Thank you Fiji!!

I have learned so much here and gained so much valuable experience. Reading through some of my blog entries, I seem a little negative at times. The fact is I am so thankful for this wonderful opportunity that was given to me. Thank you to my residency program and especially Dr. Malya for sparking global health interests.

On South Sea Island looking at mainland Viti Levu

Thank you to all the physicians and nurses from Fiji! They have limited resources and know it but when thrown obstacles, they (with a happy face) find alternative ways to manage their patients. I am glad to have got to spend some time with these dedicated physicians and staff! Many of the residents, on their few days off come to the ED (also the wards and ICU) to follow up on their patients (there is no true electronic medical records). They do this for 2 purposes; one is for their continued medical education and second for patient care. I truly admire their dedication. My deepest gratitude for allowing me to learn, practice, and teach medicine in this environment!

Rockstar Dr. Mesu doing follow ups on his day off!
Other things here: The docs wear hawaiian-esque  shirts to work with sulus/sarongs and sandals. Very laid back feel. Also its super hot here! I wish I took a picture.

Outside the presidential palace

Cannibal caves

Indian sweets carts

South Sea Island

Daily milking of the cows

Relaxing time

Delicious curried lobster
Ate a LOT of yummy food here

Big sea cucumber

Perfect day to go kayak

Met a lot of interesting people

Little goats run around everywhere

Now for a whole day of traveling to go back home!!

Anytime things take exponential long to occur or someone is late, the response is, "It's ok. We operate on Fiji time"

Good bye CWM

Check it out!!! New state of the art US that the ED just got. It is actually better than the one at my hospital. It has all 4 probes and the images are great. There is a transvaginal probe but no probe covers yet.

This is me teaching one of our interns Anorag how to do an US guided aspiration of a suprapatellar bursitis. The images are so clear here.

Other cases for the last few days:

29 y/o F with arterial bleed to the R wrist after "accidentally" falling into a glass door while fighting with her mother. The incisions don't coincide with the story, but this was her statement. She bled EVERYWHERE! VSS. I sutured off her radial artery that she ligated (only after getting sprayed with blood everywhere - way to work my last shift and go out with a bang). She had bled approximately 1500 ml, On exam, pt has a dusky hand with intact ulnar pulse. Capillary refill intact. Pt does have an ulnar nerve palsy (ulnar claw hand - pt is unable to extend her 4th/5th digit). Radial artery is ligated. Pt also had obvious ligation of her flexor tendon.

Arterial bleed, "ulnar claw hand"

She was taken to the theatre for surgical exploration repair. 

Breast cancer. This woman let this grow for >1 year before seeking medical attention. She was scared to go to the hospital. 

Recurrent TB (there are no N95 mask here just the thin basic ones, that do NOT prevent the spread of tuberculosis) 

Hepatitis

Dr. Amit pointing to a patient that is actually being ventilated with a ventilator in the ED

More sepsis from diabetic feet...

Other interesting cases (not mine but good learning case):

Case: 51 y/o F with chest pain earlier in the day (that resolved) now presenting to the hospital with generalized weakness and lightheadedness. ECG with .... 3rd degree heart block.

Her pulse was in the 30s and she was hypotensive. She was mildly obtunded. She was being treated with atropine, with very little response. There is no isoproterenol (their standard medication that they use to tx bradycardia) so they were giving her salbuterol (similar to albuterol - which is an asthma medication, that as a side effect causes elevated heart rate) to actually promote tachycardia. Huh? Interesting. It actually worked transiently. She did have an increase in mental status.  After some discussion with other consultants the patient was started on a dopamine infusion. She actually got even more alert with this. Blood pressure improved.

Like I stated in a previous post, normally transcutaneous vs transvenous pacing would be placed in the ED or the CCU until a definitive pacemaker could be placed. This could be lifesaving. However, they do not place TCP or TVP here and it takes months for a patient to get a pacemaker (if at all) so medical therapy is all they have at the moment. For third degree as well as second degree (Mobitz type 2) heart block definitive treatment is with a pacemaker.

3rd degree heart block. Sorry my phone died that day so I had to take a picture on my actual camera. 

Amit's face when I ask for something they don't have and then he subsequently states a very rehearsed/methodical, "We are a under-resourced country and we etc etc."

Suva homes

Typical Suva flats

Port at a distance on my walk home

Suva mall/shops

Last night in Suva

 Leaving Nadi/Fiji just in time. Flash flood in Nadi town and the town is being evacuated. It has rained nonstop for the last 2 days. Yikes! I wonder what happens in the villages?

Much better...

Thanks for all the concern! I'm feeling muuuuch better!

Now to one of the main reasons I wanted to do a global health elective to begin with! Ie. Alternative practices that actually improve patient outcomes but not necessarily the standard of care in the US.

Case: 47 y/o mildly obese IndoFijian M with no known medical hx, presents with sudden onset crushing chest pain a/w diaphoresis, dyspnea and radiating pain to the L arm. This occurred about 2 hours prior to arrival. Associated with mild nausea.

Ok it sounds like he is having an acute MI (myocardial infarction) and he was! ECG below...

The standard of care in the US according to AHA guidelines is reperfusion therapy. It should be given to all eligible patients with a STEMI (ST elevation MI), whether it is PCI (percutaneous intervention) or fibrinolytic ("clot buster") therapy, in a timely manner. This is for all eligible patients that have sx onset within the prior 12 hours. PCI is much more superior than thrombolytics (level A evidence) so measures should be taken to get patients to a PCI capable center as soon as possible with certain stipulations.

Most patients with a STEMI should present to a PCI center with "door to balloon" time being 30 minutes. Transfer to a PCI center should be initiated if it will take less than <120 minutes from transfer and start of PCI, according to the new 2013 AHA guidelines. If this can't be achieved than thrombolytics should be given within 30 minutes of arrival. Kinda wordy but here's a flow chart that explains it more clearly.

Being that I work in such a large tertiary care center with PCI readily available 24 hours a day, I have actually never started thrombolytics on a STEMI patient.

Pre -thrombolytic ECG, notice the scary ST elevations in V1/V2, avR with reciprocal ST depressions in the inferiolateral leads... for the non medical people, he is having an active heart attack.

Post STK ECG

Post STK ECG - notice normalization of his ST elevations

His chest pain was markedly improved. Vitals stable. Pretty cool...

So for this patient his STE are most prominent in V1 and V2 localizing to the septum. It could be branches of the LAD (s1 or d 1) or even ostial LAD very close to L main, considering all the STD and prominence of avR.

STE in avR often represent left main occlusion, however it more often implies significant subendocardial ischemia which could be due to left main or 3 vessel disease, or a severe proximal LAD disease. Left main diseases generally causes rapid death; most who survive left main ACS have some flow and thus have widespread ST depression.

He would probably benefit from having interventional cardiology treat him if he really has 3 vessel, left main disease etc. There is a team of interventional cardiologist that come to Fiji, once or twice a year for a few weeks. Patients will get CABGs, PCI, and pacemakers for those that are screened to benefit the most from these interventions (also screened for ability to pay as I am told).

Febrile in Fiji

I am a little behind in my posts but I think I have dengue fever...(my worst nightmare, getting sick in a foreign country and thinking of the million things that could go wrong.)

I have had fevers before but never the "bone breaking fever" that is classic for dengue fever. It started after my last shift. I sensed I was not feeling well at the end of the night. I was starting to get lightheaded and my bones and muscles were starting to ache. I had been feeling this way for the last couple of days but I just thought maybe I'm confabulating symptoms but then...

I started having the most intense chills of my life while my body was burning up. I threw myself on the bed as I got home, who knew I wouldn't get up again for another >24 hours. My body ached so bad. Moving exacerbated the pain and made me nauseous. So I lied there like a useless sack of potatoes, hoping to break the fever. I was so ill I did not even move to take some antipyretics or analgesics. I slept from 2am when I got home on a Tuesday night till Thursday at 8am. Wednesday was my day off, a day lost in my febrile time warp. I have NEVER called in sick but I could not physically move. I have been in car accidents, febrile with strep throat etc and still never called in to work.  I intermittently woke up to inform people I'm not dead but I did not feel better.  Then slept more from Thursday to 9pm.

This was easily the worst I have ever felt from any illness. I thought maybe I should go to the hospital, but I am the worst patient ever. I figured there is a housekeeper that comes daily to these apartments so if she found my dying corpse they would bring an ambulance and it would be fine. I would not have to move. It was THAT bad. If I am not dead or dying (or at work or doing work things) you would not catch me in the hospital for the life of me. The alternative was to go to the hospital and get lab work as well as IV fluids. They would probably stick me in the step down unit (unairconditioned- baseline 80 F). I feel ill just walking in there on a regular day, not to mention actually being a patient. I have no idea how the people deal with the heat. On a side note, I walked home during the day one day, and nearly had a heat stroke. I was so close to my apartment at that point that it seemed silly to catch a taxi for the last 1/4 mile. It was early morning so the sun was not at full blaze and it's only a little over a mile. I am such a pansy compared to the indigenous people here.

 I did not have any of the warning signs for hemorrhagic dengue minus a minor episode of epistaxis (hallelujah!). I'm suppose to work today so feeling slightly better. I think my fever finally broke, but for those that read my dengue fever blog, now I enter the critical phase of dengue after the fever breaks.

My sentiments exactly

In other news, before my deathly experience with at least clinical dengue, I had the most creepy and spooky experience ever towards the end of my shift. This is a very regular experience for the other residents but for me VERY SPOOKY. So I deal with death and dying on a daily basis, no surprise there. However, usually when an ambulance responds to a house call and the person is very obviously deceased, they never come to hospital. That is beyond repair. However here in Fiji, they stop by the hospital for a quick death exam before going off probably to the morgue.

The death exams I usually do are in the hospital in a well lit patient room after the family has decided to withdrawal care from a patient that probably has very poor functional outcome. In those circumstances, when the patient has passed I do a quick death exam (examine for pupillary reflex, corneal reflex, gag reflex, pain reflex, heart beat, lung sounds, cap refill, any signs of life etc) then if none exists you call the time of death.

This was not that experience. The patient was driven to the hospital in a old pick up truck with a back covering. Very similar to the one below. They parked in an unlit back alley of the hospital in the middle of the night. Family members had wrapped his mummified corpse in the back of their truck after they discovered him and called the police to ensure no foul play was done. They called me out to this back alley.

Shady, murder truck

Nurse: Ok crawl into that truck bed to examine the body.
Me:  My thoughts: What?! Are you for real? You want me to crawl into that dark/dim, really sketchy looking truck bed with a known dead body, with basically no one else in sight and unwrap it to examine the body?!! I have no idea what's in there or if these people will drive off while I'm in this covered truck bed and murder me.

I was being professional so I said: "Ok" Reluctantly

By the way there are no authorities, it's the nurse and me with 2 other large men who claim they are family members. I felt like this is how scary movies start. 

I do my death exam with a very obvious rigor mortis body and then pronounce him. I had the nurse hold my light (on my phone) so I could see what I was doing. Of course she had no idea what I meant by shining the light in his eye and then moving it away (to check for pupil reflex). I was trying to make this as swift as possible. Wonderful. I had to de-glove and then commence with the exam with one hand.

Very crime scene investigator style. Not on my list to ever do again. Ever. I haven't died or been murdered yet.  That's a win for today. Hopefully I'll have some more interesting cases at work today to report.

Yay! Monitors!

I don't know what happened over the last weekend but either the stars and the moon aligned or the karmic universe is on my side today which means today was a great day by ED standards. Translation: sick patients were being seen in a timely fashion and it did not take hours and hours for me to complete work ups of patients and also no one died. Hallelujah.

Also, there were no critical patients that have been sitting in the ED waiting room for an extensive amount of hours. (Still busy ED but most patients were non acute) Labs and imaging were coming back in a timely manner. Large shipment of monitors came in so we could..well MONITOR our patients' vitals! It was great.

More monitors...I cannot even begin to express the joy I get from seeing this.

Obviously it is an ER so there are still sick patients so...

Case: 2 y/o Fijian F with no prior med problems presents to ED with persistent vomiting since this pm. She had been active and of her normal self the day before. She and her sister had been playing in the rain and some other stagnant water the day before. They often play in stagnant water. They live in a very rural village. She is increasingly more listless and tired. She had poor gaze, poor cap refill on exam, weak cry. No abdominal tenderness but seemed to grimace when I palpated her calves. She was mildly tachycardia, low grade fever (no pediatric blood pressure cuff so they couldn't get a blood pressure...)

I had seen her actively vomit about 4 times in the ED and then commence to go to sleep. +mild diarrhea. +mild injection to eyes. Per dad, no signs of bleeding/hemorrhaging.  3 y/o sister had same sx but more alert and PO tolerant.

DDx: Dengue, leptospirosis, typhoid, sepsis, meningitis, OPP? (is that a thing here? - no one knew what I was talking about), gastroenteritis, poison/toxins etc.

No broselow tape and I am horrible at "guest-imating' how much children weigh. Why?! It's so cheap. 

Pt got fluid bolus according to their estimated weights. Empiric antibx, blood cultures, and admitted to pediatrics. I would do a lumbar puncture here but they do not do that in the ED. Why not?

She did not look well but I think she will have a good course. Not sure why, I just feel it in my gut or I am hoping. Any febrile illness here for the most part is just dengue considering the season right now but I already talked about dengue. So let's talk about leptospirosis since she has some features that are concerning for that.

Leptospirosis is a type of bacterial infection spread by animals. Transmission occurs through exposure to infected animal urine. Leptospirosis is more common in the tropical areas of the world. Globally, it is estimated that 7-10 million people get leptospirosis annually. However it is difficult to estimate the exact number because especially developing parts of the world, causes of death are not routinely reported. 

Symptoms often occur after 7-14 days after exposure to the leptospira bacteria. However, confirmed cases report from 2-30 days after exposure. About 90% of leptospirosis infections cause mild sx including

• -high temperture 38-40 C
• -Chills, headaches
• -Nausea, vomiting
• -Myositis, particularly affecting the muscles of the calves (often very significant) and lower back
• -conjunctival suffusion (characteristic but not common)
• -cough

Severe leptospirosis is sometimes called Weil syndrome. Sx occur after the mild symptoms dissipate. Pattern of symptoms occur in three groups depending on infected organs:

• -Liver, kidneys, and heart
• Jaundice, loss of appetite
• Extreme fatigue
• SOB
• swollen ankles 
• Hepatomegaly
• Oliguria --> renal failure
• Chest pain --> rapid/irregular heart beat
• -Brain
• Menigitis/ Encephalitis
• Seizures
• Uncharacteristic behavior including aggression
• AMS
• -Lung
• SOB
• Hematemesis
• Pulmonary hemorrhage

Rarely involvement of all three groups can occur.

Conjuntival suffusion

Luckily most people only have mild sx and treatment is with ceftriaxone or penicillin, but considering how much stagnant water there is and how all the children play in any water body, that's frightening. Other populations at risk, water sport enthusiasts (surfers and rafters) in areas prone to leptospirosis. Prolonged immersion promotes entry of the bacteria. Another differential to consider if you have a patient that endorses water sports in an area known to have leptospirosis.

In the tropics, endemic leptospirosis is mainly a disease of poverty, including low education, poor housing, absence of sanitation and poor income. It ca be acquired through living in rodent- infested, flood- prone urban slums. Large outbreaks can occur and are associated with increasing rain and flooding.

Typhoid is still a consideration. Interestingly these patients have a tell sign of high fever but no concomitant tachycardia. This is because alternative pathways are used by Salmonella enterica to promote the fever and so you actually see a relative bradycardia...interesting huh?

Other interesting case:
-This one was from a few days ago. 48 y/o Fijian F presents after suddenly coughing up blood and collapsing. Pt was brought in as an arrest (downtime of >10 minutes) and coded for about 30 minutes. Of note, she had presented to the CWM hospital ED one week prior with generalized sx of fatigue, high fever, malaise before leaving secondary to the prolonged wait. It really sounds like she had dengue fever with the hemorrhagic component, but after reviewing leptospirosis that could have been a possibility. Of course you also consider massive pulmonary embolism, maybe she had underlying cancer with metastasis etc. Interesting none the less...unfortunate that she had presented but left because of the prolonged waiting time.

Been bathing in this stuff...notice the 80% deet.  No dengue please. I might be having deet toxicity soon. Watch for signs, friends.

Anorag (our intern) and nurse Ruhi

She made us some delicious lunch
before I had to go to work

Fijian children playing in the water

Me playing in the water :/

You're discharging this acute ischemic stroke?!

Case: 45 y/o F with hx of DM, HTN presents with right sided weakness starting 2 hours prior to arrival. Pt on exam marked weakness on right side. Noticeable right sided facial droop with some dysarthria. GCS 14.

Vitals: Afebrile, Pulse 110, BP 190/110, RR 14
Glucose POC 110

So sounds like some kind of stroke.  Management usually starts with a CT to rule out hemorrhagic CVA (cerebrovascular accidents). Then if it is believed to be ischemic and their symptom onset is within the time window then we start TPA "clot busters". I'm excited because most strokes I have seen here are subacute and occur outside the treatment window, generally >4.5 hours. The risk of bleeding outweighs the potential benefit when it is outside the window. This one presented quickly and so I tried my best to get a CT as promptly as possible.

My eagerness was met with frustration when I realized (was told) they do not push TPA here. Either way if it is a hemorrhagic stroke, then maybe we can get neurosurgical involvement (if they are available, there is only neurosurgeon for all of Fiji) and possibly improve pt outcome. As much as I tried to expedite her CT. It took over 4 hours for the CT tech and the radiologist to get her CT completed. It was an ischemic stroke. When the medicine team finally evaluated her she had improving deficits and was able to ambulate with assistance. They did their own bedside swallow evaluation and she was able to swallow, so they discharged her. Well I have never discharged an acute ischemic stroke before. The medicine admit team said they would have her follow up closely.

In the states, strokes are generally admitted to evaluate the reason for their strokes. Thromboembolic strokes normally get a cardiac echo, cardiac monitoring, carotid duplexes etc to evaluate the reason for the thromboembolic insult. If the underlying reason isn't evaluated for the next stroke could be catastrophic. They are started on statins, aspirin, antihypertensives, counseled on smoking cessation, diabetes management, and get rehabilitation. This was very different.

The new trend for global health focuses more on NCD (non communicable diseases) with people living now more in urban than rural areas. Many more people around the world are overweight. The trend now is seeing more NCDs such as heart disease, stroke, cancers, diabetes and chronic lung disease. People globally now die more from NCDs than they do of infectious causes. This is direct from the Center for Disease Control. Before I did this rotation, I can't say that I knew that fact.

It is disconcerting to know that the major hospital in the capital city of Fiji does minimal for any kind of stroke. Residents tell me that most patients are lucky if they receive a CT within a day. If the patient could not maintain his airway and they were intubated, ventilators would be given precedence for patients that had potentially reversible causes of their pathology, most often sepsis. Management is often very conservative.

Hemorrhagic stroke management isn't much better. One neurosurgeon for all of Fiji and hope that it is not a bad brain bleed.

Hemorrhagic stroke

This patient was a 50 y/o M with sudden onset L sided hemiparesis. GCS 9 on arrival. Pt started vomiting so he was intubated for airway protection. Blood pressure was 250/160. They have no nicardipine here, no labetalol (only ICU use but they are out of stock). We tried blood pressure control with hydralazine, response limited. No neurosurgeon was readily available for an external ventricular drain (EVD).

We continued conservative management.

I hate strokes. It is NOT just a first world issue.