Day 10: 15th of July: Geriatric health service, CDC and KPAS

Left for KK Bukit Selambau early in the morning. We were greeted by the very loud music played in the TV and a group of 20 old aunties were moving to the beat of the music! This is the Kelab Warga Mas in Bukit Selambau.


The "aunties" following the aerobics!



HAHAHAHA :) The uncle (Sri) and aunties




This Kelab Warga Mas started in 2007 by senior citizens from Bukit Selambau who willingly raise fund on their own with some handicrafts and exhibitions. They use an empty building which initially was a quarters in the KK itself for morning exercise 3 times weekly, i.e. Sunday, Tuesday and Thursday.

They have video player in which they follow for aerobics. There are over 90 old people, with age ranging from 50+ and above who registered but only 30 are regular attendants. Normally they start their morning exercise at 8am and will end at 10am normally, in which after aerobics they will either do some Q'uran study or weave the food covers like this




They made all this to welcome us (when they are fasting that day)



After tea, the girls decided to do some weaving with them.











They also collect a sum of RM 2 per month for their membership fees. We really enjoyed spending time with these old people, they are sooo friendly and nice. They really received us well, hope to bring more of our classmates there some day!

Kala is proud of her masterpiece :)

We also visited the OPD and the KKIA (Klinik Kesihatan Ibu dan Anak) of Bukit Selambau, and there are also services like A&E, Pharmacy, Dental clinic that are provided in this KK. They also offer investigations like Pap smear, Urine FEME and Albumin, sputum culture (Acid fast bacilli, AFB), stool culture for ova and cyst of Malaria, HIV screening (Rapid screening), family planning, Serum Bilirubin checking for newborns and vaccinations for children.



Details on CDC and KPAS will be updated asap!

Cheers, Claudia.

Day 9: 14th of July: Food Nutrition

We gathered at KK Merbok at 9am and had a sh0rt briefing by Pegawai Zat Makanan (PZM) Nutritionist, Mr. Wan Nurrusabah. There are 2 officers in charge of this unit for this district, so Mr. Wan has to travel to various clinics on different days to counsel patients regarding food nutrition.

His patients are generally antenatal mothers who are anemic and requires Iron supplements, children who are underweight, obesity problems, Thyroid disorders, and adolescents problems like hypertension, Diabetes Mellitus, obesity. His job is mainly to counsel them on healthy eating habits apart from the medications they may be taking.

In the community, programmes like health talks on weight management, balanced diet, healthy eating habits for senior citizens, children, adolescents and Diabetics are also carried out. Next programmes like Rancangan Bakul Makanan (Food baskets programme), Penyusuan susu ibu (breast feeding programme) and Iodine deficiency disorders are those that are commonly done in this district, mainly by Mr. Wan himself.

When we talk about malnutrition in children, we have to probe the questions to the parents in a few aspects. E.g. who is taking care of that child? when did they start to wean? What's the pattern of weaning? e.g. after 6 months of age, are they only given a little bit of semi solids but milk of a bigger portion or they do not take semi solids at all but only drinks milk, when the child's energy requirement increases due to more physical activities? All this must be looked into, however Mr. Wan told us this condition is commonly due to poverty.

The food basket programme that was mentioned earlier, is created for those with per capita income of RM 112-115 and weight that falls into the yellow/red centile. (Refer to the follow up card of a child, the blue and red cards in KKIA) and for those of 6 months to 6 years of age.

The food basket contains food of all classes, i.e. rice, beehoon (Carbohydrates), ikan bilis, Sardines and Eggs (Protein), cooking oil, margerine (Fats), full cream milk 1kg per month, multivitamins. Only dry food are given and given according to the age of the child, but an extra 50% of the normal calories requirement for the child are given. This basket is estimated to be about RM 150.

Their weight and height will be assessed by the MO every 4 months and sometimes the nurses will travel to some houses for demonstration of cooking. They will be given this food basket until their weight returns to normal (the white centile in the growth chart) or when they start going to school at 7 years of age, and if they are still underweight at that time, they are eligible for RMT (Rancangan Makanan Tambahan).

There are currently 13 malnutrition cases in Kuala Muda district. For more information you can refer to this.

Next on the breast feeding programme, under which the Baby Friendly Hospital Initiative (BFHI) is where services are provided for the rooming in for mothers (to spend a night in the hospital with the child for breast feeding purposes), well-trained nurses are there to teach them on breast feeding techniques.

As a national assessor for BFHI, Mr. Wan also shared with us the criteria for a hospital to be called a baby friendly hospital, and this includes, no signs or formulas from other companies, e.g. pens or stationeries in the clinics by Dumex or Enfagrow or stethoscope or toys that is sponsored by a certain milk powder company etc. There must also be involvement of staff from Paediatrics and OBG for the special course to train them in breast feeding techniques and they have to fulfill the number of hours as required by the hospital.

As for Iodine Deficiency Disorder (IDD), Iodized salt is given in rural areas and they are also advised to avoid food of high Goitrogen e.g. broccoli, cabbage, pucuk ubi, and tapioca(ubi kayu?) products.

Day 8: 13th of July: Food Safety and Quality Control Unit

The Food Safety and Quality Control Unit in Kuala Muda DHO.



Under which the acts and regulations that are followed are:

1. Peraturan-peraturan (Perluasan pemakaian akta makanan 1983 bagi tembakau dan lain lain) makanan
2. Peraturan-peraturan kawalan hasil tembakau
3. Peraturan-peraturan makanan (pengeluaran sijil kesihatan bagi eksport ikan dan keluaran ikan ke kesatuan Eropah) 2009
4. Peraturan-peraturan Kebersihan Makanan 2009

The latest edition of the food acts and regulations

Next, we went to Village Mall to inspect the premises of the restaurants, e.g. Buns and Bread Bakery, Nash Donuts, The Chicken Rice Shop, and Pizza Hut. We were very privileged to have 4 officers from the food unit to take us around and show us how do they inspect the kitchens of these restaurants and how the demerit marks are given based on this form, Borang KKM-PPKM-2/09.






The things which the premises are checked for (Note the 1 and 2 in the column next to the word DEMERIT, the 1 and 2 means the 1st and 2nd visit to that premise, in which the 2nd visit is done 6 months later). So if the owner fails to fulfill the first column there with 15 demerit marks, he'll be left with 88-15=73. So if altogether after all the demerits, his score is 62 then his marks will be 70, which is the borderline for "passing" i.e. if his marks is less than 70, his premise will be closed down for not more than 2 weeks.

If 6 months after the 1st visit to the premise, it is found that the shop is closed down already, the shop will have to give the food unit 14 days to finish up the last inspection.



The scoring system

We also learnt that all food handlers must be immunized with the Anti-Typhoid injection, and to be issued this card by the DHO. This vaccine will last for 3 years once given, so if after 3 years the employee is still handling food, he/she has to receive another shot of Anti-Typhoid.


This service is provided in the DHO itself


Bilik suntikan pengendali makanan (Injection room for food handlers)

Next, we were also told that the temperature of the freezer (to store uncooked food e.g. meat) has to be within 0 to -18 degree celcius. Whereas the chiller (for chilling purposes, e.g. drinks and vegetables and not to freeze the food) has to be kept from 0 to 4 degree celcius.

Some of the equipments used for food sampling.




The bag which contains


A thermometer



masks

hand sanitizer


The WHIRL pak (memang sterilized)



Other things required for food sampling (which will be sterilized before food sampling); of course not forgetting gloves, hair cover/surgical cap looking net and apron to be worn before food sampling i.e. send the food samples to Jabatan Kimia for investigations of microbes and other chemicals that are illegal based on the food acts and regulations.

Food samples (cooked food e.g. from school canteens) will be taken and put into the WHIRL pak and put into the coolbox with ice packs stored in between 0 to 4 degree celcius. If upon receiving the food samples at the Jabatan Kimia and the temperature has exceeded 4 degree celcius, samples will be rejected.

A form called Borang A has to be filled up by the officer who took the food sample and to be given to the Chemical technologist who's going to handle the food and a Notis Persampelan Makanan has to be issued to the owner as a proof that such and such amount of food has been taken and signed by both parties.




That's all for today, Claud

Day 7: 12th of July: Antenatal and postnatal practical session at KKIA Bandar SP

Our day started with meeting with Sister Busroh in KKIA Sungai Petani (Near HSBC bank near the clock tower in town).

She is in charge of school health i.e. giving vaccinations, physical examination for students, health talks etc.. Unfortunately, we were not able to visit any schools to observe students being vaccinated which will be further rescheduled.

We then gathered at KKIA Bandar SP which is the Maternal Child Health Clinic in our DHO itself. We had a short briefing by Staff Nurse Ponnu, and we then formed pairs to various stations in the MCH clinic, e.g. antenatal care, postnatal and child health, family planning services, Pap smear, specialist clinic (on Mondays and Tuesdays) and Family Medicine Specialist (FMS) on Wednesdays.

There is one medical officer, Dr. Masdalina Azahari in this clinic, and the head of this clinic is Sister Maryam, and head of Staff Nurse, SN How Ah Moi, with 4 nurses trained under basic midwivery, 15 JM (Jururawat masyarakat), 2 drivers, 1 attendant, and 1 PRA (Pembantu Am Rendah).





Antenatal care


The antenatal books - the one on the left is a smaller version which is kept by the patient and is to be brought to the KKIA during each visit. The one on the right is a bigger book, which is the record retained in the KKIA.

We managed to do physical examination on new cases (e.g. just found out UPT positive), e.g. breast examination, hands, pedal edema, thyroid, and abdominal examination (obstetric grip).

The different colour coding for all antenatal mothers, are white, green, yellow and red.


These stickers will be put on the top right corner of the antenatal book. If you happened to see 2 stickers on the top right corner, it is because sometimes postnatally, the mothers might develop some problems and they have to change the coding accordingly.

Under the WHITE code: (case suitable for home delivery - provided trained birth attendant is present)

1. Gravida 2-5
2. No previous obstetric problems
3. No medical conditions like anemia, hypertension, Diabetes, heart diseases, Tuberculosis, Asthma.
4. No complications in the present pregnancy
5. Cephalic presentation

Under the GREEN code: (Refer cases to public health nurses)

1. Maternal age: Primigravida: <> 35 years old and Multipara: 40 years old and above
2. Gravida 6 and above
3. Birth interval of less than 2 years or above 7 years
4. Mothers with special problems, e.g. psychiatric, handicapped, single parent
5. Height <>
6. Unsure of dates

Under the YELLOW code: (Refer to doctor at healthcare centre or hospital)

1. Rhesus negative
2. Hb <>
3. Dyspnea on exertion
4. Urine albumin 1+
5. Multiple pregnancy
6. Decreased fetal movement
7. Obesity >80kg
8. Drug addiction

Under the RED code: (Immediate hospital admission)

1. Severe pre-eclampsia
2. Eclampsia
3. Antepartum haemorrhage
4. preterm labour <>
5. Meconium stained liquor
6. Cord prolapse
7. Retained placenta

Postnatal care and child health:

The child is brought to the clinic at 1 month of age for Hepatitis B injection dose 2 and developmental assessment. The nurse will also do general physical examination on the child, e.g. palpate for testis in scrotum, check for BCG scar on the arm etc.. Next the mother is checked for involuted uterus, tenderness and pedal edema. Also observe the general well being of the mother, e.g. signs of pallour/dyspnea on exertion.

The record card for child health, named KKK 1/93A

In the lab where vaccinations are kept, the few pictures below show the cool box used to keep the vaccines that are taken out from the fridge based on estimation of patients that day.




The interior of the cool box (note the ice packs put inside the four walls), and a yellow sponge is put on top of the vaccines, so that the ice pack does not come into direct contact with the vaccines, so that they are kept in their best forms.

Semasa (can be opened anytime), stock (to be opened to fill up the previous box), they also have a separate cool box for BCG.


The fridge where vaccines are kept, can only be opened twice a day, and to reset the temperature on Minimax each time before closing.

The Minimax which came out for our OSCE once upon a time


The 75g of sugar used for OGTT

The reference that this clinic follows

Day 6: 11th of July: KMAM (Kawalan Mutu Air Minum)

Went to Loji Pembersihan Air Pinang Tunggal in the morning. We had a short briefing by Mr. Haji Norazri, the operating manager of this water treatment plant. Unfortunately, we were not able to visit the plant itself and look at the process of water treatment because of some technical error. (This water treatment plant has just been privatized, and is currently under SADA, Syarikat Air Darul Aman).


Had another briefing by Mr. Kamaruddin from KMAM regarding water sampling technique.
( Will include the details asap)

The bag used for raw water (also used for testing bacteria) - WHIRL bag



Testing for bacteria, use Thio bag with a piece of ascorbic acid in it, like this.


I forgot what is the function of the Ascorbic acid in it, shall find out and edit this post! SORRY!

The various devices used for water testing, i.e. turbidity, Chlorine content, and pH.




The turbidimeter, used to check the turbidity of the water.



The pH meter which also checks the temperature of the water (note top right corner)






The 7 bottles used for water sampling, all with names and various purposes.



The blowlamp used to burn the end of the water tap after water sampling.

We also learnt about the case notification of TB and how the reporting system works. The forms that are filled up include, 10 C-1, 10C-2, 10A-3, 10A-4.