Lights..Camera..Action!

Most cases either show up in the ED from home or transported via the ambulance service, like most ERs. Here in Fiji, many cases are referred from the primary care provider or another clinic. For the patient to actually get transferred, the ED has to accept the transfer. For the most part, that way we know what is coming to us, the acuity level of the patient, and what work up has already been done. Most practitioners will send an excerpt/ summary of the care provided. Pretty routine.

Today, of course it was at the end of my shift when a 28 y/o M patient referred from clinic had presented s/p stab wounds x2. One was in the left lower thoracic posterior rib cage and the other to the left thigh. He had been arguing with his brother in law that afternoon when his brother in law got angry and stabbed him with a knife. Yikes..looks like his brother in law won that argument. 

Pt presented as a referral with the summary reading +dyspnea but no pneumothorax on the chest xray obtained from clinic and elevated L hemidiaphragm. She did notate his decrease breath sounds of the left. Pt saturation was fine on room air. The transfer was for work up of his dyspnea.

First thing we saw was the chest X-ray...

Not sure how well you can appreciate it on this XR but in person there is a very obvious pneumothorax. His injury was low enough where there is concern for diaphragmatic injury, splenic laceration etc. His vitals were stable minus his tachycardia.

In the states, all the ED residents are pretty aware and skilled at being able to put in chest tubes. Here many of them are not. The locum general practitioner that they hired to decompress the ED waiting room (she happens to be very seniored in her practice) had never done a chest tube before.

Some pictures of me teaching the other physicians how to do a chest tube. He was not a crashing patient so I would have done this in sterile fashion, BUT they had no sterile drapes and limited betadine.

No pleur-evac (or chest drainage systems) like the one in the states. I was reading the instructions on how to assemble this in front of the patient because it was not what I was familiar with. This reminds me of the old glass milk cartons someone pawned off for me to use. (The cover looked like it was from the 1980s and very dusty from non use).

I am sure that was really reassuring for the patient that I knew what I was doing. This is after I explained I would be shoving a fairly large tube into his chest to re-expand his lung.

The smallest sterile gloves they have are size 8. I am a size 6. So of course my large garbage bag gloves tore and blood got all over my pants and hands. The nurses were making fun of me. Post hand washing picture.

The patients dyspnea improved and pain subsided with

I wanted a CT considering where his injury was but this was a late night shift so no CT readily available. We had to get approval from the radiologist and then physically have to get hospital transport to go pick up the cat scan technicion to do the cat scan in the middle of the night.

Radiology to read the scan at night?...pfft * scoff* yeah right...

Surgery admitted the patient.

Note: When patients are taken to the operating room it is called the "theatre".  Interesting name to call the OR. Though I definitely had an audience today.

Pretty streamers?...NO! This is an IV pole with multiple non-rebreather masks after being "sterilized". They were hanging outside the hospital air drying for re-use later.