Experience of a screening centre for influenza A/H1N1: the first 50 days.

BACKGROUND: The authors' emergency department (ED) served as Singapore's screening centre for influenza H1N1 cases. The aims of the study were to describe their screening experience and to compare clinical and laboratory features of H1N1 versus seasonal flu cases. METHODOLOGY: The authors conducted a prospective observational study on consecutive patients aged 16 years and above presenting to a busy, urban ED for H1N1 screening over 50 days. Clinical, laboratory, radiological and PCR data were collected from the hospital electronic databases. Primary outcomes were proportions of confirmed H1N1 cases and their distribution of clinical, laboratory and radiological features. Secondary outcomes were comparison of clinical and laboratory features of H1N1 versus seasonal flu cases. Data were analysed using descriptive statistics and univariate analysis was used to compare factors between the two groups. A p value <0.05 was considered statistically significant. RESULTS: 1205 patients were screened. 31 (2.6%) and 133 (11%) of them had H1N1 and seasonal flu infections, respectively. The two groups had similar symptoms. There were six clinical and two laboratory features with statistically significant differences between H1N1 and seasonal flu cases. Clinical factors were travel or contact history, median age, respiratory rate, diastolic blood pressure and length of hospital stay. Laboratory factors were median platelet and lymphocyte counts. CONCLUSIONS: The authors report their experience as the nation's H1N1 screening centre. They identified factors that were different between H1N1 and seasonal flu cases. Future research is needed to elucidate if and how this information can be used as a screening tool for H1N1.

Predictors of frequent attenders of emergency department at an acute general hospital in Singapore.

OBJECTIVE: To determine factors associated with frequent emergency department (ED) attendance at an acute general hospital in Singapore. METHOD: Patients who attended the ED from 1 January to 31 December 2006 without prior attendance in the preceding 12 months (index attendance) were tracked for 12 months. Variables included in the analysis were age, gender, race, date and time of attendance, patient acuity category scale, mode of arrival, distance to ED and diagnosis based on ICD-9CM code. Frequent attenders were patients who attended the ED ≥5 times for any diagnosis within 12 months. RESULTS: A total of 82,172 patients in the study cohort accounted for a total of 117,868 visits within 12 months, of which 35,696 (30.3%) were repeat attendances. A total of 1595 patients (1.9%) were frequent attenders responsible for 8% of all repeat attendances. Stepwise logistic regression analysis found patients aged 75+ years, male, non-Chinese ethnic groups, Sunday and Monday, time of the attendance from 16:00 to midnight, distance to ED, chronic obstructive pulmonary disease, heart failure and acute respiratory infections to be significantly associated with frequent attendances. CONCLUSION: With the ageing population and their complex healthcare needs, elderly patients with chronic medical conditions are expected to make up an increasing proportion of the workload of ED in the future. A systems approach and a disease and case management approach in collaboration with primary care providers are interventions recommended to stem this.

Patient satisfaction in an observation unit: the Consumer Assessment of Health Providers and Systems Hospital Survey.

BACKGROUND: The growing demand for inpatient beds in Singapore has led Tan Tock Seng Hospital to set up an observation medicine unit where patients are monitored and discharged within a 24-h period. METHODS: Using the Consumer Assessment of Health Providers and Systems (CAHPS) Hospital Survey, this descriptive study examines the satisfaction levels of patients admitted into an observation unit, in particular the communication between patients and doctors and nurses. The anonymous surveys were either self-administered by the patients or by the research assistant or nurses. RESULTS: 271 patients completed the survey, with 96% of patients satisfied with the politeness (ie, treating them with courtesy and respect, listening carefully to them) of the medical staff. More highly educated patients were more satisfied with the communication between the doctors or nurses, compared with less educated patients (p<0.05). However, less educated patients gave a higher rating of their observation unit stay than more educated patients (p<0.05). CONCLUSION: With patient satisfaction becoming increasingly important as an indicator of the quality of care in the present healthcare environment, doctors and nurses should seek to improve their communication with their patients so as to ensure that patients are satisfied and receive quality care.

Helmet use and bicycle-related trauma in patients presenting to an acute hospital in Singapore.

INTRODUCTION: To describe the relationship between bicycle helmet use and injury pattern sustained by patients presenting to an emergency department (ED) in Singapore for bicycle-related trauma. METHODS: Data was collected from all individuals treated for bicycle-related trauma between September 1, 2004 and May 31, 2005 using a closed-ended questionnaire. RESULTS: 160 bicyclists with mean age of 34.4 years (range 10 to 89 years) were surveyed. Among them, 80 percent were male and 30.6 percent were non-residents. Helmets were worn by 10.6 percent of the patients. Alcohol was clinically detected in 11.3 percent of bicyclists. There was no difference in bicycle helmet use between Singaporeans and non-residents (p-value is 0.275). However, compared to younger bicyclists, bicyclists aged 30 years or older (p-value is less than 0.05), and compared to recreational or sport bicyclists, those who commute by bicycle, tended not to wear helmets (p-value is less than 0.01). Compared to Singaporeans (p-value is less than 0.05), non-residents and bicyclists aged 30 years or older (p-value is 0.011) believed that helmets did not protect against head injury. Comparing the helmeted group with the non-helmeted group, injury patterns by body region were: head injury 5.9 percent versus 40.0 percent (p-value is less than 0.01); facial injury 5.9 percent versus 37.1 percent (p-value is less than 0.05). Not wearing a helmet, being hit by a motor vehicle and age were significantly associated with higher injury severity scores, after adjusting for several potential confounding factors. CONCLUSION: Bicycle helmet use was low in our sample of injured patients. When worn, protection against injury was demonstrated. A campaign to promote use of bicycle helmets should be targeted at non-residents and older bicyclists. Authorities should consider compulsory helmet laws for bicyclists and expanding anti-drunk driving campaigns to target alcohol-intoxicated bicyclists.

Domestic violence in Singapore: a ten year comparison of victim profile.

INTRODUCTION: To investigate whether the profile of female victims of domestic violence in Singapore has changed over the past ten years. METHODS: 163 female victims of domestic violence presenting to an emergency department in Singapore were surveyed. The survey included information on the victims' demographics, assault characteristics and knowledge of help services. The results were compared against a similar survey done locally ten years ago, which involved 233 victims. RESULTS: There were no significant differences in the racial composition, marital status, weapon use and admission rates of victims ten years on. However, a significantly higher proportion of female victims in 2002 knew where to seek help, compared to a decade ago (50.9 percent versus 20.6 percent, p-value is less than 0.0001). CONCLUSION: The proportion of victims with an awareness of community and legal help services has more than doubled over the past ten years.

Are the World Health Organisation case definitions for severe acute respiratory distress syndrome sufficient at initial assessment?

INTRODUCTION: On March 13, 2003, Singapore doctors were alerted about an outbreak of atypical pneumonia that became known as severe acute respiratory syndrome (SARS). We now describe a series of patients that did not fit World Health Organisation (WHO) case definitions for SARS at initial assessment. METHODS: The Ministry of Health, Singapore centralised SARS cases in the study hospital and its emergency department (ED) became the national screening centre. A screening questionnaire and a set of admission criteria based on WHO case definitions were applied. Patients discharged from ED were tracked via telephone surveillance and recalled if necessary. A retrospective review was done of patients who did not fit WHO definitions initially, were discharged and had re-attended. RESULTS: During the outbreak, 11,461 people were screened for SARS. Among 10,075 (87.9 percent) discharged from the ED, there were 28 re-attendees diagnosed to have SARS later, giving an undertriage rate of 0.3 percent. Among the 28, six (21.4 percent) did not complain of fever and 22 (78.6 percent) had temperatures less than 38.0 degrees Celsius during their first ED visit. One patient was screened to have all three criteria but during consultation, the contact history was found to be unrelated to the known "hot spots". The initial mean temperature was 37.6 degrees Celsius (standard deviation [SD] 0.8), which increased significantly (p-value equals 0.04) to 38.0 degrees Celsius (SD 0.8) during their subsequent visit. Chest radiographs with infective changes increased significantly (p-value equals 0.009) from 16 percent to 52.4 percent over the two ED visits. CONCLUSION: The WHO case definitions were helpful in evaluating majority of SARS patients initially. However under-triage at ED is inevitable, with a 0.3 percent under-triage in our study population. In this group and asymptomatic individuals who came for screening, a tracking and recall system helped to ensure their timely return to the ED.

Presentation of severe acute respiratory syndrome (SARS) patients in a screening centre.

INTRODUCTION: On 22 March 2003, the Ministry of Health, Singapore, designated Tan Tock Seng Hospital as the nationwide severe acute respiratory syndrome (SARS) hospital and its Emergency Department (ED) took over the role as the screening center for SARS on 26 March 2003. We describe the initial clinical characteristics of probable or suspect SARS patients that presented to the ED. METHODS: A retrospective study of patients who were admitted through the ED and subsequently diagnosed to have probable SARS and suspect SARS was done. The data of these patients from the ED log were reviewed and analysed. RESULTS: From 13 March 2003 to 31 May 2003, 11,461 patients were screened for SARS and 1,386 patients were admitted. Of these, 117 patients were diagnosed to have probable SARS and 146 suspect SARS. Their mean age was 36.7 years (range 1-80). Among these patients, there were 122 men (46.4 percent), and 205 were Singaporeans (77.9 percent). 13 patients had no initial contact history upon presentation to the ED. The mean duration between onset of symptom to presentation to the ED was 3.1 days. Travel history was less common in probable SARS cases than in suspect SARS cases as the epidemic was due mainly to local transmission. Fever was the most common presenting symptom (91.6 percent), and gastrointestinal symptoms were the least (6.9 percent). In the ED, 249 (94.7 percent) patients had chest radiographs and 86 (32.7 percent) had full blood count done. 22.2 percent of probable SARS patients had normal chest radiographs when they first presented to the ED. CONCLUSION: The World Health Organisation criteria were important screening tools and admission guides, but should not be strictly followed. It was difficult to differentiate between probable and suspect SARS patients in the ED.

Pegylated interferon alfa-2b (peg-intron) plus ribavirin (rebetol) in the treatment of chronic hepatitis C: a local experience.

This was an open-label, uncontrolled study with the aim of assessing the efficacy and safety of pegylated interferon alfa-2b plus ribavirin in the treatment of chronic hepatitis C. The study was conducted in Island Hospital, Penang beween January 2002 and December 2003. Thirty-three patients were enrolled in this study with ten defaulters. The overall sustained virological response (SVR) (Intention-To-Treat analysis) in naïve patients was 39.10%. However, when the study was adjusted to only include those who completed treatment and follow-up, overall SVR as 52.9%. Side-effects were tolerable in most patients with anaemia occurring in 22 patients (66.7%), leukopenia 23 patients (69.7%) and thrombocytopenia in 15 patients (45.5%). This study showed that pegylated interferon alfa-2b 1.5 mcg/kg/week plus ribavirin > 10.6 mg/kg/day is efficacious and safe to be used in the treatment of: chronic hepatitis C.

Who dies at A&E? The role of forensic pathology in the audit of mortality in an emergency medicine department.

The authors reviewed a total of 481 deaths, which occurred in an accident and emergency (A&E) department of a major general hospital, over a 3-year-period, from 1 January, 1992 to 31 December, 1994. Of these, 428 (89.0%) were referred to the coroner, with full medico-legal autopsies being conducted in 236 (55.1%) of the latter. There was a marked preponderance of male subjects (male:female ratio = 1.86) and, not unexpectedly, the likelihood of an autopsy being performed decreased with the patient's age. Nevertheless, all patients who died from trauma (or unnatural causes) underwent autopsies, irrespective of age. In all, autopsies were conducted for 70 traumatic and 166 natural deaths, with the mean age (95% CI) of the former group being some 19 years less than that of the latter (33.2 (28.4-38.1) vs. 52.0 (48.6-55.4), (P < 0.001). A comparison of the provisional causes of death (as recorded by the attending physicians in their clinical notes) with the autopsy findings yielded a higher diagnostic accuracy for traumatic deaths than for natural fatalities (correct diagnoses: 44/70 vs. 36/166; discordant diagnoses: 2/70 vs. 24/166, P < 0.01). This difference was accentuated after the patients who were dead upon arrival were excluded (44/55 vs. 36/96; 2/55 vs. 24/96, P < 0.005). As the injury severity score (ISS) is closely correlated with mortality, the autopsy findings were also used to calculate these values for 59 of a total of 70 patients who died from trauma or from unnatural causes. This showed that 24 had scores of 75 (incompatible with life), while 33 had ISS values above 16 (poor prognosis). The remaining 11 cases were not amenable to evaluation by means of the ISS. It was estimated that in approximately a third (18/55) of the misdiagnosed and undiagnosed natural fatalities, a correct diagnosis might have substantially altered acute management. This, in turn, could have improved patient survival, at least at the A&E level. By comparison, the perceived clinical impact of wrong diagnoses (two) and failure to diagnose (four) on traumatic deaths would have been almost negligible, as these patients generally had ISS values ranging from 30-75, with only one notable exception where the score was 10. Generally, given the circumstances under which physicians are required to work in A&E departments, the time spent with each patient is necessarily short. Furthermore, as there is usually limited access, if at all, to patients' medical records, very little relevant clinical or thanatological information is available, when death occurs. Therefore, in this instance, the medico-legal autopsy assumes the role of being an important investigative tool for the emergency physician. It may also contribute, substantially, towards medical audit and the enhancement of physicians' clinical acumen.

The Ottawa Ankle Rules in Asia: validating a clinical decision rule for requesting X-rays in twisting ankle and foot injuries.

This was a study to determine if the Ottawa Ankle Rules (OAR) for requesting x-ray studies in twisting ankle and foot injuries are applicable in our Asian population. Four hundred ninety-four consecutive eligible patients presenting to the emergency department with twisting injuries about the ankle were examined by emergency physicians for clinical criteria requiring ankle and foot x-ray studies according to the OAR. Four hundred eighty-eight of these patients underwent x-ray studies that were interpreted by a radiologist. The sensitivity and specificity of the OAR for predicting the presence of fracture were calculated to be 0.9 and 0.34, respectively. When the rules were modified to cast a wider screening net, sensitivity improved to 0.99. We conclude that the OAR are not applicable to our population because of inadequate sensitivity, but when modified become acceptable and can reduce the number of x-ray studies requested by 28%.

Managing change in the emergency department: a personal view.

This is a contribution to the occasional series on simulated interactive management

Pattern of injuries in helmeted motorcyclists in Singapore.

BACKGROUND: Singapore has a mandatory helmet law for motorcyclists. This study aimed to determine the injuries sustained by helmeted motorcyclists presenting to the emergency Department (ED). METHODS: Adult victims of motor vehicular incidents (MVI) who presented to an urban public hospital ED from 1 December 1998 to 31 May 1999 were interviewed. Chart reviews were done for those hospitalised. Data collected were demographic, nature of injury, ambulance care, ED and hospital care, outcome and final diagnoses. RESULTS: Motorcyclists formed 49.1% (1018) of all MVI victims, of whom 96.1% were men. The mean age was 32.5 years (SD 13.1), significantly younger (p<0.0001) than the mean age of 36.4 years (SD 16.4) among other MVI victims. The proportions of motorcyclists and other MVI patients admitted to the hospital were not different. Among those admitted, significantly fewer (p = 0.001) motorcyclists (32.2%) sustained head injury compared with other MVI victims (46.8%) but among the motorcyclists with head injury, more than one third (34.2%) had severe head injury. The proportion of patients with thoracic injury was not different (p = 0.93) between motorcyclists (10.2%) and other MVI victims (9.9%). However, among those with thoracic injury, 79.2% of motorcyclists had severe thoracic injury, significantly more (p = 0.04) than 50% of other MVI patients. Wounds, fractures, and/or dislocations of the limbs (p<0.001) were significantly more among motorcyclists compared with other MVI patients. CONCLUSION: Compared with other MVI victims, fewer helmeted motorcyclists sustained head injury. When head injury occurs in helmeted motorcyclists, it tends to be more severe. Motorcyclists remain vulnerable to extremity injury and to severe chest injury.

Ambulance response time to emergency departments.

The study was conducted to ascertain the time it takes an ambulance team to reach a patient and transport the patient to an emergency department after a 995 call. One hundred and sixty-two cases brought to two emergency departments (Singapore General Hospital and Tan Tock Seng Hospital) between 11 March 1992 and 16 March 1992 were studied. The information was obtained from ambulance officers of the Singapore Civil Defence Force. It took an average of 11.40 +/- 4.88 minutes for an ambulance team to reach a patient and 30.50 +/- 10.62 minutes for the patient to reach an emergency department after a 995 call. With the present level of staff in Singapore, basic life support care starts 11.40 minutes and advanced life support care 30.50 minutes after a 995 call. These times are unacceptable if it involves a cardiac arrest or a trauma patient. Factors which cause these long time intervals include traffic congestion, inadequate public education, location of patient (whether on ground level or highrise) and distance from the emergency departments.

The pattern of elderly abuse presenting to an emergency department.

AIM: To determine the pattern and frequency of elder abuse presenting to an urban Emergency unit in Singapore. METHOD: The survey was conducted from May 1994 to December 1997. The patients consisted of adults who were 65 years or older who presented to the Emergency Department with non-accidental trauma or complained of other acts of cruelty. RESULT: 17 cases of elder abuse were found, out of a total of 62,826 elderly patients. The frequency of elder abuse presenting to the Emergency Department was 0.03%. Elder abuse makes up 2.9% of all cases of family violence involving adults in this period. The average age was 74.6 years old. There was a predominance of Chinese females. In 58.8% the assailants were the daughter-in-law or son. 70.5% were ambulatory. Most (76.4%) had a chronic medical illness, commonly hypertension, diabetes mellitus, or both. Blunt musculoskeletal trauma, head or maxillofacial injuries were the commonest injuries encountered. CONCLUSION: Elder abuse is a significant subset of Family Violence. It may be more widespread than thought. Awareness of its occurrence is a first step in halting its progression.

Closed head injuries in children following the use of a sarong cradle.

INTRODUCTION: Sarong cradles are unique to South-East Asian culture. Their use can lead to injuries from falls, over-enthusiastic rocking and defective equipment. We present 19 children who attended the Accident and Emergency (A&E) Department of a general hospital and who sustained injuries while in a sarong cradle. All had closed head injuries. METHODS AND MATERIALS: The data was collected over a 9-month period from September 1992 to May 1993. All patients with a documented history of fall following the use of a sarong cradle, were recruited into the study. The adults accompanying the patients were interviewed with a structured questionnaire. The information was recorded by the doctor in attendance. RESULTS: The ages of the 19 patients ranged from 13 days to 29 months. There were 17 Chinese, 1 Malay and 1 Indian. The types of closed head injuries included minor head injury with no external signs of injury, scalp lacerations, scalp haematomas and severe head injury with an extradural haematoma. The majority (14) were discharged from the A&E Department with head injury advice, 4 were admitted to the General Neurosurgical ward and one, to the Neurosurgical Intensive Care Unit. There were no fatalities in this group. The accidents happened while the children were either sleeping (14), playing (4) or feeding (1). CONCLUSIONS: While most head injuries sustained in this manner are usually mild, there is a potential that such injuries may lead to more serious injuries. Care givers who use the sarong cradle should be aware of the dangers and exercise due care during use.

Morbidity after a bite from a 'non-venomous' pet snake.

We report the first recorded case of morbidity from the bite of a red-neck keelback snake (Rhabdophis subminiatus) from South East Asia. This is a species of the Colubrid family which originated from South East Asia. Severe envenomation from this snake was reported as poisonous in the West as far back as 1978 but it is still being classified as non-venomous. This classification led our patient to keep this 'harmless' snake as a pet. We recommend that this snake be reclassified as 'venomous' or at least warnings be issued to the public not to keep it as a pet.

Case reports on acute toluene poisoning during parquet flooring.

We report two cases of acute toluene poisoning occurring during parquet flooring. Inhalation is the major route of absorption in the workplace, owing to the high volatility of the compound. Such patients should be monitored closely for respiratory distress, central nervous system (CNS) depression and cardiac arrhythmias. Both our patients manifested signs of CNS depression and one had bronchospasm aborted by salbutamol Industries using toluene must ensure that precautions like adequate ventilation are taken to protect their workers.

Work-related injury sustained by foreign workers in Singapore.

INTRODUCTION: Singapore has a resident population of 3.26 million and 0.53 million foreign workers. The objective of the study was to compare the injuries sustained by foreign and local workers presenting to an emergency department (ED). MATERIALS AND METHODS: Adult victims of work-related injury who presented to an urban public hospital ED from 1 December 1998 to 31 May 1999 were interviewed. Chart reviews were done for those hospitalised. Data collected were those of demographic, nature of injury, ambulance care, ED and hospital care, outcome and final diagnoses. RESULTS: There were 1244 local workers and 1936 foreign workers, giving a ratio of 1 local:1.6 foreign workers. The mean age of foreign workers was 29.6 years [standard deviation (SD) 6.2], which was younger (P < 0.0001) than the mean age 37.8 years (SD 14) of local workers. Fridays and Saturdays were the common days for injuries among foreign workers as opposed to Wednesdays and Mondays for local workers. Falls from height > or = 2m occurred among 9.1% of foreign workers, more (P < 0.0001) common than 4.3% of local workers, resulting in 2 out of 3 foreign workers death. Though the pattern of injuries was similar between foreign and local workers, foreign workers needed longer (P = 0.03) sick leave and more (P = 0.01) foreign workers were hospitalised, giving a ratio of 2 foreign workers for every 1 local worker hospitalised. CONCLUSION: Foreign workers had no difficulty accessing ED and hospital care for work-related injuries. The pattern and severity of injuries were similar between foreign and local workers but more foreign workers were hospitalised.

A review of pedestrian fatalities in Singapore from 1990 to 1994.

The authors reviewed 369 consecutive pedestrian fatalities, which occurred from 1990 to 1994. This represented 28.5% (range 23.3 to 37.2; 95% CI 26% to 31%) of all road accident autopsies during that time. The mean and median ages of this population were 51 (95% CI 48.63 to 53.37) and 54 years, respectively. There were 160 (43.3%) who were in the economically productive ages of 20 to 59 years. Of the 369 victims, 224 (60.7%) were males and 145 (39.3%) females, there being a preponderance of males across all age groups. Most of these accidents occurred during the hours of daylight and in conditions of good weather and visibility. It was estimated that pedestrian behaviour contributed, in part, to at least three-quarters of these fatalities. The majority of these pedestrians died from multiple injuries (181; 49.1%) and closed head injury (146; 39.6%). The vast majority of subjects (357; 96.7%) had injury severity scores (ISS) > or = 16. A total of 100 subjects (27.1%) died at the sites of the accidents. Of these, 99 had ISS > or = 16, with 31 having had ISS = 75 (maximum score). Similarly, all 55 deaths that occurred in the A & E departments were associated with ISS > or = 16, with 6 having ISS = 75. This would imply that most of the deaths that had occurred on site and at A & E departments were not unexpected. Interestingly, no pedestrian aged < or = 12 years had an ISS < or = 16, suggesting that they may be more vulnerable to serious or life-threatening injury than adults. There were 46 (12%) victims who had detectable levels of ethanol in their blood samples, of whom, 10 had ISS = 75. However, the difference between the latter proportion and that of the rest of the pedestrian population who had no alcohol detected in their blood samples (31/323), was only marginally significant (95% CI 0.002 to 0.245). There was a high prevalence of pre-existing and intercurrent diseases, such as ischaemic heart disease (58.8%), hypertensive heart disease (30.4%), chronic obstructive airways disease (47.4%), bronchopneumonia (18.2%) and evidence of systemic hypertension (40.7%). It is submitted that the existence of these underlying conditions should be anticipated, or suspected, in the management of injured pedestrians, particularly the elderly, as they may influence the outcome of their critical care.

Extent and appropriateness of emergency department services usage by foreign workers in Singapore.

The objective of this study was to determine the extent and appropriateness of emergency department services usage by foreign workers. A prospective questionnaire survey of foreign workers who attended the Emergency Department (ED) of Tan Tock Seng Hospital was conducted from 30 December 1996 to 29 January 1997. A foreign worker was defined as a non-citizen, non-permanent resident working in Singapore, excluding students and tourists. Demographic and clinical data were collected. During the study period, 7409 patients above the age of 15 attended the ED of which 1174 (15.8%) were foreign workers. Forty-seven per cent of these foreign workers could not speak English, of whom 48.2% did not come with any English-speaking companion. Most of their ED visits were on weekdays and during office hours. Of the foreign workers, 43.1% were classified as non-emergency by ED doctors compared to 6.7% of other ED patients (P < 0.01). Trauma-related complaints accounted for 43.4% while febrile and minor infectious illnesses accounted for 26.7% of foreign workers' complaints. Admissions from ED into the hospital were 17.1% for foreign workers and 28.3% (P < 0.01) for other patients. Language barrier and lack of information on types of health care services available could have led to the high proportion of inappropriate use of ED services by foreign workers. Most of their complaints were minor injuries and illnesses which could be managed by non-ED health care providers. Care provided across a language barrier raises ethical and medico-legal questions. A multi-agency approach involving the Manpower and Health Ministries, employer and foreign worker representatives is needed to eliminate language barrier and help these workers to use health care services appropriately.