The last few blog posts have focused on our projects related to emergency care capacity building at the Mae Tao Clinic (MTC); however, throughout this time the clinical staff at MTC continues to evaluate and treat a steady stream of patients, many of whom present with complex pathology. The following are a small sampling of the many cases seen at MTC just this past one week...
Pediatric Trauma:
On Friday afternoon, I was asked to come to evaluate a 9 yo M who presented with right-sided upper abdominal pain, right-sided chest pain, shortness of breath, and fever three days after falling approximately 10 feet out of a tree. The patient was ill-appearing, and given his injury mechanism, we were concerned he sustained severe traumatic injuries. He had tenderness on his right anterolateral ribs that were consistent with multiple rib fractures. He had the following findings on his eFAST exam...
Subcapsular and intra-hepatic hematomas, likely due to liver laceration
Trace free fluid (likely blood given trauma) in the suprasplenic space
Large right hemothorax, but no pneumothorax, normal left lung
ECHO showed tachycardia but no pericardial effusion or tamponade
Right upper quadrant (RUQ) eFAST view showing hepatic hematoma due to likely liver laceration. The hypoechoic (blacker) areas in the upper and left-upper part of the image is the blood.
Another RUQ eFAST view of liver
Right lung ultrasound showing large amount of free fluid in right thoracic cavity given trauma consistent with large hemothorax.
From our partners at Core Ultrasound (formerly 5 MIN SONO) here is a short video on how to perform the eFAST exam.
Case Resolution:
Two IVs were placed to begin resuscitation and the patient's blood was sent to type in order to prepare for a blood transfusion. Given the delayed presentation and fever upon arrival he was also treated with antibiotics as he is at risk of developing secondary infection due to the hemothorax and/or the intrabdominal injury. This patient requires a thoracostomy tube (chest tube) placed to drain the hemothorax and evaluation by a surgical team given his intra-abdominal injuries. He will also need CT imaging to further diagnose injuries. These interventions are not available at MTC, therefore the case was discussed with MTC senior medic team and the foundation that supports MTC patients who require transfer to Mae Sot General Hospital (MSGH) but who cannot afford the cost of medical care there. Fortunately, the MTC team secured 10,000 THB to provide to the patient's family to help cover medical costs at MSGH and arranged transportation; with the patient departing MTC approximately 10 minutes from the completion of his eFAST exam. This quick transfer was necessary as the patient's hemoglobin (red blood count) was half the normal value with his 6.3 g/dL and a normal hemoglobin is between 11.5 to 14 g/dL.
The following video is a demonstration on how to place a thoracostomy (chest) tube, using a manikin.
This next video demonstrates an actual thoracostomy (chest) tube insertion in the controlled operating room environment. I have the video set to start at beginning of the actual procedure, if you would like to watch the entire video you may back up to the beginning.
This case highlights the importance of MTC's efforts to build an emergency care unit with triage protocols and trauma criteria. Having a central location where patients arrive to be triaged and assessed helps to ensure patients with severe medical pathology or traumatic injuries receive timely care. As part of our ECU development we are creating trauma criteria based on a combination of mechanism of injury, vital signs, and clinical appearance. If a patient presents meeting this trauma criteria then the patient will be placed in our red area (resuscitation beds) and the trauma team, consisting of multiple ECU clinical and supervisory staff, will be called to bedside
Adult IPD Cases
80s yo F presented with right-sided hemiplegia (paralysis) and aphasia (inability to speak). This presentation is consistent with a stroke. MTC, similar to many other hospitals with similar resources, does not have access to CT scans, the type of diagnostic imaging used to determine if a stroke is ischemic (due to a blood clot decreasing blood flow to the brain) or hemorrhagic (due to bleeding in/around the brain). One tool used in these settings is the Siriraj Stroke Score. A score greater than 1 indicates supratentorial intracerebral haemorrhage, while a score less than -1 indicates infarction. Scores between 1 and -1 are equivocal. This patient had a score of -3.5, which is consistent with ischemic stroke. From the Siriraj Stroke Score validation study, "the diagnostic sensitivities of the score for cerebral haemorrhage and cerebral infarction were 89.3% and 93.2%, respectively, with an overall predictive accuracy of 90.3%." While not a perfect test and not something you would use to guide thrombolytic therapy (something that is not available at MTC), it is one of the tools used to help guide treatment in patients with strokes when advanced imaging is unavailable.
50s yo M who presented with shortness of breath and weakness for at least two weeks and found to have moderate right pleural effusion. He had no signs of heart failure of ultrasound or physical exam. The pleural effusion was drained and fluid sample sent for tuberculosis screening and cytology for malignancy.
30s yo M with a history of daily alcohol use who presented with symptoms of volume overload including shortness of breath, abdominal distension, lower extremity edema. His ECHO was consistent with dilated cardiomyopathy likely secondary to chronic alcohol use. He is being treated with diuretics to remove fluid and diazepam for alcohol withdrawal.
70s yo F with long history of smoking who presented with several months of progressive shortness of breath but no infectious symptoms and no clinical signs of volume overload. On ultrasound she was found to have moderate left sided pleural effusion with no signs of pulmonary edema. We have a plan to aspirate effusion and send for cytology as malignant effusion is high on our differential, the fluid will also be tested for tuberculosis. She is also planned for a chest x-ray next week.
There were many other challenging and fascinating cases seen by the MTC staff this week, including two interesting echocardiogram cases that I will present on the next blog post.
The below photo is another delicious lunch enjoyed at the clinic
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