An early severe pulmonary fat embolism with systemic embolization following bilateral femoral shaft fractures.

Pulmonary and systemic fat embolization has been recognized as a serious and life-threatening complication of pelvic and/or long bone fractures. However, articles on pulmonary and systemic fat embolism which have resulted from bilateral femoral shaft fractures alone are rarely found in the literature and the fates of such cases are under-reported as well. The authors recently experienced an early severe pulmonary and systemic fat embolism following bilateral femoral shaft fractures, resulting in a sudden death about 5 hours after injury. The authors report such a case and also review the relevant literature as to its cause, pathophysiology, clinical presentation, diagnosis, and treatment.

A fatal heroin addict with myocardial lesion.

This is a histological report of a myocardial lesion of a 44-year-old white man who was found dead in a hotel with circumstances strongly suggestive of heroin intoxication. Based on. autopsy findings and toxicologic analysis, the present case was an instance of straight forward heroin overdose in snorter. The most striking pathologic finding of the heart was a few patches of marked dark mottling appearance in the left ventricle and ventricular septum. Histological appearance of the lesions revealed marked congestion with intramyocardial extravasation of blood. Since the deceased had patent coronary arteries without evidence of atheroma, the lesions were thought to be the results ofcoronary artery spasm. There has also been substantial evidence in the previous reports to believe that the condition is secondary to heroin-induced coronary artery spasm. However its actual underlying mechanism remains unclear.

Lower interscalene approach, the novel landmark for more success rate of supraclavicular block: a comparison with the classical approach in fresh cadavers.

Objective: To create a novel landmark for supraclavicular block, the lower interscalene approach, to increase its success rate. Methods: A prospective study was performed and carried out at the Department of Forensic Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University. Both the lower interscalene approach and the classical approach were tested by simulating the supraclavicular block in forty fresh cadavers. Each approach was randomly done on each side of the same body. To determine the accuracy of the needle tip encroachment on the epineurium, staining of methylene blue on the nerves was defined as the success of the nerve localization. The localization of methylene blue was observed and the correlation between the success rates of the dye stained on the nerve trunk and the length of the patient’s neck was analyzed. Results: The success rate of three - nerve - trunk localization was 62.5 % by the lower interscalene approach, compared with 40 % by the classical approach (p value = 0.037). The success rates of superior, medial and inferior nerve trunk localization in the lower interscalene group were 70.0 %, 92.5 % and 97.5 %, compared with 67.5 %, 87.5 % and 65.0 % in the classical group, respectively. Their p values were 0.5, 0.355 and 0.001 respectively. There was neither correlation between the succsess rate of nerve localization and the clavicle length nor the neck length, but there was significant correlation between the success rate of three - nerve - trunk localization and the needle insertion depth in the classical group (p value = 0.031). Conclusion: Compared with the classical approach, the lower interscalene approach obtained more spreading of methylene blue on the brachial plexus as well as on the inferior nerve trunk. The authors therefore recommend the lower interscalene approach as the novel landmark for more success of supraclavicular block.

A sudden and unexpected death from multiple heart lacerations due to acute myocardial infarction.

A sudden and unexpected death due to simultaneous multiple heart lacerations as a result of acute myocardial infarction is very rare and has not been previously described. The authors report a case of 51-year-old woman who died of cardiac tamponade resulting from multiple incomplete left ventricular free wall ruptures due to acute myocardial infarction. At postmortem examination, 250-ml of clotted blood in the pericardial sac was detected. Three lacerations of the left ventricular epicardium and superficial myocardium were also detected. A 1.5-cm linear tear in the anterosuperior region, a 0.7-cm tear in the anteromedial region, and a 0.7-cm tear in the lateral region were visible. At histological examination, massive coagulation necrosis of myocytes and infiltration of polymorphonuclear inflammatory cells in the lacerated areas were found.

Disability evaluation in posttramatic chronic joint pain patients.

A 37-year-old single female, working as a laboratory technician at a rural public hospital, was presented at Siriraj Hospital with the complaint of chronic knee joint pain for about a year and a half. She had a history of injury by falling down on both knees in her bathroom and suffered significant aggravation to her knee joint. Her pain was constant regardless of her activities except that it was worse with knee bending. Seeking several medical doctors\' treatments did not cure the pain at all. Upon a through physical examination and investigation, the objective data did not seem to correlate the severe subjective complaint or any definite diseases. After being treated with several methods, including medication, surgery, and rehabilitation for 6 months, she quite her job and personally asked for a permanent disability certificate. The formal request was submitted to the hospital\'s director fpr a disability evaluation and the issuing the certificate 6 months later. She was then scheduled for a disability assessment and consideration of legal fitness.

Dementia : Patient's right and physician's role.

An elderly Thai widow with progressive dementia was transferred to Siriraj Hospital for properly continued supportive treatment. Due to the course of the disease, she lacked the ability to make any valid decision related to giving consent to medical treatment and to manage her own affairs. Giving medical consent was a critical issue confronting the treating physician whereas the patient\'s relatives might face with the issue of administering her personal affairs and property. In order to establish the patient's lawful substitute decision maker and administration for the patient's best interest, a declaration of the patient\'s incompetency and the appointment of suitable guardian were needed. The legal proceedings would inevitably be undertaken by filing a petition to the court. This would also have profound implications for the patient's rights and the physician's roles under the justice system.

Abortion : A case report of an abortion performed legally following a decision of the abortion committee with reference to Section 305 (2).

We report a 15-year-old woman who presented with an allegation of having been raped, with subsequent pregnancy due to the failure of postcoital emergency contraception. This case demonstrates a medicolegal perspective of how to approach the raped case and how to be safe for both the patient and the doctor to participate in an abortion legally. The management of sexually transmitted disease and termination of unwanted pregnancy is documented as well as the patient's psychological reactions in coping with the incidents.