Introduction to Community medicine อ.ชโนดม ICH1 2019

Introduction to
Community Medicine
Chanodom Piankusol, M.D. 
February 4th, 2020 
Department of Community Medicine, Faculty of Medicine, Chiang Mai University
COMMUNITY
MEDICINE
Outline
• Introduction to Community Medicine
• Example of Public Health work
- Improving Outcomes of Patients with OHCA
• Prince Mahidol Award Youth Program

Outline

Confusing terms
• Public health
• Community Medicine
• Social Medicine
• Preventive Medicine
The Distinction Between Public Health and
Community/Social/Preventive Medicine
• Community
Medicine
• Social • Public health

Medicine
• Preventive
Medicine
Preventive Medicine
• The term “Preventive Medicine" stems from a period in
the United States when public health was almost
exclusively concerned with the prevention of infectious
diseases.
• It was dominated by the medical profession.

Social Medicine
• “Social medicine” is a product of France, Germany,
Belgium and other European countries.
• Firmly based in the medical profession, it reflected a

concern with the role of social factors in the etiology of
disease, and the need for government action in the areas
of disease prevention and medical care.
• The term was widely adopted in Great Britain in the

1940s.
Community Medicine
• "Community medicine" became prevalent in the United
States as a substitute for “social medicine”, since the
latter term sounds too much like “socialism."
• Furthermore, use of the word “community” implies activity

at the local level rather than the national action abhorred
by the conservative leadership of the medical profession.
• In view of the growing trend toward political conservatism

in Great Britain, it is perhaps no accident that the term
“public health” has been oﬃcially dropped in that country
in favor of “community medicine”.
The Community/Social/
Preventive Medicine Concept
Public Health
• The concept of public health, on the other hand, is that of
a major governmental and social activity, multidisciplinary
in nature and extending into almost all aspects of society.
• The key word is “health”, not “medicine”; the universe of

concern is the health of the public, not the discipline of
medicine.
The Public Health Concept
The Distinction Between Public Health and
Community/Social/Preventive Medicine
Public Health
Medicine
Community/Social/
Preventive Medicine
Disease Prevention
Community  Hospital 
level level
Health service delivery system in Thailand :1,221 units(141,500 Beds)
Specialized (16,713)
hospitals University
40(11,441 beds) hospitals * 15
Private
Regional hospitals hospitals
33(23,953 beds) 282
Province (33,324)
Provincial hospitals Other public
83 (25,754 beds) hospitals
25
District District hospitals
780 (38,250 beds) Private clinics*
17,671
Sub-district Health centers Community Medical

Pharmacy*
9,579 Centers 365
17,017
MOPH facilities Local Government Units
1,000,000
Source : Size of private hospital: bed shares 2016 : * Thailand Health Profile, MOPH 2017 health volunteers
Health and Economic Burden of NCDs in Thailand
• Around 400,000 deaths/year (75% of total deaths)

• Societal cost of 2.2% of GDP
Injuries
Cardiovascul
NCD is #1 Killer
11%
Communicabl ar diease
e maternal, 29%
perinatal and
nutritional
conditions 8 out of 10 Biggest
18%
Burdens of Diseases
Other NCDs in Thailand are
12%
Diabetes
4% Chronic
Cancers
17%
NCDs
respiratory
dieases
9%
Proportional mortality in Thailand by cause of death, 2014
World Health Organization - Noncommunicable Diseases (NCD) Country Profiles ,
2014
Community Medicine at CMU
• First year
• Second year
• Third year
• Fourth year
• Sixth year
Outline

IMPROVING OUTCOMES OF PATIENTS WITH
OUT-OF-HOSPITAL CARDIAC ARREST IN THAILAND
Chanodom Piankusol, M.D.

PRINCE MAHIDOL AWARD YOUTH PROGRAM Scholar
Department of Community Medicine, Chiang Mai University
Department of Emergency Medicine, Emory University, Atlanta, USA
INTERNATIONAL
MENTOR
PROF. BRYAN FRANCIS MCNALLY, M.D.,

MPH.
• Executive Director, Cardiac Arrest Registry to

Enhance Survival (CARES)
• Department of Emergency Medicine, Emory
University
• Atlanta, Georgia, USA
THAI MENTOR
ASST. PROF. BORWON

WITTAYACHAMNANKUL, M.D., Ph.D., FTCEP
• Department of Emergency Medicine

• Faculty of Medicine, Chiang Mai University
OBJECTIVES
• Background
• Purposes and Methods
• Results
• Conclusions
• Future Perspective
• Take home message
• Acknowledgements
Disclosure: I do not have any relevant financial relationships with any commercial interests.
COMMUNITY Department of Community Medicine

MEDICINE Chiangmai University
BACKGROUND

In-Hospital
Cardiac Arrest
(IHCA)
Out of Hospital
Cardiac Arrest
(OHCA)

In-Hospital
Cardiac Arrest
(IHCA)
Out of Hospital
Cardiac Arrest
(OHCA)

In-Hospital
Cardiac Arrest
(IHCA)
Out of Hospital
Cardiac Arrest
(OHCA)

BACKGROUND
Out of hospital cardiac arrest (OHCA) is one of the leading
causes of death globally. No other medical emergency is
more dramatic than sudden cardiac arrest while also being
reversible with early treatment

“Every minute that the patient is untreated,
the chance of survival decreases by 10%."

THE SLOPE OF DEATH
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
1 2 3 4 5 6 7 8 9 10
COMMUNITY
MEDICINE
Minutes Department of Community Medicine
Chiangmai University
In Asia, the majority of adults experiencing OHCA have a
presumed cardiac etiology according to data collected from
seven Asian countries including Thailand by the Pan Asian
Resuscitation Outcomes Study (PAROS).

In Asia, the majority of adults experiencing OHCA have a
presumed cardiac etiology according to data collected from
seven Asian countries including Thailand by the Pan Asian
Resuscitation Outcomes Study (PAROS).

• Thailand does not have a standardized OHCA registry.
• Some local registries claim that the survival rate of OHCA in

Thailand is only 2.0-10.0%.
Time
Typical Urban Response
11:16-
00:30 02:17 03:44 09:16 09:16-11:16 13:16
Dispatch Wheels roll

PSAP Handling Turnout Travel At Scene With Patient Shock
00:30 01:47 01:27 05:32 01:00-02:00 01:00-02:00

6
Under Performing: No T-CPR, no HP-CPR, no Rapid Dispatch
100%
Turn out
90%
80%
70%
Defib 60%
Dispatch
50%
EMT CPR 40%

At scene
30%
20%
At patient side
10%
1 2 3 4 5 6 7 8 9 10
Minutes
PURPOSES & METHODS
• Explore and gather information on developed EMS systems

with better OHCA survival outcomes
• Create with a how-to guide for setting up various

programs/campaign within Thailand to help improve the
chain of survival

METHODOLOGY
Literature Review
Implementation in
Participation &
the local
Observation
communities
Course Training &

Conferences

Results

10 STEPS TO IMPROVE COMMUNITY
SURVIVAL RATES: RESUSCITATION
ACADEMY
FOCUS ON TIME AND QUALITY

LOWER HANGING FRUIT
• 1) Cardiac arrest registry
• 2) Telephone CPR
• 3) High-performance CPR
• 4) Rapid dispatch

(1) Establish a cardiac arrest registry

Why?
“You can't improve, if you don't measure.”

Department of Community Medicine
COMMUNITY
(2) Telephone CPR
(dispatcher/telecommunicator CPR)
(3) High-performance CPR with ongoing
training and QI
• HP-CPR stops the dying process
• BLS owns CPR
• Establish performance standard
(3) High-performance CPR with ongoing
training and QI
• HP-CPR stops the dying process

• BLS owns CPR
• Establish performance standard

(4) Rapid dispatch

HIGHER HANGING FRUIT
• 5) Measurement of professional resuscitations
• 6) AED for police and first responders
• 7) Smart technologies for public CPR and AED
• 8) Mandatory CPR/AED training in schools
• 9) Accountability to community
• 10) Culture of excellence

(5) Measurement of professional
resuscitations using the defibrillator recording
voice if possible
• Review all resuscitations!

• Voice recording is ideal
• Accurately determine CPR fraction
• Great teaching tool
• Should only be used for positive reinforcement

(6) Begin an AED program for first
responders, including police officers, guards,
and other security personnel.
• Must get buy-in from police, EMS, and fire

• Must be dispatched directly to an address
• Keep training simple (Hands-only CPR)
• Provide positive feedback
(7) Smart technologies for public
CPR and AED
• Alert the public
• Smartphone apps exist for this task
• PulsePoint, SMS Lifesavers, GoodSAM

(8) Make CPR and AED training mandatory in
schools and the community
(9) Work toward accountability – submit
annual reports to the community
(10) Work toward a culture of
excellence
10 Steps/Interventions
• 1) Cardiac arrest registry • 6) AED for police and
first responders
• 2) Telephone CPR
• 7) Smart technologies
• 3) High-performance CPR for public CPR and AED
• 8) Mandatory CPR/AED
• 4) Rapid dispatch training in schools
• 5) Measurement of • 9) Accountability to
community
professional
• 10) Culture of excellence
resuscitations
THE SLOPE OF DEATH
100%
90%
80%
70%
60%
50%
• FOCUS ON TIME AND QUALITY
40%
30%
20%
10%
1 2 3 4 5 6 7 8 9 10
Minutes
Under Performing: No T-CPR, no HP-CPR, no Rapid Dispatch
100%
Turn out
90%
80%
70%
Defib 60%
Dispatch
50%
EMT CPR 40%

At scene
30%
20%
At patient side
10%
1 2 3 4 5 6 7 8 9 10
Minutes
Average Performing: Delay in T-CPR, no Rapid Dispatch
100%
Turn out
90%
T-CPR 80%
70%
HP-CPR Defib 60%
Dispatch
50%
At scene
40%
At patient side
30%
20%
10%
1 2 3 4 5 6 7 8 9 10
Minutes
Best Practices: Rapid Dispatch, T-CPR, HP-CPR
100%
Turn out 90%
T-CPR 80%
HP-CPR
70%
Rapid
Defib 60%
dispatch
At scene 50%
40%
30%
At patient side
20%
10%
1 2 3 4 5 6 7 8 9 10
Minutes
Aspirational: Verified AED Responder
100%
Turn out
90%
Defib by verified responder
80%
75%
70%
Rapid
Dispatch + 60%
Activation of At scene
50%
AED alert
40%
At patient side
Stabilize 30%
20%
10%
1 2 3 4 5 6 7 8 9 10
Minutes
TIME & QUALITY MATTER
• Do it fast and and do it well.

• Only quality interventions (delivered quickly) can
snatch life from the jaws of death.

INTERVENTION MATTERS
• Interventions alter the slope of death.

• Not all interventions are created equal.

TIME MATTER
• We measure life in years but

resuscitation in seconds.
• Life is finite, death is eternal,

between the two we have about
10 minutes.

CONCLUSIONS
• Out-of-hospital cardiac arrest (OHCA)
• National effort
• Start from smaller units or local communities.
• No one-size-fits-all protocol or guideline
• National OHCA registry is essential.

CONCLUSIONS
• The Cardiac Arrest Registry
• determine if implementing changes cause improvements
• identify further steps for improvement.
• Pan-Asian Resuscitation Outcomes Study (PAROS)
• Free registry for EMS centers and hospitals.
• “It takes the entire system to save a life."

FUTURE PERSPECTIVE
• Start establishing the Thai OHCA National
registry
• Three University hospitals (Chiang Mai University,

Siriraj Hospital, and Narenthorn EMS center)
started collecting in 2018
• planning to expand to more local centers.
• received 30,000 USD in Grant through PAROS

FUTURE PERSPECTIVE
• Local community implementation;
• CPR and AED training in schools and local communities
• help from Thai Resuscitation Council(TRC)
• make the training mandatory
• Lifelong networking and mentoring

TAKE HOME MESSAGE
• Time and Quality of CPR

• Start with Collecting Data, Registry: Join us
• Help raise the awareness
• Implementation in the local levels

ACKNOWLEDGEMENTS
• Prince Mahidol Award Foundation
• Department of Emergency Medicine, Chiang Mai University,
Thailand
• Cardiac Arrest Registry to Enhance Survival (CARES)
• Department of Emergency Medicine, Emory University, Atlanta,
USA
• Georgia Poison Centre
• Resuscitation Academy, Global Resuscitation Alliance
• Pan Asian Resuscitation Outcomes Study (PAROS)
Outline

)น+ 6
)น+ 7
)น+ 8
)น+ 9
,ม   Community 
CMU Medicine
Orthopedics
Physiology
Ophthalmology
THANK YOU FOR
YOUR ATTENTION
chanodom28335@hotmail.com

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Introduction to

• Introduction to Community Medicine

• Example of Public Health work

- Improving Outcomes of Patients with OHCA

• Prince Mahidol Award Youth Program

• Introduction to Community Medicine

• Example of Public Health work

- Improving Outcomes of Patients with OHCA

• Prince Mahidol Award Youth Program

• Social • Public health

• It was dominated by the medical profession.

• Firmly based in the medical profession, it reflected a

• The term was widely adopted in Great Britain in the

• Furthermore, use of the word “community” implies activity

• In view of the growing trend toward political conservatism

• The key word is “health”, not “medicine”; the universe of

Sub-district Health centers Community Medical

• Around 400,000 deaths/year (75% of total deaths)

• Introduction to Community Medicine

• Example of Public Health work

- Improving Outcomes of Patients with OHCA

• Prince Mahidol Award Youth Program

Chanodom Piankusol, M.D.

PROF. BRYAN FRANCIS MCNALLY, M.D.,

• Executive Director, Cardiac Arrest Registry to

ASST. PROF. BORWON

• Department of Emergency Medicine

COMMUNITY Department of Community Medicine

COMMUNITY Department of Community Medicine

COMMUNITY Department of Community Medicine

COMMUNITY Department of Community Medicine

COMMUNITY Department of Community Medicine

COMMUNITY Department of Community Medicine

COMMUNITY Department of Community Medicine

COMMUNITY Department of Community Medicine

COMMUNITY Department of Community Medicine

• Some local registries claim that the survival rate of OHCA in

Dispatch Wheels roll

00:30 01:47 01:27 05:32 01:00-02:00 01:00-02:00

COMMUNITY Department of Community Medicine

EMT CPR 40%

• Explore and gather information on developed EMS systems

• Create with a how-to guide for setting up various

COMMUNITY Department of Community Medicine

Course Training &

COMMUNITY Department of Community Medicine

COMMUNITY Department of Community Medicine

FOCUS ON TIME AND QUALITY

• 1) Cardiac arrest registry

COMMUNITY Department of Community Medicine

COMMUNITY Department of Community Medicine

“You can't improve, if you don't measure.”

• HP-CPR stops the dying process

COMMUNITY Department of Community Medicine

COMMUNITY Department of Community Medicine

COMMUNITY Department of Community Medicine

• Review all resuscitations!

COMMUNITY Department of Community Medicine

• Must get buy-in from police, EMS, and fire

• Smartphone apps exist for this task

• PulsePoint, SMS Lifesavers, GoodSAM

EMT CPR 40%