We report a case of a giant bullous emphysema misdiagnosed as a pneumothorax. A 18-year-old chronic smoker presented with right sided chest pain and dyspnoea. Initial respiratory rate was 35 /min, blood pressure was 136/90 mmHg, heart rate 80/min and SpO2 was 98% on room air. Clinical examination revealed reduced right air entry and left trachea deviation. Chest X-ray helped to arrive at a diagnosis of pneumothorax. Needle aspiration was then performed followed by a chest tube thoracostomy because of no improvement. Massive amount of blood was drained and patient deteriorated further. CT thorax revealed a right haemopneumothorax with multiple bullaes. Patient was rushed to OT for emergency thoracotomy for stapling of the ruptured bullae. Giant bullous emphysema can mimic pneumothorax and physician must be vigilant if draining a suspected pneumothorax.
Emphysema

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.

Orogastric lavage has been performed since 200 years ago for intoxicated patients. Due to the risk that outweighs benefits it has fallen out of favour for the last decade. A teenage girl presented to Emergency Department with history of ingestion of a bottle of pesticide within the time frame before gastric emptying. The girl was resuscitated, intubated and orogastric lavage was performed. Fifty cc of the toxic substance was siphoned and antidote of the toxin was administered. She was admitted to the Intensive Care Unit, subsequently recovered and discharge five days later. Definitive airway management, proper technique, correct selection of patients and adequate monitoring are paramount to the success of orogastric lavage.
Gastric Emptying

Urban cities are synonym with a high incidence of penetrating chest injuries either from accidents or interpersonal violence. The outcome of penetrating chest wound can vary from immediate death to a prolonged morbidity. We here report a case of 39-year-gentleman who presented to Emergency Department Hospital Raja Permaisuri Bainun, Ipoh, Perak after being stabbed to the chest. His anterior penetrating chest wound was located at the 5th intercostal space medial to the midclavicular line. The stab wound penetrated the myocardium, causing minimal myocardial rupture. He also suffered from left haemothorax and hemopericardium. The haemothorax was drained with insertion of 32 French chest tube. The patient was admitted under the cardiothoracic team and discharged five days later without surgical intervention. He presented again to the Emergency Department with complains of shortness of breath and pleuritic pain. A left ventricular thrombus was detected via echocardiography. Unfortunately, he took his own discharge. Five days later he came again to Emergency Department with sporadic of loss of vision. The mural thrombus dislodged and embolized to the retinal artery causing amaurosis fugax. The patient was treated with aspirin 150mg and his symptoms subsequently resolved.

This study assessed the level of public awareness pertaining to risk factors,symptoms, treatment and source of information in relation to stroke and transient ischaemic attack. Stroke risk profile of the respondents was correlated with their level of knowledge. Using a validated pre-tested questionnaire, 112 respondents were recruited during two separate community events. Respondents completed the questionnaire and underwent health screening. The data were analysed using SPSS version 20. Overall knowledge was poor. Only 35% of the respondents had satisfactory knowledge of the warning signs (p= 0.94) and 29% had satisfactory knowledge on the risk factors (p=0.46). When analysed according to risk groups, 26%, 30% and 41% of respondents had satisfactory awareness in the low, intermediate and high risk group, respectively. None of the respondents knew about the availability of treatment of acute stroke in the emergency department or the importance of rehabilitation as part of stroke management. Public awareness on stroke risk factors, symptoms and management is poor.
Stroke

Data on knowledge, attitude and ST Elevation Myocardial Infarction (STEMI) electrocardiography (ECG) detection among pre-hospital paramedics in Malaysia is still scarce. It is imperative to gain this information as a pre-requisite in initiating pre-hospital thrombolysis. This was a descriptive study conducted from May 2016 until November 2017 on paramedics from Universiti Kebangsaan Malaysia Medical Center (UKMMC) and Kuala Lumpur Hospital (HKL). It was to assess knowledge on pre-hospital thrombolytic therapy and ECG detection of STEMI. One hundred and six questionnaires were answered and analyzed. More than 60% of the candidates were unable to detect STEMI ECG changes and lacked of confidence in handling and administering thrombolytic treatment at the level of pre-hospital phase. Only 20.8% candidates managed to detect more than 8/10 of the correct ECG pattern in STEMI. Less than 40% of the candidates achieved more than 80% marks in answering questions regarding STEMI and treatment. It is concluded that the overall performance and knowledge of paramedic regarding pre-hospital thrombolytic therapy is generally poor. Further training need to be done prior to implementing pre-hospital STEMI thrombolytic therapy in Malaysia.

Door to needle (DTN) time for thrombolysis in the Emergency Department, Universiti Kebangsaan Malaysia Medical Centre (ED, UKMMC) is an indicator that can reduce mortality and morbidity of patients with ST Elevation Myocardial Infarction (STEMI). This study was conducted to determine factors that influence DTN time for acute ST Elevation Myocardial Infarction (STEMI) and whether it has achieved the recommended time of 30 minutes. A cross-sectional study was conducted among patients diagnosed with acute STEMI and thrombolysed in ED, UKMMC from June 2016 until March 2017. A data collection sheet was used to collect patient’s demographic data and clinical data which included time of arrival to ED, time of initial electrocardiogram (ECG), time of drug preparation and time of thrombolytic delivery to the patient. A total of 98 patients were included in this study. Majority of patients (77.6%) were thrombolysed more than 30 minutes following ED arrival. Mean DTN in ED, UKKMC was 59.28 + 36.01 minutes. The mean door to ECG time was 7.19 + 8.08 minutes and the mean drug preparation time was 9.86 + 7.51 minutes. Out of 76 (77.6%) patients that were thrombolysed after 30 minutes of ED arrival, 59.2% (n=45) were due to multiple disciplinary referral. Other factors were delay in performing initial ECG 19.8% (n=15), incorrect initial ECG interpretation 9.2% (n=7) and unavoidable need for prior resuscitation 9.2% (n=7). As a conclusion this study showed that there was an unacceptable delay in hospital thrombolysis for acute STEMI.

This study determined factors that influence usage of automated external defibrillation (AED) on out-of-hospital cardiac arrest among paramedics in Emergency Department of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). It was a cross sectional prospective study conducted between December 2013 and January 2014. Paramedics from Emergency Department were enrolled and assessed using the self-filled questionnaire consisting of multiple sections including knowledge assessment, training and practice. In total, 53 paramedics participated in this study. Only 62% participants used AEDs previously. Not more than 83% participants admitted that they would use it if required. A positive correlation was observed between age and work experience with knowledge on AED usage (p=0.001 and p=0.005, respectively). Government’s institute graduates possess better knowledge and higher confidence level than private institutions graduates (p<0.001). Positive correlation existed between working experience and confidence level in deciding to use (p=0.006), application (p=0.019) and troubleshooting in regards of AED use (p=0.002). The main factor for low confidence level of AED use was lack of training (73.6%) which resulted in reduced confidence to initiate use (45.3%). Eighty eight percent agreed that training is essential before any AED use. Forty one percent felt that Malaysian public is not ready for AEDs use. As a conclusion, AED usage and knowledge among paramedics is still poor and further training is crucial for the improvement of pre-hospital care in Malaysia.

Bystander rate of cardiopulmonary resuscitation (CPR) is still low worldwide because of inadequate skills and knowledge. Training the public on CPR is one of the methods to increase the bystander CPR rate. This study aimed to compare the efficacy in acquiring and retaining CPR skills and knowledge among secondary school students in Klang Valley trained by school teachers and medical students. We recruited five school teachers and five medical students as trainers. They were trained in several sessions by American Heart Association (AHA)-certified instructors using the video-assisted CPR training module. The recipients were 44 secondary school students divided between the teacher’s group and the medical student’s group. We compared knowledge and psychomotor skills between these two groups prior, immediately after and at three months after CPR training. Students in the teacher’s group showed a higher increase in knowledge comparable to the medical student’s group (median score difference 3 vs 2, p>0.05) and in psychomotor skill (median score difference 5 vs. 7, p<0.05). The level of knowledge and skills decreased after 3 months but remained significantly higher than at baseline for both groups. In conclusion, teachers could provide CPR training to their students as effective and retainable as medical students. This study aims to create an opportunity to teach CPR to the public in a larger scale.