Leaving Suva

Tonight is my final night in Suva- tomorrow I head back to Nadi where I will leave the next morning to head towards Taveuni for some very appreciated time off! Some final pictures from my iPhone that hadn't made it into the blog yet! Heads up- some pretty descriptive pictures in this one.

The first is my walk home from the hospital- even that is pretty!

The next is a lady who came into the hospital today- suspected sepsis secondary to her diabetic foot infection. Awful. She came in with her foot dressed, but the dressing was covered in ants. And the smell was as bad as the picture looks. She said she wouldn't come into the hospital earlier because she was scared she would lose her foot. Unfortunately, she waited too long.

A couple of pictures of some of the hospital staff and nurses- they were awesome during a few difficult cases!

Of course- a picture of the dinner crew! Dr. Miller, Dr. Craig Adams, and myself. We never had a bad meal here!

And also a picture of the view from one of the dinner spots we went to- it was in a national park, on a gorgeous lake. It was pretty spectacular!

I will take pictures from the resort and add them- stay posted, if you're interested!

Its been kinda slower over the past few days for interesting pictures, but by no means slow at the hospital!  We had a patient who coded - would have absolutely benefited from intubation, but because the ICU had no extra vents, and the PICU only had one, we began bagging.  We were able to bag the patient for so long, pulses lost again - and back and forth it went.  Eventually we called it.  Such a difficult case to accept, she died because of the lack of options available to the Emergency Department.  

This lady was suspected to have some form of uterine malignancy - obvious ascites with an umbilical hernia that was filled with one loop of bowel.  She came to the ED with a lot of blood loss to the hernia site - she said she had a spontaneous bleed to the base of the hernia and wasn't able to stop the bleeding.  It is amazing how far along illnesses go here only secondary to access.

This family is absolutely amazing.  Her mother was normal 16 years ago, has had progressive decline of her health since then.  It started in her feet with weakness and progressively advanced more proximally.  No, it's not MS.  She has taken her mom all over the world to figure out what is wrong.  No one has been able to figure it out.  She is to the point now where her daughter even has to hold her head up to see.  But she is so happy!  Her daughter made boards with the alphabet and numbers that her mom used to point at in order to communicate - as her voice went years ago, but now with the loss of strength, her daughter now points and her mom blinks at the appropriate letter to spell out their conversations.  So inspiring.  She said her mom doesn't like to miss her shows, and always puts on her best dress when they leave the house.  And, something very similar for me, she said her mom always is upset she doesn't do her hair or put on her makeup to go places!  They have been told it's most likely MSA - multiple systems atrophy.  

What is also upsetting, is that her daughter (white t-shirt) really wanted to go to nursing school, but because they are required to live on campus and she wasn't willing to leave her mom - she was rejected.  She's okay with that - as "some things are meant to be."  

 Another sweet lady who has had a mass in her throat for over 10 years.  She has seen doctors over the years who have biopsied the mass and told her she was fine.  She came to the department a few days prior, seen by the surgeon and sent home with Tylenol.  Over the past day, she said she was having a hard time breathing and was scared.  She only tolerates liquids, no longer can swallow any solids, and as soon as we started chatting, she broke down into tears about her extreme pain from the mass.  She also had ptosis in her Left eye.  After some pain control, she finally took a nap.  I had the ENT come take a look - speechless at first, she immediately said to admit her for a potential surgery with a CT scan pending.

Yes, that small area to the left of the picture is her visible airway.  Her uvula is squished right onto the free edge of the mass.  The rest is all mass....

  

This made me laugh.  Not only am I too pale to be in Fiji, but I only have about a week and a half left here, and my registration just cleared today!  Everything on Fiji time.

Our day started with this young man complaining of pneumonia-like complaints - pleuritic chest pain, fever, seen by his PCP and given abx.  He felt that after 2 days his antibiotics weren't working, so he just stopped taking them.  Now he's concerned about the shortness of breath.  There is no concept of antibiotic resistance among the patients here.  

 This brother wasn't leaving his little sister's side.  She was hit by a car on her way to school today.  Luckily she only suffered a concussion, but due to persistent vomiting - we watched her overnight in the hospital.

 She got bumped pretty good on her face - but fortunately, no fractures.

 This precious little boy belongs to the mom lying next to him.  She and her husband got into an argument about his multiple girlfriends, and questionable extra wife.  During the middle of this argument - after he left the house, she decided to swallow bleach.  She admitted to me later that she only swallowed a drop of the bleach, but that she had doused herself in kerosene yesterday due to all of these problems at home.  She didn't follow through with setting herself on fire because of this little guy being home at the time.  She eventually eloped from the A/E.  A little different here- no room 20 to lock these patients in if there is concern for being a flight risk.

 This was a difficult day.  The next lady was one of those cases you just can't shake.  She was wheeled in to the A/E in a wheelchair with her head hanging all the way back and looked as if her forehead was separated from the rest of her face.  She wouldn't talk, only cried.  Eventually she told me that her husband - while drunk - beat her in front of his friends with a cement block.  She said she was able to escape - ran to her neighbors house, and was told to keep running because they didn't want any trouble.  She made it close enough to the police station and was brought in.  She was rightfully scared to death.  We kept her in the hospital - and I checked on her twice a day because she told me she wanted to leave her husband and was sad no one would come visit her.  This is one of those cases where I didn't know if she'd be leaving the hospital alive, much the less, the A/E.  But she didn't have any fractures or bleeds - was fully alert and oriented with no focal deficits.  Incredible.  The pictures don't even do it justice.  So after several days of going and checking on her in the wards - and asking multiple times if women's services had been notified (it hadn't), I stopped by yesterday afternoon to find her husband at her bedside.  She looked petrified - more in the regards that she didn't want me to react and was scared I would, which might make it worse for her.  I was furious and defeated from the lack of concern for this patient.  After a long conversation with my mom (surprise, surprise) I resolved to readdressing the entire issue with her the next morning, hoping beyond all hopes that she hadn't changed her mind.  I just didn't want to cause any more trouble for her than she was already facing with him after putting him in jail before his parents placed bail.  Impressively, she hadn't and had formed a plan to go back to her family.  I asked her to write to me and let me know that she was safe.

 Unfortunately, these pictures really minimize the impressiveness of the wounds.

 On a happier note - I have found temporary substitutes for Max and Jax!  These are the program director's dogs.  Mine would be squeaky toys to these guys!

 Altered mental status patient - known hepatitis B pt with obvious cirrhosis

 The only words he would answer questions with were the four-letter kind - funny what is instinctive to people!

 The set up for my paracentesis - betadine had to be borrowed from the surgical rooms as there was none in the A/E.

 

 Hooking him up to a drain

 Yes, it's a foley bag - works perfectly!

 The next morning the patient was pretty much back to baseline - smiling, conversant.  Lactulose is impressive - except, in order to give it at the hospital, the family has to take the prescription and run it to the local pharmacy and bring it back to dispense.

 This little girl started with an infected tooth - gradually worsening of the past several days - notably worse since 4 am.

 Her amount of trismus is impressive.  Eventually we got general surgery on board to drain her in the operating room - ENT declined the case.

 Look familiar to Hermann??  Two conversations going at once!

Lazy Sunday and the Queen's Birthday

Sunday was our first day off, and it was welcomed!  Finally a day to see what we could find in Suva - unfortunately not much is open on Sundays, but it still proved to be a fun day of walking around the city.

Note to self:

 Kind of an overcast day, great scenery though!

 The bay in Suva

 The bus dropping people off at town hall

Peace Garden across from Town Hall - people were all out enjoying their Sunday afternoon.  People here are so kind - after seeing us walking by, they asked us to sit and join them, it's too bad we had just grabbed food from the restaurant below!

The only open place for lunch - looks like they were prepared for the crown by the pile of chicken!   

A small beach area we found - so had the children!  It was so fun watching them play - some things transcend all cultures and waves never seem to grow old! 

 I was spotted with the camera - they were enthralled with actually getting to see pictures of themselves right after I took it!  So fun!  Precious!

 This little girl did not want to miss out on the fun...

This is the traditional dress of men on the island - the "skirt" is called a sulu - its funny because some have even been modernized to have cargo pockets!

 The precious little girl soon realized I looked nothing like mom - so she got a little nervous as to where mom was!  Too cute!

We stumbled upon the courthouse - beautiful.  This played a large part in the coup from 2000 - which occured after the last time I was fortunate enough to visit this beautiful country.

This building was once the most magnificient hotel on the island - it is due to undergo a complete renovation to restore its former beauty.  It was occupied for a while by the army, now it just stands waiting for a revamping!

A beautiful church that we saw.

Today was a holiday - which meant for the most part Suva was deserted, including the ED.  Right at checkout we met this precious child.  She was checked out as being a severe dehydration, febrile illness.  Definitely febrile, but had only vomited 2 times with the onset of her symptoms yesterday.  Story didn't quite fit.  So, time to reexamine and reevaluate.  This little girl had the most remarkable Kernig and Brudzinski's signs I have ever seen - it, unfortunately, was textbook.  As we lifted her head off the bed, she arched her back in order to move with us - absolutely unable to move her neck, wincing as we lifter her legs towards her.  We called medicine immediately regarding lumbar puncture and antibiotics - as this is standard to call and get ok on treatment.  They wanted to hold off until the little girl came to the floor - a little difficult to agree with coming from what we are used to in treatment of suspected meningitis.  But, they took her immediately.  Dr. Miller has a video of the little girl's exam - hopefully we can upload it.

Another patient from the day - yes, we soon began asking about cough, weight loss, night sweats, or any recent interaction with suspected TB patients.  Denied all the above, but the resident on shift told us it was not uncommon for people to deny those questions.  For us, the chest xray was suggestive enough to have medicine take a look at her - they agreed.

This little girl was met at triage - all wrapped up like it was middle of December in Colorado.  So, we stopped.  She had some stridor, and her sat's were mid 80's at best from triage - she walked right to the back with me.  While on nebs her sat's improved to mid 90's.

This just made me laugh - Dr. Miller at her makeshift desk filling out LBJ charts, and her iphone ready...in Fiji.

And the last patient of the day.  The battle of aVR not won in Fiji.  This woman was bradycardic on our arrival into the room - atropine given, being bagged as her spontaneous respirations had literally stopped as we laid eyes on her.  Atropine immediately improved her alertness, respirations - so, epi drip started as it was there and quicker to prep.  Hand titrated to effectiveness as there is only one IV pump in the department - currently running the heparin drip as medicine didn't agree with this as a STEMI equivalent - they felt it was more an NSTEMI - so, no streptokinase.  Of note, while she was bradycardic, the question was raised about pacing the patient.  Currently there are no options to transvenously or transcutaneously pace a patient.  After hearing that, heparin was immediately hung for treatment.