IS TYPE OF INJURY ON

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AKU JANJI

Diperakui bahawa disertasi yang bertajuk IS TYPE OF INJURY ON

PRESENTATION AT THE EMERGENCY DEPARTMENT OF A

TRAUMATIC MOTORCYCLIST PREDICTING MORTALITY WITHIN 30 DAYS? merupakan kerja dan penyelidikan yang asli dari AEHTOOSHAM BIN SULEMAN, nombor kad pengenalan: 771226-03-5085, nombor matriks: PUM 0002/08, dari tempoh 2008 hingga 2012 adalah di bawah penyeliaan kami. Disertasi ini merupakan sebahagiaan daripada syarat untuk penganugerahan Sarjana Perubatan Kecemasan, segala hasil penyelidikan dan data yang diperolehi adalah hak milik terpelihara Universiti Sains Malaysia.

_________________ _______________________________

Tandatangan Pelajar Tandatangan Penyelia Bersama,

Pensyarah Pusat Pengajian Perubatan, Universiti Sains Malaysia.

________________________ ____________________________

Tandatangan Penyelia Utama, Tandatangan Ketua Jabatan, Pensyarah Jabatan Kecemasan. Jabatan Kecemasan.

Pusat Pengajian Sains Perubatan, Universiti Sains Malaysia.

Universiti Sains Malaysia.

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ii

IS TYPE OF INJURY ON

PRESENTATION AT THE EMERGENCY DEPARTMENT OF A TRAUMATIC

MOTORCYCLIST PREDICTING MORTALITY WITHIN 30 DAYS?

B Y

D R . A E H T O O S H A M B I N S U L E M A N

Dissertation Submitted In Partial Fulfillment Of The Requirements For The

Degree Of Master of Medicine (EMERGENCY MEDICINE)

UNIVERSITI SAINS MALAYSIA MAY 2012

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iii

ACKNOWLEDGEMENT

Alhamdullilah gratefulness to Allah S.W.T that I am able to complete my dissertation as a partial fulfillment for my Master programed. It was many sleepless night and wishful thinking with my wife support Julie James Binti Abdullah who never knew tiredness to help me get through the writing of this dissertation.

Thanks to Associate Professor Dr. Nik Hisamuddin Nik Abdul Rahman as the head of the Emergency Department and my main supervisor who despite his commitment and work had given me ample of opportunity to consult and help me in understanding my research in depth until I manage to complete my dissertation. Special thanks to Associate Professor Dr. Rashidi bin Ahmed, Dr. Shaik Farid Bin Abdul Wahab, Mrs. Anis Kausar Binti Ghazali, Dr Aniza Ab. Aziz for their encouragement and help full support in my dissertation. Thank you to all lecturers who never knew tiredness and gave their knowledge to help me get through.

Thanks to Pusat Pengajian Sains Perubatan (PPSP), Universiti Sains Malaysia.

I am always proud to be a student of USM, and I am extremely grateful to be tutored by many great lecturers and teachers from my first to final year during my current master in medicine training.

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iv

LIST OF TABLES

Table 1: Describe the length of hospital stay according to the categories of illnesses

65

Table 2: Factor associated with the length of stay among the study population (n: 103)

67

Table 3: Showing simple cox regression for mortality 81

Table 4: Showing multiple cox regression for survival. 84

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ix

LIST OF FIGURES

Figure 1 Regional Fatality Trend. 2

Figure 2 Mortality rate per 100 000 populations by nation. 3

Figure 3 The number of vehicle registered in Kelantan. 12

Figure 4 The number of motorcycle in the road of Kelantan. 13

Figure 5 Trend of mortality after trauma, the trimodal death distribution.

23

Figure 6 Flow chart of the study. 47

Figure 7 The age distribution of the rider and pillion rider for the case of motorcycle accidents.

51

Figure 8 .Age Category for Motorcyclist/ rider 52

Figure 9 Male and Female fraction among rider and pillion 53

Figure 10 Ethnics Distribution Among the rider and pillion 54

Figure 11 Distribution of rider and pillion. 55

Figure 12 Referral or direct case 56

Figure 13 Patient wearing helmet or not 57

Figure 14 Triage differences among the patient 58

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x Figure 15 Pain score of patient with motorcycle trauma 59

Figure 16 Type of injuries affected motorcyclist and pillion rider

60

Figure 17 Revised trauma score 61

Figure 18 Mechanism of Accidents 62

Figure 19 Disposition from Emergency Department 63

Figure 20 Death among the Patient 64

Figure 21 The distribution of length of stay for 107 patients after removing patient who was not admitted.

66

Figure 22 Survival analysis within 30 days of a motorcyclist and pillion rider after an accident had occurred and having at least a vital sign in emergency department

72

Figure 23 Kaplan-Meier curve for age category 73

Figure 24 Kaplan-Meier curve for male and female 74

Figure 25 Kaplan-Meier curve for revised trauma score 75

Figure 26 Kaplan-Meier curve for type of injury 76

Figure 27 Kaplan-Meier curve for referral or walk in case 77

Figure 28 Kaplan-Meier curve for wearing helmet or not 78

Figure 29 Kaplan-Meier curve for mechanism of accident 79

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xi Figure 30

Figure 31

Figure 32

Kaplan-Meier curve for rider or pillion.

Total Number of Patient Visited during the study Period

Monthly statistic of Emergency department

80

86

87

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xii

LIST OF ABBREVIATIONS

AIS APEX

Abbreviated injury Scale

Accelerated Programme for Excellent ARDS

ATLS ED GCS HR HUSM ICU ISS MAP MODS MOF OT RR RTS SBP SD SIRS SPSS TRISS

Adult respiratory distress syndrome Advanced Trauma Life Support Emergency Department

Glasgow Coma Scale Heart rate

Hospital Universiti Sains Malaysia Intensive care unit

Injury Severity Score Mean arterial pressure

Multiple organ dysfunction syndrome Multiple organ failure

Operation Theatre Respiratory rate Revised Trauma Score Systolic blood pressure Standard deviation

Systemic inflammatory syndrome Statistical Package for Social Sciences Trauma and Injury Severity Score EMS Emergency Medical Services MMC Malaysia Medical Council

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xiii

ABSTRAK

Pengenalan

Kemalangan jalanraya adalah masalah global, dimana motosikal adalah kenderaan yang kurang selamat dari segi binaannya dalam melindungi pengguna daripada kecederaan-kecederaan seperti kepatahan anggota-anggota ekstrimiti, kepala, tulang belakang dan abdomen. Terdapat 4 perkara yang dialami oleh pengguna motosikal semasa kemalangan. Pertama, motosikal melanggar pada objek (impak kenderaan). Kedua, penunggang motosikal terhentam pada objek (impak tubuh).

Ketiga, organ-organ dalaman badan terhentam pada tulang rangka dan terakhir, impak sekunder dari pembonceng atau kenderaan lain. Kajian ini melihat pada adakah faktor jenis kecederaan dapat menganggar kematian pada pengguna motosikal dalam tempoh 30 hari selepas kemalangan.

Objektif

a. .

b. Untuk mengenal pasti bahawa jenis kecederaan boleh menganggarkan kematian dalam penunggang motorsikal selama tempoh 30 hari dari kemalangan.

c. Untuk Mengkaji bahawa adakah umur, jantina, ‘revised trauma score’, dan bagaimana kejadian kemalangan boleh menjangkakan mortaliti penungang motorsikal selama tempoh 30 hari.

d. Analisa deskriptif tempoh kemasukkan ke wad pesakit terlibat dalam kemalangan motosikal

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xiv Metodologi

Kajian ini melibatkan 234 pesakit yang telah bersetuju menjadi responden;

selepas mengalami trauma akibat kemalangan motosikal samada penungang atau pembonceng yang telah dirawat di Jabatan Kecemasan Hospital Universiti Sains Malaysia dari Jun 2010 sehingga Januari 2011, dimana telah memenuhi kriteria dan informasi responden dicatat dalam borang semasa kemasukan. Faktor-faktor yang menyebabkan kematian pesakit dalam masa 30 hari dianalisa dengan menggunakan Statistical package for Social Science (SPSS) software version 18.0 dated 30th July 2009.

Keputusan

Seramai 81.5% daripada 211 responden adalah lelaki dan kumpulan umur pengguna motosikal yang utama adalah dari 16 hingga 25 tahun. Diagnosis atau kecederaan utama yang dialami oleh responden adalah kecederaan ringan (kecederaan tisu) dan kepatahan pada anggota-anggota ekstrimiti.

Responden yang dianalisa dari Kaplan Maier menunjukkan purata pesakit hidup adalah 28 hari bagi penunggang yang mengalami kematian.. Faktor yang dijangkakan menyumbang kepada mortaliti ialah ‘revisedtrauma score’dengan peningkatan markah meningkatkan kelangsunagn hidup.. Jenis kecederaan tidak dapat dibuktikan sebagai factor yang boleh menentukan jangka hayat penungang yang mengalami kemalangan.

Median masa untuk hospitalisasi adalah 6 hari dan julat interquartile adalah 9 hari.

Faktor yang menentukan jumlah penginapan dalam wad adalah bedasarkan kecederaan mengikut sistem badan samaada kecederaan pelbagai, kepala, abdomen, pelvik dan kepatahan tulang serta kecederaan ringan.

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xv Kesimpulan

Pakar Kecemasan dapat mengenalpasti faktor kelangsungan hidup pesakit dalam masa 30 hari selepas kemalangan motosikal berdasarkanrevised trauma score,dan masa hospitalisasi berdasarkan penglibatan sistem badan selepas kecederaan

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xvi

ABSTRACT

Introduction.

Road traffic accidents are a major issue worldwide and motorcycle is the least safe in term of production to protect its occupant from multiple injuries particularly extremities fracture, head and cervical injury and abdominal injury. An occupant of motorcycle is subjected to 4 forces, first the motorcycle hit an object (vehicle impact), then the rider hit object (body impact) and the mobile organ hit a solid structure and lastly secondary impact from pillion or other vehicle. This paper discusses whether type of injury is a predictor of trauma death in motorcyclist.

Objective.

a The descriptive study of the rider and the pillion rider age distribution, ethnicity, gender and distribution of the type of injuries sustained by the patients.

b. To ascertained whether type of injuries on initial presentation at emergency department can predict survival of patient within 30 days after admission.

c. To evaluate whether the age category, gender, revised trauma score, and mechanism of accidents can predicts survival ability after 30 days of admission.

d. Descriptive study to ascertained days of admission according to system of involvement among the patients.

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xvii Methodology.

The research had enrolled 234 patient who had consented, after had a trauma as an occupant of motorcycle either rider or pillion who had visited emergency department Hospital Universiti Sains Malaysia from June 2010 till January 2011 who fulfilled the inclusion and exclusion criteria and their information are recorded in a form. The type of injury in the motorcyclist at emergency department predict the survival of the patient within 30 days using Kaplan Maier and Cox Proportional Hazard Model Statistical package for Social Science (SPSS) software version 18.0 dated 30^thJuly 2009.

Result.

The cases are mainly male 81.5%, majorly from the age group of 16 to 25 years of age, and majorly are diagnosed soft tissue injury with fracture extremities. The mean of survival for the mortality group is is 28 days. Type of injury does not predict the mortality. However factor significant enough to predict mortality is revised trauma score with increasing score improves survivability. The hospital length of stay median is 6 days and interquartile range was 9 days. The predicting factor for admission is based on the type of injury.

Conclusion.

In this research, the independent factor to predict mortality is revised trauma score, the paper failed to show that type of injury is predictor of mortality within 30 days, and type of injury predict the length of hospital stay.

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Bahagian C :

Biodata Abstrak Penyelidikan Lampiran A : Contoh Abstrak

Abstract

IS TYPE OF INJURY ON PRESENTATION AT THE EMERGENCY DEPARTMENT OF A TRAUMATIC MOTORCYCLIST PREDICTING MORTALITY WITHIN 30 DAYS?

Dr. Aehtoosham Bin Suleman.

MMed Emergency Medicine

Department of Emergency Medicine,

School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kelantan, Malaysia.

Introduction : Road traffic accidents are a major issue worldwide and motorcycle is the least safe in term of production to protect its occupant from multiple injuries particularly extremities fracture, head and cervical injury and abdominal injury. An occupant of motorcycle is subjected to 4 forces, first the motorcycle hit an object (vehicle impact), then the rider hit object (body impact) and the mobile organ hit a solid structure and lastly secondary impact from pillion or other vehicle. This paper discusses whether type of injury is a predictor of trauma death in motorcyclist.

Objective :

a The descriptive study of the rider and the pillion rider age distribution, ethnicity, gender and distribution of the type of injuries sustained by the patients.

b. To ascertained whether type of injuries on initial presentation at emergency department can predict survival of patient within 30 days after admission.

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c. To evaluate whether the age category, gender, revised trauma score, and mechanism of accidents can predicts survival ability after 30 days of admission.

d. Descriptive study to ascertained days of admission according to system of involvement among the patients.

Methodology : The research had enrolled 234 patient who had consented, after had a trauma as an occupant of motorcycle either rider or pillion who had visited emergency department Hospital Universiti Sains Malaysia from June 2010 till January 2011 who fulfilled the inclusion and exclusion criteria and their information are recorded in a form. The type of injury in the motorcyclist at emergency department predict the survival of the patient within 30 days using Kaplan Maier and Cox Proportional Hazard Model Statistical package for Social Science (SPSS) software version 18.0 dated 30^thJuly 2009.

Result : The cases are mainly male 81.5%, majorly from the age group of 16 to 25 years of age, and majorly are diagnosed soft tissue injury with fracture extremities. The mean of survival for the mortality group is is 28 days. Type of injury does not predict the mortality.

However factor significant enough to predict mortality is revised trauma score with increasing score improves survivability. The hospital length of stay median is 6 days and interquartile range was 9 days. The predicting factor for admission is based on the type of injury.

Conclusion : In this research, the independent factor to predict mortality is revised trauma score, the paper failed to show that type of injury is predictor of mortality within 30 days, and type of injury predict the length of hospital stay.

Associate Professor Dr. Nik Hisamuddin Nik Abdul Rahman : Supervisor Dr Aniza Ab. Aziz : Co - Supervisor

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1

CHAPTER 1: INTRODUCTION

Trauma is an important health related issues to the developed or developing nation. It is an increasing problem nationally and globally. Trauma is the leading cause of mortality and morbidity worldwide. About 3000 people dies daily worldwide on the road (Global Road Safety Partnership, 2002). This number is similar to the death rate in September 2011 the World Trade Centre, New York which was the headline of every major newspaper in the world. But measures put to stop the road traffic accidents are not as substantial as the measure taken for World Trade Centre incidence.

Internationally the World Health Organization (WHO) has taken an initiative in year 2008 for measure to cope with road traffic accidents by releasing a report to make the government and agencies in all country worldwide to understand that it is a global health issues (World Health Organization Geneva, 2009).

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2 Figure 1: Regional Fatality Trend (source: (G Jacobs et al., 2000))

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3 Figure 2: Mortality rate per 100 000 populations by nation. (source :(G Jacobs et al., 2000))

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4 The graph (Figure 1) above shows the trend mortality according to regions. The regions were divided into Africa, Asia/Pacific, Central and Eastern Europe (CEE), Latin/Central America and the Caribbean (LAC), Middle East and North Africa (MENA) and Highly motorised countries (HMC), for example North America, Australia, New Zealand, Japan and Western Europe. Across all regions the trend of mortality was showing an increasing trend.

Figure 2 showed that Malaysia having a higher death rate comparing to other regional countries like Thailand, Brunei, Indonesia, and other Asia Pacific countries.

These data is taken latest available from the year 1995-1999 as for comparison regarding death according to regions.

In our nation, it has never been a day without reported cases of trauma in the newspapers. Sometime it hits the major headlines but most of the times due to the number of road traffic accidents that the news are reported in national news or in a smaller column. The national trauma registry has been created in year 2006 just to cater the increasing demand for closer monitoring of the trauma cases in Malaysia. Among its objective are to determine the frequency, mechanism of injury and distribution of major trauma in Malaysia (Sabariah et al., 2008).

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5 Trauma cases that were seen in Malaysia may be varieties from the road traffic accidents, industrial accidents and others. Among the trauma cases that were seen by healthcare providers in Malaysia, road traffic accident are leading cause of admission 73.1% , and others 26.9 % are contributed by industrial accidents, injuries at home, assaults and other (Sethi et al., 2007). Similarly in the Malaysian national trauma database report which was release in 2008, showed road traffic accidents accounts for 72.6% and the rest are trauma by other causes (Sabariah et al., 2008).

Human has been using transportation as a mean of way to move around from one place to another place. It enable human to do communication, provides mean of transport for job, factories transportation of products, education, recreation and businesses. The increase nature of economic demand in a particular area resulting in increased demand for good transportation system. These show a symbiotic episode between human and transportation. By increase number of jobs and opportunity nationally, the number of registered vehicle seems to be increasing readily from year to year and seems to be not much affected by economic situation.

In the year 1990 the number of registered cars were 1,811,141 and motorcycles were 3,035,930. Ten year later in the year 2001 the number of registered cars increased substantially to 4,557,992 and motorcycles were 5,609,351. Furthermore, in the year 2007 the number yet had increased markedly to 7,419,643 for cars and 7,943,364 for motorcycles (PDRM, 2008). The increasing number of vehicles may affect the number of vehicle per road and thus the number of mishap at a particular area.

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6 As a sensible user and population with increasing number of vehicles on the road and massive traffic jams, the population tend to see the motorcycle as a perfect alternative mode of transportation. The reason behind the trend is that motorcycles can pass through jams and roads more readily despite of lack of safety equipment on the vehicle.

With the increasing number of vehicles year by year surely there were an increasing number of accidents per area. There were steady increases in number of road traffic accidents from the year 2002, 279,711 to 414,421 in the year 2010. Similarly, the statistic of accidents between January and May 2011 showed there were 170,048 cases of accidents without injuries, and another 8,650 accidents with injuries.

The number 8650 accidents with injuries were further divided to 2,500 deaths, 2,029 with severe injuries, 4,121 with minor injuries. The index of road traffic accidents to 100 thousand of population was 24.20 and index of road traffic accidents to every 10 thousands of registered vehicle is 3.40 in 2010 (JKJR Malaysia, 2011).

In response of overwhelming accidents and rampage of deaths in Malaysian road the Royal Malaysian Police department had done a lot of prevention programmed to prevent road traffic accidents among which were the „Ops Sikap‟. The „Ops Sikap XXII‟ which was done on 27^th January to 10^th February 2011 showed that there was 17288 accidents that occurred, among which 199 deaths and an average of 13.3 death per day during that festive season (JKJR Malaysia, 2011).

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7 The Haddon Matrix states that all accidents are preventable and not accidental.

In the event of rapid and increments of accidents that were seen, the government had multiple approaches to reduce the number of accident by doing preventative measurements. Among the strategies taken by the governmental agencies involved in accident reduction and prevention involves the application of “Four E‟s”(Haddon, 1970). This concept consists of education, engineering, enforcement and environment.

The concept involves the application of appropriate safety policies, vehicle and road engineering approaches, and medical and trauma management. Added to that further strategies were done under Ministry of Transportation of Malaysia, which is a „Road Safety Plan 2006-2010‟ have been drafted and agreed by the Government to provide guidelines and initiatives for road safety in Malaysia by providing strategies which include improve accident-prone spots on major roads as well as inculcating good road ethics among road user (Department of Prime Minister, 2006).

Health fact published by Ministry of Health, Malaysia showed that accidents were fourth out of tenth principal causes of hospitalization in Ministry of Health hospital which accounts 8.03% of total admission in 2009. The accidents admission fall shorts by normal deliveries, complication of pregnancies, and diseases of respiratory systems admission. The number of deaths cause by road traffic accidents were seventh (4.89%) out of tenth principal causes of death in ministry of health hospitals. Accidents cause of death followed shortly by heart diseases 16.09% , septicaemia 13.82%, malignant neoplasm 10.85% , pneumonia 10.38% cerebral vascular accidents 8.43%

and disease of digestive systems 4.98% (Ministry of Health Malaysia, 2010).

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8 The number of registered car and motorcycle in the year 2007, 7,419,643 were car and 7,943,364 were motorcycle. In the same year 428,475 cars and 111,958 motorcycles were reported to involve in accidents. In another statistic in the similar publication stated that the number of death according to type of vehicle involved from September 1^st to 12^th September 2008 showed that number of death due to motorcycle riders were 42 (50%), pillion riders 4 (5%), driver of car 9 (11%) and passenger of car 12 (14%) and other constitute 14 (20%)respectively (PDRM, 2008). The number of lower reported cases of motorcycles can be due to cheap repair cost that does not involved insurance claims and not involving other third party vehicle, which may be the cases, causes low reported cases.

There were a significant number of death combined both rider and pillion rider of motorcycles than other type of vehicles. In term of admission to the hospital in Malaysia, motorcycle is leading cause of admission by 79.9% followed by motorcars 10.7% and other 9.4 % (Sethi et al., 2007). This if further strengthen by the Malaysian national trauma database which report that 64.9% out of the trauma is due to motorcycle (Sabariah et al., 2008).

In our neighbouring country Singapore, due to its nature of being the smaller country comparing to Malaysia, Thailand and Indonesia we expect that the number of accident to be low. However in reality, there is a significant numbers of accidents, 11,258 were actually involve in road traffic accidents, with 198 fatalities with the rate of 3.8 per 100 000 population death in year 2010. Out of 198 fatalities, 89 (44.9%) were pillion riders and motorcyclist, 55 (27.8%) was pedestrian, and others constitute 54 (27.2%). There were a total of 15,277 accidents in year 2010, out of it 6,866 were cars and 5,016 were motorcycle (Singapore Police Force, 2010).

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9 In Thailand, there were 91,623 numbers of accidents, with 13,116 fatalities with the casualty rate of 20.9 per 100 000 population death in year 2002. Among the number of accidents, 53,272 were in involved in motorcycle accidents, 44,019 passenger cars, 26,116 were pickup and the rest were other mode of transportation. The rate of admission due to motorcycle is 75%, pedal cyclist 11% and other is 14%

(Tanaboriboon and Satiennam, 2005).

In Indonesia, there were 178746 cases of accidents reported with 148282 cases of injured and 30464 death reported by the Ministry of Health, Indonesia in the year 2002. The total number of accident in year 2002 reported by the police are 24,632,330, out of these figure 18,016,414 (73.1%) were motorcycle, and 3,868,579 (15.7%) were passenger cars (H. Sutomo et al., 2003).

World health organization has estimated that about 1.2 million people die each year from road traffic accidents, and 20 to 50 million suffer minor injuries. High income countries has lower mortality rate of 10.3 per 100 000 population while the low and middle income groups have higher mortality rate 21.5 and 19.5 per 100 000 population respectively. It is estimated that in year 2004 the road traffic accidents is ranked 9^th (2.2%) in ten list of causes of death worldwide. This however is projected to increase in year 2030 to 4^th (3.6%) ranked of death globally (World Health Organization Geneva, 2009). In the middle income country it is estimated that road traffic accidents cause life of 0.94 deaths in millions and ranked 7^th out of 10^th cause of deaths (World Health Organization Geneva, 2008).

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10 A similar paper published in lancet showed that globally the incidences of mortality from road traffic accidents were ranked 9^th out 10^th, this was a data collected from eight region of the world (Murray and Lopez, 1997b). The projected cause of death from 1990 to 2020 is estimated that road traffic accidents is 3^rd in the list after ischemic heart disease and unipolar depression worldwide, while in the developed country it rank 5^th after ischemic heart disease, cerebrovascular accidents, unipolar depression, and respiratory cancers. However it is interesting that the same paper projected that mortality rate from road traffic accidents is ranked number 2 after unipolar depression in developing country (Murray and Lopez, 1997a).

In United States the picture of road traffic accident by motorcycle shows a declined phase from year 1995 to 1997 but its trend is increasing from year 1998.

Motorcycle fatality has increase to a substantial figure of 89 per cent from year 1997 (2,116) to year 2004(4,008). There has been a steady inclined of number of fatalities during year 1998 to year 2004. The projection of increment of mortality of road traffic accident due to motorcycle is expected to be 7.7 per cent per year (Varghese, 2006).

Kelantan, with the land area of 14,931 square kilometres with estimated of 1,595,000 population in mid-year 2008 with annual growth of population 2.2 per cent and equal male to female ratio. The annual registration of cars shows increment steadily from the 2006 to year 2008 (Figure 3). There is also increment of percentage of vehicle in the road in particular there is an increment of number of motorcycle in Kelantan road.(Figure 4) (Prime Minister's Office Malaysia, 2009).

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11 Local researcher in Universiti Sains Malaysia showed that in 2010, there were about 56,662 visited the emergency department, 3265 were trauma cases which accounts to five per cents of visit rate were due to trauma. From that figure 73 per cents were male and 92 per cents were Malays. Among the trauma patient 65 per cents were due to road traffic accidents, and a substantial percentage were due to fall and assault (14 per cents) (Hafidawati, 2010).

Thus the important of motorcycle accidents in Kelantan, Malaysia, and South East Asia and the world is paramount important for it‟s to be studied in depth for mortality, and morbidity as itself non-mixing with the other trauma data which includes other modes of trauma and injuries.

It comes to one mind that trauma is a major contributing factor to one health.

Among the highest contributing death of trauma is a motor vehicle accident. Among the motor vehicle accidents motorcycle is the highest attributed the cause of disability and morbidity. However there are no papers that actually see the survival of victim that arrive to casualty and admitted to ward with their surviving time on average excluding the victims dies on scene based on literature review done. This paper is hoped to give ideas regarding factors that can predict motorcyclist survival after having a trauma.

On the other hand it is hoped that by giving certain information as to whether type of injuries can signify or predict 30 days mortality as to any patient who had been to Emergency Department. This will assist emergency physician to as giving a guarded prognosis to patient who had arrive to casualty and their survival time.

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13 Figure 4: The number of motorcycle in the road of Kelantan. (Source : (Prime

Minister's Office Malaysia, 2009))

Perangkaan Jumlah Kenderaan 0; Negeri Kelantan Tahun 2006·2008 Number of vehicle in Kelantan year Z()()6-Z()()8

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14

CHAPTER 2: LITERATURE REVIEW.

2.0 Overview.

Motorcycle accidents and its analysis of the trauma patients involve in motorcycle accidents is unique in its own way as the rider and its pillion is directly impacted to the part of the road, the motorcycle itself or with the incoming vehicles.

There is always an adrenaline rush by the attending doctors, surgeons and physicians to see victims of motorcycle who are rolled over or severely injured in emergency department. It is during this time the emergency department will be chaotic with most of the man power used to stabilize patient, diagnosing and ultimately treating either operatively or conservatively.

The number of man power used per patient greatly varies when managing motorcycle accidents especially when it involved a polytrauma cases. In one side emergency physician handling the resuscitation and stability of the patient, the trauma surgeon deciding on laparotomy, neurosurgeon on craniotomy, the otorhinolaryngology trying to stop torrential nasal bleeding, the maxillofacial surgeon stabilizing mandible and Le Fort fracture while the orthopaedics are stabilizing fractures of the limbs.

After such a great effort taken what actually happen to this patient, what was the cost involved, does initial emergency department management really helps, how long does one really stays in ward and what is an overall cost for a patient. These are important factors as emergency physician to take into consideration as to advice family members on prognostic factors for the involve patient to be explained to the patient if feasible, family members and relatives.

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15 Despite advancement in trauma management and researches done all over the world, including the implementation of advance trauma life support, there were patients who succumbs to the complication of trauma (Bilkovski et al., 2004).

Recently in October 2011, Marco Simoncelli age 24 died in Malaysia Moto Grand Prix cup that was held Sepang International Circuit which is considered as a control environment and the road is very conducive road. Despite medical standby and early resuscitation and state of the art equipment he succumbs to death after 45 minutes (Huat, 2011). Such a death was not preventable despite strict rule and protective equipment worn by the racer during the motor GP race. Sepang International Circuit was considered one of the safest tracks in the world and not much of accident had occurred since Moto GP started having the event there.

Despite good road may be predicted to have less accidents, road or off road condition does not predict the severity and the condition of the motorcyclist (CDC United State, 2006) but it may be neglected by the authorities (Mikocka-Walus et al., 2010).

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16 2.1 Motorcycle

Motorcycle is the as seen in the introductory segment is the least safe of mode of transportation that is available. It account from 50-60% of the number vehicle involve in accidents in all country and region (Sethi et al., 2007; Sabariah et al., 2008;

Singapore Police Force, 2010).

Motorcycle is defined as (noun) a vehicle with two wheels that is powered by a motor and that can carry one or two people (Webster, 2011). Motorcycle by mean of its kinematic is defined as structural parts consist of a spatial mechanism compose of four parts which are the rear assembly, the front assembly, the front and the back wheel. The back assembly consist of frame, saddle, tank and motor transmission drive train group. The front assembly which is responsible for turning consist of the fork, the steering head and the steering handle bar (Cossalter, 2006).

The current architecture or the basis of the motorcycle is interestingly has not change since 1902 by German Werner Brother (Minton et al., 1981) despite many attempt to change the pattern. The posture is like traditional man on the horse. The handling of motorcycle puts the rider as a one with its machine, which mean the rider is a part of the machine. A motorcycle does not hold the rider in a close confine space thus exposes him to his own mistake or shortcoming.

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17 The body movement of the rider affect the movement and the stability of the ride. Thus there are major differences when engineers designing a motorcycle or car.

As a rider, he has all his limbs attached to certain part of the machines, both foot is either on brake or gear, both hand is either handling brake, clutch or accelerator, fingers and thumb for important switch toggles (Minton et al., 1981). Major movement of turning is not done by the handle of the motorcycle but it is by the gesture of the body movement.

Despite a lot of advancement in modern engineering of the motorcycle, man has failed to put any protective equipment and measure to protect the rider in the motorcycle itself. The initiative of any protection is concentrated on the rider itself rather than the motorcycle. Thus the rider needs to utilize protective equipment‟s such as helmet, leather protective gears, boots and gloves, and conspicuous clothing. An essential checking of the brake light and tyres pressure besides keeping the front light switch on all the time may ensure further protections the rider.

Safety programme all over the world and Malaysia is to ensure the safety of the pillion and its rider (Radin Umar, 2006). Legislation in Malaysia, mandate the rider to switch on the light on daylight to make the rider to be more visible. This is to make the rider more visible in case of darker or low light environments and reduces fatalities among motorcycle users (Radin et al., 1996; Wells et al., 2004). Besides being visible, wearing a safety clothing for protection of the rider proves that it reduces minor abrasion and wounds (de Rome et al., 2011).

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18 A brief overview of helmet wear and its legislative process has showed that it reduces many fatalities (Heilman et al., 1982; Kelly et al., 1991; Houston and Richardson, 2008; Brown et al., 2009). Pattern of injuries whether the occupant wearing helmet and non-helmeted is also vastly described in many literature (Bachulis et al., 1988). Among the worries was neck trauma among the non-helmeted which was thought to cause more significant cervical trauma. The neck trauma within helmeted and non-helmeted occupant shows no differences in term of the severity, and furthermore it is shown that helmet protect occipito-antlanta joint (Yang et al., 2006).

In many countries and in Malaysia, wearing a crash helmet or a safety helmet is compulsory and mandatory by law. Helmets are available as many type, full face helmet, trial or moped helmet, Moto-X helmets and jet helmet. The helmet has its own standard for its manufacturing and its safety regulation and in Malaysia the bodies that ensure helmets are safe are SIRIM Malaysia. Moto-X helmet and jet helmet are not legalized in many countries to be use on the road (Minton et al., 1981). The most safety helmet is the full face helmet as it has protection for the maxillofacial injury. Helmets should be keep carefully, should not fall or bruised, should not be repaired or modified because these could weakened the structure and is useless for the protection of the rider.

In European countries, there are two mechanism protection standard for protective clothing wear by the motorcyclist. First the protective mechanism involves the protection of the soft tissue from abrasion and cut and the second mechanism to absorb impact and distribute it for the exposed area such as the elbow.

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19 Usage of protective body armoured clothing is not yet legislative in many part of the world. De Rome et all reported that there is a significant reduction of minor cut and abrasion with usage of the protective armour clothing as the above standard(de Rome et al., 2011). They further concluded that usage of protective gloves and boots also help in reduction of the injuries to the extremities. Furthermore they also reported then usage of normal jacket and pants.

In Malaysia there are three tiers of driving licence according to the horsepower of the motorcycle. B for horse power more than 500cc, B1 for less than 500cc and B2 for less than 250cc.Thus a person who only own B2 licence only can ride the motorcycle less 250 cc and will not able to ride motorcycle with larger capacities. The reason behind this is the training for the higher capacity of engines differs from the smaller one.

Literature reviews done on motorcycle mechanism of accidents reveal that most accidents occur due to two major factors. Firstly the motorcycle is not conspicuous enough for the other motorist to see. Most of the accident occurred because other motorist not able to see the motorcycle. Due to this reason the legislation of motorcycle to switch on the light all the time. The second reason is lack of speed and distance judgemental error. This accidents typically occurs when the car is try to enter a road and his judgement on the incoming motorcycle is wrong and thus accidents occurs (Pai, 2010).

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20 2.2 Physics of motorcycle occupants and its impact.

Motorcyclist is not free from physics law, so does the medical fraternity. It is interesting to know that much regarding the impact of the occupant of vehicle follows simple physics law. The law that is directly related to the accident is regarding the basic law of motion which state that “energy cannot be created or destroyed, but it can change in form or be absorbed” (Halliday; et al., 2011). Motion injury that occurs to the motorcyclist is as a result of body‟s absorption of the energy change during the accident.

A motorcyclist has a forward motion or movement with a force of directing towards the forward wheels. According to basic law of motion “a body in motion remains in motion unless acted upon by outside force” (Halliday; et al., 2011).

In a normal condition the deceleration of the motorcycle is acted by the brakes of the motorcycle and the force is change from kinetics force to heat and abrasive action of the brake pads. In accidents however the decelerations is transferred to the patient‟s body and absorb by the body itself and causes shears force that causes fractures and wounds to the patient. For motorcyclist, and most of other type of vehicle the commonest form of injury is from rapid forward deceleration.

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21 When an impact occurs the occupants of the vehicles actually receive three difference types of impacts. For an example a motorcyclist running at a speed of 50 miles per hours, hits a tree or a static object; first the motorcycle part is impacted which may include the front tyre, the front structure of the motorcycle, this is call as vehicle impact. Second the motorcyclist hits the structure of the motorcycle, such as the handle bar, the meter or any other structure, this is call body impact. Third, within the bodies itself, when moveable organ such as brain, heart, liver, spleen or intestine impact with the supporting structure for example with skull, sternum, ribs, spine or pelvis.

The motorcyclist with the pillion rider will have the fourth impact from the pillion rider which may aggravated the condition of the rider. With the basis of the basic impact rule, the health care provider, particularly a first responder can assess patient severity from the extend of the damage of the vehicle (vehicle impact), blood stained at a particular part of the vehicle than may suggest body impact with vehicle part and or shape of injury mimicking structure of motorcycle and evidence of organ impact such as obvious soft tissue injury regarding the area involved.

Motorcyclist and the pillion rider may have secondary impact from any other vehicle. Bear in mind that the motorcyclist does not have any protective shield surrounding them, and protecting them from other secondary incoming vehicle injuries.

This can be, a tyre roll over mark, a second vehicle impact that may further aggravated the patient condition.

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22 For example the accident of Marco Simoncelli, the Gresini Honda rider lost control of his bike on the second lap of the circuit in Sepang at turn 11 and was hit by Colin Edwards and then Rossi as he slid across the track. He had a secondary impact that thrown off his helmet.

2.3 Trauma

Accident is noun defined by Webster dictionary as a sudden event (such as a crash) that is not planned or intended and that causes damage or injury. Trauma on the other hand is also a noun, defined by learner dictionary as a very difficult or unpleasant experience that causes someone to have mental or emotional problems usually for a long time. Trauma as a medical term is defined as a serious injury to a person's body (Webster, 2011).

The study of trauma death and its audits has being the driving force to improve regional trauma centre and outcome of patient deaths. The study of trauma death also the driving force to see whether which part of the trauma should be further research into. Realising this trend Malaysia had started its own trauma registry and from this registry the medical community has realism to improve its trauma care to the ever rising motorcycle injuries (Sabariah et al., 2008).

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23 When discussing regarding trauma the concept of trimodal death comes into the picture. As early as 1970 the concept of trauma death by distribution of peak was introduced and it was found that death distribution had three distinctive period (Trunkey and Lim, 1974; Baker et al., 1980b). Trauma death can occur at the scene of the accidents, during the within one to four hours of the accident known as the golden hours popularized by R. Adams Cowley in 1963 and the third peak occurs in within days and weeks (Trunkey, 1983). Immediate resuscitation and emergency surgery is primarily aimed at saving life by correcting the physiological defects that are present in this phase. The third peak (45%), days or weeks following injury represents the vast majority patients that reached the hospital (Baker et al., 1980a). The graph (figure 3) next page shows the trimodal of death in trauma.

Figure 5 : Trend of mortality after trauma, the trimodal death distribution (source:(Trunkey, 1983)).

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24 Although the concept of trimodal death is a very old concept, has been taken into practise for more than 30 years, it is still applicable to the current situation as a standard routine teaching in advance trauma life support course (ATLS) and Malaysian trauma life support (MTLS). There are many paper attempts to show the trimodal concept is no longer valid but it may have change due to advancements of medical fraternity and pre hospital care (Demetriades et al., 2005; de Knegt et al., 2008; Pang et al., 2008). Most of the death however seems to occurs the first 24 hours of life as suggested, it is said as the most crucial part of the survival of trauma patient (Acosta et al., 1998).

However this paper concentrate on the patients who manage to arrive in emergency department and involved in accidents by motorcycle and was follow up through after that for at least 30 days. Thus in concept of the trimodal death this paper will only include second and third trimodal of death.

At the pre hospital triage and response there are many new development of protocol to predict severity of injuries. Among which, the mechanism of injuries are used to predict the severity of patient and to classify of high impact mechanism to cause severe trauma. Among the criteria are ejection from vehicle, vehicle rollover, explosion, fatality in the same vehicle, motorcyclist impact more than 30 km/h, high speed more than 60 km/h, fall from height more than 5 meter, prolonged extrication more than 30 minutes or pedestrian hit more than 30 km/h (Boyle et al., 2008).

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25 However in the same paper, Boyle et al stated that mechanism alone is not adequate to quantify the occupant or rider as severe trauma, the only two significant mechanisms are fall from height and prolonged extrication of more than 30 minutes.

Long et al also included prolonged extrication and death of another occupant to signifies the mechanism to be stated as major trauma (Long et al., 1986). With this review a rider motorcycle with the impact of 30km/h may not be used as a general rule as high to predict high trauma.

Coagulation problems occur early in trauma patient and this occurrence occurs even before fluid resuscitation (Hess et al., 2009; Floccard et al., 2010).

Hyperglycaemic is also a predictive value beside lactate, acid base deficit and systemic response syndrome (Yendamuri et al., 2003; Aslar et al., 2004; Sung et al., 2005;

Callaway et al., 2009; Hindy-Francois et al., 2009; Hafidawati, 2010; Hobbs et al., 2010).

2.4 Pattern of injuries to motorcycle occupant.

Vast majority of trauma death is related to its severity of the injuries. Most of the trauma early trauma death occurs at the site or within the first few days is attributable to are from severe central nervous system injuries and great vessels injuries and are deemed unpreventable. Late deaths are considered preventable death and intense research is done to prevent such death.

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26 Vast majority of trauma death are due to multiple injuries (Bachulis et al., 1988;

Rogers et al., 1991). Most of motorcyclist has facial injury which is associated with head injuries (Kraus et al., 2003) which, about one half of the deaths in motorcyclist are due to head injuries (J.F. Kraus and P.R. Cooper, 1989). After head injuries, chest and abdominal injuries are the second most common cause for fatality in motorcyclist (Sarkar et al., 1995b; Wyatt et al., 1999; Ankarath et al., 2002). Despite all the head chest and abdominal injuries causing the death to the occupant of motorcyclist, the lower extremities in the other hand are the commonest site for injuries (Bachulis et al., 1988).

Pfeifer et all in 2009 has done literature review to see whether there is a pattern change of the trauma since 1980 to 2008. They concluded that the pattern has not changed within the decades that they studied. The main cause of trauma death is central nervous system followed by exsanguination, sepsis and multi organ failure (Pfeifer et al., 2009).

Study done in the state of Yorkshire showed that head and facial injuries account to about 11.8%, chest injuries 17.4%, abdominal injuries 12.8%, spinal injuries is 10.4%, and axial skeletal injuries 94.3%. The total percentage is higher than 100%

because a patient may have more than single type of injuries does if the person has more than one injury it is put in one or more categories. The same paper says that among the deaths head injuries 56.8%, chest injuries 32.4%, abdominal injuries 29.8%, spinal injuries 28.4%, and axial skeletal injury 97.3%. This statistic may shows that perhaps multi organ injuries account to more number of death rather than single type of injury. This paper may mislead its reader to see that axial skeletal injuries may be sole cause of death in the patients (Ankarath et al., 2002).

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27 Usage of severity score is now used regularly for in most of the centres to classify patient severity in view of helping the emergency physician for initial management and initial presentation to emergency department. The usage of revised trauma score (RTS), The Trauma and Injury Severity Score (TRISS), and GAP score has no significant difference (Ahmad, 2004; Qureshi, 2004; Kondo et al., 2011;

Schluter, 2011) in term of prognostic death in patient. RTS is use for this study as to evaluate patient severity.

2.5 Admission pattern for motorcycle occupants.

Inevitably patient with trauma requires admission. In United State it is interesting to see that there were an estimated 30,505 admission, of which age average is 30 years old and this accounts about 62% of cases, and males accounted for 89% of cases. The commonest causes of admission were fractures of the lower limb (29.4%), fractures of the upper limb (13.1%), and intracranial injuries (12.3%). The mean length of stay was 5 days, and the median hospital charge was $15,404 (Coben et al., 2004). A similar study but concentrating on the orthopaedics referral and admission showed that 71.5% of patients who visited the emergency department required orthopaedic consultation and a total of fifty-seven patients (52.8%) sustained open fractures requiring emergent orthopaedic intervention. Average hospitalization for patients is 13.8 days with orthopaedic consultation (Peek-Asa et al., 2010; Amin et al., 2011).

Admission rate increases in certain season. One study showed that weather and seasoned affect the admission whereby bad weather has increased in admission rate (Bhattacharyya and Millham, 2001).

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28 A follow up of 105 patients with motorcycle accidents in United States for a mean of 20 months, showed that $2.7 million were spend, with an average of $25,764 per patient. Out of the cost 60 per cents of the substitute direct costs were accounted for by the initial hospital care and more than 23 per cents of the total costs were for rehabilitation care or readmission for treatment of acute problems (FP et al., 1989). In another study in Australia, a trauma patient admitted to ward would cost about A$7363 per hospitalization with a mean length of stay of 5.3 days (Chen et al., 2011).

It is to surprise that much argument occurred when Princess Diana died in an accident whereby people were arguing whether she was send to a far hospital instead of nearby area. Results of literature review state that patients directly admitted to a trauma centre or a non-trauma centre without transfer were found to have a non-significant increasing risk of mortality. The admission policy of transporting major trauma patients to the nearest hospital and, if necessary, then transferring them to the trauma centre (de Jongh et al., 2008; Cheddie et al., 2011). This principle is also is widely practised in Malaysia, whereby the cases are seen by the nearest hospital than if required are transferred to tertiary centre or trauma centre where available.

Based on literature review it was found that motorcycle is important cause of major concern in world population and by studying the survival of the motorcycle accidents hope to give more information to emergency physician, trauma surgeons and traumatology on survivability of a person involve in road traffic accidents involving motorcyclist.,

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29

CHAPTER 3: RESEARCH HYPOTHESIS AND OBJECTIVE.

3. 1 Hypothesis.

Motorcyclist and pillion rider initial arrival type of injury at emergency department predicts survival in 30 days from admission.

3.2 Research Question.

Motorcycle rider and pillion rider initial type of injuries will predict mortality within 30 days of admission, after an accident.

3.3 Objective

3.3.1 General Objectives.

To evaluate whether the motorcycle rider and pillion rider initial condition on arrival to casualty can predict survival ability within 30 days of admission.

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30 3.3.2 Specific objectives.

3.3.2.1 The descriptive study of the rider and the pillion rider age distribution, ethnicity, gender and distribution of the type of injuries sustained by the patients.

3.3.2.2 To ascertained whether type of injuries on initial presentation at emergency department can predict survival of patient within 30 days after admission.

3.2.3 To evaluate whether the age category, gender, revised trauma score, and mechanism of accidents can predicts survival ability after 30 days of admission.

3.2.4 Descriptive study to ascertained days of admission according to system of involvement among the patients.

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31

CHAPTER 4: METHODOLOGY

4.1 Study design and duration.

This study was a prospective survival analysis study of a 7 months period from June 2010 until January 2011. The primary endpoint of the study was to determine whether type of injuries of the rider and occupants predicts the survival of the patient within 30 days.

4.2 Study Venue:

This study was conducted at the Emergency Department Hospital Universiti Sains Malaysia (HUSM), Jalan Raja Perempuan Zainab 2, 16150 Kubang Kerian, Kelantan which was a regional tertiary centre and a state referral centre for head trauma and surgery. Hospital Universiti Sains Malaysia is the centre for excellent with its status of APEX (Accelerated Programme for Excellent) and a teaching institution for undergraduate and post graduate in Malaysia. It is in process to complete its regional trauma centre which a strategic location for this particular study.

4.3 Study approval

This study is done as a part of the requirement for partial fulfilment of the emergency medicine post graduate study and it is done under the department of emergency medicine. The study is approved by the departmental board review and research ethics committee(Human) Universiti Sains Malaysia on the 2nd June 2010(reference USMKK/PPP/JEPeM [226.4(1.3)])(appendix 3).

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32 4.4 Selection of Subject.

The reference population were all trauma patients presented to Emergency Department Hospital Universiti Sains Malaysia. The source population were all trauma inflicted to the rider or pillion rider of motorcycle presented to Emergency Department Hospital Universiti Sains Malaysia as a patient. The eligible population were the source population that fulfilled the inclusion and exclusion criteria. The study population consisted of rider and pillion rider of motorcycle with trauma secondary to road traffic accidents whom presented to the Emergency Department Hospital Universiti Sains Malaysia during the study period from June 2010 till January 2011 whom consented to be included in this study. (Figure 5) Convenience method sampling was used, involved patients whom met the inclusion criteria and absent of any exclusion criteria.

4.4.1 Inclusion Criteria.

The inclusion criteria for the patient to be accepted as a sample population are as follow:

1. All patients who presented to emergency department in Hospital Universiti Sains Malaysia with motorcycle accident from 3rd of June 2010 till 30th of January 2011 whom consented (appendix 1) has been included as sample in this study.

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33 2. These patients had involved in road traffic accidents while riding a motorcycle which include the rider and the pillion rider.

3. Patient who was alive on the time of arrival to emergency department.

4.4.2 Exclusion Criteria.

The sample size must not have the following criteria‟s so that can be included in the studies which are:

1. Trauma patient without a definitive mode of transport and or not involved with motorcycle.

2. Patients who are brought in dead.

3. Patients without enough information that are needed for the study, example missing vital sign on admission to emergency department or using other type of monitors.

The normal process of patient coming to the emergency department is not disrupted by the conduct of this study. As per normal procedure all this patient are being triaged in the triage area before the decision of the treatment. The patients who involve with motorcycle accidents are identified and these patients had being followed up if they are consented (appendix 1). The normal processes of treatment were given by trained medical officer and master students and cases were consulted as usual if required to the registrar and specialist either patient consented to the study or not.

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34 The researcher does not interfere in the decision making, flow of the patient in the emergency department, decision to admit or discharge the patient. Normal investigations were done as required. The researcher with the help of some colleagues had documented patient detail at the time of presentation in the form as per attachment of this dissertation (appendix 2). These patients then received the same standard of care as per other patients who were not recruited in this study.

Patients were being resuscitated by the hospital protocol and advance trauma life support protocol as needed and usually are evaluated by the emergency physician and the registrars. Fluid resuscitation was given as needed. Patient who requires admission will be admitted to intensive ward, high dependency ward or normal ward according to patient severity and the assessment of the managing team. Patient who do not require any admission are discharge and follow up were given as normal procedure.

To minimise the error and results discrepancies, the vital sign data are taken from the triage counter as to standardise the machine that are used as far as possible with exception of the cases that are triage red whereby the vital sign are taken from the red zone monitor. These machines were maintained by the Hospital Universiti Sains Malaysia engineering department and are calibrated from time to time. The parameters used for this study such as systolic blood pressure, pulse rate and heart rate were recorded on the PROPAQTM CS vital signs monitoring instrument.

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35 Patient with pre-existing illnesses such as diabetes Mellitus, Hypertension, Ischemic heart disease and other are documented in the patient information sheet. This patient are not disregarded and included in this study. Study information and consent forms were given to patients for patient to read and understand. However, in unconscious or severely injured patients, consents were taken from immediate relatives who accompany the patients (surrogate consents). If no immediate family were available the cases were not included in the study. Patient past medical illnesses and other required information are taken from the relative or the passer by who brought the patient, or from the ambulance personnel regarding mechanism of accident and whether patient were wearing helmet or not.

After the family and patient understood about the study, the consents were obtained by the researcher or research assistant once the managing doctor has determined that the patients fulfilled the criteria to be included in this study.

These patients were then being followed up and the final outcome after 30 days were documented in the patient information form. Patient‟s outcome of either dead or alive was obtained from the medical records 30-days after being seeing and given treatment in Emergency department. Telephone follow-up were conducted when patient‟s outcome in 30 days cannot be obtained from medical records or in cases where follow-up appointments were not arranged. Patients whom were lost during follow-up or withdrew from the study were also noted.

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36 4.5 Plan for minimizing the error.

The aims in doing studies are to minimize the error that could have misled the data that were acquired during the studies. Among the steps were taken by the researcher to reduce and minimize the error for this study was:

1. The consent (appendix 1) were taken before taken any information from the patient, this is to reduce any error taking data

IS TYPE OF INJURY ON

AKU JANJI

IS TYPE OF INJURY ON

UNIVERSITI SAINS MALAYSIA MAY 2012

ACKNOWLEDGEMENT

TABLE OF CONTENTS

Chapter 2: Literature Review

Chapter 5: Results

LIST OF TABLES

LIST OF FIGURES

LIST OF ABBREVIATIONS

ABSTRAK

Pengenalan

Keputusan

ABSTRACT

Introduction.

Result.

Abstract

Department of Emergency Medicine,

CHAPTER 1: INTRODUCTION

Minister's Office Malaysia, 2009))

CHAPTER 2: LITERATURE REVIEW.

2.0 Overview.

2.3 Trauma

2.4 Pattern of injuries to motorcycle occupant.

2.5 Admission pattern for motorcycle occupants.

CHAPTER 3: RESEARCH HYPOTHESIS AND OBJECTIVE.

3. 1 Hypothesis.

CHAPTER 4: METHODOLOGY

4.1 Study design and duration.

4.4.1 Inclusion Criteria.

4.4.2 Exclusion Criteria.