pyxis 101

just an idea of one of the limitations to practicing here....these are your options of medications to give in the ED:

pain relief

1. morphine

2. pethidine a.k.a. demerol *they really like this for pain control, given IM

3. ibuprofen

4. paracetamol (similar to acetaminophen)

anti-emetic

1. maxolon a.k.a. reglan

2. phenergan

GI

1. ranitidine IV

cardiac

1. aspirin

2. GTN (glyceryl trinitrate) a.k.a. nitroglycerin

3. amiodarone

4. verapamil IV

5. nifedipine

6. lasix

respiratory

1. ventolin nebs

2. hydrocortisone

3. aminophylline (similar to theophylline)

antibiotics

1. amoxicillin

2. ampicillin

3. flucloxacillin

4. gentamicin

5. chloramphenicol

pharma don't sleep

I had the pleasure of being pitched on some medications by a pharm rep even here in rural Fiji.  I thought they were interesting...

This is basically baclofen topical for MSK pain.  The nurses really dug this.

From left: Alusil is basically Maalox, Alernyl is a cough syrup with beta-agonist in it, and Neutrazole is omeprazole with domperidone - an anti-emetic not FDA approved

what would you do pt. 2

It's hurricane season here in Fiji so it rains every other day and when it rains it pours!  On the plus side the temp is significantly cooler when it rains so it makes not having AC *almost* bearable.

Here's a case I managed where my plan was vastly different from what is done here in Fiji.

40 yo M involved in auto vs. ped at <10 mph, hit on left side of body and fell down hitting left side of face.  He denies LOC and his only complaint is of left sided facial pain.  He was ambulatory after the accident and walks into the ED without any problems.  On exam, VS are within normal limits, pupils equal and reactive, he has a 3 cm superficial laceration lateral to his left eyebrow and some swelling over his nasal bridge, neck is non-tender midline with full active range of motion.  There are no external signs of trauma on his chest, abdomen, or extremities.  Chest is clear and non-tender and abdomen is soft and non-tender.  Pt is alert and oriented with GCS 15.

What would you have done with him?  I wanted get some x-rays and send him home...

Well, here is what was done according to Fijian practice:

1. Patient placed in c-collar

2. Started IVF bolus and oxygen by mask

3. skull XR, chest XR, c-spine XR, and abdominal U/S - significant only for old nasal bone fx

4. Admitted to surgical service for 24 hour neuro status observation

what would you do?

66 yo Indian female reports no medical history presents with epigastric pain intermittently for the past day.  She has no other symptoms and pain sometimes occurs with exertion, sometimes occurs after eating.  Vitals are: BP 200/100s, HR 95, RR 15, O2 sat 100% RA.  Physical exam is unremarkable, she looks comfortable.  Here's her EKG:

I didn't manage this patient primarily but I happened to see her EKG and get the story from Dr. Roy, one of the other EM staff here.  What do you think?

just another day

So last night was supposed to be Krishneel's (one of the AE registrars) last night in Labasa.  He had gotten a transfer to another hospital so that he can be closer to his family who is in Suva.  To celebrate, we went out to one of only two nightlife options and I discovered this lovely Fijian specialty called Tribe Fusion, particularly lime flavored.  I would equate it to Smirnoff Ice but it is deeeelicious.

Unfortunately, since the doctors here in Fiji are subject to the whim of their government, Krishneel's transfer was temporarily canceled today (apprx 1 hour before his flight home!) so he still had to show up for work this week.  Who knows when they'll let him actually transfer?

Here's proof that I've actually been working:

20 year old Indo-Fijian male who was assaulted with a machete to the back of the neck (purposefully and he wouldn't say he did to piss the other person off).  Initial vital signs were normal and GCS 15, moving all extremities well.  It's difficult to appreciate on this photo but the cut is actually several centimeters deep and he had persistent oozing of bright red blood from the left lateral aspect of the laceration.  Oh and did I mention that he came from a small village apprx 1-1.5 hours away?  After sitting in the ER for about 5-10 min, he became unresponsive and his BP dropped to 85/68.  The entire sheet underneath him was blood-soaked.  We initiated fluid resuscitation with NS immediately while holding pressure over the area and consulted the surgical registrar who happened to be down in the ER anyways.  His BP responded well to 3L NS and but his HR remained tachycardic (strange that he wasn't tachycardic before hypotensive).  He clearly had some small arterial bleed deep inside the cut and I ended up holding pressure for about 2.5 hours during resuscitation before the bleeding stopped enough that the surgical registrar felt that he could throw a few simple interrupted sutures over the left lateral aspect of the cut.  The patient was admitted for surgical exploration of the wound in the morning.

Labasa ER

Critical Care area with another bed facing the opposite wall

Airway box!  Apparently they're pretty lucky if there's a bougie available

I see some familiar things in their crash cart

home away from home

This is the main living area of the apartment that the University of Fiji has gotten for me.  It's actually got a working gas stove (which I am too nervous to use - there's propane and matches involved!), fridge, and microwave.

The bedroom is cozy too!

Since I have a kitchen I figured I'd use it and not eat out a lot so look what I found at the grocery store instead...ramen, rice krispies, tabasco, and peanut butter.  Feels like college again...

made it!

Made it to Nadi, Fiji!  After a 2 hour delay in LA, it didn't seem possible.  Too bad the weather here is gloomy...not quite the tropical paradise I think everyone pictures.

Post NYE night shift...

Probably not one of my smartest moves but I went ahead and worked a Medicine night shift that ended about 5 hours before my flight left Houston.  Almost missed my flight because I fell asleep waiting at the gate and luckily a very nice co-passenger found me and woke me up so I made it on the plane.  Now that I have like 7 hours to kill in LA while waiting for the flight to Fiji I finally have time to really get excited about this experience.  I mean, who gets to say that they're going to a tropical paradise for a month to really experience local life (while getting paid to work!) and a week of the touristy thing?  No one I know of and definitely not any PGY-2 at any other Emergency Medicine residency program.