First day at work

First day at work is like the very first day of school.  You are super excited and completely frightened at the same time, ready to start a new adventure, and then you know you are inevitable going to get beat down. Today, it happened to be BIG TIME. Overall though, it gives you a new outlook that you survived. Then you start another day fresh, but it did not seem that way..ALL day.

My first day happened to be on a weekend. As slow as bloodwork (lab studies), X-rays and other imaging work on the weekdays, it is about a thousand times slower on the weekend. Being that it was my first day and not quite knowing the proper channels and how to navigate to get studies/work ups of patients done, it took LONGER. I picked up my first patient for the day.

I sifted through the bin of charts (no electronic medical records here, folks) where it is hard to triage because out of all the charts I sifted through to find the most acute patient to see first...it's difficult. Why you ask? Because most all the patients are febrile, mildly hypotensive and tachycardic! No, not that wimpy barely a fever 38 C or 100.4 F. but the >42 C or >107.6 F. I thought surely this is a mistake in an adult. Sometimes, in children it is not uncommon to see higher fevers but 107 is really high. It turns out...nope that is right.

Case: 37 y/o Indofijian M with no significant medical problems lives in a rural area presenting with dry cough, generalized weakness/ myalgias, and persistent fever for 5 days. Mild nausea. No cp/sob. No abdominal pain. No diarrhea. No dysuria. Nonsmoker.
ROS: +headache and pain behind eyes. +gum bleeding. No hematemesis or lower GI bleeding. No rash.
Vitals: Febrile 42 C, Mildly tachycardic, hypotensive SBP 90, RR 10
Physical Exam: Generally healthy looking male, pt very diaphoretic (however, I saw him in the UN-airconditioned hallway, no beds or rooms to see the patient in. It is friggin' hot in Fiji but really, he was REALLY diaphoretic). AA0x3.
Exam otherwise unremarkable. Heart/lung sounds clear.

Things to consider/ differential dx: pneumonia, meningitis, sepsis, neutropenic fever if he was immunocompromised, and then the more rare dx..malignant hyperthermia, malignancy, pheochromocytoma, thyrotoxicosis.

Mild gum bleeding..gingivitis, thrombocytopenia..SCURVY?..I don't know...

But really because infection is high in the differential and we are in Fiji..dengue fever, typhoid fever, leptospirosis.

Labs when they finally came back...

WBC: 2.6
Hgb 13
Hct: 42
Platelets 100,000

Glucose POC 110
Basic metabolic panel was unremarkable.
VBG with 7.54/23/65 HCO 20 with BE -1
CXR clear, no infiltrates

Dengue and leptospirosis serologies are pending.

So...he is leukopenic. ANC was fine and also thrombocytopenic.

Final answer, probably dengue fever.

It turns out dengue is endemic here and now there is a huge dengue outbreak! To be honest, I had to brush up on my tropical medicine because I have only learned about dengue in medical school (meaning about a 15-20 minute lecture probably 3-4 years ago!) and maybe the occasional board exam review question. I have never seen anyone have a case of it and even more so what to expect. In the US, I would have never even considered it. Mainly because I do not see it enough and it doesn't immediately formulate in my differentials to work up patients for, but look at this gem I found.  I am from Texas so not as prevalent as the South Pacific but something to add to my differential for patients.

My first google search pop ups

Bad...

VERY BAD...epidemic bad...

Oh yeah, there is no prevention except DON'T GET BIT. Also when it rains, which is all the time in Suva, stagnant water causes a surge in dengue cases.

Let's learn about Dengue...

Dengue fever  also known as breakbone fever is an infectious tropical viral disease transmitted by mosquitoes, usually Aedes aegypti. Symptoms commonly include sudden onset high grade fever, headache (typically located behind eyes), muscle and joint pain and generalized weakness (very vague constitutional complaints) with some patients presenting with a skin rash similar to measles. 

Dengue hemorrhagic fever (DHF) is a specific syndrome that tends to affect younger children and young adults. It typically causes abdominal pain, hemorrhage and then shock. It is a more severe form of the viral illness. Petechiae often develop as well as mucous membrane bleeding and then internal hemorrhage. This presentation is potentially fatal and can lead to dengue shock syndrome (DSS).

The course of infection consists of 3 phases: 

• -Febrile
• Often with high grade fever, generalized pain and headache lasting up to 1 week. N/V can also occur. A rash often develops in 50-80% of patients. Petechiae can develop. Mucosal bleeding.
• Fever classically is biphasic (breaking and then returning)
• -Critical
• Fever resolves and in this stage you have increase risk of bleeding from thrombocytopenia as well as blood plasma/capillary leakage --> causes dehydration --> decrease blood supply to vital organs
• Organ impairment can happen in this stage. DHF and DSS 
• -Recovery
• Resorption of leaked fluid occur in this phase and fluid overload can occur. 
• Fatigue can lasts for weeks.

Most people infected with dengue are asymptomatic or with only mild uncomplicated symptoms such as fever (80%). Others approximately 5% can develop the severe illness. Diagnosis is mainly based on clinical diagnosis in endemic areas. If labs are available low WBC count, low platelets and a metabolic acidosis. Rising hematocrits can also indicate dengue secondary to hemoconcentration. Serologies are also available.

Treatment is often supportive care and to r/o hemorrhaging. I have noticed that most patients uncomplicated will be sent home regardless of presenting vitals after IV fluids and antipyretics if vitals improve. If there are lab abnormalities then a repeat will be drawn the next day and if they are not hemorrhaging or labs are stable they will be discharged.

Labs take an eternity to return and a lot of these observation patients stay boarded in the ED so limited space to see other patients.

Some of the other cases for the day:

-More febrile illnesses r/o dengue/typhoid/leptospirosis

-Chest pain r/o ACS (acute coronary syndrome)

-Lacerations requiring suturing

-MVC (motor vehicle accidents)- mild 

-Conscious sedation on a really bad supracondylar frx (Type III) in a child and me making the worst splint I have ever made in my life. Why? Limited plaster and the nurses gave me 2x2 gauze to do the splint. Don't worry we finally found some stretchy cotton and a sheet we ripped up to finish the splint and to make an arm sling. He was NV intact but compartments were so tight to do an adequate reduction of the fracture would be impossible. Ortho admitted for surgery at later unspecified date. Hopefully soon.

List of frustrations for the day: 

-Patients that I saw from the start of my shift and labs drawn but labs were not back on them until maybe 10 minutes toward the end of my shift. 

-The fact that I am NOT efficient at all here. 

-Having to not only do my own peripheral IVs but start saline, drugs, etc by myself while still tending to my other critical and not so critical patients (Where are my awesome ER nurses from back home?)

-No electronic medical record to look up previous patients hospitals stays/course etc (all paper charts and found IF YOU'RE LUCKY)

-Handwritten orders for labs, WITH a handwritten overtime slip (because its the weekend/holiday) for EACH lab that you want
-Realizing that cardiac enzyme panel does NOT come with troponins adding to your poor efficiency and having to redraw blood for lab work and to wait another million hours to get labs back
-No space to see patients
-Only size Medium and Large gloves (No smalls), so they are like large trash bags on my hands. It does not help with my dexterity...oh and we ran out of gloves.

On a positive note...

Being placed in tough situations and less than ideal circumstances, while learning different pathology and seeing it in real life...let's go!