Case 1: Last week, we had a patient who presented to the emergency room booked as heart failure. He was transferred from a district hospital with hypoxia. The team there had started treating him with a beta blocker and Lasix but he was not improving. His oxygen saturation was 76% on RA and 90 on a NRB. His HR was in the 60's ( B-blocked), and he was midly hypotensive with SBP in the 90's. His chest xray was clear without pneumonia or pulmonary edema. Given his Hypoxia, the resident suggested we perform a point of care Ultrasound ( I was so happy he initiated this Ultrasound ). A formal ultrasound could take up to 2 days to obtain, and with the rate of patient turn over at this hospital, who knows if patient would last that long. His Bedside Cardiac Ultrasound showed a severely dilated RV and a large dilated non-collapsing IVC ( sorry the other videos won't download, so only one cardiac view). We of course suspected a pulmonary embolism in this patient. We performed bilateral point of care 2 zone DVT studies which were negative. Emergency team decided to heparinize this pt given these findings. This week I checked on him and he was off oxygen and sitting up breathing comfortably waiting for a bed on the medical service. Never got CT PE...family could not afford to pay ( you pay for everything at this hospital...including the gloves that clinicians use to care for the pt). No money, insurance = limited care.
Case 2: Young male in his 20s who had a motorcycle accident presented from District hospital with minor pelvic fracture. It took him about 2 days from his trauma before he presented to our referral hospital. He complained of severe abdominal pain with us. He was scheduled for a CT scan of his abdomen but it was taking a while. We performed FAST ( Focused Assessment with Sonography for Trauma) on him and saw this. Yeah....That's a ruptured bladder. He got antibiotics and a Urology consult. They requested a CT scan which happened 2 days later and confirmed a bladder rupture. He was then discharged with antibiotics, a foley and was scheduled for outpatient cystogram...This basically motivated the residents to do FAST's on all traumas even if transferred 3 days after injury!!!!! This helps form habit....and the residents get to perfect their Ultrasound skills.
This is a necrotic leg...This woman's leg has been like this for a few months...why did she not appear that ill???...Well Doppler U/s of the vessels of her legs showed a femoral arterial clot but also incidentally bilateral DVT's which probably prevented severe systemic illness. She had bilateral DVT's due to large pelvic mass. She ended up having her leg amputated and last time I checked she was doing well on the surgical service. Unclear what work up she would have for her pelvic mass.
Soooo Much Pathology here...Because CHUK is the referral center in Rwanda and has the only public CT scanner ( other one is at a private hospital and you need lots of dinero), we get everything at this hospital. On any given day we have many positive FAST's, large pericardial effusions, and cardiomyopathies. Great learning cases!! These were just a few. Thanks for Reading
~Phindile Erika Chowa MD
Emergency Medicine Residency, MGH/BWH, PGY3