forgotten to pay your fees for the past few years.
Joint Colleges Congress of Medicine
This Congress, held for the frst time as a joint effort between THREE Academies of Medicine (Malaysia, Singapore and Hong Kong) will be held from 11th-13th November 2010 in Hong Kong with the theme “Benefts and Risks of Recent Medical Advances”. Unfortunately we only managed to get one speaker slot for our College, but there will be other speakers from our Singapore and Hong Kong counterparts, as well as other Malaysian speakers from the Academy of Medicine Malaysia. Please mark you diary so that you can be part of this historic event!
National Specialist Register
The number of Anaesthesiologists registered in the NSR under “Anaesthesiology and Critical Care” now stands at 284, with a few applications still being processed. The number for Intensivists is of course much smaller, with only 19 specialists registered under this category. As I have mentioned in my messages as President of MSA previously, since there has been a change in the name of the specialty, it should now be clear to patients and to administrators that all anaesthesiologists are qualifed to manage critical care or intensive care patients, so there is actually no need to register as an intensivist unless your practice is mainly (more than 50%) in intensive care. I hope members are now happy and are not encountering problems with your patients and their relatives with your hospital administrators or third party payors.
AFTA and the ASEAN MRA
It is now 2010 – the year that the ASEAN MRA (Mutual Recognition Agreement) for specialists in various specialties is supposed to be implemented. I have included details about this in an article in this issue – at the moment, it does not seem as if it will affect us very much, but there are a couple of things to note – not all specialties are covered under AFTA, but anaesthesiology and intensive care are included – the list of 14 specialties covered was drawn up many years ago, in the 1990s, and presumably anaesthesiology was included because of the shortage in the number of specialists in the country at that time; currently we are producing anaesthesiologists at a rate of at least 50-60 per year, and although there is still a shortage in some government hospitals, this is not so in the private sector. We are still short of intensivists but if you look at the ASEAN region, it would seem that other countries are also short of these specialists, so one would assume that we would not get an infux of intensivists from other ASEAN countries. However, we should also note that there are limitations in AFTA, for example only private hospitals with more than 70 beds can employ a maximum of TWO foreign specialists – so it would also seem that this is not a big threat to our practice.
On the other hand, we can also look at AFTA and the MRA as an opportunity – this is a MUTUAL recognition agreement, which means that any of us, who are registered as specialists in our own country, can move to another ASEAN country to set up our practice, also within limits. The limits regarding where one can practice would depend on the commitments made by the government of the country where you want to go – I have not included that information in the article, but you can always contact the Policy and International Relations Division of the Ministry of Health or the Ministry of International Trade and Industry (MITI) for more details.
What actually happens in reality with regard to anaesthesiology practice in the region remains to be seen. What is clear though is that we are practising medicine in an increasingly borderless world, and that medicine is becoming increasingly commercialized – and we should be aware of what is going on around us and how (and if) we need to change with the times.
The next few years are going to see drastic changes in the health system in our country. Most of us are aware that the government has been saying in the past few years that health care costs are escalating and it is not possible for the government to bear this increase in costs; to this end, a national health fnancing mechanism is being worked out. The latest plan is called “1Care” along the lines of the 1Malaysia concept. The main feature of this system is the integration of public and private healthcare in Malaysia and the setting up of a national health fund – details are still not worked out, but it looks like the Ministry of Health is serious about implementing this in the near future. However, the implementation will start with primary care, i.e. with the GPs and primary care clinics in the country – the 1Malaysia clinics were purportedly one of the steps in this direction. So again, it does not look like specialists are going to be affected directly YET – but it will come, in the not-too-distant future.
Keeping up with the times
In order to prepare ourselves for all these changes, we need to ensure that we maintain our skills as specialists and keep up with all the developments in our feld, by reading journals and attending CPD programs regularly. The College, together with the MSA, is committed to ensuring that CPD programs are available for our members and for all anaesthesiologists in the country, but you as an individual should also play your part (i.e. attend these CPD activities! do your reading! etc). We also welcome contributions to the Berita Anestesiologi in the form of CME articles, and we are also happy if members will offer to give a lecture or two at the CPD sessions or at the refresher courses for Masters students – no better way to update yourself than to commit yourself to give a lecture – this will force you to do your reading and to gather your thoughts together so that you can deliver the concepts and updates to your colleagues and juniors.
I look forward to an active an fruitful year ahead, and wish everyone all the best.
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Some information on AFTA/GATS and the ASEAN MRA... taken from talks given to the Academy of Medicine and the MMA by Mr Fabian Bigar from the Policy and International Relations Division, and Dr Nik Shamsidah from the Medical Practice Division, Ministry of Health on 16th August 2009.
The Cabinet on 14th November 2008 had agreed that Malaysia should take immediate steps to liberalise the services sector (excluding fnancial services) especially under ASEAN Framework Agreement on Services (AFAS). To date, Malaysia has made a few commitments for liberalisation of health services namely the private hospital services, private specialised dental services, specialised medical services and specialised nursing services.
The WTO and GATS: Background and Malaysia’s Commitments
The World Trade Organisation (WTO) was established on 1st January 1995 after seven and half years of negotiations. It replaced the General Agreement on Tarifs and Trade (GATT), which dated back to 1948. While GATT dealt with trade in goods only, WTO’s creation expanded international trade rules into new areas such as trade in services and intellectual property rights. As an institution, WTO serves as a forum for multilateral trade negotiations and currently has 153 members.
The core Principles of WTO agreements are as follows:
The key WTO agreements related health and health policies include:
Under GATS, which covers all internationally traded services (except services supplied in exercise of governmental authority and air trafc rights), there are four modes of delivery of services as shown in the table below:
|1.||Cross-border supply||non-resident service suppliers to supply services cross-border into Member's territory||Tele-consultation
|2.||Consumption abroad||Freedom for residents to purchase services in the territory of another Member||Health Tourism
|3.||Commercial presence||Foreign service suppliers to establish or expand a commercial presence in Member's territory||FDI in foreign hospitals
Foreign presence in health insurance sector
|4.||Presence of Natural Persons||Entry and temporary stay of foreign individual in Member's territory||Temporary movement of medical specialist to provide services abroad|
Malaysia’s commitments under GATS:
As WTO has not been able to come to an agreement to which every single one of its members can agree, several bilateral and multilateral trade agreements have been, and are still being, negotiated. Malaysia is negotiating several of these agreements, one of which is the ASEAN Free Trade Area (AFTA) Agreement.
Other Relevant Agreements
To facilitate the movement of health professionals, Malaysia as a Member of ASEAN is also party to three Mutual Recognition Arrangements (MRA involving healthcare providers. These MRA enables the qualifcations of healthcare professionals to be mutually recognised by signatory member countries, hence facilitating easier movement of services providers in the ASEAN region to supply services across ASEAN borders.
The ASEAN Mutual Recognition Agreement (MRA) for medical specialists
The objectives of the MRA are:
Recognition of Foreign Medical Practitioner
In order to be recognized, the medical practitioner must meet several conditions, as stated below:
Implications for medical practitioners
According to the Ministry of Health ofcials, liberalisation of the healthcare sector does not mean uninhibited entry into the local market by foreign services providers. This is because, under international trade rules, the Government is entitled to put in place limitations to market access.For example, foreign medical specialists from ASEAN are not allowed to practice in hospitals of less than 50 beds; they are also not allowed to set up individual or joint practice, but have to be employed by a hospital.
The government is also imposing quantitative restriction on the number of specialist allowed in the country depending on the market conditions, and foreign specialists are subjected the same standards and qualifcation requirements as locals and they have to be registered with professional bodies like the MMC and be granted a license to practice locally. Foreign doctors are only employed on contract basis and the term of contract is usually not more three years.
The MOH also thinks that liberalisation of the health care sector can encourage participation of well known foreign health care providers or companies and that this will assist Malaysia to develop and promote highly specialised medical services and may move on to become regional centres of excellence for certain niche services. In addition, the other possible benefts to Malaysia are that this will
As Medical practitioners in Malaysia and in ASEAN, we can look at AFTA and the MRA as a threat but also as an opportunity.
“Malaysian medical practitioners should explore the opportunities and beneft to be gained from the reciprocal market openings provided in other countries as Malaysia has the expertise and capabilities to establish medical practices in these countries.” (Dr Nik Shamsidah, Medical Practice Division, MOH)
This same view was also expressed by Mr Fabian Bigar from the International Relations Division of the MOH who added some examples of opportunities – “Vietnam has ofered market access of 100% ASEAN equity in foreign invested hospital while Singapore has no limitation except number of new foreign doctors registered each year may be limited depending on the total supply of doctors domestically. Thailand and Myanmar ofer 51 per cent ASEAN equity while Cambodia and Laos call for joint ventures at 49 per cent ASEAN equity.”
What happens in reality remains to be seen.
Dr Mary Cardosa
President, College of Anaesthesiologists 2009/2010
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Your country pays about $2.50 US dollar for you as an annual membership fee to the WFSA. Did you know that the WFSA is now an organization with educational activities going on across the world in order to improve anaesthesia services to our patients worldwide, be it in Micronesia, Malawi, Moldova, Mexico or Mongolia?
The 14 training centres across the world are important for this. For instance, young specialists from Vietnam, Laos, Mongolia, Burma and more go to Bangkok in Thailand to be trained in modern anaesthesia for a year. The programme has been running since 1996, initiated and chaired by Prof Thara Titrakarn. The 56 fellows that have been there until now have left their (sometimes small) children and friends behind to improve their professionals skills in a foreign country, a real sacrifce. The teachers in the three university hospitals and three other hospitals work together with them all the time – teachers and fellows in a foreign language alike. Despite this only three have dropped out of the training, and all except two are practicing anaesthesiology in their home countries. In Mongolia, these fellows now have now been able to form a critical mass to become infuential in improving anaesthesia services and education in that country.
But Bangkok is not the only training centre in Asia – for years, it has been possible to learn paediatric anaesthesia in Vellore, India, and recently, also in Singapore and in Hong Kong. In the Maldives, for instance, the (until recently) only anaesthesiologist in the country went to Vellore to train under Prof Rebecca Jacob, and this has meant a major change in how the Maldivian children are being anaesthetised.
In Israel, Prof Gaby Gurman started a training centre for Eastern Europeans in Beer Sheva. When he retired, the programme was moved to Tel Aviv, and Prof Tiberiu Ezri took over and opened it to young colleagues from Kenya and Nigeria, as well. Moldovan colleagues can be trained in Romania, as well (by Prof Yuri Achalowski), and this centre is run in co operation with the European Society of Anaesthesiology (ESA). In the same way, the WFSA works with the Latin American Regional Section (CLASA) to establish a training centre for regional anaesthesia in Brazil. In Chile, Prof Silvana Cavallieri runs an excellent training centre for paediatric anaesthesia, and Latin Americans can learn obstetric anaesthesia in Bogotá, Colombia. If you are African, your best bet to learn obstetric anaesthesia would be to go to Tunisia to learn from Prof Mohamed Benammar or to learn paediatric anaesthesia in Tunisia or in South Africa. Intensive care medicine training programmes are run in India and in Israel.
There have been Fellows learning neuro- and paediatric anaesthesia in Cape Town, and we are in the process of developing a training centre for paediatrics in Nairobi, Kenya. Some of these initiatives are co-sponsored by national societies who wish to contribute more than just membership fees. The typical funding for a Fellow means that the home institution pays their salary, the hosting institution waives fees and the WFSA covers housing expenses and per diem. The Fellows are selected based upon their applications, CVs and recommendations from their home institution and national society. After the training, they will have improved their competence and received a diploma to show that.
In countries where anaesthesiologists are particularly scarce, the WFSA has also supported basic post graduate training, e.g. for a colleague from Zimbabwe and from Congo. WFSA can also support other activities where there are no or very few doctors, like update meetings for clinical offcers in Malawi and examination support.
WFSA will also support speakers to national meetings several places in the world, and, for major regional congresses, we now offer WFSA panels. To some countries, we are sending examiners for national exams, and these experts will often combine that with speaking at national congresses.
We are also working with other organizations such as the International Association for the Study of Pain with whom we co-sponsor a training programme for pain specialists in Thailand; Baxter Inc for Fellowships to regional and world congresses and for production of educational CD ROMs in obstetric anaesthesia; the Society for Pediatric Anesthesia (USA) in supporting training Fellowships in paediatric anaesthesia in Vellore, India. Also Drager has been a major sponsor to our programmes, particularly to paediatric anaesthesia in Tunisia and in South Africa. We expect to work even more closely with other specialty organizations in the future, for instance the obstetricians and the surgeons.
Some of the major organizations that work with WFSA are established by our own colleagues. For instance, the Primary Trauma Course (PTC) programme (www.primarytraumacourse.org) was initiated by Dr Douglas A Wilkinson and Dr Marcus Skinner in 1996 with the aim to train surgeons, anaesthesiologists and other health professionals involved in the prevention and early management of severe trauma victims. During a two day course, they are taught the basics of primary and secondary survey and early resuscitation, but within the confnes of their time, experience and resources. The course continues with a teaching module, so that the participants in turn can train others. As an example, four PTC instructors went to Iran early in 2007 and trained 30 people. By the end of that year, 300 more health workers in Iran had undergone the same training. PTC courses have now been held in 46 countries throughout the world and are now a part of the trauma strategy of the WHO.
Another course series that has spread across the world, was initiated in 1986 by Prof Scherpereel of France and more European colleagues – the ”Foundation for European Education in Anaesthesiology” (FEEA). This is a course series to improve CME/CPD initially in Europe, but from 1995 in Latin America, in 2004 in Africa and in 2006 in Asia. Impressively today there are course series in 102 centres in 47 countries across the world. The series consists of a cycle of six courses, covering all aspects of our speciality in an interactive programme. Although the topics are the same, the contents will be adapted to local conditions. If the anaesthesiologist completes one course per year, the full cycle will be completed in six years, ready to start again. ESA has taken over the practical organisation of the programme, which has changed its name into the Committee for European Education in Anaesthesiology. The ESA sponsors European centres; the WFSA the rest of the world. All the educational material can be found on a website sponsored by GE Healthcare, www.euroviane.net.
An extremely important part of education is to facilitate teaching. Not all eminent scientists are naturally gifted teachers, and some tricks of the trade can be learnt. Dr Gaby Gurman of Israel came up with the idea of establishing the “International School of Instructors in Anaesthesia” (ISIA). The frst course involved colleagues from fve countries in Eastern Europe, and that was so successful that a new class has started, now in co-operation with ESA. It consists of three weeks of courses, some months apart. The students come from various countries and are supposed to exercise their newly acquired competence in-between courses and then to establish courses in their own countries afterwards. The students have been extremely enthusiastic and have later formed their own networks to train others. There is a great demand for similar courses from other regions, and WFSA expects that training of teachers will be an even more important activity in the future.
The Education Committee is composed of nine members. Currently the members come from Colombia, Israel, Japan, New Zealand, Norway, Russia, Singapore, Tunisia and the USA Traditionally, there has been a geographical spread with each member responsible for one part of the world. The Committee both starts and facilitates educational activities, in addition to fnding partners to fnance them.
During 2010, we would like to co-operate even more closely with national societies. Many of those have their own important international activities, sometimes together with WFSA, sometimes on their own. If we could join forces, then we would accomplish even more. What would you like the WFSA to do for you? What do you want to do to share your competence with those who do not have your knowledge base – be it that you come from a high income part of the world with access to all facilities or you have become an excellent clinician because you have little basic equipment and few drugs in your vicinity?
One of my personal experiences after I got involved in the WFSA is that I have learnt much more than I have taught. I have experienced that when I meet colleagues, we always have something in common. That gives us a shortcut to conversations on other aspects of life. I have learnt that no matter what my religion, colour or cultural background is, we anaesthesiologists as human beings mostly share the same aspirations and hopes for our lives, no matter where we live: Food, water, shelter, safe living conditions, love from family and friends, and interesting working conditions and being able to provide a future for our children. Being involved in WFSA activities makes us better professionals and wiser human beings.
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The Malaysian Society of Anaesthesiologists would like to congratulate the following candidates (names in alphabetical order) for passing the Final Examination held at UMMC November 2009
Universiti Kebangsaan Malaysia
University Sains Malaysia
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Hospital Melaka, Melaka
Report by Datin Dr V Sivasakthi
National Anaesthesia Day falls on the 16th of October every year and in conjunction with this, several activities were planned to commemorate this historical event.
Among these were:
Universiti Kebangsaan Malaysia Medical Centre
Report by Dr Muhammad Maaya
The Department of Anaesthesiology and Intensive Care, Universiti Kebangsaan Malaysia Medical Centre held an exhibition booth in the hospital foyer between 5th and 8th October 2009 to celebrate our National Anaesthesia Day. It was held in conjunction with the hospital’s “Minggu Kualiti”, so it was a busy time with many booths and visitors.
The two anaesthetic topics highlighted at the booth were designed to raise the public’s awareness on certain aspects of anaesthesia. A brief history of anaesthesia was exhibited in poster format, which included ancient innovations, milestones in the frst usage of the early anaesthetic gases and recent anaesthetic developments. A patient’s guide on what to ask the anaesthetist and what expect of the various types of anaesthesia was also made available to the public. Pictures depicting and describing the various activities of the department were also shown. Epidural analgesia for labouring mothers was the other topic of interest. It was presented in pictorial form and also via brochures for the layperson. The committee involved in organising the exhibition were Assoc Prof Datin Dr Norsidah A Manap, Prof Lee Choon Yee, Dr Muhammad Maaya, Dr Nadia Md Nor, Dr Navin Durairatnam and Encik Nor Muslim.
The event was a success and was made possible with the assistance of Dr Melvin Kandasamy, Dr Brenda Saria, Dr Mazlila Meor Ahmad Shah, Dr Afnizar Akbar, Dr Normah Abdullah, Dr Fakhrurazzi Md Salleh, Dr Darlina Dhari and Dr Samsul Johari Mohd Amin. Our grateful appreciation also goes out to the Malaysian Society of Anaesthesiologists for their support.
Hospital Raja Permaisuri Bainun Ipoh
Report by Ng Ching Choe, Medical Offcer
16TH OCTOBER 1846 - A day to be remembered by all anaesthetists. This is the day when Dr William Morton astonished the doctors in Massachusetts General Hospital USA when he administered the frst ether anaesthetic to a patient. Ever since then, the science of anaesthesia has spread around the world. It has evolved as a medical specialty with various subspecialities dedicated to total care of patient before, during and after surgery.
The Anaesthesia and Intensive Care Department of Hospital Raja Permaisuri Bainun Ipoh did not want this meaningful day to go unnoticed and we took the opportunity to publicise what anaesthesia is about to the hospital staff as well as members of the public. On 16th October 2009, at the hospital foyer, we set up an information booth and dispersed information to the public.
The day kicked off with the display of colourful and informative posters depicting the history of anaesthesia, various modalities of anaesthesia and analgesia including spinal/ epidural anaesthesia, management fow chart of patients undergoing an operation, as well as a brief introduction about our department and its role in this hospital. Medical offcers from our department were on hand to explain to the visitors as well as clear their doubts about anaesthesia.
A comprehensive video on how the patients are managed by the anaesthetists perioperatively and some real-time anaesthetic procedures were shown throughout the day. The display of our anaesthetic machine & monitoring devices had indeed attracted many eyes.
Apart from that, our display booth was popular the public as it provided free blood pressure and capillary blood sugar check as well as anesthetic advice. We had recorded a crowd of 150 people curious to fnd out more and clear up their misconceptions of anaesthesia.
The highlight of the day was the interesting quiz with questions pertaining to anaesthesia in which about 40 members of the public had taken part. The winners went off happily with a gift bag prepared by our department.
All in all, it was a memorable and enjoyable day for all of us.
Airway Workshop HRPB Ipoh - 22nd October 2009
Dr Sukhminder Kaur, Medical Offcer
The airway workshop held on the 22nd October 2009 was organized by the Department of Anaesthesia and Intensive Care of Hospital Raja Permaisuri Bainun, Ipoh in colloboration with MSA and PGMES Ipoh, at the Ambulatory Care Centre.
It was held to create awareness among the anaesthetic medical offcers, medical offcers from various departments, nurses and paramedics regarding the diffcult airway, problems to anticipate, new modalities available and the latest airway adjuncts which are being introduced in operating theaters.
The turnout on the morning of the workshop was great with participants from all over Perak. We were fortunate to have with us, Dr Ruban Poopalingam, Head of training and Consultant Anaesthetist from Singapore General Hospital who gave a talk on ‘The Diffcult Airway’. This was later followed by case discussions and presentations by Dr Foong Kit Weng and Dr Sidney Saw, anaesthetists from the organizing department.
A question and answer session took place, which saw active participation from the participants. A short tea break was given followed by the hands on session. All the participants were divided into colour coded groups and went along each station accordingly from then on.
Six stations were put up: Station 1 was by the Aerotrach company projecting their range of LMA supreme. Station 2 was by the Paltime medicare company mainly on Glidescope intubation for adults and neonates. Station 3 was by Maycare and Station 4 was by Insan Bakti. Station 5 showcased fbreoptic intubation by Endodynamics company. Station 6 was put up by our department to teach everyone about diffcult intubation with manequins using equipment commonly available in the OT.
After the participants had a good lunch break, they continued with the hands on session, each group fnishing all the 6 stations. A last question and answer session was held before the closing ceremony. Dr Kavita Bhojwani, Consultant and Head of Department of Anaesthesia and ICU of Hospital Raja Permaisuri Bainun, Ipoh thanked Dr Ruban and the participants for their enthusiastic participation and for making the whole workshop a success. Certifcate presentation was held and everyone adjourned by 5 pm, looking forward to the anaesthesia update to be held the next day.
Anaesthesia Update - MORPHEUS 2009 HRPB IPOH
The Anaesthesia Update, Morpheus 2009, was held on the 23rd October 2009 at the Ambulatory care Centre, organized by the Department of Anaesthesia and Intensive Care Hospital Raja Permaisuri Bainun, Ipoh in colloboration with MSA and PGMES Ipoh. Participants came from mainly the Northern region as well other states.
The distinguished panel of speakers consisted of Professor Dr Felicia Lim, Consultant Anaesthetist fomerly of UKM, Dr Mohd Rohisham Bin Zainal Abidin, Consultant Anaesthetist from HKL, Dr Devanandhini Krishnan, anaesthetist from HRPB, Ipoh, and Dr Suresh Kumar A/L Chindambaram, consultant ID physician from Hosp Sungai Buloh.
The morning started with Professor Dr Felicia Lim’s talk on upper respiratory tract infection and laryngospasm in paediatric pateints, followed by Dr Mohd Rohisham’s talk on Labour Analgesia. This was part of the regular weekly Friday morning CME organized by the HRPB Ipoh.
The event was then offcially launched by Dr Kavita Bhojwani, Consultant and Head Of Department of Anaesthesia and Intensive Care, Hospital Raja Permaisuri Bainun Ipoh.
The crowd was enlightened as to why the name Morpheus was chosen for this update. Morpheus is the Greek God of dreams and therefore appropriate with the line of work we are involved in.
Professor Dr Felicia Lim spoke on Fluid and Electrolyte Management In Paediatrics followed by a presentation by Dr Mohd Rohisham on Current Updates in Obstretics Anaesthesia and Analgesia. After a short tea break, Professsor Dr Felicia Lim gave an interesting talk on anaesthesia for removal of foreign body in the airway. Later, Dr Devanandhini spoke on Acute and Chronic Pain Management. She also spoke about the implementation of Pain as the 5th Vital Sign. Subsequently, Dr Mohd Rohisham presented on resuscitation of the obstetric patient, comprising of CPR in pregnancy and local anaesthetic toxicity management. A question and answer session was held at the end.
A lunch break followed thereafter. The afternoon session was taken over by Dr Suresh Kumar, who updated us on multi resistant organisms, MRSA and the antibiotic regimes available to combat these organisms.It was an extrememly informative and interesting talk.
All the speakers were given a souvenier and a token of appreciation for taking time out of their busy schedules that day and sharing valuable information with the participants.
The day ended with a tea session and evaluation forms were flled and feedback noted. We hope to be better next year. See you then!
Dr Sukhminder Kaur
Department of Anaesthesia & Intensive Care
Hospital Tengku Ampuan Rahimah, Klang
Report by Dr Nor Hafzah Mohd Yunus & Dr Jessie Tan
In conjunction with World Anaesthesia Day that falls offcially on 16th October every year, Hospital Tengku Ampuan Rahimah, Klang, Department of Anesthesia and Intensive Care held an exhibition at the lobby of the Ambulatory Care Center. The exhibition showcased posters on the conduct of general anaesthesia and regional anaesthesia. The public not only had a chance to view the posters but also had the opportunity to take part in a quiz which rewarded them with a little token and goodie bags. Further, to enhance an anaesthetic and intensive care experience, an operating room and intensive care mock- ups were done respectively. Both mock-ups had monitors, operating tables, intensive care beds, and “life” ventilation on mannequins. The public were pleasantly surprised with the ‘state of the art’ equipment for both intensive care and the operating room.
A few medical companies dealing with anesthesia machines and airway products participated this year. Doctors from various disciplines, nurses and medical assistants had an insight to different airway management available and were able to practice their intubation skills on mannequins. They too enjoyed the little goodie bags!
Hospital Tuanku Ja’afar , Seremban,Negeri Sembilan
Report by Dr Tengku Alini Binti Tengku Lih
We celebrated the National Anaesthesia Day on 16th October 2009 by conducting an exhibition held at the ground foor foyer of specialist clinic, chosen to ensure good public audience.
“Wajah Di Sebalik Tabir” and “Keselamatan Anda Keutamaan Kami” were chosen as the theme to educate the public regarding the importance of perioperative care and services provided by the anaesthesia team.
The opening ceremony was offciated by our Hospital Director, Dr Jaafar Che Mat. We also invited all deputy directors and all heads of department during the ceremony.
The exhibition consisted of posters regarding history and services of anesthesia and intensive care plus multimedia presentation showing main procedures done by us such as intubation, laryngeal mask insertion, spinal, epidural and also peripheral nerve block. Besides that, we also set up a mock OT and mock ICU.
To encourage more participation from the public, we organized a quiz based on the posters displayed. We also created “Guess The Ampoule” competition in which all the visitors guessed on the total number of Esmeron ampoules that we used to decorate a Minangkabau house. We had total of 350 visitors. Attractive prizes were given away to all participants. We also presented gifts to the lucky visitors (50th, 100th, 150th, 200th respectively).
Judging from overwhelming response from the public, we felt that we achieved our objectives. A vote of thanks to the proactive and committed team members who contribute to the success of this event. We look forward to next year’s event!
Hospital Tuanku Ja’afar, Seremban
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The Evolution and Revolution and Teaching / Training
by Datuk Prof Emeritus Dr Alex Delilkan
Anaesthesiology and Critical Care, University of Malaya, Kuala Lumpur
Te Field of Anaesthesiology as a Clinical Specialist
Discipline is mirrored by the changing attitudes to the Teaching and Training in the feld as part of medical education.
In the traditional British medical undergraduate curriculum (Signifcantly infuential in Malaysian medical schools) the “Anaesthetic Posting” is usually listed as a “Short Posting” of 2-4 weeks duration. This posting for medical undergraduates was geared towards the principles in the basics of how to give gas to a patient requiring a painful operative procedure; the frst such painful procedure (a dental extraction) performed under a gaseous inhalational agent was recorded in world literature on 16th October 1846. The “anaesthesia” was intended to make the patient unconscious of the pain involved. It was administered by the dental surgeon. The historic moment was a disastrous beginning- the operative pain was unbearable and “anaesthesia” was booed off (there was an audience in attendance) as a show, a bogus. Over the years that followed the effciency of the anaesthetic agents improved and general anaesthesia achieved the aims of pain relief (analgesia), unawareness (unconsciousness) and relaxation (in the operative feld).
The scrambling nature of the beginnings of anaesthesia implanted in the minds of everyone that anyone could give “gas” as an assistance to enable surgeons to perform painful procedures. The “anaesthetist” was looked upon as a provider of a service. The importance of Airway Patency during unconsciousness (patient under general anaesthesia) extended the anaesthetist’s function to include a vital contributory role in Resuscitation (Acute unconsciousness) and Intensive Care (prolonged unconsciousness). Pain Relief further developed as for Acute Pain (Post operative analgesia, obstetric or Labour Analgesia, Sports Trauma Analgesia) and Chronic Pain (Cancer or Non-cancer origin) Analgesia.
The “Gas man” emerged from the confnes of the operating theatres unmasked to become a Physician-based Critical Care Specialist.
Teaching in Anaesthesiology in Malaysia
The ‘short-posting” for anaesthesia in the traditional undergraduate curriculum was entrenched when the frst academic department in Anaesthesiology was established in the frst medical Faculty (University Malaya) in 1965 in Malaysia/Singapore (the frst academic department for Anaesthesiology in Singapore was established in 1985 – prior to this date short-posting in Anaesthesia was conducted by the Service Anaesthestic Unit (“Department” of the Government Service Hospitals).
The “short-posting” for Anaesthesia continued in the Department Anaesthesiology in the frst Teaching University Hospital, Kuala Lumpur which commenced function in 1967 Anaesthesia posting was boring, irrelevant (no exams involved!) almost farcical for students. A personal survey conducted by the author (1968-1989) revealed that 37% of students were asleep during the lectures/Tutorials.
The conclusion was that from the students’ point of view the short-posting was a waste of time, for all concerned or that the anaesthetic potency of the Lectures anaesthetised the audience! A minor revolution in the mind-set of the attitude towards the teaching of anaesthesia crept in. Teaching in Anaesthesia belongs to the Postgraduate arena and it is illogical, irrelevant, anachronistic and nonsensical to list Anaesthesia as a “short-posting” aiming to teach undergraduates the principles in the PRACTICE of Anaesthesia. The advances in cardiopulmonary resuscitation (CPR) with the emphasis on the importance of the potency of the airway brought into focus the realization that the Anaesthetic Posting should be used to teach undergraduates the principles in caring for the unconscious, the Critically Ill. The Anaesthesiologist would be the logical teacher in this feld – Critical Care. The Anaesthesiologist induces unconsciousness using drugs/agents daily when administering general anaesthesia, ensures patency and protection of the airway (for oxygenation and carbon dioxide clearance while not allowing secretions or particulate material entry into the breathing passages and lungs). The Anaesthesiologist monitor and support the vital systems (the Brain, Heart, Lungs, Liver and Kidney) while administering anaesthesia for invasive operative procedures. The Anaesthesiologist expertise in supporting the vital systems can be used to teach undergraduates the principles of how to Resuscitate the sudden or acute unconscious subject outside the operating theatre and the principles of how to support and care for the prolonged unconscious patient in the Intensive Care or High Dependency Wards. Control and Relief of Pain has always been a basic function of the Anaesthesiologist and can be the platform for teaching undergraduates the principles of caring for the patient in acute pain (postoperative analgesia, Obstetric Analgesia, trauma analgesia). The extension of the Anaesthesiologist roles in Caring for the Critically Ill, the unconscious has radically changed teaching in the short posting for anaesthesia in the medical undergraduate curriculum. Anaesthesiologist and Critical Care had Evolved.
Anaesthestic Training in Malaysia
Anaesthetic training after World War II (from 1945) was basically a postgraduate clinical apprenticeship for medical offcers “to give gas” for surgical operative procedures performed in the Ministry of Health (MOH) Service Hospital. Surgical Housemanship training included learning endotracheal intubation and administering basic inhalational general anaesthesia. Very few medical offcers (post-Housemanship) choose to take up Anaethesia as a Clinical Specialist career. This was the era when selected medical offcers were sent to England to sit for postgraduate degrees in the popular clinical disciplines (General Medicine, general surgery and obstetrics/Gynecology for the MRCP, FRCS, MRCOG degress). Anaesthesia was an unpopular clinical discipline because of its very technical beginnings- anyone who could pass a tube into the correct offcer or intubate the trachea was considered capable of giving gas. The surgical doctors underwent this technical training. Male paramedics were also trained to perform this task under the surgical doctor’s orders. The unpopularity of Anaesthesia continued because most doctors in the country have graduated from Singapore. Where there was no academic anaesthetic department in the medical faculty of the only university (initially a Medical College, from 1905, which became a Medical Faculty when the University of Malaya in Singapore was established in 1949/50). The University of Malaya, Kuala Lumpur was established in 1962 and the frst Medical Faculty was set up in 1962/63 with the various Non-clinical and Clinical Departments. A landmark in anaesthetic undergraduate education via the frst academic department commenced in Malaysia and Singapore with the establishment of such a department in the University of Malaya, Kuala Lumpur on 1st June 1965. This was followed by the completion of the frst University Teaching Hospital in 1967. The clinical experience/training confrmed in the Ministry of Health hospitals but Undergraduate Teaching and Education was conducted in the Medical Faculty, University of Malaya, Kuala Lumpur via the inaugural academic department of Anaesthesiology. The short-posting minor discipline listing and programming continued. Attracting doctors to take up anaesthesiology as a career in the frst medical school and teaching hospital in the country only took off when the Postgraduate Training programme was establish to prepare local candidates to sit for foreign (UK and Australia) Fellowship examinations. The commencement of local postgraduate training (the four years Clinical Masters Degrees) the local clinical specialization and certifcation in the mid- eighties dramatically changed the attitude towards the discipline of Anaesthesiology. Obstetrics/Gynecology and Anesthesiology were the two clinical felds which attracted the biggest numbers of medical offcers from the Ministry of Health to follow the local Clinical Masters Degree course in the Universities (University of Malaya with its own teaching hospital and the National University of Malaysia)! It was the establishing of the local Clinical Masters in Anaesthesiology that changed the Ministry of Health’s initial retrogressive plan in the late 1970’s to develop a paramedic programme to train technical “anaesthetists” (non-doctors) as an attempt to solve the chronic intractable problem of the unpopularity of Anaesthesia as a career choice for local doctors. It was a back to the future project resurrecting the servile beginnings of Anasethesia for surgery.
Postgraduate teaching and training in Anaesthesiology brought in new concepts in the 1980’s and 1990’s, and opened up new awareness for the clinical contributories roles of the Anaesthesiologist. The changing image of the Anesthesiologist as a physician/surgical based clinical specialist playing a crucial role the Team Management of the unconscious and the Critical Ill emerged. Anaesthesia for Surgery became Peri-Operative Care (Pre-Intra-and Post-Anaesthesia) essentially involved in patient-care safety and pain relief.
The Anaesthesiology expertise in Airway support and Cardio-pulmonary resuscitation (CPR) contributed to the development of Resuscitation (Care of the acute unconscious. The Anaesthesiologist expertise in monitoring and supporting the vital systems (Medically and pharmacologically) led to the development of the concept of Intensive Care (caring for prolonged unconscious).
One can now appreciate how advances and changing concepts/attitudes in casing for the unconscious, the critically ill have infuenced the listing (15th June 2009) of the Anaesthesiologist on the recently established National Specialist Register as under “Anaesthesiology and Critical care”. Critical care can now be accepted as Peri-operative Care, Resuscitation, Intensive Care and Pain Relief. The masked mysterious doctor (some people still do not know he is a doctor!) has been unmasked and he/she is accepted as a Clinical Specialist who cares for the unconscious, for the critically ill.
* (This is Part I. Part II will be published in the next issue of the newsletter)
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Running into its 6th year, the annual Paediatric Anaesthesia & Analgesia Workshop was held in the East Coast of Malaysia. Attended by 35 Specialists and Medical Offcers, the frst day of the workshop featured a series of lectures encompassing various aspects and issues on paediatric anaesthesia and neural axial blockade in children. Two case discussions concerning fuid resuscitation and an obstructed airway were also presented. The second day focused on hands-on practical sessions in the Operating Theatres.
A total of ffteen surgical cases (mainly inguinal hernia and circumcision) and four orthopaedic cases (three on upper limb blocks and one on lower limb block) were arranged for the operating theatre sessions. Faculty members including invited faculty, Dr Nik Azizah Junoh and Dr Ruwaida Isa, demonstrated the various central and peripheral nerve blocks and guided the participants, who were given the opportunity to perform these blocks.
The “Fluid, Electrolytes & Blood Transfusion in Children” handbook, which was written by Dr Sushila Sivasubramaniam, Prof Dr Lucy Chan and Dr Felicia Lim was also launched by the Deputy President of College of Anaesthesiologists, Dr Mohd Namazie Ibrahim. This handbook contains the basic principles and guidelines on fuid, electrolytes and blood transfusion for paediatric patients. Copies of the handbook were distributed to all participants.
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The ICU Care Bundle Seminar was held at Regency Specialist Hospital, Bandar Seri Alam, Masai Johor on the 3rd October 2009, in collaboration with the Intensive Care Section, Malaysian Society of Anaesthesiologists. The target group of the half-day seminar was ICU and CCU nurses in the private hospitals in the Southern region, aimed at reeducating and inculcating strict compliance to standard regime in caring for critically ill patients in ICU.
The seminar received overwhelming response from not only private hospitals but also public hospitals in the Southern region. It was attended by more than 110 participants. The topics discussed in the seminar included all the components of the Ventilator Care Bundle (Head of Bed Elevation; Sedation Algorithm & Sedation Vacation; Stress Ulcer Prophylaxis & DVT Prophylaxis) and the Central Venous Catheter Care Bundle (Hand Washing; Maximal Barrier Precaution; Chlorhexidine Skin Antisepsis; Catheter Site Selection & Daily Review). The three speakers representing the MSA were Dr Tan Cheng Cheng, Dr Jenny Tong and Dr Tai Li Ling.
The effort by the Intensive Care Section of MSA to narrow the gap of continuous education between ICU nurses in the public hospitals and those in the private hospitals should be acknowledged and lauded.
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