One of our doctors recommended this app for one of my friends who is a nurse and is a bit … frenetic.
Here’s the introduction video
Here is an excerpt from session three of Take 10.
If you want some help to cope with the stress of work, or of life in general, or you want to boost your performance in your work, try meditation. Headspace is a great place to start.
Get the app here
A woman was seen in ED with bleeding in early pregnancy.
Her ßHCG had fallen from 95,000 to 50,000 over 2 weeks.
On the basis of this she was told she had miscarried.
The next day she had an ultrasound which showed a viable pregnancy.
It is normal for ßHCG to fall in early to mid pregnancy.
In our shop if a woman presents with threatened miscarriage we will rule out a life threatening miscarriage or ectopic pregnancy:
If she passes all of the above we will usually discharge with advice to return if she is gushing blood, feeling faint or has severe pain. Give paracetamol and a weak to moderate opioid for pain (not a NSAID in early pregnancy)
She will be asked to return in the morning to Early Pregnancy Clinic (EPC)
Our EPC and ultrasound doesn’t run on the weekends so often one of the ED senior docs will do a bedside ultrasound to try to confirm an intrauterine pregnancy. If we can’t we might get the woman to return to ED or EPC in 2 days for repeat ßHCG and repeat scan.
One day you may find yourself working somewhere with a defibrillator that uses paddles instead of adhesive pads, because the health system of that country cannot afford the cost of single-use defibrillator pads.
You may also find that your team takes an awfully long time to first shock because they are mucking around trying to read the rhythm through the monitor or defibrillator leads, rather than through the paddles.
So key points to using an old school defib:
All defibrillators should default to reading through the paddles or pads. If not you will need to change the lead to “paddles” or “pads” on the defibrillator
Some defibrillators have a single button (the yellow button in the photo above) which charges the defibrillator. Some defibrillators are charged by depressing the same two buttons used to deliver the shock. Alternatively you can ask someone else to push the “charge” button on the defibrillator machine.
Put gel on the paddles.
Put the paddles on the patient’s chest.
Stop CPR briefly while you read the rhythm.
If it is a shockable rhythm, deliver the shock as soon as charging is complete.
Recommence CPR as soon as the shock is delivered.
Here is a video of some Fijian doctors resuscitating our old friend Annie with an old-school defibrillator with paddles.
By getting them to change to reading the rhythm through the paddles rather than via the leads, time to defibrillation was reduced from about 2.5 minutes to 40 seconds.
At 0300 the next morning some of the doctors were able to put this into practice and got ROSC (return of spontaneous circulation) on the second shock.
A 30-year-old indigenous Fijian male presented to a Fijian emergency department with several days of productive cough and lethargy. He had normal vital signs and had decreased air entry and dullness to percussion at the right base.
This is his CXR
I thought this was a right lower lobe pneumonia and would have treated his as such.
One of the good local docs, Vivek, put an ultrasound on the patient’s chest and found the real cause.
He then went on to CT. This is a video of the CT captured by phone (this is known as “mobile PACS” (picture archiving and communication system): there are no computers in that ED for viewing images, clinicians go to radiology and take images on their phones and take them back to ED to share with the team).
This is a massive liver abscess with a small pleural effusion. The productive cough was a red herring. Liver abscess in Fiji are usually seen in young adult males and are believed to be due to amoebic infection from contaminated water used to prepare kava. Kava is prepared from a local plant appears to have anaesthetic properties causing tingling of the lips and tongue and sedation. It tastes like mud and probably should be tried once to keep your hosts happy.
A couple of times a week in this ED young men were diagnosed with liver abscesses. They usually presented due to jaundice (this patient was not jaundiced) +/- mild right upper quadrant pain +/- fever.
Patients are treated with antibiotics eg oral metronidazole. Ultrasound is used to see if the abscess is fluctuant (ie changes shape with pressure). If it is fluctuant the abscess is drained percutaneously. If the abscess is not fluctuant the patient is treated with antibiotics for a few days until the abscess becomes fluctuant.
UpToDate says aspiration or drainage of amoebic liver abscesses is not usually required, but drainage of pleural effusions is recommended. I don’t know why the practice in Fiji differs from this. Maybe someone from Fiji can let us know in the comments. Perhaps they have some with bacterial superinfection. UpToDate recommends subsequently treating with paromomycin to eliminate intraluminal (within the gut) cysts. UpToDate also reminds us that oral metronidazole has excellent bioavailability and there is little to be gained by IV treatment if the patient is able to take oral meds – and oral metronidazole is much cheaper.
So keep liver pathology in mind with a patient with right lower zone dullness / opacity, especially if they have recently travelled to a Pacific Island.
Approach to the CXR
When viewing a right lower zone opacity our radiologist recommends considering:
This CXR does not particularly suggest something subdiaphragmatic is going on, our radiologist had his money on a subpulmonary pleural effusion.