I wanted to post two last interesting cases from Labasa.
The first case was a 11 yo girl with rheumatic heart disease. Unfortunately I treated her before the US arrived. She presented feeling chest pain, weakness, and shortness of breath. She had very audible cardiac murmur, hypoxic and tachypnic. We immediately placed her on oxygen and got an ECG. After reviewing her folder I learned she suffered from rheumatic heart disease, she had multiple valvular disease (aortic stenosis/mitral valve stenosis) and was on a list to have a heart transplant in India at a non profit hospital. She presented in obvious heart failure after missing a few doses of her medication. We gave her oxygen and Lasix and admitted her to pediatrics.
This last case was a 44 yo Fijian F with no known history. She presented with fever, weakness, nausea/vomiting, and diarrhea. On exam she was febrile (40 C), tachypnic, and tachycardic. She also was very jaundiced. Her clinically picture was suspicious for Leptospirosis, and interestingly her glucose was higher than could be read on the glucometer. At the hospital we are unable to check a blood gas, nor are we able to check a bicarb. We initially treated her with multiple rounds of SC insulin, but it be came very clear clinically that she was acidotic (remained tachypnic). After treating here with multiple IV fluid bolus, antibiotic, we finally decided to try an Insulin drip for presumed DKA. The tricky part is knowing when the gap is closed and the acidosis has cleared as there were no lab values to follow.
I spent my last week in Fiji working in Suva and the experience in Colonial War Memorial Hospital was much different. It is the largest hospital in all of Fiji and is the tertiary care center for many. The ED it sent up a little differently than Labasa, but a new ED is currently under construction. Suva has a critical care bay, admitted unit, and an observation unit. There are many transfers and patients to be seen. And a lot of room for improvement. Again these A&E residents work very hard and are so eager to learn.
One the first cases I encountered at Suva, was a young teenager who was assaulted and stabbed in the chest found to have a large right sided pneumothorax. I helped teach how to place a chest tube.
Also encountered a case of sepsis secondary to diabetic foot.
Of course no day would be complete without the ultrasound. Another great use of ultrasound is guiding fluid therapy as an indirect marker of CVP in septic patients. The A&E residents were super excited to learn the RUSH exam and measuring IVCs.
This next patient was 18 yo M recently discharged after having an empyema. He apparently had persistent fevers and continued to be SOB. On arrival he was febrile, tachycardic, and tachypnic. Bedside US revealed a pleural effusion. Interestingly this patient went into SVT after 4 L IVCs, his IVC on US was full, but HR of 180. His EKG appeared to have p waves, but after one of the registrars had him cough his heart rate went down to 110! Great technique for SVT in a young, first time patient.