Proximal femur fracture in paediatric patients are very rare and can easily be missed especially when the history of trauma is so trivial, and associated with pathological fracture. We report a case of 6-year-old girl with a history of left knee pain following a fall from a height of 2 feet. She was treated as a soft tissue injury of the left knee as the left knee radiograph was normal. She was reassessed at day 3 of injury with worsening symptoms. Radiograph of the pelvis and left knee revealed a comminuted intertrochanteric fracture of left femur with an underlying bone cyst. We would like to highlight this case report to avoid missing a proximal femur fracture where a trivial trauma resulted In the presentation of a non-specific knee pain. Femur fracture in peadiatric age group can result in the significant complication of growth such as osteoporosis.
Leptospirosis adalah salah satu penyakit yang endemik di Malaysia. Ia mempunyai pelbagai manifestasi klinikal bermula daripada yang ringan sehingga yang boleh membawa maut. Kami melaporkan sebuah kes tentang seorang lelaki berumur 56 tahun dengan pelbagai masalah kesihatan terdahulu, dengan sejarah tidak sihat kerana demam, batuk dan sakit perut selama dua hari. Pesakit datang ke Jabatan Kecemasan dalam keadaan tidak sedarkan diri dengan Pulseless Electrical Activity (PEA) cardiac arrest. Pesakit telah diresusitasi dan berjaya dipulihkan dengan mencapai peredaran darah spontan (return of spontaneous circulation) tidak berapa lama selepas itu. Keadaan pesakit dirumitkan lagi dengan keadaan Hyperosmolar Hyperglycemic State (HHS), oliguric acute kidney injury, dan non- ST elevation myocardial infarction (NSTEMI). Pesakit kemudian dimasukkan ke unit rawatan rapi dan dirawat dengan IV Ceftriaxone 2 g sekali sehari selama empat hari, dan kemudian ditukar kepada IV Ceftazidime 2 g dua kali sehari untuk seminggu disebabkan ventilator acquired pneumonia (VAP). Keadaan pesakit bertambah baik dan akhirnya di benarkan pulang ke rumah pada hari yang ke 18.
Aspirasi bendasing boleh mengancam nyawa. Presentasi yang tidak tipikal dan kekurangan pengimejan diagnostik, telah membuatkan kecurigaan klinikal adalah penting. Kami ingin melaporkan kes aspirasi bendasing dalam seorang dewasa yang hadir ke Jabatan Kecemasan dalam keadaan yang tidak sedarkan diri. Lelaki berusia 31 tahun yang lumpuh disebabkan oleh keretakkan ‘cervical 7th fracture’ dihantar ke Jabatan Kecemasan selepas tidak sedarkan diri dan mengalami penurunan peratusan oksigen disebabkan oleh aspirasi bendasing. Ini adalah kes atipikal aspirasi bendasing pada pesakit yang berjaya didiagnosis dan dirawat menggunakan bronkoskopi fleksibel di Jabatan Kecemasan. Aspirasi bendasing pada orang dewasa sering diabaikan terutama jika ia tidak menyebabkan sesak nafas. Indeks kecurigaan yang tinggi diperlukan terutamanya untuk pesakit berisiko tinggi yang menunjukkan simptom atipikal. Bronkoskopi fleksibel dan ‘rigid’ adalah kaedah diagnosis dan rawatan pesakit yang disyaki aspirasi bendasing. Kesimpulannya, pelbagai jenis penemuan klinikal aspirasi bendasing yang tidak aspirasi dalam saluran udara pada orang dewasa telah dipaparkan. Faktor diagnostik yang paling penting adalah indeks klinikal curiga yang tinggi. Walaupun bronkoskopi ‘rigid’ terus menjadi instrumen pilihan untuk menghilangkan bendasing yang tidak aspisasi di saluran udara orang dewasa, tetapi bronkoskop optik gentian optik juga boleh digunakan dalam keadaan yang tertentu.
Emergency Department Overcrowding (EDOC) has been a longstanding problem. It is defined as a situation where the demand for emergency services exceeds the ability of an Emergency Department (ED) to provide quality care within appropriate time frames. Hospital beds closure or access block to ward admission is one of the most important cause of Emergency s e.g. disaster. A surge response entails even greater responses including implementing Department overcrowding. This could be compounded further in events of a patient surge eg affirmative measurement in order to mitigate the issue in tackling the situation. The steps in managing EDOC were: 1. Recognizing EDOC, 2. Initiating action, 3. Maintaining patient flow, 4. Setting clinical goals and 5. Deploying a Surge Team for Advance Triage or Fast Tract.
Damage control resuscitation, characterized by hemostatic resuscitation with blood products, rapid arrest of bleeding and when possible, permissive hypotension with restricted fluid load form a structured approach in managing a polytrauma patient. When complicated with traumatic rhabdomyolysis however, permissive hypotension strategy may cause more harm resulting in subsequent ischaemicreperfusion injury and acute kidney injury. We present a case involving a 20-yearold man who was rolled over by a lorry and sustained an open unstable pelvic fracture with vascular injury and left lower limb ischaemia. Permissive hypotension strategy was pursued for 4 hours prior to bleeding control in OT. This was followed by protracted surgery of 6 hours. Coagulopathy, acute kidney injury and rhabdomyolysis ensued in the post-operative period and patient succumbed to his injury on Day 3 post-trauma. Challenges and pitfalls in managing a complex polytrauma patient and recent evidences on damage control resuscitation is discussed.
Orbital cellulits is one of the life threatening event that should not be missed out and must be distinguished from preseptal cellulitis. It is an infective process involving ocular adnexal structures posterior to the orbital septum. High index of suspicion is the key to its diagnosis as even experienced physician can miss. Here, we present a case of a 15-year-old female who presented with progressive swelling over right forehead associated with high grade fever, headache and purulent discharge of the swelling. She was diagnosed with sepsis due to right forehead abscess and was treated with intravenous antibiotics followed with admission. However, she suddenly deteriorated in the ward which required intubation and thereby Intensive Care Unit (ICU) admission. Investigations revealed fluid collection at right retrobulbar space suggestive of an abscess where emergency drainage was carried out. Unfortunately, her condition worsened and patient succumbed at day-10 of admission, despite all efforts.
Acute appendicitis is one of the most common differential diagnoses for acute abdominal pain made by emergency doctors. Suspected cases require surgical referral for observation or definitive intervention to prevent complications. A high index of suspicion and good clinical skills with the aid of scoring systems allows early decision making, which includes optimal pain control. The objective of this study was to identify the pain score and is relationship to the cut-off points of the Alvarado scoring system so that justifies early surgical referral or discharge for suspected acute appendicitis from the Emergency Department of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). This was a cross sectional study of acute abdominal pain from June 2007 to September 2008. All patients who fulfilled the criteria and consented to the study were assessed for Alvarado score, verbal numerical pain score (VNRS) and their subsequent management. Patients with an Alvarado score of ≥7 were likely to have acute appendicitis (80.1% sensitivity and 52.63% specificity) and those with the score of ≤3 were unlikely to have acute appendicitis. The median pain score was 7.00 (IQR: 5.00-8.50) but 72.5% did not receive any analgesia. There was no direct relationship between the pain score with Alvarado score. Oligoanalgesia in patients with acute appendicitis still exist in Emergency Department of UKMMC.
Salah satu dari strategi untuk memperkasakan petugas kesihatan di dalam menentang kesan pandemik COVID-19 ini adalah melalui latihan yang berkesan. Keselamatan dan ketidak laziman merupakan dua perkara pokok yang menyebabkan modul ini dihasilkan. Modul latihan ini dibentuk berdasarkan tiga strategi utama iaitu belajar dari pengalaman lalu, mereka-bentuk modul latihan yang khusus, dan mengenal kelemahan yang ada. Modul yang dihasilkan ialah pemakaian-penanggalan alat perlindungan kendiri (PPE), pengurusan salur pernafasan dan resusitasi kardiopulmonari bagi pesakit yang disyaki COVID-19. Seramai 178 Perawat Kesihatan Barisan Hadapan (PKBH) telah dilatih. Setiap modul disertakan dengan senarai-semak yang mana peserta merasakan ianya sangat membantu. Tiada peserta yang jatuh sakit atau mengalami simptom setelah lebih dua minggu tamat latihan dan ini berkemungkinan hasil dari pelaksanan senarai semak persediaan pra-latihan yang ketat. Senarai semak pra-latihan ini mempunyai tujuh perkara penting iaitu ruang latihan, bilangan peserta, saringan COVID-19, pemeriksaan suhu badan, sanitasi tangan, PPE, dan pensanitasi peralatan sebelum dan selepas latihan. Latihan menggunakan senarai semak yang terarah didapati sangat membantu para petugas di dalam menguruskan situasi COVID-19. Kesimpulannya semasa menghadapai keadaan yang di luar kelaziman serta masa dan sumber yang terhad, latihan praktikal bersama senarai semak merupakan satu kaedah yang dapat membantu. Mengikuti langkah keselamatan pra-latihan yang betul juga boleh mengurangkan penyebaran penyakit ini.
This case series reports four patients who used religion and spirituality to relieve symptoms of post traumatic stress disorder (PTSD) following motor vehicle accidents. Their symptoms subsided after a few weeks and the recovery is sustained after one month. This demonstrates that in a country where psychological help is still scarce and religion is central to its culture, intervention based on spirituality and religion can be used as an alternative early intervention to relieve symptoms of PTSD and hence protects them from developing the condition.
Child birth is associated with severely painful experience for the parturient, and often exceeds one’s expectations. Even though, severe pain is non life-threatening condition in healthy parturient women, it may lead to undesired neuropsychological consequences. When no analgesia was used, postnatal depression may be more common, and this labour pain leads to the development of post-traumatic stress disorder. Epidural analgesia is now considered gold standard for effective pain relief during labour. We here report a case of a 37-year-old G1 P0 patient at term gestation who successfully used epidural analgesia for labour pain management.
Globally, stroke is the commonest cause of long-term disability. The residual disabilities among post stroke patients affect their daily living activities. The aim of rehabilitation therapy is to help stroke survivors to gain back their functional ability. The present study aimed to determine the relationship between post stroke duration with functionality status of post-stroke survivals at a teaching hospital in Kuala Lumpur. A cross-sectional study involved one hundred nine five post stroke patients who attended the Rehabilitation Clinic over a 4-month period. The data on post stroke duration was reveale from patient’s cleckship. Their functional status was assessed with Modified Barthel Index (MBI). Results showed the mean age of participants was 61 years (SD=13.86, range:22-87 years), with 118 males and 81 females having a median duration of 12 months post-stroke (range: 1-79 months). The prevalence 123 (63.1%) of stroke survivors are found to be dependent in their daily living activity. A Chi-square test for independence indicated there was significant relationship between post-stroke duration with levels of functioning, χ2 (2 , n=195) = 6.455, p<0.05,phi = 0.182. Patients in post-stroke duration of 13-24 months were independent (52.1) than ≤ 12 months and ≥ 24 months.
Keywords: functional status, post-stroke disability, mbi, activities of daily living, rehabilition therapy
Study site: rehabilitation clinic , Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
Stroke is frequently associated with long-term disability. Stroke leads to high risk of physical and neuropsychological consequences. Residual disabilities among post-stroke survivors can lead them to depression. This study aimed to determine the relationship between clinical characteristics and the levels of depression among post-stroke survivors at a teaching hospital in Kuala Lumpur. This cross-sectional study recruited 195 post-stroke survivors who attended follow-up Rehabilitation Clinic of a teaching hospital over a study period of 4 months. Information collected included socio-demographic, clinical characteristics (post stroke duration, stroke types and stroke severities) and level of depression. Beck’s Depression Inventory (BDI) was used to assess the level of depression. The mean age of participants was 61 years (SD=13.86, range: 22-87 years), with 118 male and 81 female survivors having a median duration of post-stroke of 12 months (range: 1-79 months). This study showed post stroke survivors 116 (59.5%) with depression. A Chi-square test for level of stroke severity was significantly associated with depression, χ2 (2,n=195) = 28.724, p
Uncontrolled bleeding due to pelvic fractures contributes to trauma-related morbidity and mortality. Three main strategies that have been outlined to combat this condition which include reduction of pelvic volume that lead to tamponade-like effect, arresting haemorrhage through angioembolization of the major vessels, and stabilization of the pelvic bone with external fixation need to be initiated early. A prehospital device that allow these strategies will aid significantly in the management of the patient. At present most devices used to treat pelvic fractures in the pre-hospital setting do have its’ own advantages but also have some limitations. A characteristic ‘wish-list’ of a good pelvic and lower limb immobilization device was created and the research team from UKM takes the challenge to design and produce a device that concurs to it. A two phase development project that incorporate anthropometric, biomechanical, cadaveric and radiological study was carried out over a period of seven years. Finally, BRIMTM immobilizer, a new pelvic and lower limb immobilization device that is user friendly, tough, cost effective, radiolucent, light and reusable that answers most of the requirement of a good device was invented.
Access to an intravenous (IV) route is very crucial in emergency patients under resuscitation. The difficulty to access and administer fluid and drugs through intravenous will influence the outcome of patient. In case of unavailable of intravenous route, the alternative is intraosseous access. To date, there is no data available on the prevalence and pattern of intraosseous cannulation knowledge among emergency paramedics in the published literature from our country, even though the use of intraosseous cannulation for emergency patients is being practices. Therefore, the purpose of the present study was to determine the level of knowledge regarding intraosseous cannulation among emergency paramedics. The knowledge related to intraosseous cannulation among emergency paramedics was assessed through structured validated test questions. Fifteen paramedics participated in this study. Majorities of participants were male (86.6%). The age group ranged from 22 – 45 old years. The working experiences were from two to thirteen years. There was only 1 out of 15 participants who had scored 75%. The majority (10) scored 40% to 50%. This suggests that necessity in teaching of intraosseous cannulation among emergency paramedics needs to be emphasised.
Patient-controlled analgesia (PCA) via an infusion pump enables patient to
administer their own analgesia. The aim of this study was to evaluate the effect
of an educational programme in managing post-operative pain and satisfaction
on PCA following orthopedic surgery. A pre-test and post-test interventional study
design with implementation of patient education programme on PCA was provided
to 54 respondents. The control group received conventional PCA briefing from
the Acute Pain Service protocol. Pain intensity was measured at 2 hrs, 6 hrs and
24 hrs following surgery and pre-test and post-test of the Revised American Pain
Society Patient Outcome Questionnaire (APS-POQ-R) was administered. There
was difference in respondents’ level of pain score among the study respondents’
medians for control group at 2 hrs, 6 hrs and 24 hrs following surgery and they were
7.00 (IQR=3.00), 5.00 (IQR=2.00) and 3.00 (IQR=2.00); intervention group at 2 hrs,
6 hrs and 24 hrs following surgery were 6.00 (IQR=2.00), 3.00 (IQR=1.00) and
1.00 (IQR=1.00) respectively. There were significant differences in median of pain
score between intervention and control group at 2 (U=142.0, p
Information technology use in healthcare education has become a popular
medium of instruction. One of the medium of instruction is video assisted learning
(VAL). The use of VAL as an instructional method in the teaching and learning of emergency skills is not new. However, there are lack of studies on the perception of
using this method in learning emergency skills. This qualitative study involved four
focused discussion groups following a VAL instruction on emergency skills. A total
of 20 paramedics were divided into four groups. They were involved in a focussed
discussion after a VAL instruction session. Findings reveal that the paramedics
perceived three major themes which were categorized as : i) advantages of video
as teaching tool, ii) barrier in using video as a teaching tool; and iii) suggestions on
using video as teaching tool. The findings indicate that the paramedics perceived
VAL as a potential tool for learning emergency skills. However, they suggested the
language of instruction should be in their mother tongue for better understanding.
This implies that using English language has disadvantage in technology enhanced
learning for better understanding.
The use of simulation as a teaching methodology in medical institutions has been in Malaysia for over two decades. This study aimed to evaluate the current scenarios of simulation impact and utilization in Malaysian academic healthcare institutions (AHIs). We conducted a population-based survey on all AHIs in Malaysia including public and private. We performed an online survey followed by a face-to-face interview evaluating the number of institutions that used simulation, duration of experience, purpose, funding, users’ category and healthcare domain, research activities, dedicated-trained staff and the challenges faced. Out of 75 healthcare institutions approached, 38 agreed to participate in this study. Twenty-two (57.9%) were public hospitals while 16 (42.1%) were private institutions. Thirty-five (92.1%) out of 38 institutions used simulation as a teaching method. The majority (15, 42.9%) had less than five years’ experience, and about a third (11, 31.4%) used simulation for teaching, training and performance assessment. Nurses (30, 26.1%) were the main users followed by physicians and paramedic (19, 16.5% each respectively). In-hospital and procedural group were the top two domains of utilizers. Almost three quarters (25, 71.4%) have dedicated support staff to manage the centre. Funding was mainly from internal institutional support mechanisms. Seven different categories of challenges were identified, the biggest being financial support. In summary, even though healthcare simulation has been in Malaysia for the past two decades but the most substantial impact happened over the last five years. Utilization was mainly for teaching, training, and performance assessment with minimal use in research.
Coronary Artery Bypass Grafting (CABG) surgery has increased the survival rate for individuals suffering from myocardial infarction or coronary ischemia. The present study aimed to examine the perception of quality of life amongst post CABG patients at the National Heart Institute Malaysia. A total of 69 post CABG patients, were studied using the Medical Outcomes Short Form 36 (SF-36). The findings showed that post CABG respondents possessed good level of quality of life (SF-36) physically and mentally. There were significant differences between the role physical in the physical functioning domains of quality of life with gender (t=0.286, p
Neck pain presents as a symptom of dull pain or discomfort mainly along the trapezius muscle. Dry needling is an invasive procedure which uses acupuncture needle directed at myofascial trigger points. The aim of the study was to evaluate the effectiveness of dry needling in managing patients with neck pain. A pre-test-post-test interventional study design was used. Patient education package was provided to 32 respondents who fulfilled the inclusion criteria. A 13-item Pain Catastrophizing Scale (PCS) questionnaire was used to assess Rumination, Magnification and Helplessness. Subjective pain intensity was measured by Visual Analogue Scale (VAS). These questionnaires were given before and after the dry needling intervention. The findings reported that respondents scored high in pre-test total PCS score (27.41±13.652). Post-test result revealed a significant improvement in total PCS score (23.06±13.938) (p = 0.000). Post-test VAS score (4.78±1.237) was also significantly better than pre-test (6.47±1.414) (p = 0.000). There was no significant difference in pre-test PCS in terms of marital status (p > 0.05) whereas there was significant difference between marital status and rumination in post-test (Z = -2.303, p = 0.021). There was significant difference between pre-test magnification in terms of respondents’ occupation (p = 0.008) and race (p = 0.035) but no significant difference in post-test. Respondents’ age group showed no significant differences between pre-test and post-test PCS and VAS (p > 0.05). In conclusion, patients who received dry needling showed improvement in pain intensity and catastrophizing towards neck pain.