First day in Suva

First day in Suva..

I finally made it to Suva where I will be working at Colonial War Memorial Hospital. I met up with Dr. Amit, chief resident at the Emergency Medicine Residency there to have a quick orientation before I start work the next day. Of note, Emergency Medicine is a brand new specialty there and there is yet to be any graduates from their program.

As I walked in I thought, "Well this is not as primitive as I thought it was going to be..." and then I walked into the ED.... MAD HOUSE (not unlike at my home hospital sometimes but worse, so much worse).

The first thing I saw was several intubated patients, some on monitors to assess their vitals, some not (that REALLY should be). There is not enough monitors available for everyone. There was one patient in particular I noticed that was intubated with an endotracheal tube and a BVM (bag valve mask), no ventilators at all. She had agonal respirations (no one was tending to her in the last 15 min I was standing there) and I thought, "Why is no one bagging this intubated woman or why is she not on a ventilator?"  

No one else seemed alarmed, but there was also many other sick patients. So I asked the nurse...

Nurse: The ventilator (no pleural) is being used and everyone is too busy to bag her, but she is breathing spontaneously so she is fine. Note: She was a septic patient and was breathing maybe 6x a minute but her saturation was great though. 

Me: I talked to Amit to confirm. He did. My thoughts, "Well this is going to be very different..."

I finally ran into Dr. Maggie Daniel, global health fellow at my home hospital. She would be able to give me insight. All doctors do their own peripheral IVs here and she was currently tending to a patient that was mildly comatose with glucose POC in the 30s. No one was able to get access and so she was doing a femoral stick. Yay they have ultrasound, that will save the day, but...no vascular probe, just an abdominal. Also the ultrasound takes about about 5-10 minutes to start so if it is an acute situation, you better anticipate turning it on early. She was also busy from the 3 code blues she had early in the day and this hypoglycemic comatose one had slipped through the cracks. 

In yet another bed, a patient was bradycardic in the 20-30s, in and out of consciousness and not intubated. I asked, Dr. Daniel, "Why are we not pacing (either transcutaneous or tranvenously) this patient or doing our ABC's / ACLS etc?"

-Dr. Daniel: He was a recent MI and they don't have pacing here and if he needs a pacemaker it will be months for him to get it. He's not intubated because his vitals otherwise look fine and sats are good. Resources limited so probably not in his best interest to be intubated because no one would be there to bag him.

-Me: Hmm...Ok. 

Apparently, he was being medically managed with recurrent doses of atropine. He would transiently respond and then be semi conscious again. Definitely symptomatic bradycardia that should be on a drip or paced. I'm assuming they started him on dopamine or epinephrine drip later since we've exhausted what we could do for him in the short term. 

It was time for check out and so I followed them though the process. Lots of boarded patients in the ED (nothing new there).

Interesting preview of the ED in Fiji today. I'm excited to start work and see the pathology and different ways medicine is practiced here. As a primer...

No pyxis system here and only a few blood pressure cuffs for the entire ED.

Limited resources...hand washing station, "USE WISELY"