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.

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.

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<0.001, phi = 0.384. The results of the present study showed that survivors with mild stroke had less depression (44.0%) compared to moderate stroke (81.7%) and severe stroke (87.5%).
Stroke ; Depression

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.
Computer-Assisted Instruction

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<0.05), 6 (U=150.50, p<0.05) and 24 (U=120.00, p<0.05) hrs following surgery. There were statistically significant differences (p<0.05) in the median of patient’s pain severity at all pain levels i.e. least pain, worst pain, and severe pain between intervention and control group (least pain, U=219.50, p<0.05; worst pain, U=117.0, p<0.05; severe pain, U=49.0, p<0.05). In conclusion, patients who received pre-operative structured education programme showed improvement in managing post-operative pain and satisfaction on PCA after orthopedic surgery.
Analgesia, Patient-Controlled

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.

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.
Stroke

Sexual dysfunction is highly prevalent in gynaecological cancer patients. Most of the time, sexual dysfunction in gynaecological cancer is underdiagnosed as there is overlapping of symptoms with other psychological morbidities, interplaying of multiple risks, patients’ reluctance to complain or incompetence of health care provider to assess. Determining the risk factors of sexual dysfunction in cancer patients enables us to pay more attention to those who are vulnerable and to device strategies for early detection, prevention and treatment of sexual dysfunction in them. The main aim of the study was to determine the prevalence of sexual dysfunction and its risk factors in gynaecological cancer patients in Hospital Sultanah Bahiyah, Alor Star, Malaysia. Sexual function of eighty-three gynaecological cancer patients who were married were assessed with self-rated MVFSFI (Malay version Female Sexual Function Index). Self-rated WHOQOL-BREF (World Health Organization- Quality of Life- 26) which assessed the domains of quality of life was used while MINI (Mini International Neuropsychiatry Interview) was used for diagnosis of major depressive disorder. The prevalence of sexual dysfunction among the married gynaecological cancer patients was 65% (54/83). Sexual dysfunction was significantly associated with low education level (OR 3.055, CI 1.009-9.250), shorter duration of cancer(OR 0.966, CI 0.966- 0.998), ongoing chemotherapy (OR 3.045, CI 1.149-8.067),pain perception (OR 3.230, CI 1.257-8.303), absence of sexual intercourse for more than one month (OR 1.862) and three domains of quality of life such as physical health, psychological health and social relationship (OR 0.942, CI 0.908-0.978; OR 0.955, CI 0.916-0.995; OR 0.933, CI 0.894-0.973, respectively). However, sexual dysfunction was not associated with major depressive disorder (χ2 ² = 1.224, p = 0.268). The prevalence of sexual dysfunction in gynaecological cancer patients was comparable to other studies of similar population. Since, the risk factors of sexual dysfunction in gynaecological cancer patients are multidimensional, the process of assessment and management need to be holistic and patient-oriented.
Sexual Dysfunction, Physiological