Foreign body aspiration presenting as life-threatening bronchial asthma

A two-year-old male, a known case of bronchial asthma was admitted as a case of exacerbation of asthma. He did not improve with standard treatment and required invasive ventilator support twice during his admission. The chest x-rays only showed hyperinflation but CT scan of the thorax revealed a foreign body [a piece of Betel nut] lodged in the right main bronchus. It was removed under bronchoscopic guidance. A foreign body may not be radio-opaque and therefore may not be visible in chest x-ray. The possibility of foreign body aspiration should always be considered in children presenting with an exacerbation of bronchial asthma

Misunderstanding of the term [DNR] in a middle-eastern teaching hospital

Do-not-resuscitate [DNR] order has been practiced for many years; though it is one of the most commonly misunderstood and misinterpreted orders in medical practice. It has many ethical, legal, geographic, religious and cultural aspects that contribute to this misunderstanding. To assess the perception amongst the acute specialties who deal with DNR orders. A Cross-Sectional Questionnaire Type Study. Setting: King Hamad University Hospital, Bahrain. Anonymous questionnaire was designed. Physicians working in the acute specialties were included. The questionnaire included several general questions about when DNR should be implemented and what are the appropriate aspects of management that should be given. Fifty doctors completed the questionnaire; 49 [98%] of the physicians thought that a hospital should have a DNR policy, 23 [46%] of the physicians believed that the DNR decision lies in the hands of the responsible doctor, 10 [20%] of the participants thought that it is a family decision only, whilst 17 [34%] thought that it is a joint decision by the family and the physician. All of the physicians agreed that there should be no code blue activation in case of cardiopulmonary arrest of a DNR labeled patients. The term DNR should not be used as it is confusing and liable to misunderstanding. In addition, we need to educate healthcare professionals about the terminology of the management of end-of-life situations

Metabolic Acidosis and Rhabdomyolysis with Metformin overdosage

Metformin is a biguanide oral hypoglycemic agent used as first-line or as a part of multi-drug therapy in the treatment of Type 2 Diabetes Mellitus [DM]. Lactic acidosis is a well-known but relatively uncommon adverse effect of Metformin, especially in patients with co-existing renal failure. There are several case reports of inadvertent or intentional Metformin overdosage resulting in severe metabolic acidosis with hyperlactatemia and often fatal outcome. Continuous hemodiafiltration with other supportive therapies have resulted in successful management of the metabolic derangements and is presently the accepted standard therapy of Metformin intoxication. A twenty-two-year-old female presented with Metformin over-dosage of 50g and developed severe metabolic acidosis and rhabdomyolysis. Metabolic acidosis was prolonged; the pH level was 6.72, bicarbonate level <4 mmol/L and lactate level was more than 25 mmol/L. The patient was managed with crystalloids, bicarbonate infusions and continuous venovenous hemodiafiltration. The blood gas parameters normalized 48 hours after initiation of the treatment. Hemodiafiltration was continued for longer than usual due to the prolonged metabolic acidosis and until the elevated Creatine Kinase [CK] levels returned to normal. She made an uneventful recovery, without residual sequelae

Status Epilepticus: an intractable case with a successful outcome

A thirty-two-year-old male patient with a history of fever presented with generalized tonic-clonic convulsions and a low Glasgow Coma Score [GCS]; an endotracheal tube was inserted to secure his airway. The patient had malignant generalized tonic-clonic convulsions for six weeks, he was diagnosed as status epilepticus [SE] on the electroencephalogram [EEG]. Achieving control was very difficult even with various antiepileptic medications. More than six antiepileptic drugs were used in addition to continuous infusion of anesthetic medications to control the convulsions. After four-months in the ICU, the patient became fully conscious with no residual neurological deficit and good control of convulsions but with generalized muscle weakness. The patient was eventually transferred to the regular ward and was discharged after few days

Parental satisfaction in pediatric daycare surgery

Pediatric surgery performed in a daycare unit has become the norm in the last few years. Children need special care in terms of psychological stress during the perioperative period1. There are many ways to reduce stress in children scheduled for surgery, including preoperative sedative premedication, induction of anesthesia in a familiar environment and "steal" induction in the mother's arms2,3. It is important to consider parental satisfaction while delivering a healthcare service to children. To assess the overall parental satisfaction throughout the patient's journey, including the preoperative, intraoperative and the postoperative periods. Daycare Unit, Department of Anesthesia, King Hamad University Hospital, Bahrain. A Prospective Study. Fifty parents were consented for the questionnaire-based study. Children of these parents were posted for different types of daycare surgery. The parents were asked to fill a form either in Arabic or English, before their children were discharged from the daycare ward. The parents were given an 11-point questionnaire4. Scoring these questions was based on their choice of 5 options including: [1] strongly agree, [2] agree, [3] neutral, [4] disagree and [5] strongly disagree. Fifty parents had been included in the study. Patient's CPR numbers and telephone numbers of the parents were recorded. Questions 7 and 11 demanded individual answers rather than box-ticking. "Strongly agree" and "agree" were taken as positive responses. The majority of parents answered positively to the questions asked. "Strongly disagree" and "disagree" were taken as negative responses. Neutral response was taken as a parent's wish not to comment either positively or negatively. The majority of the parents were in positive agreement with the questions asked. The majority of the parents were satisfied that the PAC clinic gave them enough information about the anesthetic. The majority of parents were also satisfied with the amount of pain relief given in the recovery room and in the day-care ward

Is it time for a virtual autopsy service in Bahrain?

Post-mortem examination, or autopsy, is known to have been first performed by the ancient Egyptians to prepare the deceased by embalming and other means for their journey into the after-life. In the second century AD, Galen established the concept of autopsy in Rome, albeit mainly in monkeys; this was the first attempt to correlate the physical findings on post-mortem with the symptoms and signs experienced by the patient before death. Autopsy appears to have then become unfashionable or undesirable until the time of the Renaissance and afterwards. In the mid-sixteenth century, Vesalius practiced autopsy and taught it to his students. In about 1543 or 1544, he published De humani corporis fabrica on the composition of the human body based on his post-mortem studies, which is probably the most important anatomy textbook ever published1. Of interest to intensivists, he was the first to describe artificial ventilation by attaching a pair of bellows to a post-mortem trachea-lung preparation. In the nineteenth century, the study of the body post-mortem became more widespread. Doctors such as Rudolph Virchow [Virchow's node] in Germany described an organized technique of carrying out a post-mortem; and much of the progress in western medicine during that time can be attributed to the postmortem study of Virchow and others. The practice of teaching anatomy using cadavers also became widespread during the nineteenth century. Since then, post-mortem science has progressed greatly. It is now possible to extract a healthy infant from the womb of a pregnant woman immediately after death, and it is even possible to harvest the spermatozoa of a dead man, either by the transrectal electro-ejaculation method or by collecting the contents of the epididymis immediately post-mortem. It is important to remember that the harvesting of entire organs for use in transplantation takes place during post-mortem dissection, either with or without a beating heart. The benefits of performing a post-mortem today include: 1. Discovery of the cause of death when the cause is unexplained. 2. As a quality marker, to assess whether the diagnosis and treatment were correct. 3. To assess the effect of treatment given. 4. To look for genetic conditions and give genetic counselling as a result. 5. Teaching medical students and trainee doctors. 6. Forensic purposes. There are particular areas in a hospital where the availability of a post-mortem service is important. Clearly, a patient dying of multiple long-standing illnesses in a hospital medical ward would not usually merit a post-mortem, but a patient dying of a sudden unexplained illness in an emergency department or an adult Intensive Care Unit would need post-mortem investigation to determine the cause of death and to rule out foul play. In addition, neonates and older children dying of unexplained conditions need to have their cause of death investigated to satisfy the parents' unanswered questions and to establish the presence or otherwise an inherited cause of death. It has been a source of considerable frustration to the first author that no post-mortem study has been possible in patients where the cause of death has not been fully explained. Different religions have different views on post-mortem study. No religion encourages it. Christianity tolerates it as a necessary aspect of science. However, Muslims, Hindus and Jews have similar views; all three religions object to post-mortem dissection on three grounds: first, the body should be moved as little as possible, second, the integrity of the body as a whole must not be compromised, and third, post-mortem delays burial [or cremation in the case of Hindus] as burial should take place quickly, preferably on the same day. It is probably reasonable to assume that all religions in olden times viewed corpses as a potent source of infection, and were anxious for burial or cremation to take place as soon as possible after death

Management of a self-inflicted laryngeal injury

We present a case of deliberate self-inflicted trauma to the airway. The patient presented with a slit throat secondary to attempted suicide. The patient had a GCS score of 15 in the emergency department with an ability to maintain his own airway and phonation. A cuffed tracheostomy tube was inserted through the wound to maintain the airway. The patient had full wound exploration and repair of anterior tracheal wall. Repeat laryngoscopy and bronchoscopy was done postoperatively which revealed left vocal cord palsy which recovered completely after 2 weeks

Development and evaluation of a medical communication scale

To evaluate the degree of communication with patients and their relatives based on a predesigned medical communication scale. A Prospective random sample assessment study. Intensive Care Unit, King Hamad University Hospital. We studied the scale randomly in 50 adult patients admitted to ICU. The degree of communication with the patient's next of kin was assessed by a native English speaking intensivist according to a scale designed for the purpose. Twenty-three [46%] relatives required the help of an interpreter for communication [class 4]. Full communication was possible with 15 [30%] relatives [class 2]. Twelve [24%] relatives did not have a full grasp of the working language or were informed to a below average level or were unwilling or uninterested in obtaining further knowledge. There was no relative with whom communication was impossible [class 5] nor was there any well-informed relative with whom communication was fully fluent [class 1]. The medical communication scale can help the physician to objectively quantify the ease or difficulty in communication with the patient's relatives. In the ethnically mixed workforce of our hospital, while the physician could fully communicate with many relatives, a significant percentage of the relatives were not proficient in the working language of the hospital and required the help of an interpreter to communicate with the physician