I refer to the letter Impossible to have 'zero death' for NS .

I would like to highlight an important issue regarding the death of the poor student. First of all, I am also a doctor, trained in general surgery that deals with cases similar to the cause of the student's death. I totally disagree with Dr K that it is easy to miss the diagnosis when the student was examined by the paramedics.

Based on the patient's general condition and physical examination, the medical staff could make the right diagnosis. The important point here is the ‘sign of abdominal tenderness on palpation’. Tenderness on palpation is a sinister sign that can not be taken lightly.

Many medical staff and - sorry to say - even doctors take for granted this vital sign on physical examination. If any of us went to any government clinic or hospital in Malaysia with ‘stomach pain with vomiting’, you will be labelled with ‘gastric pain’ and treated with anti-acid medication in 9 out of 10 times as that is the only way they are used to when they treat similar cases.

If the pain does not go away after the initial medication, pain killer injections will be given which serves to ‘hide’ the main problem until it gets worse. Then, the patient will be left in the Accident & Emergency observation ward for hours till the pain goes away or the patient requests to get admitted. Nine out 10 times, the patient never gets admitted.

Personally, I have seen many patients die for being given similar treatment for ‘stomach pain’. One patient was presented to Ipoh GH for several months in 2005 and was treated for ‘stomach pain' and sent back home on every visit after sleeping overnight in th A&E ward. After some time, he finally refused to go home and was admitted to the ward. He died from advanced stage of stomach cancer two weeks after the first admission.

By the time he was seen in the ward, the disease has spread and it was too late for any surgery. Another patient with infection to her gallbladder was diagnosed with ‘stomach pain’ and sent back home after an injection given by an A&E doctor. She came back the next day, was admitted directly to ICU and died two days after admission.

My point here is very simple. Look at the issue as a general issue, not only limited to the PLKN student's death. It shows the poor standard of care given in our public hospitals. What about the patient who was mismanaged for his stomach cancer and the lady who died because the doctor thinks that it is only ‘gastritis’. Are their lives not as important as the student’s life? The PLKN student's family will get compensation for her death but what about the other victims' families?

Back to the PLKN issue, there are several things that can be done to prevent the future deaths.

1. There are paramedics attached to all the PLKN camps. This is not right anymore. Get only senior staff with at least five years and above of experience in service. And also, only paramedic staff working under emergency care and trauma should be posted to all the NS camps. Currently, the Health Ministry chooses the staff randomly from all over the country to work in the NS camps.

I personally know a situation where a nurse who only deals with pregnant ladies for 15 years were posted to a PLKN camp in Perak. What is the aim of these random postings? It is just a mockery of the health service provided for the innocent students in PLKN.

2. Since there are cases where students died of ‘unknown causes’ and the government had to wait to see the postmortem reports before announcing the cause of the students’ death, all treatment process should be rearranged. All patients who do not improve within a given period of time (depends on each case) should be sent directly and fast to the nearest state hospital with a specialist only.

This patient must be seen by a specialist on duty and given the necessary treatment. Referral to a general doctor in this case is out of the question. This will ultimately prevent the ‘unknown cause of death’ as the specialist is trained to deal with any rare illnesses.

Last but not least, the latest case of the student who died from toxic megacolon is not over yet. The doctor needs to find out what and how the student got the problem as she was only one out of many at the camp who came done with stomach pain and constipation. The real culprit (if it is an organism) that cause the bowel death might be hiding some where in the camp or even in the student's home only to ‘attack’ another innocent victim.