I hope my blog has painted a small picture of my time in Fiji. I am thankful and humbled by the opportunity to help teach and learn in this country. The A&E Registrars have an amazing future and path to pave. They have taught me to be to trust my clinical skills. They are so hard working and I am excited to be a part of the making of Emergency Medicine as a specialty in Fiji. My goal is to remain involved and I hope to come back again. For now we hope to set up lectures via internet so that when we do not have a resident present in Fiji, the registrars will still have a chance to learn.
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.
Sorry for the long delay but I am back in the states and I have a few more posts.
“Reunited and it feels so good” this is what I was singing when Dr. Noland brought an US to Labasa.
With the Ultrasound I was to change management in many ways. My first patient was a man with arm pain, he slipped and fell one month ago, thought that he had bamboo stuck in his hand. He was c/o persistent pain with movement. And this is what our US discovered.
We should the surgery registrar and the attending. The patient was taken to the OR for removal.
After being impressed with our skills, the surgery attending asked us to see one of his patients on the floor. It was a 34 yo F with abdominal pain, found to have pancreatitis, a pancreatic mass, and ascites. He asked us to US her looking for fluid pockets, as they were unable to perform a blind parascentesis. Once we found the pocket I then performed an US guided parascentesis for the surgeons.
Another patient was noted to have hematuria, fever, pyuria, and flank pain. Bedside US revealed a verly large heterogenous mass on her kidney. The mass was suspicious for malignancy vs abscess. This patient was also taken to the OR for biopsy.
Needless to say I love the use of Emergency Ultrasound. I also took time to make sure the A&E registrars learned the machine. With the hope that we may be able to donate one to them soon.
Like I have mentioned before part of the reason I came to Fiji was to teach. And I was able to do a lot of that. I gave multiple lectures and a lot of bedside teaching.
Wednesday mornings from 7-8 am is protected CME time. The first lecture I gave was an introduction to Emergency Medicine. Then I talked about Rapid Sequence Intubation and Emergency airway.
This day I gave a CME lecture for all of the Hospital. I talked to the assistant MS, medical registrars and AE registrars about Chest Pain. From this talk we have made protocols now for triage for all chest pain patients so that ECG would ideally be performed and read within 10 minutes, and sick CP, SOB, weakness/syncope patients are triaged swiftly and appropriately. Also, the aim was to stress to administration and faculty the importance of proper labs (ie need for troponin and CK-MB). Current cardiac enzymes consist of CK, AST, and LDH. The next step for Labasa Hospital is to modify STEMI protocol so that Streptokinase administration will start to be given in the ED. Currently patients are not receiving STK until placed in CCU, but time is heart so we are making steps forward to change that.
Dr. Noland arrived and on her first day gave a lecture to nursing about triaging. The nurses were very eager to learn. We talked about sick vs not sick, what are appropriate triage levels, how important nursing is in an ED team, and what can be done by nursing early to help move patients along.
Interestingly Labasa Hospital is considered a trauma center. Trauma team here consists of ED team and General surgery. There is no code system here, and when a major trauma arrives, the general surgery registrar is called in. Luckily we had some interesting cases and the residents and I had a chance to go over ATLS. Next month the goal is to have them get certified.
Here are some of my cases:
Chain saw vs abdomen.
This was a 24 yo M working outside when machine slipped and cut him in his abdomen. He presented tachycardic, diaphoretic, but normotensive. We were able to call in the US tech, after primary survey, FASTed him, luckily initially negative, but had an obvious open abdomen (+finger DPL). This patient was taken to the OR within about an OR and luckily for him no bowel injury.
22 yo with large avulsion/laceration to right leg after having a machine part fall on him.
36 yo with laceration to foot. No vascular or tendon injury
Let me step back one second and explain the step up here in the Emergency Department. The ED is called A&E here for Accident and Emergency. There are two main sections to the A&E:
- 1st GOPD = General Outpatient Department. People come here first during business hours on weekdays from 8 am-4pm. This is more of a fast track set up, but if people are deemed ill, they are sent to the main ED.
-2nd is main ED- People come here directly if it is after hours or true emergencies.
There is a procedure room for any suturing, invasive procedures, splinting, or exams.
Charting here means the patient or the family picks up there folder from medical records. And the folder is brought to the A&E. Folder contains any prior A&E visits, lab results, and prior hospitalizations.
It truly is a worldwide phenomenon. Monday Morning medicine was very busy, which was good for me. One of the main complaints I have seen over and over here is Vomiting and diarrhea. The fun part is differentiating viral from bacterial. And standard of care here is to send most elderly with co-morbidity and after re-hydration is to send them home with Chloramphenicol and stool cultures. Typhoid is problematic in Fiji.
Some interesting cases thus far:
Chest pain. The work up chest pain is very clinical. Most people complaining of chest pain receive an EKG but not until they are placed back in a bed. This gentleman is a 65 yo with a known history of CAD, HTN, and DM who presented with 1 day of pressure like chest pain radiating to his left arm with associated SOB. Work up includes EKG and your only lab work is CBC, CK, AST, and LDH. There are no troponins or CK-MB. Luckily for him, his EKG did not show a STEMI but story concerning for ACS. STEMI’s here are treated with Streptokinase and their protocol consists of giving the medicine within 6 hours and usually meds are not started until patient is in the CCU. There is no cardiologist here so CCU ran by medicine. I’ll be giving a lecture next week on Chest pain, work up, and management. With the help of some of the residents here we are hoping to change some guidelines.
I have seen my fair share of CVAs here. This gentleman was a 68 yo M with h/o DM, HTN, known smoker who presented with left sided weakness, facial droop and aphasia, onset at 4pm, arrived to AE at 7 pm. The weakness gradually improved but pt remained with a mild facial droop and aphasia. Unfortunately there is no tPA and medicine admitting does not allow for CT scan while patient in the A&E. If a patient has severe symptoms they may receive a CT on day 1 or 2 of hospital stay.
I am amazed by the vast number of patients here with asthma. Every day I see at least 2-4 patients. There is an asthma bay set up where people will come for the occasional neb. Compliance with meds is very poor and the thought of most of the population is that the neb is more effective than their MDI.
This is Dr. Krishneel (AE resident) with a known asthmatic. 54 yo h/o asthma who presented unable to speak, tripoding, tachypneic, using accessory muscles and hypoxic. Dr. Malya gave a lecture to the A&E residents which really stuck with Dr. Krishneel and helped change his management. This patient received continuous nebs x 1 hour, IV steroids, and SC epinephrine. Pt’s clinically picture did a complete 360. He after treatment was able to talk in full sentences and wheezing much improved.
On Friday I got a surprise visit from another AE Registrar (=EM resident). He traveled to Labasa from 3 hours away in a smaller town called Nabouwalu. He arrived on a Friday and surprisingly our A&E was not that busy so we were able to go over Mock codes and ACLS/ATLS guidelines. Everyone is very eager to learn here!
I am also becoming an excellent IV starter! (Yes, without the ultrasound!) If you want any of the limited blood work you must get it yourself!
I was off on Saturday and went flat hunting (= apartment). Also had the chance to visit the market where I was amazed by all the fresh home grown veggies. All at a very low price.
Dr Lavinesh kindly invited us into his home where he was celebrating his wife’s birthday. We had a traditional Fijian meal-Lovo.
I also got to play dress up! Lol traditional Sari
So far smooth sailing. I gave my first lecture this week as an Introduction to Emergency Medicine. My plan is to give a series of lectures on various presentations and management guidelines that we follow everyday. Its been some what of a challenge working and a good lesson on resource management and utilization. Everyone has been a big help and excited to learn!
Let me introduce my home for the next month.
Koica Accident & Emergency Center
Emergency Department – Beds and Equipment
I received a very warm welcome
I finally arrived to Fiji and what an experience so far. First off let me explain why I choose this elective and what global health means for Emergency Physicians. As we continue to expand our specialty part of our duty is to expand the specialty internationally and helping our neighbors set up foundations. That is what attracted me to the global health elective here in Fiji. My goal is to help teach the local residents the foundation of Emergency Medicine. Stay tuned and follow me on this journey
Here is a good article from Dr. Kapur with BCM on the role of International EM and academic EM:
Alagappan K, Schafermeyer R, Holliman CJ, Iserson K, MD, Sheridan IA, Kapur GB, Thomas T, Smith J, Bayram J. “International Emergency Medicine and the Role for Academic Emergency Medicine.” Academic Emergency Medicine. 2007;14:451– 456.