Typhoid fever remains a common problem in Malaysia, but for its diagnosis both blood culture and the Widal test have drawbacks. A dot enzyme immunoassay (EIA) has been developed which detects IgM and IgG antibodies to a specific 50 kDa outer membrane protein on Salmonella typhi. This study was performed among outpatients attending the university hospital in Kelantan, a state on the east coast of Peninsular Malaysia where typhoid is endemic. The dot EIA was done on 149 outpatients of all ages in whom typhoid was suspected. Of these, 60 were not analysable due to insufficient data. The other 89 were retrospectively classed as typhoid (total = 21), or not typhoid (total = 68). The criteria for diagnosis of typhoid was either, blood culture was positive, or with blood culture negative, temperature was at least 38 degrees C and Widal O and/or H titer greater than or equal to 1/160. We then compared the diagnosis with the EIA result. For the result where either IgM or IgG was positive, sensitivity was 90%, specificity 91% and negative predictive value 97%. For IgM positive, specificity was 100%. But the specificity of IgG positive alone was reduced by six false positives, which were probably due to persistence of IgG after acute infection. Other cases were found where IgG positive alone appeared in the first week of typhoid fever, probably due to rapid response in a second or subsequent infection. We also found that IgM-producing patients were significantly younger than those showing IgG alone positive.
Study site: Community Medicine clinic, Accident & emergency department, Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia
Chest pain is a common presenting complaint in the emergency room of which acute aortic syndrome is a sinister cause associated with high morbidity. A contrastenhanced CT aortogram is often performed for initial evaluation at the first instance of suspicion. We present a patient with Stanford Type A intramural haematoma complicated by haemopericardium and acute cardiac tamponade and highlight the relevant CT signs that would alert the managing physician to urgent echocardiogram correlation and emergent cardiothoracic intervention.
Although a vital test, blood culture is often plagued with the problem of contamination and false results, especially in a chaotic emergency department setting. The objectives of this pilot study is to find out the level of understanding among healthcare staffs in emergency department, Hospital Universiti Sains Malaysia (HUSM) regarding good blood culture sampling practice.
Trauma is an ever increasing problem and it is the leading cause of morbidity and mortality in the under 40s age group. The main purpose of this study is to determine the pattern of death related to trauma cases presenting to the emergency department (ED) of a university hospital. This was a retrospective analysis of 75 consecutive trauma case records at a university hospital for a one year period. The most common cause of deaths is motor vehicle crashes. The mean score for the injury severity score (ISS) and revised trauma score (RTS) on arrival to the ED among the succumbed patients were 27.8 (s.d 8.6) and 5.7 (s.d 1.1) respectively. 58.7% of deaths occurred within 48 hours after the admission. Less than 50% of studied patients were still alive beyond 45 hours post admission and less than 10% still alive beyond 11 days. Our analysis also showed that 28% (n=21) and 56% (n=41) of the studied sample had a probability of survival between 50% to 75% and more than 75% respectively upon arrival based on the initial vital signs in the ED and the trauma and injury severity score (TRISS) methodology. Overall, we observed similar injury mechanisms, demographics and causes of death compare to other studies. The figures from this study, mandate further exploration of preventive issues and management improvements that should be applied not only to the current trauma system, but also to the health care system in general.
INTRODUCTION: Our study was to examine prevalence and treatment outcomes of medical emergencies at two urban public health clinics in the Petaling district, Selangor, Malaysia.
METHODS: A prospective universal sampling was employed to recruit all emergencies over one month period (12 April to 11 May 2011). A structured case record form was used to capture demographic data, whether the index case was selfpresenting or decided by health care workers as a medical emergency, presenting complaints, diagnoses, concurrent chronic diseases and their treatment outcomes at the clinic level. Emergency presentations and diagnoses were classified according to the International Classification of Primary Care, revised second edition (ICPC-2-R).
RESULTS: A total of 125 medical emergencies with 276 presenting complaints were recorded. The mean age was 30.7 years old (SD 19.9). The prevalence of medical emergency was 0.56% (125/22,320). Chief complaints were mainly from ICPC-2-R chapter R (respiratory system) and chapter A (general and unspecified), 40.0% and 28.0% respectively. The most common diagnosis was acute exacerbation of bronchial asthma (34.6%). Forty percent were referred to hospitals. After adjusting for age and gender, patients who presented with painful emergency (OR 4.9 95% CI 2.0 to 11.7), cardiovascular emergency (OR 63.4 95% CI 12.9 to 310.4) and non-respiratory emergency were predictors of hospital referral (OR 4.6 95% CI 1.1 to 19.1).
CONCLUSION: There was about one medical emergency for every 200 patients presenting to these urban public polyclinics which were mainly acute asthma. More than half were discharged well and given a follow-up.
Study site: Klinik Kesihatan Seri Kembangan and Klinik Kesihatan Puchong, Selangor, Malaysia
A report of a patient with Lazarus phenomenon (the return of spontaneous circulation after cardiopulmonary resuscitation) following cardiac arrest (myocardium ischemia) is presented. A 65 year patient was found unconscious at home. He taken to the emergency department On arrival he was unconscious, his pupils fixed and dilated bilaterally. Resuscitation proceeded for 55 minutes. He was then pronounced dead. Forty minutes later spontaneous breathing was noted and his blood pressure was 110/48 and heart rate 90bpm. He survived a further 13 days in the coronary care unit. The implications for management of cardiac arrest in the emergency and medical department are discussed.
INTRODUCTION: The importance of early recognition and treatment of sepsis and its effects on short-term survival outcome have long been recognized. Having reliable indicators and markers that would help prognosticate the survival of these patients is invaluable and would subsequently assist in the course of effective dynamic triaging and goal directed management.
STUDY OBJECTIVES: To determine the prognosticative value of Shock Index (SI), taken upon arrival to the emergency department and after 2 hours of resuscitation on the shortterm outcome of severe sepsis and septic shock patients.
METHODOLOGY: This is a retrospective observational study involving 50 patients admitted to the University of Malaya Medical Centre between June 2009 and June 2010 who have been diagnosed with either severe sepsis or septic shock. Patients were identified retrospectively from the details recorded in the registration book of the resuscitation room. 50 patients were selected for this pilot study. The population comprised 19 males (38%) and 31 females (62%). The median (min, max) age was 54.5 (17.0, 84.0) years. The number of severe sepsis and septic shock cases were 31 (62%), and 19 (38%) respectively. There were 17 (34%) cases of pneumonias, 13 (26%) cases of urological sepsis, 8 (16%) cases of gastro intestinal tract related infections and 12 (24%) cases of other infections. There were a total of 23 (46%) survivors and 27 (54%) deaths. The value of the shock index is defined as systolic blood pressure divided by heart rate was calculated. Shock Index on presentation to ED (SI 1) and after 2 hours of resuscitation in the ED (SI 2). The median, minimum and maximum variables were tested using Mann-Whitney U and Chi square analysis. The significant parameters were re-evaluated for sensitivity, specificity and cut-off points. ROC curves and AUC values were generated among these variables to assess prognostic utility for outcome.
RESULTS: Amongst all 7 variables tested, 2 were tested to be significant (p: < 0.05). From the sensitivity, specificity and ROC analysis, the best predictor for death was (SI 2) with a sensitivity of 80.8%, specificity of 79.2%, AUC value of 0.8894 [CI 95 0.8052, 0.9736] at a cut-off point of > or = 1.0.
CONCLUSION: (SI 2) may potentially be utilized as a reliable predictor for death in patients presenting with septic shock and severe sepsis in an emergency department. This parameters should be further analyzed in a larger scale prospective study to determine its validity.
Ring removal is indicated in a number of clinical circumstances to manage or prevent tourniquet effect of the digit. A ring made from hardened metal may defy commonly known methods of removal. We reported a case of unusual difficulty in removing a ring of hardened metal composition using a dental drill. We believed the unusual circumstances of this case is likely to be repeated in some other clinical practice and this instrument is an appropriate option to consider in such cases.
In this study, we sought to determine whether laboratory and physiological parameters can be useful in predicting mortality in patients with sepsis-induced hypotension and septic shock.
Pain management in Malaysian Emergency Departments has not been studied well. Convenience sampling was used to recruit 402 patients who presented with acute pain over a 2-week period. The 11-point Numerical Rating Scale was used to quantify pain. Pain relieving medications were prescribed to 178 patients (44.3%) in the Emergency Department. These patients had a median pain score of 7 on arrival. Nonsteroidal anti inflammatory drugs were the most commonly prescribed class of analgesic. Pain was found to be inadequately treated.
The study compared the effectiveness of ketamine and midazolam/fentanyl as procedural sedation and analgesia agents for reduction of fractures and dislocated joints. Forty-one adult patients were enrolled by convenience sampling. They were randomized to receive ketamine or midazolam/fentanyl. Depth of sedation, pain score, procedural outcome and memory of the procedure were documented. The ketamine group had deeper sedation, but there was no statistical difference in other variables between the two groups. Three patients in the midazolam/fentanyl group had oxygen desaturation. More adverse effects were associated with ketamine. Intravenous ketamine is as effective as midazolam/fentanyl for procedural sedation.
Despite the progresses made in the science of cardiopulmonary resuscitation, there is lack of published works on this area in the Malaysian context. This survey was done to look at the outcomes of all cardiopulmonary resuscitation performed in Emergency Department (ED), Hospital Universiti Sains Malaysia (HUSM). This is a one year cross-sectional study from March 2005-March 2006. All adult cardiac arrest cases with CPR performed in ED, HUSM were included in the survey. The end points are return of spontaneous circulation (ROSC) and survival to ward admission. Out of the total 63 cases of cardiac arrest with CPR performed, only 19 cases (30.2%) had ROSC after CPR performed on them. Eventually only six patients (9.5%) had survival to ward admission. Patients with shockable intial arrest rhythm has a significantly higher chance to achieve ROSC (60.0%) compared to non-shockable rhythms (24.5%) (p = 0.025). However, there was no different in survival to ward admission between shockable and non shockable rhythms groups. The survival after cardiac arrest is still dismally poor. Perhaps we should be more selective in initiating CPR especially for out of hospital cardiac arrest.
Needlestick injury has been recognized as one of the occupational hazards which results in transmission of bloodborne pathogens. A cross-sectional study was carried out among 136 health care workers in the Accident and Emergency Department of two teaching hospitals from August to November 2003 to determine the prevalence of cases and episodes of needlestick injury. In addition, this study also assessed the level of knowledge of blood-borne diseases and Universal Precautions, risk perception on the practice of Universal Precautions and to find out factors contributing to needlestick injury. Prevalence of needlestick injury among the health care workers in the two hospitals were found to be 31.6% (N = 43) and 52.9% (N = 87) respectively. Among different job categories, medical assistants appeared to face the highest risk of needlestick injury. Factors associated with needlestick injury included shorter tenure in one's job (p < 0.05). Findings of this study support the hypothesis that health care workers are at risk of needlestick injury while performing procedures on patients. Therefore, comprehensive infection control strategies should be applied to effectively reduce the risk of needlestick injury.
Inappropriate utilization of Emergency Departments (ED) services may result in compromised management of patients requiring true emergency treatment. Significant attendance of non-emergency cases in ED was found in several countries. A cross-sectional study was conducted in Universiti Sains Malaysia Hospital (HUSM) to determine the proportion of the inappropriate cases and the utilization pattern by time (over 24 hours and within a week) and by diagnoses. A sample of 350 cases was randomly selected from ED-HUSM register of the year 2000. A decision flowchart, which was adopted from 4 guidelines, was applied to classify appropriate and inappropriate cases. There were 55% inappropriate cases in this study. The inappropriate cases increased considerably in early morning, late evening, during the weekend and early part of the week. Most common diagnoses of inappropriate cases were upper respiratory tract infections, mild acute gastroenteritis and urinary tract infections. Considerable attendance of inappropriate cases calls for interventions.
BACKGROUND: Good coronary care begins from the patient's home, including early transportation. As such, it is recommended that the patients activate ambulances, rather than to use their own transportations to reach the hospitals. It is not known whether Malaysian patients prefer to use private transportations or ambulances when they develop chest pain.
OBJECTIVES: This study is conducted to explore the question of the choice of transportation modes among patients with acute coronary syndrome and the reasons behind their choices.
METHODS: This is a structured interview survey on patients diagnosed with acute coronary syndrome (ACS) in emergency department of Hospital Universiti Sains Malaysia from April 2012 to September 2012.
RESULTS: Out of the 110 patients surveyed, 105 (95.5%) patients chose to use own transportation when they developed symptoms suggestive of ACS. Only 3 patients (2.7%) came to the emergency department within 1 hour of onset, and all these 3 patients chose to use ambulances as their modes of transportation. None of the patients who chose own transportation came within the first hour of symptoms onset. This is shown to be statistically significant (p<0.001). The level of education as well as past history of ischemic heart disease did not significantly influence the patients' choice of transportation.
CONCLUSION: The admonishment by various international resuscitation councils that patients with chest pain should be transported via ambulances may not be as straightforward as it seems. Numerous local and regional socio-cultural and logistic factors may need to be addressed.
INTRODUCTION: Aimed at providing integrated multi-level crisis intervention to women experiencing violence such as rape, One Stop Crisis Centre (OSCC) in Malaysia is often located in the emergency department. Hence, it is imperative that emergency department healthcare providers possess adequate knowledge and acceptable attitudes and practices to ensure the smooth running of an efficient OSCC work process.
METHOD: To study the knowledge, attitude and practice of rape management in OSCC among four groups of healthcare providers in the emergency department [i.e., the emergency medicine doctors (EDs), the staff nurses (SNs), the medical assistants (MAs) and the hospital attendants (HAs)], a selfadministered questionnaire in the form of Likert scale was conducted from January to October 2013. Correct or favourable responses were scored appropriately.
RESULTS: Out of the 159 participants invited, 110 responded (69.2% response rate). As all data sets in the Knowledge, Attitude and Practice sections are non-parametric, Kruskal- Wallis test was performed. Homogeneity of variance was verified using non-parametric Levene test. In all three sections, there are statistically significant differences in scores obtained among the four groups of healthcare providers with H(3) = 16.0, p<0.001 for Knowledge, H(3) = 27.1, p<0.001 for Attitude and H(3) = 15.8, p<0.001 for Practice sections. Generally, the SNs obtained the highest mean rank score in the knowledge and practice sections but the EDs obtained the highest mean rank score in the attitude section. Some of the responses implied that our healthcare providers have the victim-blaming tendency that can negatively impact the victims.
CONCLUSION: Healthcare providers must not only have adequate knowledge but also the non-judgemental attitude towards victims in OSCC.
Non-steriodal anti-inflammatory drugs (NSAID) are not only associated with bleeding in the stomach and duodenum, but can also complicate pre-existing diverticular disease of the colon. Here, a 58 year-old male with severe per rectal bleeding is presented and the role of NSAID as a causative factor of his problem is discussed.
A total of 37,152 patients attended the Accident & Emergency (A&E) Department of Hospital Universiti Kebangsaan Malaysia (HUKM) from 1st January to 31st December 1998. Attendance during early hours (midnight to 0659 hrs.) constituted only 10.4% (3853 cases) whereas that for three other time periods of 0700-1159 hrs., 1200-1759 hrs., and 1800-2359 hrs. was 29.4% (10,927 cases), 30.8% (11,448 cases), and 29.4% (10,924 cases) respectively. Two hundred and fifty-one patients were direct admissions from other hospitals into our hospital wards and they attended the A&E department for registration purposes only. Of the remaining 36,901 that were triaged, 196 (0.5%) were resuscitation cases [Triage 1], 3648 (9.9%) were emergency cases [Triage 21, 18,935 (51.3%) were urgent cases [Triage 3], and 14,122 (38.3%) were non-urgent cases [Triage 4]. Despite fluctuations in monthly patient attendance, the proportions of patients according to time of attendance, age group, gender and triage categories remained similar throughout. As majority of patients attended during convenient hours (89.6% from 0700-2359 hrs.) and a high proportion of patients (38.3%) belonged to the non-urgent Triage category, we feel that public emergency services are possibly being abused.
A study was undertaken to determine the assessment and management of adult asthmatic patients presenting to the Accident and Emergency department. The records of 50 consecutive adult asthmatic patients presenting to A & E with acute bronchial asthma between June 1993 to April 1994 were reviewed. Patients were also interviewed on their subsequent visit to hospital. Observations and measurements used to assess the severity of asthma were recorded with variable frequency--cyanosis 8%, inability to speak 2%, chest auscultation 64%, heart rate 10%, blood pressure 6%, respiratory rate 4%. The failure to record more objective measurements of severity of asthma and in particular extent of airflow obstruction is cause for concern. The drugs used to treat acute asthma in order of frequency were Beta agonists by nebuliser, 49 patients; intravenous aminophylline, 8 patients; and intravenous corticosteroids, 6 patients. 15 patients were admitted to the medical ward. The decision to admit patients appeared to be due to a lack of symptomatic improvement after treatment. Of the 35 patients who were discharged from A & E, 13 (37%) had an acute relapse within 10 days. None of the patients on discharge from A & E were given a short course of oral steroids or were advised an increase in steroid inhaler therapy. There was therefore a gross underuse of corticosteroids.
Study site: Emergency department, Hospital Muar, Johor, Malaysia