Hospital de Pronto Socorro, Porto Alegre

A few months ago emergency medicine was declared a recognized specialty in Brazil; however, at Hospital de Pronto Socorro (HPS) in Porto Alegre, they have been training residents in emergency medicine (EM) for over 10 years.  As such, HPS is considered the birthplace of EM in Brazil.



The front entrance of HPS



Ambulance bay at HPS



Trauma resuscitation room AKA: "the red room."  HPS is primarily a trauma hospital, meaning medical cases are mostly diverted to Hospital das Clinicas or another nearby hospital while trauma cases are preferentially brought to HPS.  However, many times medically ill patients are brought to HPS as "walk-ins" or if another hospital is on divert.



My good friend "Mr. Siemens."  Although the contact surfaces to the transducers have become desiccated and crumbled apart, the machine still produces surprisingly good image quality.  See my other posts for some examples.





Mr. Siemens' younger brother, Mr. Toshiba, is used by radiologists in a room around the corner from the trauma resuscitation bay to perform official ultrasound studies.  Ultrasound technicians do not exist in Brazil.  Ultrasound studies and performed and interpreted by the radiologists themselves.  In fact, in other hospitals, sometimes radiologists will be asked to hold the linear probe for another physician while they place a central line.  However, most physicians in Brazil still place central lines by landmarks and not under ultrasound guidance.



Ross Simcoe, a 3rd year EM resident from Jefferson rotating with me through Brazil, performs an EFAST exam on a trauma patient in the red room.



Ultrasounding left handed and teaching residents at the same time?  No problem.  Due to space constraints I had to learn to become ultrasound ambidextrous at times.




Teaching residents with Dr. Daniel Pedrollo, an attending EM physician at both HPS and Hospital das Clinicas.



The lower acuity side of the emergency department (ED).



Alongside the emergency department are specialty consult rooms (ophtho and ENT shown).  Interestingly, there is a specialist always available to see consults and if the patient presents with a complaint related only to that specialty, the patient will be seen only by that specialist and not by an emergency physician.



Triage.  Here patients are triaged using the same Manchester criteria used at Hospital das Clinicas in Porto Alegre.  However, different from our ED's back home, the triage staff may divert patients to outpatient clinics without ever seeing a physician if they determine the patient's complaint to be low-acuity and non-emergent.



Ross and I pose with EM resident Andre.

Why do we check the common femoral vein for DVT at the level of the greater saphenous?

59 year old female who presented with chest pain in addition to right leg pain, her right lower extremity DVT study revealed the following:

View of a clear right common femoral vein, but large thrombus in the greater saphenous vein.  Patient was found to have a pulmonary embolism on her chest CT and was admitted to medicine for anticoagulation.

View compressing right common femoral vein showing no clot, but incompressible greater saphenous vein with large thrombus.

Hospital das Clinicas

The emergency department at Hospital das Clinicas in Porto Alegre will be starting an emergency medicine residency in March.  Currently other departments such as internal medicine rotate through the emergency department in addition to emergency medicine residents from Hospital de Pronto Socorro, 1 of only 2 emergency medicine residency programs in the country currently.



This is the resuscitation room where "red" patients will arrive to be evaluated and treated immediately.  Emergency departments in the public hospital system in Brazil (SUS) use the Manchester system to triage patients into several color groupings from Red (severe) to Green (minor complaint) based on their acuity, similar to the ESI system used in the US.



This is room is called the "Laranja" (orange).  Usually it is much more full, with just enough room to squeeze between stretchers, but as the ED closed due to flooding from the storm, the room is relatively empty. The Laranja is a mid-acuity area where patients will usually wait for days for a bed to open up on the floors upstairs.  Average patient stay in the emergency department is approximately 5 days due a lack of open beds on the floor during which time the emergency physicians have to manage their care.  Boarding is a serious issue throughout emergency departments in Brazil.



This hallway leads to a room called the "green room" with chairs where low acuity patients sit waiting either disposition or a bed to open up on the floors.  Boarding times in the green room can be days as well.



This is the red room where the highest acuity patients stay.  In this picture it is closed due to leaks/flooding from the storm.



This room is next to the red room where patients who need a higher level of care such as vasoactive medication drips and continuous monitoring are lodged while awaiting rooms upstairs.  Although, not seen in this photo, to the left there are also isolation rooms here for patients with active tuberculosis (common in Brazil) amongst other infectious disease concerns.  This room is also relatively empty in this picture due to the emergency department closing after damage from the storm.



Here are some of the Hospital das Clinicas attending staff who hosted us during our stay in their emergency department.  A million thanks to everyone at Hospital das Clinicas for their hospitality and help during our time in Porto Alegre!!

Middle aged woman presents with shortness of breath

This middle aged woman with a history of rheumatoid arthritis presented with shortness of breath after recently starting a new disease-modifying anti-rheumatic drug (DMARD) and was found to be pancytopenic.  Some of her ultrasounds are displayed below.



It would appear that she has a small pericardial effusion.  Although probably not clinically significant at this time, it should be watched.






Her left ventricular systolic function appears to be intact



She may have diastolic dysfunction, but we do not have tissue doppler to confirm the diagnosis




A small right pleural effusion.  Unlikely clinically significant, but also should be monitored.




Look at the A-lines this Siemens produces!!  I've never seen anything like it.  It goes to show how far ultrasound technology has come in eliminating artifact.  As the "B-lines" in this clip are interrupted by the A-lines, this exam is not consistent with alveolar interstitial syndrome (such as pulmonary edema).

Suprapubic pain in elderly woman

This elderly woman with dementia was complaining of suprapubic pain.  See if you can tell what might be causing her pain and what else it might be affecting.

Hospital das Clinicas closed by enormous storm!

Aside from the general destruction caused by the massive thunderstorm in Porto Alegre, Hospital das Clinicas had to close both its emergency room and intensive care unit due to excessive flooding and leaks within the hospital itself!

Flooding outside of the ICU



Leaky ceiling dripping into buckets in the acute area of the emergency department




Acute side of the emergency department closed due to flooding

Front door to the emergency department locked with a bench in front of it.  This was a bit of a shock when we arrived for work that day!

Increased ICP in a patient with intraparenchymal hemorrhage

Although it is primarily a trauma hospital, many times medical patients will present to the Hospital de Pronto Socorro (HPS) in Porto Alegre such as this woman with massive right sided intraparechymal hemorrhage with midline shift.

Ultrasound showing increased diameter of the right optic nerve sheath indicating increased intracranial pressure