Mui Teng Chua¹, Jin Ye Yeo²

¹Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²ATM Editorial Office, AME Publishing Company

Correspondence to: Jin Ye Yeo. ATM Editorial Office, AME Publishing Company. Email: editor@atmjournal.org

Expert Introduction

Dr. Mui Teng Chua (Figure 1) is Senior Consultant and Deputy Research Director at the Emergency Medicine Department (EMD), National University Hospital, Singapore and Assistant Professor at the Yong Loo Lin School of Medicine, National University of Singapore (NUS). She obtained her Master of Public Health in 2016 from the Saw Swee Hock School of Public Health, NUS. She was the inaugural Chief Resident of the National University Health System Emergency Medicine Residency Program.

She has strong clinical interests in emergency ultrasonography and critical care. She regularly conducts training of emergency medicine residents through ultrasound scan shifts and pioneered the use of high-flow nasal cannula oxygenation in the EMD.

As an avid clinician-investigator, Dr Chua has special research interests in critical care, infectious diseases and ultrasonography. She was awarded the National Medical Research Council New Investigator Grant in 2017 and has over 20 publications to her name, including one that was awarded the Annals of the Academy of Medicine, Singapore, Best Publication Silver Award in 2017. She has mentored several junior clinicians and medical students in their early research years.

Figure 1 Dr. Mui Teng Chua

Interview

ATM: What drove you into the fields of critical care and ultrasonography?

Dr. Chua: In emergency medicine, we see a spectrum of patients, ranging from those who are relatively well and ambulatory to those who are bedbound and critically ill. In emergency critical care, we deal with very sick patients who may have extremely low blood pressure or are imminently dying. I like that I can make positive differences to their outcomes by managing them in the emergency department (ED). When we attend to these acutely ill patients, everything moves very fast, from instituting treatment to conducting investigations. I feel a great sense of fulfilment when I observe their conditions improve at the bedside. Ultrasonography is a field that has been up and coming in recent years. Only in the past decade have we started doing more ultrasound scans at the bedside in the ED. Point-of-care ultrasonography (POCUS) functions like the modern-day stethoscope and allows us to obtain visual images, giving us real-time information about the patient’s condition and underlying pathology. For example, a cardiac POCUS would inform us of the patient’s ejection fraction or obvious structural abnormalities of the heart. Additionally, POCUS can even help us monitor response to treatment, such as fluid tolerance through serial lung ultrasonography. This adjunct has revolutionized the way we manage our patients.

ATM: Could you provide an overview of the advancements in ultrasonography over the years?

Dr. Chua: When I first started as an intern, the use of ultrasonography was not as widespread. In the past decade, ultrasonography has advanced drastically. We have now incorporated it into the residency training program, so all emergency medicine trainees will undergo a curriculum to perform and interpret bedside ultrasound scans proficiently. The ultrasound machines have been enhanced from before, in terms of image resolution and the integration of artificial intelligence (AI) algorithms for various measurements, such as ejection fraction. The portability of such devices has also improved into tablet- and mobile phone-sized handheld forms. There are even applications that can be downloaded onto one’s mobile phone and used with phone-compatible probes to do ultrasound scans. There is great potential for the primary care setting to take advantage of its portability, particularly in rural areas where advanced imaging modalities such as magnetic resonance imaging (MRI) are not available or accessible.

ATM: How have these advancements contributed to changes and progress in the Emergency Medicine Department (EMD) in Singapore?

Dr. Chua: The advancements have contributed to more rapid diagnosis and management of patients, as well as the right-siting of care. In the ED, we attend to undifferentiated patients, some of whom present with very vague symptoms. Previously for some conditions, we may have to admit them to the ward before a formal diagnosis was made. Currently, we can diagnose serious conditions such as pulmonary embolism at the bedside from POCUS findings, guiding decisions for further advanced imaging like computed tomography. Through increased experience and proficiency, diagnosis of conditions like deep venous thrombosis could be made in the ED, enabling earlier institution of treatment rather than awaiting admission to the wards for diagnostic workup.

ATM: Your team pioneered the use of high flow nasal cannula (HFNC) oxygenation in the EMD through the Pre-AeRATE trial (1). What were some concerns or unforeseen challenges that your team faced when conducting the Pre-AeRATE trial?

Dr. Chua: The logistics and coordination of the trial were quite challenging. Being a multicenter study, a lot of coordination and training of site investigators were required. We had to obtain buy-in from physicians and explain how they could help identify patients to be recruited into the trial. To minimize bias, we also aimed for consecutive enrolment where we would randomize patients round-the-clock. However, due to limited funding, we were not able to hire research assistants to cover all shifts and I had to answer calls at night to randomize the enrolment. That was part of the challenges but a good learning experience for me. Additionally for data collection, since it was such a critical condition where patients were seriously ill and required intubation, there was immense stress on the nurses and physicians to ensure the patients did not deteriorate while still ensuring data collection for the trial was accurate.

ATM: How did the results from the Pre-AeRATE trial affect apnoeic oxygenation strategies in the EMD?

Dr. Chua: From the trial, we found that HFNC oxygenation was not as useful for patients with good cardiorespiratory reserves. Those patients did relatively well even with routine management using 15 L/min of nasal prong oxygenation for apneic oxygenation instead of 60 L/min. Instead, HFNC oxygenation benefitted those with poorer cardiorespiratory reserves, such as those with heart failure and severe infection of the lungs, by prolonging safe apnea time. Presently, the criteria for using HFNC remain highly selective, so we select patients who may benefit more from HFNC, instead of using it as routine management.

ATM: In your opinion, what are some significant research gaps in the field of critical care?

Dr. Chua: Currently, we are still lacking reliable bedside point-of-care testing and more specific biomarkers. For example, during resuscitation for sepsis, we utilize lactate levels to guide our resuscitation endpoint. However, lactate itself is non-specific as it can be affected by many factors such as tourniquet time, concomitant medications, and the patient’s ability to clear lactate. Therefore, it remains as a surrogate to direct our resuscitation. Additionally, the turnaround time for results for biomarkers used in critical care is too lengthy. For example, serum procalcitonin level requires 1 to 2 hours to be obtained, which may be too delayed for the severely ill who require immediate treatment with antibiotics and fluid resuscitation. Ideally, these tests should be point-of-care and results should be obtained as fast as the finger prick test for glucose.

With the advent and trend towards personalized medicine, we are also lacking host response biomarkers. In infection, we detect bacterial growth in the blood using blood cultures. However, we do not know how the body responds to the bacteria. We often witness deterioration in patients as a result of the body’s own immune system rather than directly from the organism, a phenomenon demonstrated widely by the recent COVID-19 pandemic.

ATM: Could you share some ongoing projects you are currently involved in? Is there anything that you look forward to seeing in the next few years in the field of emergency medicine?

Dr. Chua: I am exploring the use of artificial intelligence (AI) and large language models, and how they can help with some administrative processes to reduce doctors’ administrative burden. These include answering patient complaints, drafting discharge summaries, and summarizing patient records. I am also working on medical technology and developing host-based biomarkers for identifying critically ill patients at the bedside. I am looking forward to seeing how AI can help us improve patient care, and also in developing bedside biomarkers that can be used as point-of-care.

ATM: How has your experience been as an Editorial Board Member of ATM?

Dr. Chua: My experience has been interesting. I highly enjoy writing the narrative reviews for the journal to summarize information and I can also choose the topics that I feel are more relevant and recent. The invited article that we wrote on the definition of translational medicine (2) was also very interesting as I had the opportunity to collaborate with board members from other countries.

ATM: As an Editorial Board Member of ATM, what are your expectations for ATM?

Dr. Chua: I hope the journal can assist in furthering our collaboration with international researchers. We can potentially link up with investigators from other countries to look at case series and epidemiology-related studies where we can pool information from different institutions and work on some large datasets to explore various topics such as trauma and sepsis.

Reference

1. Chua MT, Ng WM, Lu Q, et al. Pre- and apnoeic high-flow oxygenation for rapid sequence intubation in the emergency department (The pre-aerate trial): A multicentre randomised controlled trial. Ann Acad Med Singap. 2022;51(3):149-160. doi:10.47102/annals-acadmedsg.2021407
2. Zhang K, Cheng Y, Peng Y, et al. Scope highlights of Annals of Translational Medicine based on a review of the history, definition, and scope of translational medicine. Ann Transl Med 2023;11(11):381. doi: 10.21037/atm-23-1798