PROGRAM AND ABSTRACTS - PHC Malaysia · Mr Arun A/L Adi Mr Thiagarajan A/L Mutusamy Mr Muhammad Sazuan Bin Zakaria Mr Nik Mohd Nor Azam Bin Nik Aziz Mr Abdul Shakir Bin Zainal Abidin

Organized by:College of Emergency PhysiciansMalaysiaIn collaboration with:Asia Association of EMS (AAEMS)

In conjunction withEMAS MEETING 2019

PROGRAM AND ABSTRACTS

http://www.emsasia.org/subsectioncontent.php?secid=16&subsecid=14

https://www.mycep.org/

https://www.phcmalaysia.com/www.phcmalaysia.com

1ST PARAMEDICS ASIA 2019

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CONTENT

Welcome Address ......................................................................................................... 2

Organizing Committee ................................................................................................ 3

Expert Panels ................................................................................................................. 4

Paramedics Asia 2019 Program .............................................................................. 6

Abstracts – Oral Presentation ................................................................................ 10

Abstracts – Poster Presentation ............................................................................ 38

Acknowledgements ................................................................................................... 52


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Welcome Address

Friends and colleagues in the EMS fraternity, and honored participants of the 1st Paramedics Asia 2019 Conference.

On behalf of the organizing committee, I would like to extend my warmest welcome to all speakers and delegates participating in Paramedic Asia 2019.

It is an honor for me to have this opportunity to share some of my thoughts. For many of us involved in the Emergency Medical Services (EMS) and working in the PreHospital Care (PHC) arena, we are faced with the vast range and diversity of situations and challenges constantly in delivering equitable patient care daily.

It is demanding work that can often be strenuous both physically and mentally but it can also be an extremely rewarding experience when we see a victim on the brink of death brought back to life and priceless when they thank you for saving their lives. The impact of actions carried out by paramedics on communities reach out far and wide and paramedics are the “unsung heroes” in many a community.

In line with our theme this year: “Building Capacity, Strengthening Cooperation”, we hope the program prepared will serve as a good platform for all to share their experiences and learn from each other. Let us all network and update ourselves on the latest in EMS as well as find practical solutions or innovative ways to improve and address the many challenges of our work.

Organizing this conference would not have been possible without the dedicated support of the entire organizing committee and so I sincerely thank them all. My gratitude and appreciation also goes to all speakers, panelists, committed delegate paramedics and industry partners who have all contributed to make this conference a success.

Last but not least, wishing everyone a most fruitful conference and enjoyable stay here in Putrajaya!

Dr Kwanhathai Darin Wong Chair, Organizing Committee, 1st Paramedics Asia 2019 Putrajaya, Malaysia


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Organizing Committee

Advisor Dr Sarah Shaikh Abdul Karim

Conference Chairperson

Dr Kwanhathai Darin Wong

Conference Vice Chairperson Dr Low Mook Yuang

Secretary

Dr Umul Khair Mohamad

Treasurer Dr Leong Yuen Chin

Dr Jahlelawati Binti Zul

Secretariat Dr Mohd. Zaki Fadzil Senek Dr Ummar Qayyum Bin Ahmad Dr Lawrence Tan Chor Loon Mr Thiayagaraj A/L Sundarasan Mr Shamsury Bin Mohamad Majidi Mr Samsuri Bin Md Isa Mr Sufrie Bin Shukor Mr Mohd Hazlimi Bin Hazis Mr Ahmad Faizal Bin Azmi Mr Mohd Syazwan Bin Ramli Mr Khairul Nasrullah Bin Mohamad Mr Arun A/L Adi Mr Thiagarajan A/L Mutusamy Mr Muhammad Sazuan Bin Zakaria Mr Nik Mohd Nor Azam Bin Nik Aziz Mr Abdul Shakir Bin Zainal Abidin

Mr Ng Wei Hong Mr Mohamad Syaqimi Bin Mohd Norizan Mr Mohd Khairul Faiz Bin Kamarudin Mr Kwan Yong Kitt Mr Muhamad Najmi Nazuddin Bin Abdul Nasir Mr Tan Teik Kien Mr Vasanthan A/L Raja Mogan Mr Muhammad Haris Bin Ismail Mr Mohamad Shahriman Bin Mohamad Ms Siti Hasmani Binti Baharudin Ms Nur Azeka Binti Abdul Aziz Ms Noor Fatihah Binti Abdul Halim Ms Rozita Binti Ajis Ms Siti Aishah @ Badrini Abdullah


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EXPERT PANELS

Professor Ronald G. Pirrallo

Emeritus Director of Medical Services

Milwaukee County Emergency Medical Services

United States of America

Professor Hideharu Tanaka

Chairman and Professor of Graduate School Emergency Medical Systems

Kokushikan University

Japan

Professor Matthew Huei-Ming Ma

Vice Superintendent National Taiwan University Hospital Yunlin Branch

Taiwan

Dr Faith Joan C. Mesa-Gaerlan

Clinical Associate Professor University of the Philippines

College of Medicine

Philippines

Professor Brett Williams

Head of Department Monash University

Melbourne

Victoria

Australia

Dr David I. Page

Director Prehospital Care Research Forum at UCLA

Center for Prehospital Care

University of California United States of America


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Dr Sattha Riyapan

Assistant Hospital Director Siriraj Hospital Thailand

Col (Dr) Shalini Arulanandam

Chief Medical Officer Singapore Civil Defence Force

Singapore

Dr Teo Aik Howe Consultant Emergency Physician

Penang General Hospital Malaysia

Dr Chan Hiang Chuan

Consultant Emergency Physician

Sarawak General Hospital Malaysia

Dr Sarah Shaikh Abdul Karim

Consultant Emergency Physician Emergency and Trauma Department Hospital Sungai Buloh Malaysia

Dr Kwanhathai Darin Wong

Consultant Emergency Physician Emergency and Trauma Department Penang General Hospital Malaysia


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PARAMEDICS ASIA 2019 Program

Venue Paramedics Asia: Putra Hall B1

EMAS (plenary sessions): Putra Hall B2

DAY ONE:

07TH OCTOBER 2019 (MONDAY)

TIME SESSION SPEAKER/ EXPERT

PANEL

0830 –

0900

EMAS Plenary 1:

Building Capacity, Strengthening Cooperation

Dr Ridzuan Md Isa

0900 –

0930

EMAS Plenary 2 (PHC):

How to spend next RM2 to develop EMS system

Prof Dr Ronald G. Pirrallo

0930 –

1015

Opening Ceremony and Keynote Speech

EMAS and Paramedic Asia 2019

Chairpersons:

Dr Fazrul

Dr Elaynie

1015 –

1100

TEA TALK & BOOTH VISIT

1100 –

1300

PARAMEDIC ASIA: Medical Clinical Case

1. To start CPR or not to start CPR. The next best step in an austere environment (Kumbong Anak Ikau, Malaysia)

2. I had a thought but I did not speak (Olescyhthya Anak William, Malaysia)

3. Polymorphic VT (Shang Chiao Yang, Taoyuan, Taiwan)

4. Characteristics of EMS referral ST-elevation myocardial infarction patients: A retrospective cohort of single regional hospital (Szu-Chieh Huang, Taoyuan, Taiwan)

5. Stroke and a road traffic accident – every second count (Tay Guek Khim, Singapore)

Expert Panel:

Prof Brett Williams(Chief)

Dr Faith Joan Gaerlan

Dr Sattha Riyapan

Dr Teo Aik Howe

Chairpersons:

Mr Ahmad Faizal B Azmi

Mr Mohd Fadzlullah B

Abdullah

1300 –

1400

LUNCH TALK 1


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1400 –

1445

PARAMEDICS ASIA Plenary:

Dealing with Vulnerable Populations: Perspectives

From Two Paramedics Studies

Prof Brett Williams

Chairperson:

Mr Vasanthan a/l Raja

Mogan

1445 –

1615

PARAMEDIC ASIA: Kopitiam Talk

1. The impact of fires related to personal mobility device and power-assisted bicycle in Singapore (Kwek Qi Wei Jason, Singapore)

2. Reducing PTSD risk in paramedics: What factors are best for intervention? (Bernice Han, USA)

3. How PAROS grant initiates the paramedicine program in Indonesia (Suryanto, Indonesia)

4. Help! I am going to deliver the baby but not at the stadium (M Badrulhisham H, Malaysia)

Expert Panel:

Dr Sattha Riyapan (Chief)

Prof Matthew Ma

Col(Dr) Shalini

Arulanandam

Chairpersons:

Mr Shamsury B. Md Majidi

Mr Thiagarajan a/l

Mutusamy

1615 –

1700

KAHOOT-ING with the Experts:

PHC and Disaster

Dr Teo Aik Howe

Dr David Page

1700 TEA BREAK & END OF DAY 1

1615 -

1745

*AAEMS SEA Chapter Meeting

(Venue: Suite 7 Level G)

Dr Kwanhathai Darin

Wong


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DAY TWO:

08TH OCTOBER 2019 (TUESDAY)

TIME SESSION SPEAKER/ EXPERT

PANEL

0730 –

0900

PAPER Meeting

(Venue: Suite 7 Level G)

Dr Sarah Abdul Karim

0800 –

0830

EMAS Plenary 3 (Paediatrics Emergency Medicine):

Management and Care of Children during Disaster

Assoc Prof Jeremiah

Smith

0830 –

0900

EMAS Plenary 4 (Toxicology):

Asphyxiants and Inhalants: Management and

Precaution Strategies

Dr Anisah Adnan

0900 –

1050

PARAMEDIC ASIA: Special Situations

1. An ambulance call which turned to a hilux call (Billie Mesten Pang, Malaysia)

2. Transporting patient with bleeding placenta percreta (Lionel Jimbau, Malaysia)

3. PHC in PHC (pre-hospital care in primary health care) – The water ambulance of Sarawak (Paul Vicentjo Anak Digen, Malaysia)

4. Pasir Gudang chemical exposure: Importance of teamwork (Nor Yazjehan Bt Yahya, Malaysia)

5. I need help! Even GIRN refuses to help me (Ting Ching Ching, Malaysia)

Expert Panel:

Dr Faith Joan Gaerlan

(Chief)

Prof Matthew Ma

Col(Dr) Shalini

Arulanandam

Chairpersons:

Mr Rathina Kumar a/l Kriehnan Mr Samsuri B Md Isa

1050 –

1120

TEA TALK & BOOTH VISIT

1120 –

1310

PARAMEDIC ASIA: Trauma Clinical Case

1. Usage of Tranexamic Acid in hemorrhage control in pre-hospital care (Arun Saravanan, Malaysia)

2. Management of injured patient with femur fracture in pre-hospital setting: A case study (Jenpanitpong C., Thailand)

3. Management of traumatic cardiac arrest patient in pre-hospital setting: A case study (Nuanprom C., Thailand)

4. Why he does not response to my fluid resuscitation? (Rathina Kumar, Malaysia)

5. ‘Livewire’ in action (Edmund Philip, Malaysia)

Expert Panel:

Col(Dr) Shalini

Arulanandam (Chief)

Prof Ronald G. Pirrallo

Prof Hideharu Tanaka

Chairpersons:

Mr Muhammad Sazuan B

Zakaria

Mr Sufrie Shukor

1310 –

1400

LUNCH TALK 2


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1400 –

1445

PARAMEDICS ASIA Plenary:

Prehospital Care Solutions to Access Block?

Prof Ronald G. Pirallo

Chairperson:

Dr Jahlelawati Zul

1445 –

1655

PARAMEDIC ASIA: Different Shades of Grey

1. Violence 1: Self-reported incidence of verbal and physical harassment of EMS personnel in Singapore (Abdul Rahman, Singapore)

2. Violence 2: Managing different shades of agrressive in ambulance service (M Najmi NAR, Malaysia)

3. Resuscitation 1: Should I or should I not proceed? (Peter Kenny AK Nihang, Malaysia)

4. Resuscitation 2: The non-crispy rendang (Wan Nadzeri B Mohd Mohiadin, Malaysia)

5. Medical coverage 1: Ironman – The war within (Nik Riduan B Nik Lah, Malaysia)

6. Medical coverage 2: The volunteer EMS paradox: Helping in a mega mass gathering (Stephanie Reyes, Phillipines)

Expert Panel:

Dr Chan Hiang Chuan

(Chief)

Prof Brett Williams

Prof Hideharu Tanaka

Dr David I. Page

Chairpersons:

Mr Thiagarajan a/l

Mutusamy

Mr Ng Wei Hong

1655 –

1715

Closing Remarks for Paramedic Asia Dr Kwanhathai Darin

Wong


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ABSTRACTS – ORAL PRESENTATION

MEDICAL

TO START CPR OR NOT TO START CPR. THE NEXT BEST STEP IN AN AUSTERE ENVIRONMENT

Kumbong anak Ikau, Kar Ling Chin Malaysia

Case Description

We report a case of challenges in responding to cases of OHCA in the rural district of Kapit, Sarawak. Our team was dispatched to a case of generalized body weakness. We responded to the wharf and waited for the patient arriving in a longboat. We noted that the patient was gasping with GCS 3/15. To get to the ambulance from the boat is about 50 meters. The wharf ground was uneven with no proper area to unload the patient. Our team carried the patient up a slope into the ambulance before initiating CPR.

We informed our hospital regarding ongoing CPR. The hospital staff was well prepared and patient Return of Spontaneous Circulation (ROSC) at the Hospital.

Discussion

Early initiation of Cardiopulmonary Resuscitation (CPR) is vital to increase the chance of Out Hospital Cardiac Arrest (OHCA). However, in our response, CPR had to be delayed until we got the patient to our ambulance. We only had 3 staff during an ambulance call.

Lessons Learned

Despite hindrances to starting immediate CPR to ensure the safety of anyone; performing high quality of CPR as soon as condition permits also increase the chance of OHCA patients.

I HAD A THOUGHT BUT I DID NOT SPEAK

Olescynthya William, Kar Ling Chin Malaysia

Case Presentation

I would like to share a case with a trainee working with a senior. We responded to 66 years old, gentleman, who fainted after complaining of severe chest pain. Upon our arrival at the scene, the patient was weak, pale and diaphoretic. His pain score was 7/10. The patient was in shock and breathless with oxygen saturation of 77% on a high flow mask. An electrocardiogram was performed revealing Myocardial Infarction.

The senior ordered me to administer sub-lingual nitrate. I hesitated but said nothing. The senior then proceed to administer the medication himself. The patient collapsed upon arrival to the hospital and CPR was started. Unfortunately, the patient succumbed.


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The patient was at 5.40 am. I informed the SAMO that the patient was in shock as the Blood Pressure was 90/75mmHg, PR: 64/min, SPO2:77% under HFM. Using the Zoll monitor defibrillator available in the ambulance, I immediately did an ECG which revealed the SAMO ordered me to give the patient a S/L GTN.

Subsequently, he served GTN to the patient after seeing my hesitation.

Discussion

Doubting one’s capability and knowledge happens to everyone. Health care staff are not spared by this too. When I received that order, many thoughts passed through my mind. The patient was in shock and GTN might be contraindicated. I wanted to suggest to give aspirin instead but did not dare as I worry he might get offended. I also wondered why he did not call base for medical direction since it was an unstable patient, but I did not dare to voice out my concern.

Lesson Learned

The confidence to voice out opinions is important as sometimes it might make a difference to our patient.

POLYMORPHIC VT

Shang Chiao Yang Taiwan

Case Description

A 42-years old male who has no past medical nor allergy history. A bystander called 119 and got a PAD by the dispatcher’s advice then delivered electric shock once while he passed out at the time he was playing tennis and felt chest pain.

The patient got ROSC (return of spontaneous circulation, ROSC) when the EMT arrived. When they were ready to send the patient to the hospital, the patient got an altered state of consciousness on the ambulance and the Carotid pulse was absent. Once the EMT did the chest compression, the patient could wave his hands and made some voice. The rhythm of the AED was VF (ventricular fibrillation, VF).

The EMT got confused that was it AED malfunctioned or signal interference from the vehicle moving? Discussion Should we stop for rhythm-analysis on the way? Lesson Learnt When a patient still has action rhythm-analysis VF. We must shock it


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CHARACTERISTICS OF EMS REFERRAL ST-ELEVATION MYOCARDIAL INFARCTION PATIENTS: A RETROSPECTIVE COHORT OF SINGLE REGIONAL HOSPITAL

Szu-chieh Huang, Yi-ming Weng MD, Shang-chiao Yang Taiwan

Case Description

From July 2017 to March 2019, Taoyuan general hospital received 115 STEMI patients. 14 were medical-referred (12.2%), while only 20 (17.4%) were EMS-referred. 70.4% were self-referred. Among EMS-referrals, pre-hospital care providers considered 55% as emergent. An average response time, on-scene time, and transport time were 7.3, 4.7, and 6.4 minutes, respectively. The mean door-to-ECG, door-to-cardiologist consultation, and door-to-balloon (DTB) time were 3, 55, 74 minutes, respectively. 4 have died during admission (3.5%), and the mean length of hospital stay (LOS) was 4.8 days. 15% EMS referral patient presented with non-chest pain initially (vs 1.2% self-referrals, p=0.024). All EMS referred patients received oxygen therapy with 80% using oxygen mask or non-rebreathing mask. The comparison of variables between EMS- vs. self-referred groups showed no difference of door-to-ECG time: 4 vs 3 mins (p=0.821), cardiologist consultation time: 68 vs 58 mins (p=0.558), DTB time: 89 vs 76 mins (p=0.424), and the mortality rate:13.3 vs 3.1% (p=0.175).

Discussion

To improve the STEMI bundle of care, characteristics of EMS referral STEMI patients needs to be explored.

Lesson Learnt

The activation of the EMS system among STEMI patients remained low with initial non-chest pain complaints and complicated symptoms. The further strategy should focus on public recognition and activation among chest pain patients.

STROKE AND A ROAD TRAFFIC ACCIDENT – EVERY SECOND COUNT

Tay Guek Khim Singapore

Clinical Case Description

The EMS crew was dispatched to a case of Road Traffic Accident. The initial scene assessment was that a private car had collided into a lamp post. The car’s bonnet was dented with no cracks on the windscreen. The airbag was not deployed. There were 2 casualties – the driver and his rear-seat passenger. The driver was not trapped in the vehicle.


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However, the driver, a 72-year old Chinese male was unable to get out of the seat as he was not able to move his left extremities. The passenger was unharmed. According to the driver, he was traveling at 50km/hour when he lost control of the car and knocked into the lamp post at the side. He noted weakness over his extremities after the collision. However, the account obtained from the passenger noted that he was having difficulty in driving straight before the accident.

The driver presented with slurred speech with facial droop, and complained of numbness and was unable to move his left extremities. He denied neck or back pain. Urine incontinence was also noted. His right pupil was noted to be sluggish. He had a raised blood pressure of 193/113 and his blood sugar level was normal. The patient also had a medical history of Hypertension, Hyperlipidemia and Ischemic Heart Disease (IHD).

Discussion

The differential diagnoses are:

1) Traumatic Brain Injury

2) Neurological deficit due to spinal injury from the RTA

3) Cerebrovascular Accident

The account given by the passenger of the driver having difficulty driving straight raised the paramedic’s suspicion that the driver had experienced a stroke prior to the accident. The paramedic decided to convey the patient to the nearest stroke centre instead of the nearest hospital and alerted the hospital for a standby case of possible acute stroke. The patient underwent an MRI scan immediately and was diagnosed with an acute proximal middle cerebral artery occlusion. The patient was able to receive endovascular intervention within 4 hours and was discharged after a week in the hospital with complete neurological recovery.

Lesson Learnt

In this case, the thorough history and physical examination enabled the paramedic to discover the underlying stroke, instead of being distracted by the fact that it was a trauma case and stabilizing the patient according to trauma protocols. Close communication with the hospital to notify them of the case also enabled timely intervention to improve the patient’s outcome.


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KOPITIAM TALK

THE IMPACT OF FIRES RELATED TO PERSONAL MOBILITY DEVICE AND POWER-ASSISTED BICYCLE IN SINGAPORE

A. Lim, J. Kwek, L. Ang, S. Arulanandam, S. Shali Singapore

Background

There has been an increased use of personal mobility devices (PMD) and power-assisted bicycles (PAB) in Singapore as alternative transportation modes. However, such devices carry fire risks. This study aims to investigate the impact of PMD/PAB-related fires to the health of the users, and to describe some notable cases attended by the Singapore Civil Defence Force (SCDF) Emergency Medical Services (EMS) over the 2 years in 2017 and 2018.

Materials and Methods

PMD/PAB-related fires attended by SCDF were identified through a retrospective review of fire investigation reports by the SCDF Fire Research Unit (FRU). Where the fires resulted in injuries, the EMS patient records were studied. Variables studied include injury type, severity, and injured body region. Three notable cases resulting in partial-thickness burns and classified as Patient Acuity Category 1 (PAC 1) are described in this study

Results

Out of 123 cases of PMD/PAB-related fire incidents, 17 cases resulted in 44 injured persons, with 7 cases involved multiple casualties. 34 casualties were conveyed to the hospital, of which 7 (20.6%) were classified as PAC 1. 47.1% of the patients sustained only smoke inhalation injuries, and the remaining sustained burn injuries only or both. Most commonly, the upper limbs were injured. One notable case involved an adult patient who sustained smoke inhalation injury and 50% partial-thickness burn over the head, face, torso, and all limbs. Two pediatric patients sustained 40% and 7% partial thickness burn injuries respectively, affecting mostly the torso and limbs. In all cases, the patients were in the same room where the devices were being charged when they caught fire.

Conclusions

Although PMDs and PABs offer convenience and increased mobility, the fire risk, especially during the electrical charging process, carries a significant impact on public health. Increased public education may be needed to manage the fire hazards related to such devices.


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REDUCING PTSD RISK IN PARAMEDICS: WHAT FACTORS ARE BEST FOR INTERVENTION?

Bernice Han, Prof Steve Ryan USA

Background

United States (US) paramedics have double the risk of developing Post-Traumatic Stress Disorder (PTSD), 10 times the risk of suicide contemplation, and 13 times the risk of attempting suicide compared to the general US population. This descriptive, cross-sectional study compared PTSD/depression prevalence with multiple personal and organizational factors through an online survey (n=249) and interview (n=30) administered to a convenience sample of practicing paramedics.

Discussion

In this study, paramedics enjoyed the excitement and altruism but disliked the long shifts, low pay, poor equipment maintenance, and abuse and misuse of EMS for non-emergencies. Ninety-three percent experienced multiple traumatic incidents in the past year, 65% had PTSD/depression, and 27% had Alcohol Use Disorder. Incidents involving children, acquaintances, suicide, elder abuse, and violence were most traumatic. Higher PTSD/depression prevalence was found in participants who were female, mid-career, lacked colleague support, had poor job satisfaction, a greater number of traumatic exposures, and poor organizational communication or satisfaction. PTSD/depression rates doubled when paramedics had insufficient downtime to recover after a traumatic incident. Meanwhile, multiple pieces of training on how to emotionally handle traumatic incidents, having strong resilience and a sense of coherence and turning to religion correlated with lower PTSD/depression rates.

Conclusion

Providing emotional and psychological training and encouraging healthy coping strategies may reduce PTSD/depression prevalence in paramedics. EMS organizations can increase organizational satisfaction by allocating sufficient downtime, implementing shorter shift hours, paying a higher salary than commensurate with required skills, and cultivating a healthy work environment. Legal measures should be enforced to curb abuse and misuse of the EMS.


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HOW PAROS GRANT INITIATES THE PARAMEDICINE PROGRAM IN INDONESIA

Suryanto, Ali Haedar, Suryanto Eko Agung Nugroho, Purwoko Sugeng Harianto Indonesia

Background

Currently, nurses are responsible for providing prehospital care in Indonesia. However, there is no formal education for those nurses. A team consisting of emergency physicians and nurses from Universitas Brawijaya and Saiful Anwar General Hospital was granted the PAROS grant to establish the paramedicine program in the country. This study will describe how the PAROS grant supports the establishment of a paramedicine program in Indonesia.

Discussion

The project involves ten professionals as a core team consisting of emergency medicine specialists, nursing lecturers, and emergency nurses. Similar to other countries, instead of establishing a new professional in prehospital care, the paramedicine program in Indonesia will train nurses in prehospital care. The project consists of two main activities, the development of human resources and the curriculum. The human resources development activities include training the trainers, fellowship/attachment on prehospital care and attending prehospital-related courses or training. While the activities of drafting curriculum include depth analysis of the curriculum with the involvement of experts from Singapore, the Ministry of Health of Indonesia, and the Indonesian National Nursing Association. During the implementation of the program, the team is assisted by experts from the Unit for Prehospital Emergency Care (UPEC) of Singapore and also the Nanyang Polytechnic of Singapore. It is projected that the paramedicine program will be launched in July 2021.

Conclusion

The establishment of the paramedicine program in Indonesia is fully supported by the PAROS grant. It is expected that nurses graduating from this program will be the beginning of prehospital care providers in Indonesia.

HELP! I AM GOING TO DELIVER THE BABY BUT NOT AT THE STADIUM

Mohamad Badrulhisham bin Harun, Jahlelawati Zul Malaysia


The stadium was very crowded with estimated people 25,000 for the opening ceremony of National Sports event ‘SUKMA’ on 11th September 2018. The medical standby team already set in place. At 7 pm, a 30-year-old lady, in her third pregnancy at term was having labour pain. She managed to get help from people who alerted the bicycle team around the area. The patient hemodynamically stable but is having leaking liquor and frequent contraction pain during assessment. The field report was given to the incident commander who then decides the


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nearest ambulance which is from outer stadium team D who has a female nurse on board to bring the patient to the nearest labour room which is at Hospital Raja Permaisuri Bainun Ipoh.

Discussion

It is good that the patient had recognized labour pain and get help early. The mobile team response and the availability of the ambulance who parked in a well-planned manner make the patient management at ease. This case has shown that it is good to have a tier response approach whereby the mobile team can approach the patient early before the arrival of the ambulance team, which might take time due to crowds. The medical standby team also need to consider a special situation like emergency labour, and to consider to have a female nurse in each ambulance for treatment and as chaperon.

Lesson learned

Proper planning in where to put the mobile team and ambulance team, the egress and ingress, the backup ambulance and effective communication among the team make the standby a success.


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SPECIAL SITUATIONS

AN AMBULANCE CALL WHICH TURNED TO A HILUX CALL

Billie Mesten Pang, Kar Ling Chin Malaysia

Clinical case Description

We responded to a 33-year-old pregnant lady with the chief complaint of ‘fainting’. We meet the patient halfway through the hilly roads and found her fitting at the back of a Hilux, 4-wheel drive (4WD). She was obese, estimated around 200-250 kilograms, and was fitting. We decided to manage her at the back of the 4WD. During the 10-minutes transportation to the hospital, she had a total of 2 episodes of the fitting, both self-aborted. We had the ambulance with lights and sirens on in front of the 4WD to clear the weekend market crowd to rapidly get the patient to definitive care in the hospital. She has Emergency Lower Segment Cesarean Section (LSCS) and delivered quadruplets but one of them succumbed.

Discussion

Responding to a pregnant patient emergency call is challenging. Preparation of the team may require getting extra personnel with expertise, special equipment, and equipment.

In managing eclampsia in prehospital, the responders must adapt and respond quickly to the ongoing fitting. Our protocol allowed us the use of intramuscular MgSO4 in eclampsia.

This patient was obese and pregnant. We gauged the ambulance stretcher was unable to fit her overall size and with the ongoing fitting, she might fall off the stretcher, thus we choose to just manage her on the 4WD. To prevent us from falling and our safety on the speeding 4WD, we sat on the floor of the 4WD while managing the patient as we do not have any safety harness on.

Lesson Learnt

1. Call triaging and getting salient information is important to better prepare the responding team. This has to be balanced against the time to rapid dispatch as the public expected fast response time once the distress call has been communicated.

2. Working in the chaotic and unexpected prehospital environment required a high degree of adaption, endurance and fast critical thinking to be able to act in an uncontrolled environment.

3. With adaptation, care must be taken to ensure the safety of the responders and patients.


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TRANSPORTING PATIENT WITH BLEEDING PLACENTA PERCRETA

Lionel Jimbau, Rosnydan, Teresa Bilon, Anselm Angnga Malaysia

Case Description

We report our experience in ground retrieval service to transport a patient with bleeding placenta percreta from Sri Aman Hospital (SAH) to Sarawak General Hospital (SGH), which is about 3 hours of transport time by ground ambulance. An ambulance request was made to retrieve a patient, 32 years old Para 2, who had an emergency Lower Segment Cesarean Section (LSCS) done but developed severe hemorrhage.

A multidisciplinary team consisting of anesthesia and obstetrics, along with extra blood products and resuscitation equipments, were dispatched to SAH to transfer the patient over to our Intensive Care Unit (ICU) in the tertiary hospital. We received the ventilated patient in the Operation Theater (OT) and she was hypotensive with ongoing blood transfusion and inotropic support.

Our team spent time to meticulously package the patient for the transport. The transport was uneventful. After a few days, both mother and baby were discharged well.

Discussion

Placenta percreta, which can affect any neighboring uterine structure, is the most severe form of placenta acreta. It is a potentially life-threatening condition due to its propensity for severe hemorrhage. Therefore a multidisciplinary approach is necessary to ensure the morbidity and mortality of the patient are kept to the minimum level whenever feasible.

Patient retrieval can take place in various environment including from the OT. The clean, sterile and controlled OT environment and its equipment are opposite to the unpredictable, non-sterile prehospital care setting. Our team needs to adapt and abide by the strict OT rules and protocol. This includes changing into clean OT attire and performing surface sterilizing of all the equipments, stretcher with an alcohol swab before entering OT.

Transferring and transporting a critically ill patient with the complication of hemorrhage is extremely challenging. Every movement of the patient during transfer can disrupt the clots formed. Patient movement requires proper coordination and gentle care.

Lesson Identified And Lesson Learnt

1. Escorting a bleeding obstetrics emergency patient is challenging especially when the journey by land is long. With proper preparation and planning, the effect of any untoward complications can be mitigated.

2. Handling maternal complications can cause undue stress to the healthcare personnel.

3. When working in a new environment such as OT, some basic knowledge, briefing, and training must be done to prepare the team.


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PHC IN PHC (PRE-HOSPITAL CARE IN PRIMARY HEALTH CARE) – THE WATER AMBULANCE OF SARAWAK

Paul Vicentjo Anak Digen

Klinik Kesihatan Nanga Stamang, Pejabat Kesihatan Bahagian Sri Aman, Malaysia

Introduction

The practice of emergency medicine in a rural area has unique challenges. We describe our unique challenge in transporting patients from rural Sarawak to the nearest hospital using multimodalities of transport.


We received a 70-year-old gentleman, complaining of generalized unwell and agitation to our clinic. To get to our clinic, the patient had to walk 10-15 minutes on a suspension bridge from the opposite longhouse.

Upon arrival he appeared anxious, otherwise no other significant findings. Point-of-care testing revealed a high index of glucose reading. We suspected the patient may have diabetic ketoacidosis requiring transfer to the hospital. This interfacility transfer involves a 90-minutes longboat journey across the dam, followed by another 20-minutes of land transportation to the referral clinic before another 75-minutes transportation to the nearest hospital.

Discussion

Interfacility transfer via multiple modes of transportation is common in our operational area. Using water transportation across the dam, there are times where transportation is not recommended especially when the water condition is rough during bad rainy days and intervals of dam water releases. Some days there are also floating logs and rocks. We were trained briefly on water safety when we first reported to duty to ensure we can perform safe transportation of patients.

The longboat usual passengers are the patient, a paramedic monitoring the patient, another healthcare staff watching at one end of the longboat and a boatman handling the engine. The monitoring of the patient is challenging because of limited space and equipment, and it is worse when transporting a critically ill and uncooperative patient.

Lesson Learnt

Working in a remote healthcare facility providing medical services to the rural community is challenging. Most of these villagers face inherent challenges to reach our service on top of our challenges to deliver standard healthcare to them. The ability to adapt in rural and sometimes


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wilderness environment needs resilience and extra training to be able to deliver standard healthcare service to the community.

PASIR GUDANG CHEMICAL EXPOSURE: IMPORTANCE OF TEAMWORK

Noryazjehan Y, Rashdan R Malaysia

Case Description

We were shocked with chemical exposures in Pasir Gudang, Johor. It struck twice in the 3 months - March and June 2019. Mobilizations of resources were extremely challenging. Many man-hours were required to put everything back to normal. The involvement of medical personnel was greatly felt. Ops Kim Kim was due to illegal dumping of factory products at Kim Kim River, whereas the source of origin remains unclear in Ops Mawar.

The incidences affected students with giddiness, headache, shortness of breath, nausea, vomiting and fainted. MCI team of HSIJB was deployed immediately to the schools upon receiving the distress call. The distribution of tasks was made instantaneously. Zoning of the incident site was done accordingly despite the chaotic situation. The medical base was set up in yellow zone with an EP as the On-site Medical Commander. Decontamination was performed on all patients. Early oxygenation was given to treat the victims on site. Nearly 6,000 victims were treated during this stressful 2-weeks period including few medical staff. Out of 432 patients that were admitted to HSIJB, 13 were intubated due to respiratory distress. Fortunately, no mortality among the victims.

3 months later in Ops Mawar, we were more prepared, geared up with respirators. It lasted for more than a month affecting more than 1,200 patients. None was intubated. Cocktails of chemicals were identified - methyl mercaptan, acrolein, acrylonitrile, and benzene. Hence, it was challenging for the medical team to respond without proper information from the appropriate sources.

Throughout the incidences, continuous communication and discussion were done to have efficient management. Inter-agency inputs were elicited to have a better outcome. Engagement with public health counterparts was done systematically to coordinate the process. Assistance from the private sectors and industries were tremendous.

Lesson Learnt

Teamwork is vital in disaster management. Strengthening cooperation, improving communication and aligning the coordination must be emphasized to give a great result.


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I NEED HELP! EVEN GIRN REFUSES TO HELP ME

Ching Ching Ting, Kar Ling Chin Malaysia.


We responded to a 74 year old gentleman with difficulty in breathing, in a small community clinic interior of Sarawak. Initial management has been initiated by the clinic team and requests for interfacility transfer to the hospital were made. The information conveyed to us were incomplete and patchy because of existing poor network coverage for both telephone line and radio.

Patient appeared to be a candidate for elective intubation before transporting but we brought along only a crash airway kit. Thus, we decided to just transport him to the hospital with ongoing nebulization which he has been refusing. Monitoring and management were challenging in the ambulance due to his ill condition and restlessness, on top of space constraint and the long bumpy journey on the uneven hilly road. He was subsequently handed over to the hospital team for further management.

Discussion

Working in the interior is challenging due to its inherent challenging geography and unreliable network for radio or telephone communication. Our community clinics are usually minimally equipped with resuscitation equipment as they are meant to cater for minor and chronic stable medical illnesses only. The transportation of a patient with severe respiratory distress over an hour is challenging as smaller patient compartment will restrict the personnel movement.

Lesson learned

1. Preparation for retrieval or interfacility transfer of patients can be made safer with proper communication of important information for the preparation of the operation.

2. In the known inherent challenging geography and network conditions, training of advanced care providers is important to maximize the management of the patient in areas far from the equipped healthcare facility. Offline medical direction for appropriate common conditions should be made available to facilitate standard patient care.

3. Adherence to the standard precautions and PPE is important to ensure the responder's risk of contracting any communicable disease, are kept to a minimum, especially when the history is already suggestive.


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TRAUMA

USAGE OF TRANEXAMIC ACID IN HEMORRHAGE CONTROL IN PRE-HOSPITAL CARE

Arun S, Leong YC Malaysia

Clinical case Description

44 years old male was stuck under a timber lifting machine in a remote jungle with difficult access. Our team reached the scene in 50 minutes, navigating through the narrow jungle path. The machine was already moved before the arrival of the ambulance and it was known that the patient was impinged for about 15 minutes. The initial assessment noted the patient is in shock with crush injury at his left leg. The severed leg is partially embedded into the soil. Blood is oozing out slowly from the amputated stump. Fluid resuscitation of 1000 ml saline initiated, the injured limb was cleaned with saline, dressed using a bed sheet and splinted. Initial vital signs: BP 84/59 mmHg, HR 124 bpm, SpO2 99%. IV Tranexamic acid 1 gram bolus was given and the vitals improved to BP 96/64 mmHg, HR 116 bpm. The patient was transported to a hospital, treated for crush injury of the left leg and subsequently went in for emergency surgery.

Discussion

CRASH-2 trial concluded that the early administration of tranexamic acid safely reduced the risk of death in bleeding trauma patients and is highly cost-effective. We did not prepare our ambulance to go through a jungle path which is a rocky uneven trail. Active bleeding from the amputated stump was controlled using direct pressure and pressure bandage.Fluid resuscitation is important in crush injury. However, we keep in mind that over resuscitation with fluid will cause further bleeding and subsequently DIVC. Therefore, we tailored the fluid resuscitation to 1 liter of saline.

Lesson Learnt

1. Traumatic patients with evidence of hemorrhage will benefit from the early administration of tranexamic acid in the pre-hospital care setting which will help to reduce mortality.

2. Fluid resuscitation should be adjusted accordingly to provide adequate hydration for crush injury and not too much to cause DIVC.

3. Direct pressure is still the mainstay to stop bleeding while tranexamic acid will help to slow down the breakdown of the blood clot to prevent new bleeding.


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MANAGEMENT OF INJURED PATIENT WITH FEMUR FRACTURE IN PRE-HOSPITAL SETTING: A CASE STUDY

Jenpanitpong C., Apitlakkitkan W., Termkitvanich P., Watcharakitpaisan S. Thailand.


A 29-year-old male fell from twelve-meters height building with no history of loss of consciousness. Upon EMS arrival, he was placed on a neutral position with manual stabilization while paramedic examined life-threatening conditions.

His airway accumulated with bloody secretion and was maintainable by suction. The ventilatory status was normal and no signs of hemopneumothorax. Bleeding with fat globule and deformity on the right anterior thigh indicate opened femur fracture, which caused compensated hemorrhagic shock (tachycardia, 118bpm, and BP149/117mmHg). The neurological status was E4V5M6 and pupils both reacted to light. Other examination founded contusion with crepitus at left side face, suspected maxillofacial injury.

Before transportation, the fracture site was stabilized to prevent further injury. The patient was applied a cervical collar, placed on a long spine board and administered isotonic solution to prevent decompensated shock.

Discussion

The femur is surrounded by several arteries. Fracture of the femur can lead to approximately 1-2 liters of internal blood loss. In suspected or obvious femur fracture, traction splint should be applied to realignment and makes the patient feel more comfortable. Appropriate application of traction splint can decrease internal bleeding and reduce severe pain from misalignment.

Lesson Learnt

Internal hemorrhage, a life-threatening condition commonly associated with musculoskeletal trauma like femur fracture. In case of suspected or obvious femur fracture, the prehospital provider should apply traction splint to the patient before hospital transportation.

MANAGEMENT OF TRAUMATIC CARDIAC ARREST PATIENT IN PRE-HOSPITAL SETTING: A CASE STUDY

Nuanprom P., Aussawanodom S., Laksanamapane T., Patchkrua J. Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand.


An about 25 years old female presents through an emergency call after a train collision. On scene arrival, the patient was unconscious, with no spontaneous breathing but palpable weak pulse. There was active bleeding from complete amputation at the right leg and degloving injury at the scalp.


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On primary survey, her airway was coma and compromise suspected from severe TBI. Primary treatment was oropharyngeal airway insertion, assist ventilation by bag-valve-mask device and C-collar was applied. The patient still has a rapid and weak pulse and blood pressure could not be measured, suspected class IV hemorrhagic shock. GCS was E1V1M1. Before transport, the patient was given an aggressive LRs solution and was applied pressure dressing at her right leg and scalp.

En route, the patient turned to cardiac arrest, ECG was PEA. 2 minutes of resuscitation was performed, a dose of epinephrine was given then she had ROSC.

Discussion

If an ALS team is available in traumatic cardiac arrest, the effective cardiopulmonary resuscitation should be initiated immediately. The airway should be secured by appropriate devices simultaneous with spine immobilization and physical examination should be performed to identify any life-threatening conditions. Intravenous access and aggressive fluid should be considered in a severe bleeding patient. Patients with traumatic injury are best served by short scene-time and rapid transport to an appropriate facility.

Lesson Learnt

In case of traumatic arrest, a prehospital provider should stabilize the patient’s airway, ventilatory and circulatory status while performing cardiopulmonary resuscitation. Immediately transport with further treatment or resuscitation should be performed en route.

WHY HE DOES NOT RESPONSE TO MY FLUID RESUSCITATION?

Rathina Kumar, Thiagarajan Malaysia


We responded to a 20 year-old motorcyclist alleged skidded and fell into a nearby monsoon drain. It was raining heavily and the victim was already rescued to the roadside. He indicated to us that he was having pain over his left leg and hand.

On examination, he was in a decompensated shock state. We found an open wound posteriorly over the upper thigh with active bleeding. Immediate hemorrhage control measures were applied, including a tourniquet. He was given intravenous (IV) fluid resuscitation and tranexamic acid, and immediately transported to a hospital. However, his circulation parameters did not improve. In the hospital, he was found to have an open book pelvic fracture.

Discussion

The high impact of the trauma caused an open book pelvic fracture and other co-existing injuries. The patient was in decompensated shock and with distracting injuries made the detection of the source of bleeding very challenging. We managed to stop only the external


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hemorrhage but missed occult pelvic injury that caused massive blood loss into the retroperitoneal space.

The pelvic injury if detected can be minimized with on-site pelvic immobilization to help promote clot formation and prevent further tissue injuries.

We administered vigorous fluids resuscitation with crystalloids. This has led to further disruption of the clot and dilution of the clotting factors leading to a vicious cycle of fluid resuscitation and subsequently the lethal triad of trauma.

Lesson Learnt

1. Responders should always be vigilant and systematic in trauma initial assessment to detect life-threatening injuries especially for occult injuries that are rapidly lethal such as pelvic injuries.

2. In high impact traumatic injuries, we should maintain a high index of suspicion for the possibility of an open book fracture, especially when associated with shock. The patient history and examination will be unreliable as confounded by the poor brain perfusion. Thus a pelvic binder should be applied empirically. The potential risks of missing an occult pelvic injury outweigh the risks or complications associated with pelvic binding.

3. Reassessment is important for checking the response to intervention and to check for any deterioration early to initiate early intervention. In the event of poor or non-responsiveness to any intervention, the plan of management should be reevaluated to search for any other significant occult injuries.

‘LIVEWIRE’ IN ACTION

Mohd Faizal Ismail, Jack Jemat Malaysia


We responded to a middle-aged man found struggling on the power lines of an electric pole. At the scene, the victim was still hanging upside down on the power lines. We engaged assistance from the local energy plant to temporary disconnect the power supply. Finally, after two hours, he was handed over to us for medical attention. On examination, he was screaming in pain with an estimated 75% Total Burn Surface Area (TBSA) burn injuries including the face. He was hypotensive and hypoxic. Immediate resuscitation with high flow oxygen and IV fluid bolus was given while preparing for rapid transport to the hospital. Cardiac monitoring showed sinus tachycardia. In the hospital, he was intubated, started on inotropic support and admitted to Burn Unit. He succumbed to his injuries the next day.

Discussion

All “downed power lines are live until proven otherwise”. Getting the correct authority to disconnect the power supply is challenging. We can only perform our gross assessment through inspection and communication from the ground while waiting for him to be extricated. In the


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field, with that high percentage of burned upper body and facial, we faced the challenge of controlling his pain with limited choices of analgesia, monitoring for arrhythmias and managing the burned area while maintaining our accessibility on monitoring for deterioration. Fluid boluses were initiated both for the hypotension and high possibility of rhabdomyolysis.

Lesson Learnt

1. Responders should always be vigilant of the scene and surroundings safety during each response especially those associated with power lines even when there is an urgency to extricate the alive victim and pressure from on-lookers.

2. Engaging help from other agencies early help in expediting the retrieval of a patient. Call takers upon getting the suspicious scene hazards and possible need of relevant authorities and agencies can pre-alert them to assist.

3. High-voltage burn injuries can be fatal causing deep tissue injuries and rhabdomyolysis. Generous fluid boluses should be given even without hypotension while transporting to the hospital.

4. Other life-threatening injuries include active management of cardiac arrest, especially if witnessed during monitoring, despite the high percentage of TBSA burn injury

5. For pain control in prehospital, analgesia especially opioid via the intravenous route, in titration doses, is preferred to control the associated extreme pain.


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DIFFERENT SHADES OF GREY

SELF-REPORTED INCIDENCE OF VERBAL AND PHYSICAL HARASSMENT OF EMS PERSONNEL IN SINGAPORE

Tay Guek Khim, Abdul Rahman, Kenneth Foong Singapore

The Singapore National Emergency Medical Services (EMS) attended to more than 180,000 ambulance calls in 2018. This study aims to determine the incidence of verbal and physical harassment of EMS personnel as reported anonymously, understand why abuse may not be reported through formal channels and to outline what measures have been rolled out and could be rolled out in the future to curb EMS abuse.

An online survey was conducted among 246 paramedics to determine the incidence of physical and verbal harassment encountered in the last 12 months, the possible risk factors in such incidents, their knowledge and attitudes toward the reporting process, and their views about how to reduce the incidence of such encounters.

64% and 36% of respondents reported encountering at least one incident of verbal or physical harassment respectively. The top risk factor is the patient being under the influence of alcohol.

While 78% were aware of reporting procedures, only 20% and 49% said that they would routinely report verbal or physical abuse respectively. Empathy for the patient’s frame of mind and the absence of physical injury to the crew were among the top reasons for crew members choosing not to report these incidents.

SCDF has rolled out the use of body-worn cameras for EMS crew in phases and will be studying its usefulness in investigating and mitigating violence towards EMS. Besides, paramedics suggested police presence when handling violent or intoxicated patients, campaigns to raise public awareness, stiffer penalties for offenders, red-flagging of high-risk patients based on past incidents, and more training on de-escalation techniques and self-defense were possible avenues to reduce verbal and physical violence towards EMS personnel.


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MANAGING DIFFERENT SHADES OF AGGRESSIVE IN AMBULANCE SERVICE

M Najmi NAR, Hazlimi H, Sarah AK1 Malaysia


We describe three different cases highlighting the spectrum of aggressive patients in our ambulance response.

Our first scenario involved mass stimulant misadventure in a group of teenagers. They had a party of vodka and pills believed to be stimulants. The assistance of the ambulance team was requested for police to transport them safely to the hospital. At the scene, our team reported the clinical condition of patients as aggressive, loud, disinhibited and hot.

Our second scenario involved a family requesting an ambulance for their relatives with psychiatric illness. The patient is said to be violent and threatened to hurt them. Their local police advised them to get ambulance assistance.

Our third scenario involved trauma a patient with suspected head injury with a little too much alcohol consumption. Patients are always described as having facial trauma but combative in the ambulance.

Discussion

All three scenarios pose a potential risk of injuries to responders. Many times, assistance is delayed because there is a misunderstanding between what is a police case and what is a medical response.

In our protocol, aggressive patients are divided into two different categories. The first category is a potential risk to safety and security to either personnel or bystander. Here, police presence is compulsory before approaching the patient. The second category is a potential medical risk to the patient-self. In both categories, the use of restraint and sedation are options available to responders.

Lesson Learnt

Having a protocol on managing aggressive patients in the field is important. It helps to provide prompt response and creates better relationships between responding agencies.

SHOULD I OR SHOULD I NOT PROCEED?

Peter Kenny AK Nihang, Leslie Sonja AK Mike, Maxwell AK Joseph Malaysia


We received a request for assistance to ‘determine’ death at home around midnight. A 50-year-old lady claimed stopped breathing 30 minutes. The location was across a river. Our journey to


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assist the villager involved, a boat ride across the river followed by walking on raised wooden planks about two meters high. When we arrived, family members already gathered to pay their last visit. We determined the victim has no signs of life by brief examination and rhythm check as per local protocol. The advice was given on subsequent steps to be taken and before we leave.

Discussion

Requests for medical assistance to attend and determined death outside the hospital is common in our local setting. There are a few challenges when we received such a call. Should we response urgently? Should we go with our usual configuration of the ALS trained team? The location of the incident may be remote with multiple possible hazards, for example, you need to use a private boat without proper lighting and life jackets. There are also wild animals in the river.

Lesson Learnt

Community awareness and education are important to assist the responding team and guide the configuration of response through proper call triaging. Based on local geographical information, training and logistics preparation need to be considered to ensure responders can respond safely and efficiently especially in a remote or challenging environment.

THE NON-CRISPY RENDANG

W Nadzeri MM Malaysia


A 23 years old guy was presented with a history of sudden collapse at a restaurant while eating Beef Rendang. Upon arrival, the patient was unconscious with no spontaneous breathing. CPR was initiated by the PHC team at site and the patient was brought to the Emergency and Trauma Department (ETD) immediately. During airway assessment, there was a foreign body measuring 4x4cm seated above epiglottis. Later it was confirmed to be the Beef Rendang. After successful removal with Magill’s Forceps, the patient’s airway was secured with an advanced airway. After 2 cycles of CPR, the patient managed to return spontaneous circulation. The patient was then admitted to ICU for the continuation of care and extubated on day 2 of admission. He was discharged well afterward without secondary damage to the brain.

Discussion

Choking is a life-threatening condition characterized by the blockage of air entering into the lungs partially or completely. It is an uncommon cause of sudden cardiac arrest and frequently treatable. However, choking is fatal if it not recognized in time. At other times it can be confused with syncopal attack, stroke, seizure or drug overdose.

Lesson Learnt


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This case highlights the importance of extensive Basic Life Support training to the community. When PHC team arrived at scene, bystanders were standing there without doing anything as they weren’t sure about what to do. The ability to recognize the sign of chocking and to intervene early will help produce a better outcome for the patient.

IRONMAN – THE WAR WITHIN

Nik Riduan B. Nik Lah Malaysia

Background

Ironman Malaysia is an annual international sporting event that showcases the race along the pristine coast of Langkawi - the paradise tropical island of Malaysia. It is the epitome of fitness and endurance where athletes in Ironman events push their limits with a 2.4 mile (3.86km) swim, followed by cycling for 112 miles (180km), before finishing off with a 26.2 mile run (42km). A medical team from the state of Kedah, Malaysia is responsible to provide medical coverage for this exciting event. A total of 1,223 athletes from all over the world participated in this extravaganza sport.

Discussion

We will discuss the challenges in the management of this austere event from a medical perspective ranging from as simple as jellyfish sting to dehydration, hyponatremia, heatstroke, etc. The war within the ironmen will challenge the medical team to perform like ironman from the preparation phase, event phase, and post event phase. Expect to witness the enormous preparation and the long tedious standby expanding through a nonstop 24 hour triathlon. We will showcase specific protocols and innovations created from years of experience to cater to the specific needs of ironman warriors.

Conclusion

Ironman Malaysia provides an opportunity for the medical team to develop a new protocol and create innovation from different perspectives.

THE VOLUNTEER EMS PARADOX: HELPING IN A MEGA MASS GATHERING

Stephanie P. Reyes, RN, EMT, Jayvee Guerrero, MD Philippines

Background

Millions of devotees in procession celebrate the Feast of the Black Nazarene, also known as Traslacion, every 9th of January. As a measure for disaster preparedness for such mega mass gathering, numerous groups from government-, private- or NGO- based EMS, fire, search and


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rescue, security and military personnel, all volunteer in the spirit of public service. They are subdivided into ten (10) segments in strategic locations to cater to both ill and injured, and ensure everyone’s safety.

Discussion

In Segment 9, a patient surge arising from a crowd-related event flooded the tents. The majority of patients reported having difficulty breathing and altered levels of consciousness. While this was ongoing, a bomb threat has been reported. Later on, it’s been identified as an unattended belonging. Amid limited resources and a busy crowd, crowd dynamics and behavior must be predictable. An analysis of risks must be done early. Data from resource utilization and injury data from advanced medical posts mass gathering hazards must be reviewed and studied.

Conclusion

Event organizers should continue developing opportunities to address the gaps in providing patient safety and ensuring volunteer safety. This can be achieved through inter-agency collaboration, crowd monitoring, and early warning systems. More importantly, to prevent panic, there is a need to distinguish different hazards. Lastly, use the golden nuggets of this case study as guidelines and public health policy incorporation to prevent emergencies in religious mass gatherings from turning into disasters.


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ABSTRACTS – POSTER PRESENTATION

MEDICAL

AN OUT-OF-HOSPITAL CARDIAC ARREST SURVIVING AFTER USE OF AED BY UNTRAINED LAYPERSON WITH DISPATCHER ASSISTANCE

Jundong Moon, ByungJun Cho, Jongho Kim, Hyunmo Yang, Dongmin Shin Republic of Korea


A 59-year-old man with no specific medical or family history complained of chest pain and became unconscious. A member of his family, who was a witness, called 119 and gave him dispatcher-assisted cardiopulmonary resuscitation, followed by defibrillation using an automated external defibrillator placed in his apartment. Afterward, he was given two sessions of defibrillation by the EMS providers, then transferred to an emergency medical center with the return of spontaneous circulation. The patient was discharged with a cerebral performance category (CPC) 1 15 days later.

Discussion

Early defibrillation is the single most important intervention for out-of-hospital cardiac arrest with shockable rhythm and its efficiency is highly time-dependent. Current CPR guidelines support the use of AED by the laypersons with no previous training, however, the evidence is very limited. Depending on the country, the protocol does not include instructions on how to acquire and use an AED. This case suggests it can be particularly useful for helping untrained witnesses use an AED, which may have important implications in regions in which there are delayed responses of the EMS providers to the site.

Lesson Learnt

In addition to compression only CPR, dispatcher protocols assist the untrained layperson to access and use AED properly.

“GIDDINESS” – A GREAT DECEIVER

Foong Keng Kiat Kenneth Singapore


A call had come in from dispatch in the late afternoon for a case of a 64 year old Indian male with giddiness.


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Upon EMS arrival at the patient’s residence, the patient was standing at his main door waiting for the EMS. My first observation of the patient was that he was very tachypnoeic and diaphoretic. Hence I immediately got the patient to sit down before conducting an assessment.

The patient’s chief complaint was intermittent giddiness on exertion accompanied by swelling of lower limbs for about a month. The patient was unable to sleep properly the previous night due to his giddiness. The patient usually sleeps on 2 pillows. He also claims he had rashes and itch over his hand for about a month and had been prescribed aureomycin for the rash. The patient denied having any breathlessness, chest pains, diaphoresis, fever, URTI or cough with sputum.

The patient had a history of diabetes (type 2), ischemic heart disease and was currently on Digoxin, Amlodipine, Simvastatin. The patient was also a chronic smoker.

Patient initial vitals sign were as follows; BP 150/91 mmHg, HR 65 BPM, SPO2 89% (Room air), RR 25 BPM. The ECG showed a heart rate of 65-75BPM, and indicated atrial fibrillation with no hyperacute ST changes. There were rhonchi bilaterally.

Discussion

It was interesting because although the patient’s main complaint was dizziness, and he did not complain of breathlessness, the signs of a high respiratory rate, low oxygen saturation, and rhonchi pointed to a respiratory problem. The “giddiness” he presented may have been a symptom of hypoxia.

Given the previous history of orthopnoea, leg swelling, and giddiness worsening on exertion, and his background risk factors of ischaemic heart disease, I decided to treat the patient as for pulmonary edema secondary to congestive heart failure

The patient was given 100% oxygen via an NRM with an improvement of sats to 96%. The patient was also given 4 sprays of GTN (0.4mg) every 5 mins and nebulized Ventolin (10mg). Through theses prehospital interventions, a patient there was an improvement in patient giddiness however the patient was still tachypneic.

Lesson Learnt

In this case, the patient’s complaint of dizziness was not typical of the textbook presentation of cardiac failure and pulmonary edema. It is necessary to ask for details of the past medical history and functional status, the presence or absence of associated symptoms, and to conduct a thorough physical examination to pick up clues to discover what the case might be.


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A FITTING PROBLEM: WHEN THE EXISTING DIAZEPAM IS NOT ENOUGH!

Olescynthya William, Kar Ling Chin Malaysia.

Clinical case presentation

I report a case of an ambulance call of a status epilepticus patient. We responded to a call by the patient’s father complaining of recurrent fitting. As we are in a small minor specialist hospital with limited human resources, we could not bring a doctor for the ambulance call. Our Pre Hospital Care bag has Rectal Diazepam 5mg. I contemplated bringing additional IV Diazepam.

Upon arrival at the scene, further history revealed that the patient has been intermittently fitting for the past 5 hours. Rectal Diazepam was given during transportation back to the hospital, however, the patient continued to have persistent, intermittent fit. We had no further medications available to stop the fit and could only provide patients was supportive care. The patient was intubated upon arrival to the ED and was discharged well two days later.

Discussion

Fitting is a medical emergency faced by an ambulance team. Aim of treatment is to abort the fit as soon as possible to reduce damage to the brain due to hypoxia.

Our bag was equipped with rectal diazepam only which was inadequate to abort the seizures. In our system to provide intravenous diazepam, we would be required to call back for Medical Direction. The communications network in our area is unstable and often unavailable.

Lessons Learned

It is important to anticipate problems when going for an ambulance call and be prepared for the worst.

STEMI CARE, WE CARE

Rathina Kumar Malaysia

Clinical Case Description:

We responded to a 48 year-old security officer complaining of chest pain while at work. He was immediately transferred into the ambulance for an electrocardiogram (ECG) given the high possibility of an acute coronary syndrome (ACS) especially ST-elevation myocardial infarction (STEMI). During 12-lead ECG recording, he deteriorated and developed a brief episode of seizure-like activity.


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He had pulseless ventricular tachycardia. Cardiopulmonary resuscitation was commenced immediately and he was shocked once. The brief duration of chest compressions was stopped when he suddenly regained consciousness. He was transported to the hospital immediately where he was diagnosed with an acute STEMI.

Discussion:

ACS is one of the commonest causes of chest pain. ACS especially STEMI is a timely diagnosis as time is myocardium. It takes a system to improve morbidity and mortality from STEMI.

Everyone plays a role in the STEMI system of care. The community should be aware of the signs and symptoms of STEMI and call for emergency medical help as soon as possible.

The call taker in the call center apart from dispatching the correct configuration of responders with appropriate types of equipment, they can also advise the patient to chew Aspirin immediately if available.

The prehospital care responders should get a targeted history and performed a 12-lead ECG immediately. This can assist in diagnosing STEMI earlier and STEMI network activation to prepare for primary percutaneous intervention (PCI).

During transportation to the hospital, responders should anticipate sudden deterioration and be prepared for resuscitation if a cardiac arrest happened.

Lesson Learnt:

Always be prepared to respond to chest pain cases and assist in improving STEMI patient care by having a high index of suspicion of ACS or STEMI, performing a prehospital ECG and activating the STEMI network to facilitate for PCI.

SURVIVAL OF AN OUT-OF-HOSPITAL CARDIAC ARREST AFTER HIGH-QUALITY CPR BY ST JOHN AMBULANCE MALAYSIA: A CASE REPORT

M. Abdullah Malaysia


We report the survival of a 55-year-old man from out-of-hospital cardiac arrest (OHCA) who underwent a coronary artery bypass graft a month before collapsing. The nearest ambulance received the call at 0406 while cardiopulmonary resuscitation (CPR) was performed by a bystander before the arrival of First Responders at 0420, who then continued with High-quality CPR (HQCPR) after confirmation of pulselessness. Initial automated external defibrillator (AED) analysis indicated no shockable rhythm, hence airway was secured and ventilated before being transferred onto the ambulance. HQCPR was continued throughout the journey from 0430 until arrival to Emergency Department at 0443. Subsequent advanced cardiac management reestablished the circulation and the patient was sent to the Coronary Care Unit, and discharged 5 days later with intact neurology.


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Discussion

The average survival of OHCA in adults was 7%. In this case, early CPR and HQCPR by Paramedics may be the prime factor in survival from OHCA. The department adheres to the advice of the American Heart Association to change from a two-yearly refresher course into frequent training in Basic Life Support (BLS) as providers are likely to encounter a cardiac arrest. Since studies have shown that BLS skills deteriorate in as little as 3 months after initial training, frequent and low-dose of practicing chest compressions in the department’s skills lab using feedback devices would improve staff’s competency. Moreover, HQCPR being a new emphasis would demand familiarization via constant training.

Lesson Learnt

This effort proves that First Responders who frequently practice HQCPR can improve clinical outcomes in the out-of-hospital setting.

NATURE OF VOMIT IN DIAGNOSING DIABETIC KETOACIDOSIS

Lim Jun Bin Malaysia


Based on experiences of the past 5 years, notice DKA patients will present with vomiting and Hyperglycemia. But the nature of vomiting is different from the involvement of Gastrointestinal.

Discussion

In terms of cost effective or the available of resources, the responder can’t perform the Serum Ketone test on all hyperglycemia patients. Hence clinical decision and patient complaint would assist on make a different diagnosis in this scenario. Vomiting in DKA patients usually is associated with unable to tolerate orally, whereby the nature of vomiting is different from other GI involved. Based on experience, these signs, random blood glucose test– Hyperglycemia and tachypnea could help in rule in DKA compare with some other signs. For the past confirmed DKA cases, patient with the complaint of vomiting with the nature of vomiting is unable to tolerate orally, which explain as whenever there is a solid or liquid oral intake even with a few sips of water patient will start to vomit, but once they stop all the oral intake symptoms will relief.

Lesson Learnt

Whenever patient complaint vomiting, responder required to justify the nature of vomit, if the nature of vomit is related with unable to tolerate orally and serum RBS test show high ( > 25.0 mmol/L). The responder should suspect DKA without or without the history of Diabetes. Serum ketone tests may perform to confirm the finding, subjective to the availability of resources at the facility.


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KOPITIAM TALK

RETROSPECTIVE DESCRIPTIVE STUDY ON OUT-OF-HOSPITAL CARDIAC ARREST (OHCA) CASES RESPONDED BY PREHOSPITAL TEAM, SARAWAK GENERAL HOSPITAL (SGH), MALAYSIA IN THE YEAR 2018

Mohd Faizal Ismail, Dicky Tatom Malaysia

Background

OHCA is a global disease and a strong Chain of Survival is fundamental in improving the survival and recovery for the OHCA victims. The first three of the five links of the chain of survival focus on the lay rescuers or bystanders nearby the victim. We analyzed the cardiac arrest calls responded by our prehospital care (PHC) team to facilitate the improvement strategies for our population.

Methods

PHC records of patients coded as ‘cardiac arrest’ by our PHC team from January until December 2018 were reviewed. We excluded cases for active resuscitation that transported to the hospital. Data on patient demographics (chief complaint) and call characteristics (mechanism, distance from hospital, priority, and triage code) were collected for analysis.

Results

1847 patient’s records were reviewed, 353 patients were included.

The chief complaint is cardiac/respiratory arrest/death with 251 cases, 66 of unconscious/fainting, 13 of breathing problem, 8 of traffic/transportation incident, 4 with falls, 2 cases each for sick person, and unknown problem, while each one case of abdominal pain, chest pain, diabetic problem, electrocution, hemorrhage and pregnancy/childbirth. Call characteristics described in Table 1 below. There are only 13 cases are provided Dispatch assisted-CPR. Most of the cases are reported as ‘rigor mortis’ on the assessment by the PHC team and no CPR was provided.

Conclusion

Majority of cases priority one cases however there are no survival reported and very low rate of DA-CPR. There is a lot of room for improvement in the chain of survival: dispatcher recognizing and initiating DA-CPR, community awareness of cardiac arrest as an emergency and the importance of early CPR and defibrillation.


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MINOR ONLY, CAN IT BE DONE AT PRIMARY CENTER?

Edmund Philip, Mohd. Faizal Ismail, Ng Chiew Wai Malaysia

Background

The Pan-Asian Trauma Outcome Study (PATOS), started in November 2015, aims to establish a collaborative standardized study to measure the capabilities, processes, and outcomes of trauma care throughout Asia. Sarawak General Hospital (SGH) in Kuching is the main referral hospital covering a southern zone of Sarawak.

Methods

We reviewed the patient care records (PCR) of all the trauma cases referred from the district hospitals and also the peripheral clinics to Sarawak General Hospital, from 1st January 2016 until 31st December 2017. Information and criteria used to calculate the patient injury severity were collected for analysis based on the abbreviated injury score (AIS).

Results

A total of 626 PCR were reviewed. 24.6% were referral cases transferred in from other healthcare facilities in southern Sarawak. From these, 60.38% was a minor injury, 19.48% moderate injury, 7.14% severe injury, 11.68% serious injury and 7.79% critical injury respectively.

Discussion

The majority of the referral trauma cases are categorized as minor injuries followed by moderate injury. There are multiple possibilities for this as SGH is the only center in the southern zone with a surgical specialty. Most referrals are cases that have already discussed with the relevant surgical disciplines before transfer. Apart from that some of the referring centers only have basic radiographs resources.

Some cases that were categorized as minor injury may also require further surgical review, follow up or operations. Thus they also made up to the larger number of referrals to our center.

However, past few years, the Emergency Department (ED) of SGH has been overcrowded with a worsening access block. These minor injuries may need to be further analyzed for possible solutions to be managed outside the emergency department. Suggestions include more applicable criteria for trauma referrals to SGH, a better network of referrals to facilitate the inadequately equipped healthcare facilities outside SGH, clusters hospital concept, and trauma lane with collaborations with the surgical disciplines.

Conclusion

Better inter disciplines cooperation and communication can assist in ED overcrowding, especially for minor trauma cases. With collaborations from the managerial, administrative and clinical specialties, we believe this is achievable and it not only benefits the hospital but ultimately the overall patient care and satisfaction.


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KNOWLEDGE, ATTITUDES, AND PRACTICES TOWARDS NEEDLE-STICK INJURIES AND REPORTING BEHAVIOURS AMONG PARAMEDICS IN SINGAPORE

Siti Noraini Kasbani, Masnita Rahmat, Cheng Karen Lynn, Dr Shalini Arulanandam Singapore

Needle-stick injuries (NSI) can transmit blood-borne pathogens and are a well-studied occupational health hazard. Despite the possible health consequences of sustaining NSIs, healthcare professionals may under-report their occurrence. This study aims to estimate the prevalence of NSI and reporting behaviors amongst paramedics in Singapore and understand the knowledge, attitudes, and practices towards NSI and NSI reporting.

An anonymous electronic cross-sectional survey was used to collect data on NSI prevalence, reporting prevalence, demographics, knowledge, attitudes, and practices. The survey contained 31 closed ended questions and one open ended question.

17.6% of participants reported sustaining NSI in their careers, and 2.5% reported NSI within 12 months of the survey. Among 43 participants who sustained an NSI before, 67% reported the NSI and 33% did not. Experienced paramedics were more likely to have sustained NSI than junior paramedics but were less likely to report it. Trainees were the least likely group to report NSI. Reasons for not reporting NSIs included knowledge factors (such as type of NSIs that should be reported) and misconceptions about the consequences of reporting.

In general, paramedics were knowledgeable about the risks of NSI and reporting procedures, with more experienced paramedics having better knowledge than trainees. The incidence of NSI among paramedics in Singapore is lower than in other EMS systems. While it is not possible to eliminate the occurrence of NSI, strategies to further educate paramedics about NSI and to encourage reporting will help promote their health and reduce their occupational risks.

LOCAL SOLUTION TO INTERFACILITY TRANSPORT PROBLEM

Sufrie Shukor, A Jali Rajit Malaysia

Introduction

Our institution does on average daily transfers of critically ill patients. In these transfers, a minimum of three personnel is required to facilitate the movement of the patient. Such patients have many tubes and medical equipment attached to. The most difficult task we had was where do we put all the equipment whilst pushing the stretcher into the ambulance. Depending on the experience of our staff different solutions methods were used. Commercial bridges for equipment are available but they are not affordable to be purchased by our institution.


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Discussion

In a ventilated critically ill patients; care must be placed on maintaining the ET Tube position, prevent ventilation circuit disconnection, and maintain oxygen flow. Most responders will place equipment between patients’ legs on the stretcher, however, this is not the best option in obese patients. We created two equipment holder that can be fixed to our ambulance. The first is an oxygen fixator device and second, an equipment fixator device to the stretcher. By properly fixing the equipment, we were able to load patients easier and better.

Conclusion

In our system, the purchase of an ambulance is done centrally. In such environment equipment provided are general and non-specific to the needs of the institution. Doing simple innovation to improve patient care may be required to manage service specific needs of an institution.


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SPECIAL SITUATIONS

RELATIONSHIP BETWEEN THE NUMBER OF INTERVENTION AND EMS ON-SCENE TIME INTERVAL IN PSC 119 PURWOREJO REGENCY, INDONESIA: A PILOT STUDY

Anggun Setyarini, Respati S Dradjat, Heni Dwi Windarwati Indonesia

Background

Providing appropriate interventions in appropriate on-scene time (OST) interval is a prehospital problem that needs to be managed by Emergency Medical Services (EMS) agencies in developing countries. This study aimed to identify the relationship between the number of interventions and OST at the Public Safety Center (PSC) 119 as an evaluation of the implementation of the EMS system in Purworejo Regency, Central Java, Indonesia.

Method

This study conducted by a Retrospective chart review (RCR) design. 105 data obtained from trauma and medical patients since January-December 2018. Bivariate analysis was carried out using the eta test with SPSS software.

Result

The majority of patients included in level 1 triage (35.2%), level 2 (40%), and Level 3 (23.8%). The average OST is 12.58 minutes. The number of interventions given amounted to 1 intervention 55% (e.g. administration of oxygen to medical patients or dressing splints in trauma patients), without intervention 25.8%), 2 interventions (20%), and 3 interventions (2.9%). Bivariate analysis showed no association between the number of interventions with OST in patients treated by PSC 119 (p = 0.576, r = 0.019).

Conclusion

Policies regarding the standard of OST for high-level triage need to be clarified. In the future, prehospital intervention given by PSC 119 officers needs to be improved.

MOTHER LOST HER PRECIOUS ONES

Collin Belasan Edwin, Kar Ling Chin Sarawak

An emergency involving a pregnant lady is nerve wracking by itself. To who is in labour transport and manage a second trimester pregnant lady is worst.


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I report a case of a 21 year old Iban lady G2P1 at 23 weeks 6 days of POA who called for an ambulance on 28/3 at 3 am. The call was made by her sister and the information we received is that the patient has abdominal pain, PV bleeding and is around 20 weeks pregnant. Our team consisting 1 AMO, 1 SN and 1 driver and we responded to the case immediately. There was no MO accompanying us as we only have 1 MO on call who is covering the whole hospital. It was a rainy night. The ambulance had to park 100m and we climbed the slippery steps and muddy road slowly with our ambulance call bag, defibrillator, and stretcher. The room where the patient was waiting was really small. We had to maneuver ourselves to fit in the room. The patient was pale, sweating and mildly tachypnoeic. Her “kain batik” was soaked with blood. The patient also mentioned that her water broke. At that point in time, I was very worried as it has been a long time since I conducted a delivery and the SN who was with me was also not confident. We decided to bring the patient to the ambulance quickly and I realized we had a second problem; we were not strong enough to lift the patient and carry her to the ambulance. I went around to look for villagers to help carry the patient and after about 10 minutes we managed to find sufficient people to help us bring the patient to the ambulance. Patient’s labour did not progress during transportation and we arrived safely. The patient delivered a 480g baby in ED at 4.30 am. There was spontaneous breathing. Resuscitation was started but withheld after further discussion with the pediatrician.

In conclusion, knowing a little about everything is important in managing emergency cases as it can be from any discipline and can compromise of any age.

2018 TAIWAN EARTHQUAKE SEARCH AND RESCUE MISSION

Huang Kuo Wei Taiwan


On February 6, 2018, an earthquake magnitude of 6.0 occurred in Hualien, causing two buildings to collapse. Specialized search rescue teams were sent from all over Taiwan to support.

During the rescue, aftershocks continued, but the rescue team did not give up til the last moment. Finally, on February 11 rescue was called to an end with a total of 106 hours.

Discussion

If the patient still has conscious but is unable to get out immediately during the search and rescue process, what can we do?

Lesson Learnt

Problems encountered in emergency medical care at confined spaces:

1. Personal safety.

2. Insufficient light.

3. The building causes the Vertigo


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DROWNING IN THE RESORT- AGAIN? A NEED FOR WATER SAFETY AWARENESS

MS Ramli , NSN Mohamad , MZF Senek, KN Mohamad Malaysia

Drowning contributed around 360 000 death worldwide and it had been reported that an average of 286 children died secondary to drowning per year in Malaysia. We present a fatality case of child drowning that occurred in Cherating, Pahang. We felt that intervention involving water safety awareness might help to prevent this kind of case from reoccurring. The case involved 6 years old, Malay, boy, alleged drowned in a resort at Cherating, noticed by the passerby unresponsive in the swimming pool. The emergency number 999 was activated and the nearest ambulance station which is situated 15 km away from the scene had been despatched. Public CPR was initiated, however, the parent decided to send the patient to the nearest hospital (located 28km away) via private car. In the hospital, the CPR was resumed for another 1 hour. This case report will illustrate the common case of child death by drowning in Malaysia. The majority of cases involved children, males and those who have access to water activity. The discussion will revolve around the presumed contributor to death and the suggestion to reduce such cases from reoccurring. We will also layout the strategies which include awareness and community education to prevent future cases.

MASS CASUALTY INCIDENT MANAGEMENT: WAY FORWARD IN MINOR SPECIALIST HOSPITAL

Tan Soo Teck Malaysia

Background

Mass Casualty Incident (MCI) is uncommon in Bintulu but any moderate scale manmade accident can be an MCI for district hospitals due to its smaller capacity. Generally, the majority of staff are not familiar with the MCI concept and internal disaster management. Several shortfalls were identified and rectified when two moderate MCIs recorded within the first five months of this year.

Description

First MCI happened on February 2019 when eleven victims involved in a bad road traffic accident (RTA). Emergency Response Team (EMT) scooped and ran in response to the MCI. There were four critical cases managed in Red Zone, five cases in the Yellow Zone and two cases tagged black. Few patients were wrongly identified and labeled at the triage counter. During the post mortem meeting, the patient's wristband was suggested to be prepared at the triage counter before the patient’s arrival when the MCI was declared. The wristband would be tagged to victims immediately. The patient would be later re-registered when actual identity was available. Ideal disaster management was subsequently reinforced during the hospital disaster course in April 2019.


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Outcome

The second MCI occurred on May 2019 when ten victims crashed in an RTA. EMT stayed at the scene to command and control out of hospital MCI management. Four cases were triaged to Red Zone, three to Yellow Zone and three to Mortuary. No wrong identity was registered in the Hospital Information System, thus no delayed inpatient management. The intervention (pre-prepared patient wristband and disaster course) had helped to minimize mismanagement and improve the work process in ETD.

Conclusion

There was an improvement in workflow, knowledge, and skill in MCI management after repeated exposure to MCIs. We learn and grow with each internal disaster management.

PRE-HOSPITAL CARE CHALLENGES IN LABUAN – INTO THE WOODS

Muhammad Shaiful Rahim Bin Zainal Abidin Malaysia


We responded to a mother, postnatal 7 days, complaining of bleeding per vaginally and was categorized as unstable on call triaging. The location of the incident was at one of the squatter homes built on a mangrove area. It was 500 metes off the main road and connected by a narrow wooden-plank bridge built by the villagers themselves. There were not proper signage nor access to the squatter homes. The mother was clinically pale and lethargy with poor capillary refill and tachycardia. We initiate our resuscitation and had to transfer her to the ambulance using a scoop stretcher.

Discussion

Scene assessment is always the first step as a responder approaches the scene. This is of utmost importance to ensure the safety of everyone at the scene, including the responders so that they can perform their duties to reduce morbidity and mortality to the patient. Scene assessment starts early during the call triaging itself and before arrival to the exact location of the incident. No incident scene is or can be made absolutely danger-free, especially in complex situations. However, a scene can be less dangerous if scene precaution and control is applied. This can reduce the probability or the severity (consequences) of the risk, to as low as reasonably practicable. When the scene is deemed unsafe based on the responder's critical judgment, they can request further assistance or make an emergency move before starting patient management.

Lesson Learnt

Scene safety is of top priority during each emergency response in the challenging pre-hospital care environment. However, it may delay initial patient management. Thus each responder must practice critical thinking and decision making, including all their five senses, during each response to ensure the patient gets the best standard care possible.


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BREECH DELIVERY IN PREHOSPITAL CARE: EXPECT THE UNEXPECTED

Mohammad Khir Bin Mahaiyuddin , Muhamad Nor Hazlim Bin Mohd Yusof, Dr Aishah Binti Mohd Hafiz, Dr Ng Siew Gar Malaysia


Pre-hospital care (PHC) is becoming increasingly important in many parts of the world including Malaysia as any initial medical care given to an ill or injured patient beyond the wall of the hospital. The type of cases that the PHC team provides services varies greatly, including obstetrics emergencies. Furthermore, many a time the informed presenting complaint and the patient’s actual condition differs, posing a challenge to the attending team. In this instance, we report a case in which our team was called for a 34-years-old lady with abdominal pain. On arrival, she was actually in active labour and breech presentation. Standard PHC management was carried out to her and was immediately brought to the hospital. The baby was delivered in cardiac arrest due to difficulty in breech delivery. Fortunately, she was successfully resuscitated and is currently well.

Discussion

Responding to obstetric emergencies such as breech delivery is rare. However, our PHC providers need to adapt to unique situations. At that time the decision was made to immediately bring the patient to the hospital as the team was not equipt with knowledge nor skill to attempt delivery. In Malaysia currently, there is no proper training for PHC providers to manage cases such as this. Incorporation on how to manage such situations in standard training would assist the PHC team in providing better care and a greater chance of favorable outcomes.

Lesson Learnt

PHC team should be prepared to face a range of different situations, including obstetric emergencies. Education and training on this subject should be included as standard practice.


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TRAUMA

MULTIPLE HORNET STING

Samsuri B Md Isa Malaysia


We received a call regarding a 57-year-old male with multiple hornet stings. Our team responded with 3 personnel. When we arrived at the scene, we saw 1 medical patient lying on the floor at home. Relatives informed us that the incident occurred at the backyard about 50m away. We saw a tamarind tree with a huge hornet nest. The patient was responsive to the call. He was hypotensive, tachypneic but not tachycardic. We could see multiple sting marks and swelling of his upper and lower lips. His pain score was 10. We administered intramuscular adrenaline and high flow oxygen to the patient. IV access was performed over the right hand.

Discussion

Hymenoptera Vespidae sting contains protein toxins, biogenic amines, and enzymes that allow the toxins to spread. The hornet’s nest was near to our patient care area which poses risk to our safety. Care was taken to ensure we were not in immediate threat.

Our patient had an anaphylactic shock from multiple hornet stings. Besides providing the intramuscular adrenaline, we also considered corticosteroid and antihistamines administration. We had time to ensure these medications were brought along as the patient’s condition was known during dispatch.

The decision on whether intubation is required for anaphylaxis is also an important consideration especially when the presence of mucosa swelling at the lips.

Lesson learned

Continuous medical education learning (CME) on the topic such as anaphylaxis, and sting management is important. Knowledge of anaphylaxis shock, medication, and emergency intervention should be the main priority in terms of managing patients with sting or bites.

THE ALLERGIC REACTION- A RARE PRESENTATION OF JELLYFISH STING

AS Mat Ali, WN Wan Rosdi, MZF Senek, KN Mohamad Malaysia

Clinical Case Presentation

We report a patient with an allergic reaction induced by jellyfish envenomation. Our team transported a 39-year-old diver stationed in Kemaman Port complaining of swelling over the


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upper lips and right cheek after jellyfish sting while diving. He had also suddenly developed generalized skin itchiness, wheals and feeling nauseated. He received treatment at his station’s medical sickbay and was treated with vinegar. He had no medical problem and allergy reaction in the past. He had engaged previously with jellyfishes due to the nature of his work but did not react in the past. In the hospital, he received intravenous hydrocortisone 200mg stat and intravenous chlorpheniramine 10mg stat. He was discharged the next day.

Discussion

A sting by jellyfish involves an injection of microscopic cnidaria bathed in venom through the skin. Patients with jellyfish envenomation usually presented with immediate burning pain and redness.

Recurrent exposure to jellyfish envenomation may lead to immune mediated reaction especially the occupational and recreational water enthusiasts. Our patient had multiple exposures in the past with no allergic reaction. This time he developed allergic reaction.

Managing jellyfish sting in our coastal prehospital care service is quite common. The treatment protocol consists of reduction of envenomation through vinegar rinse, anaphylaxis reaction treatment and comfort care with analgesics during transport. Our service organizes training modules to prepare not only our team but also local first aiders and lifeguards on the management of marine bites and stings.

Lesson Learned

Coastal prehospital care teams must have knowledge of common marine bites and stings. It must also include local first aiders and lifeguards in the training program.

Allergic reaction although uncommon, must be anticipated for occupational and recreational water enthusiasts.

LOPPED OFF NIGHTMARE

Mohd Rizal, Mohd Fadzlullah Malaysia


Our team received a call regarding a construction building collapsed. At the scene, we were informed there was a victim entrapped at his upper limb. After five hours and due to safety concerns, Fire and Rescue personnel requested consideration for amputation to allow the extrication of the victim.

Amputation could not be performed by our team as the space was too small and none of our members to access it. Thus, we had to instruct our Fire and Rescue personnel on how to perform the amputation. Victim safely taken out from the unsafe scene, management of crush syndrome and amputated limb was done in the ambulance whilst en route to the hospital.


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Discussion

This case highlights the importance of deployment strategy in handling confined space response. The first response team would always be the usual team nearest to the site to provide support. However, a second team should be activated when a complex entrapment situation occurs. In such cases, the presence of an Emergency Physician at the scene should be requested by the team.

In an extreme environment such as this, field amputation should be anticipated and freely discussed between commanders at the scene. There are several indications for field amputation and our situation is a clear indication of one.

Lesson Learnt

1. Always be prepared.

2. Always communicate with Medical Control

3. Always consider the need for Specialized Medical teams in extreme situations.

4. EMS Physician should be competent in providing instructions to personnel to perform specialized procedures.


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DIFFERENT SHADES OF GREY

PREVALENCE OF VIOLENCE CASES TOWARDS STAFF IN HOSPITAL KEPALA BATAS, PENANG

Mohd Farize bin Mohd Rodzi, Mohd Anis farhan Bin Jamaludin Malaysia

Background

Violence against healthcare workers often heared nowdays, either in hospitals or clinics and that issues received growing national attention. It can happen to anyone among us regardless of any rank or position.

Discussion

Data are collected from ‘Jawatankuasa Kesihatan dan Keselamatan Pekerja (JKKP)’ Hospital Kepala Batas, Penang. Affected staff who reported to JKKP are being interviewed to get detail informations and datas. All the data will be collected and classified to three major types of violences . Data are collected within 3 years, starting from January 2017 to June 2019. From January 2017 until June 2019 , 12 cases have been reported to JKKP.

Conclusion

Based on data that have been collected, its shows that cases of violence towards health care workers are increasing in trend, from 1 case in 2017 and increasing to 8 cases in 2018. We believe that this is just the tip of iceberg, where a lot of cases were under reported due to certain limitations. Indeed, this is a serious issue and its required immediate attention and effective solution. We hope that this research will instill awareness among civilians and health care workers regarding health care workers safety.

PARAMEDIC IS RESPONSIBLE FOR TRAINING A BYSTANDER

Yusuke Takayama, Toshimitsu Takanashi, Mizuki Sakamoto, Tadaomi Kikugawa Japan


The importance of bystander CPR is recognized in saving one’s life from OHCA. Today, we report on one clinical case that reminds us of the importance. The patient was 68 years male, he got cardiac arrest during a conversation with his wife at 11 am, and she called an ambulance. When we arrived at the scene, his son was performing dispatcher-assisted bystander CPR. Initial ECG was coarse VF. We conducted defibrillation 3 times every 2 minutes(the first defibrillation was on 13 minutes from the onset of cardiac arrest), laryngeal tube insertion for airway management, and drip intravenous injection. The patient's god return of spontaneous


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circulation(ROSC) before arriving at the emergency department. In this case, the chain of survival contributed to surviving the patient from cardiac arrest.

Lesson Learnt

Researchers know how important bystander CPR is through the Utstein registry. However, paramedics know the importance through experience, and we responsible for training bystander.


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Acknowledgements

BOEHRINGER INGELHEIM

ZOLL

ASTRAZENECA

UMC

KUASA SAKSAMA SDN BHD

INSAN BAKTI

MINDRAY

AXISBIO DIAGNOSTICS

TMI MEDIK GROUP

MEDICA SYIFA TECHNOLOGY

UMMI SURGICAL

KL MED SUPPLIES (M) SDN BHD

INFINITY MEDICAL

BECKMAN COULTER

PUBLIC SAFETY GROUP


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Organized By

Asian Association of Emergency Medical Services

College of Emergency Physicians (CEP), Malaysia

Prehospital Care Services Special Interest Group, CEP, Malaysia

In Conjunction With

Supported By


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Documents

PROGRAM AND ABSTRACTS - PHC Malaysia · Mr Arun A/L Adi Mr Thiagarajan A/L Mutusamy Mr Muhammad Sazuan Bin Zakaria Mr Nik Mohd Nor Azam Bin Nik Aziz Mr Abdul Shakir Bin Zainal Abidin