Rotting carcass?..no, it's a diabetic foot

In the ED, we see a LOT of homeless patients and others that often have also less than stellar hygiene. I take pride in trying to not make my patients uncomfortable. More often than not, they have grown accustomed to the malodors and the worst thing to do is to make them even more self conscious. I have been able to stomach most foul of foul odors at least until I leave the patient vicinity.

On that note, I have NEVER actively dry heaved in a patient room/area until NOW. I thought I had seen some of the worst abscesses, infections etc. I work in one of the county hospitals in Houston and also did my clinical years in El Paso, TX, which you see tremendous pathology. The worst undiagnosed cancers/malignancies, the worst infections and so forth but this was another yet another beast in its own.

In the short time I have been here I have seen some really bad sepsis secondary to carbuncles. That should NOT happen. Patients present all the time with furuncles, carbuncles, abscesses etc. Most of the time you can do a bedside I&D and send them out with oral antibiotics. If it is that severe than go ahead and give them IV antibiotics and if they are septic then full labs and admission for IV antibx, and debridement as indicated.

I did not get a picture of the worse diabetic, gangrenous foot/leg I have ever seen but here are some others.

That is a forearm if you are disoriented. He said this developed within 3 months and started as a small boil. An outpatient clinic told him to do warm compresses and he did not return for medical care until it got this severe. That is purulent foul pus draining from the back side by the way. 

We put him in the step down unit of the ED, which is essentially a large room with beds lined parallel to each other in rows. There is no air conditioning and the temperature in that room is probably at baseline 78-80 F. The heat exacerbates the smell, imagine the rest of the patients and patient's families feelings on this. There is no isolation rooms in the ED, that I know of. There are no monitors for him or in the ED observation unit. 

Bad carbuncle. He also had faruncles all over his body.

No not an upper lobe pneumonia or intrathoracic pathology but...

This..very, very large thyroid mass. His mass now is metastatic to liver and spine.

Note: This is not even the worse of what I have seen in my short time but the ones I happened to get photos of but stay tuned for further updates.

The locked cabinet that apparently contains the "good" drugs. Morphine and other narcotics  are not routinely given here as opposed to the U.S.
-Most patients for pain will get paracemetol (tylenol) or ibuprofen (when it happens to be back in stock)

Grievances for today

-Penicillins are still in prevalent use here because Fiji has not seen too much resistance. Any confirmed MRSA is in isolation when they get admitted. They ran out of penicillin today. Cloxacillin is still available.

-Handwashing station does not have paper towels so no wash hand sanitizer is the modality to use.  Hand sanitizer is often empty. I make it a habit to always touch my patients only with gloved hands. Doing IVs here without gloves bc gloves are often missing/ empty. I have come into contact with more blood products via direct skin contact then I have in the 5 years that I have done medicine. 

-Also I have been feeling crummy (generalized malaise), having some calf pain (sign for leptospirosis) but no fever.. No dengue or leptospirosis please :(

Nurse Ruhi, my favorite nurse!

Some of my diving pictures from my vacation week