Mother of a 15 month old boy (weighs 11 kg) presents to the clinic with a bottle of massage liniment.
A quick glance at the label tells you the active ingredients are;
Per 50 milliliter:
Mother of a 15 month old boy (weighs 11 kg) presents to the clinic with a bottle of massage liniment.
A quick glance at the label tells you the active ingredients are;
Per 50 milliliter:
OK. This is just plain out there. We see some unusual stuff in the remote areas – things you only read about in the books! I am going to put this in the category of medical voyeurism. This is not how we should go about our business, but I had to share these pics!
20 yo with pleuritic chest pain, not much else, but hypertensive BP = 160/90 [not that unusual up here in the tropics]
He managed to get a D-dimer… and then the inevitable CT angiogram (probably PERC negative)
Here is a slice from the CT -
OK – spot diagnosis, what is going on?
Today’s case is not in the ED. This one unfolds on the ward – the morning after the admission. So imagine yourself there – on the Paeds surgical ward.
6 year old boy was admitted last evening after referral from the local GP to the on-call Surg team.
He has a 24 hour history of increasing central abdominal pain. The pain wa initially periumbilical, but overnight it has localized to the lower abdomen – maybe a bit more on the right. Urinalysis was normal
The surgical team have been on their super-early orning rounds and seen the child – they have written in the notes:
“ tender lower abdo, no rebound, guarding, otherwise soft, afebrile. Bloods all normal. PLAN: Med team consult please.? epurients”
OK, now that is Surg -speak for – we aren’t operating on this kid – not a likely appendix. Turf to med, maybe its constipation?
Half way though your ward round the nurse- coordinator calls you to say: “You had better come see this kid – he has just had a bout of melena”
Hmmmm… not sounding like your average “un-appendix”. So you pop in and see him. Mum is looking worried. His obs are normal, his belly is ‘as described’ by the Surg team. When you pull down his jocks for a gander at his bottom you notice his scrotum is a bit red, and on examination his left testis is tender and there is a definite hydrocoele. Hmmmmm…
OK – can you solve this Paediatric puzzle?
What is going on? Well here is the clincher.
What are you going to do next?
Congrats to Dr Bek – who as it turns out practices about 500m down the road from me at the local Aboriginal Medical Service. Bek gave the right and most insightful answer. Good call from Maj and Patrick also – honorable commendations. I happen to know Bek was at a recent talk I gave which covered HSP – so technically she did cheat? But I think she already knew before I got to her!
Monitoring includes urinalysis testing, BP monitoring – as there is about a 7% recurrence rate and the risk of renal disease goes up with recurrence and older-age of the kid.
This week’s case is “chest pain” in a relatively young man.
I am going to make it tricky by giving you info bit by bit – see if you smart buggers can work it out.
Step 1 – here is the initial ECG. 2 hours of central chest pain. What is happening? what are you going to do?
Does he meet criteria for thrombolysis?
OK – so you all seem to agree he has pericarditis on the ECG. And the history was convincing – 23 yo, pleuritic left chest pain, radiating to the left arm. He had a story of an acute “strept throat” and was just finished a week of oral penicillin. BUT – the initial tropT was 0.88, and in the morning it was up to 16! So he clearly has more than a simple pericarditis.
Just to be sure, late at night I did a bedside ECHO to check if he had anything suspicious. This showed a small pericardial effusion and no “eyeball” evidence of regional (inferior) wall motion abnormality (for what it is worth with me – an ECHO gumby looking with my eyeballs!)
So lets say he has a myopericarditis. Let us now look at the treatment. How do you manage this? And if you are super-smart – are there any other causes to consider other than “viral”?
If you are unaware of Dr Smith’s ECG blog then check out the section on pericarditis here - lots of pearls for telling MI from pericaritis.
Let me know on he comments.
When I was an intern in a big old hospital one of the tasks we did was taking blood cultures off of patients who spiked fevers on the wards. In fact thinking back on it, I think I was taking cultures to appease the senior ward nurses and not really stopping to think about the why? Probably stabbed any number of patients with early sepsis and happily continued onto the next job without even worrying about the BP, lactate, line sepsis etc etc… It was an annoying task as it was “time critical” – you had to get the cultures ASAP as the fever spiked – or else the boss would be grumpy, we might “miss the sepsis”.
Were we right to worry about getting the cultures done in a timely fashion? Did it have to be “during the rigors?”
My colleague pointed out this paper by Riedel et al, Journ Clinical MIcro (April 2008). This case-review looked at 1436 patients and their fever – culture timing profile and found that it really didn’t matter when you took the cultures in realtion to the spike of a fever – the majority of positive came from cultures taken hours after a fever. This study cannot comment on the numbers of “missed” bacteremias as a result of wrong / delayed timing.
So what does it all mean for you, next time the nurse calls to tell you Mr Jones has spiked a temp….
Thanks Ben for the article. Interns – relax, but do a more thorough job! Casey
Last week I received the following comment from a reader in a country nearby. This was a great story for me to hear as it made all my long hours of reading and writing seem worthwhile. There are plenty of podcasts and blogs that will teach you how to do life-saving stuff – but this story is about how a reader took something from Broome Docs and ‘saved a life’ in a very different way. It is not about a single trick or a procedure – but about how to approach the daily practice of medicine in a better, patient-oriented and effective manner. For me this is the essence of why I do what I do at Broome Docs. Here is the story from Dr Tom:
Straight after I read your first article on Consult Skills, I clipped and saved it using Evernote so that I could access it on my iPhone whenever needed.
Lo and behold, last week I had my first opportunity to use it when a middle–aged lady presented with a two year history of severe low back pain, bilateral hip pain and right leg pain. She had had multiple visits to her GP, several locums and 3 different orthopedic specialists over that time. Even though she was on a benefit, she had paid to see a couple of specialists privately because she was so desperate.
When she arrived in our ED, one of our relatively new Resident Medical Officer’s went to see her. The RMO came back very frustrated and said that both the patient and accompanying relatives were very angry and demanding, and that she wasn’t really able to get anywhere with her.
At that stage I said to the RMO that we had two important functions to fulfill:
1. To make sure that the patient didn’t have any emergent orthopedic conditions e.g. cauda equina syndrome, spinal abscess etc.
2. To try to understand the patient’s point of view.
The latter was met with a slightly quizzical expression so I pulled out my iPhone, opened my Evernote application and showed her the section I had clipped a few weeks ago:
1. They want to know the doctor is listening to them
2. They want to know that the doctor cares
3. They want to make sure the doctor understands what is going on
4. They want the Doc to “get it right” – that is make the right call / decision / do the right test etc…
5. They want to know what to do next “what will happen to me now?”
At that stage I went into the patient’s room and said:
‘Hi, my name is Tom – I am the senior ED doctor on duty today. I understand you have been going through a really rough patch lately. The first thing I am going to do is to take your pain way with some morphine. Once you are comfortable, I would like you to tell me everything that has happened to you over the last couple of years; then I will have a good look at you, review your results, talk to the orthopedic specialist on call today and together, we will try and come up with a plan to get things sorted for you.
After 10mg of morphine she said – ‘Doctor, you know this is the 1st time in over two years that I have not been in pain’.
She then proceeded to tell me:
• Her marriage had broken up and she was looking after 6 children on her own.
• She was in so much pain that she was unable to dress herself (mainly because she could not bend down or stand on one leg), was unable to walk more than a few steps, had hardly been out of her house in the past few weeks and was largely confined to her bed or a chair.
• She had a history of multiple severe drug reactions and was not currently taking any analgesics.
• She suffered from stress incontinence and wet herself at least 2-3 times every day.
• When she fell over, she was physically unable to get off the floor unaided.
• Her teenage son had to take time off school to help dress and wash her, clean the house and do the cooking – this was now starting to adversely affect both his education and their relationship.
• She was not eligible for any government subsidies (e.g. home help).
• She was often tearful due to a combination of pain and frustration.
After listening to her history, I briefly re-capped to make sure that I had not missed any important points. I then examined her and reviewed her recent imaging.
Next I rang the on-call Orthopedic Specialist and said – ‘I’ve got a lady with chronic severe lower back, hip and leg pain; a plain film of her pelvis and hips shows severe bilateral hip OA; she doesn’t appear to have any new emergent orthopedic conditions but I would like to admit her so that we can sort out her analgesia, home help, mobility and definitive treatment’.
I returned to the patient and told her: ‘Great news, the Orthopaedic Surgeon has agreed to bring you into hospital, sort out your pain, get you a bit more mobile and most importantly, try and fast track some surgery on your hips.’
At that point she started crying and said:
‘You know, of all the doctors I have seen over the last few years, you are the only one who has ever sat down and really listened to what has been going on. Thank you so much’.
After initially being admitted to hospital for a week, she has gone on to have her 1st hip replacement done and is due for her 2nd operation in 3 months time.
Great work Dr Tom. I really appreciate your sharing this story with me and knowing that we can do better by changing the way we think and talk to patients.
I was sitting at the desk writing up some notes when the triage nurse stuck the following ECG strip under my nose.
The story was that this chap was a hypertensive, obese, diabetic vasculopath with impaired renal function who had presented with a fever of 39 deg and nasty looking diabetic feet (see Clinical case 047 for example…). He was looking unwell so she did an ECG on the off chance he might be having a silent infarction.
So here we are – sick looking, high-risk sounding patient.
OK, all you smart ED types. Can you make the diagnosis? What is going on here? There might be a trick or two …..
2. If something doesn’t add up, check the basics, repeat the test and ask, ask, ask
3. Septic patients can develop nasty arrythmias – SVT, AF, transient heart blocks (RBBB), VT etc – so beware the sepsis with tachy, find those P-waves – as all the other options are not good for their cardiac output.
4. Lewis leads (S5) actually works, it is cheap, easy and makes you look smarter!
We have a great job, but sometimes it sucks! Forget the annoyance of shift work, the heirarchy and long hours – for me the worst part of the job is when we find something nasty, or have a poor outcome – giving bad news to nice people is never easy. Why? well it goes back to the type of people we medicos are ‘on average’. We are usually pleasant, we like to make others happy, ease suffering and get good results – this is one scenario where none of these is likely to occur. So how do I think about “giving bad news”?
There are a lot of teachings out there, and anyone who has done any GP training will have had this drilled into them throughout their training. In Australia you can be guaranteed that you will get a “bad news” case on your fellowship clinical exams. So here is a case and my “rules” for being good at bad news.
You are in your office checking your emails when the radiographer calls you to say she needs help….She has been doing a 19/40 anatomy US on a nice young lady with her husband watching to catch a glimpse of a face or a gender. All seemed well, until the radiographer realised that this baby had no brain – it is anencephalic. It is a small town – the radiographer plays netball with the expecting mother and cannot hold her poker face. She stops scanning and tells her she is going to find a doctor to get a second opinion. This is when she called you.
If you are like me – you know what this means, but the exact logistics of dealing with anencephaly are well beyond my scope of practice. I need help and will be calling my local ObGyn for advice. However, the young couple are aware that something is wrong. You need to talk to them and provide counsel – so how to do this in real terms…
Here are my rules:
This might mean doing some research or asking for specific specialist advice – but you have to know. If you are unsure – you know that will be the first question they ask – and you need to be able to provide clear and concise counselling. This is not the time for ummm or errs – the patient needs clarity and a direction. Any vague responses will likely provoke anxiety and confusion in a person who is already having the worst day of their life.
You do not need to have encyclopedic knowlege – but you should be able to provide clear and accurate information now, today! So take a few minutes – call someone who does know and get the facts straight in your noggin
Beware that some folks will have a dramatic response – crying is normal, butI have seen a few people have syncope and prolonged, almost catatonic responses – so it is helpful to have a bed or somwhere the patient can lay down if the need arises.
- Talking to somebody alone is not advised – they need a support person to help them through and share the experience. Sometimes even to get them home safely.
- If an important family member or person is not there – they will likely get the message indirectly and inaccurately – this will lead to tension, misinformation and sometimes anger
The use of subtlety or pleasant euphemism is not allowed – that is about you wanting to avoid the unpleasant nature of the conversation. In order to do this right you will probably feel uncomfortable – that is your problem – not the patient’s!
OK – that is my simple approach to the delivering of bad news. Do you have any pearls or strategies that you have found useful in your practice? Let me know
Last week I completed the APLS course over 3 days. I am an impartial educator and thought I would give my review – so what did I think?
APLS is a well organised and run course. It covers a lot of material over 3 days. The level is pitched at the post-graduate trainee – ideally PGY 2 -4 I think. The days were long – 11 hours of material in a day… this is probably counterproductive. The course could be streamlined I think without losing too much.
At ~$1900 – it is a reasonably expensive course. For that money you get a lot of theory, manikin-based scenario training, but no animal / cadaveric models to improve your clinical skills.
The learning is largely based around lectures – not everybody’s preferred format! I found the lectures a bit long and repetitive, especially if you had done the required pre-course reading of the manual. The teachers were friendly and well-informed, and an effort to remain entertaining was evident.
The scenarios and skills stations were OK. As a more experienced participant I found being put on the spot in simulation to be a strong learning tool and allowed me to identify my weaknesses and cognitive errors. I was aware that some of the more junior participants found the live simulation a bit confronting.
The material presented is largely up-to-date, though there are some areas where there is a lack of evidence base. For a ‘resus course’ the absence of ultrasound strategy was striking. The preference for ETT over LMAs in resus seemed odd given recent changes in most major guidelines
The testing and scenarios were OK, but did lack some flexibility to allow more experienced clinicians to make judgement calls rather than blindly follow protocol – ie. there is some ‘lowest common denominator’ effect – I guess this is a function of running such a broad ranging course. Good for jnior staff, but a bit frustrating if you are 10+ years into your career.
APLS is a well run course that covers an ambitious amount of material in 3 days. The educators are entertaining and well-versed. I recommend it to junior doctors, and staff who are unfamiliar with Paeds patients and wanting to extend their knowledge from adult care. For the office GP who wants to brush up their resus skills – it is OK.
If you already do a lot of Paeds, especially in ED or anaesthesia environments than this course might e aiming a bit below your educational needs.
Any one out there got experinces of the APLS to share? Casey
This week a classic Australian remote area case. There is so much to discuss on this case! But I have isolated a few key points to put under the microscope, and get your input / expertise.
47 yo. Aboriginal woman has returned to the ED complaining of painless purulent lesions on her left foot. She was seen a week ago by the nice city locum who diagnosed cellulitis and commenced her on a week of oral flucloxacillin. She has been taking this for 6 days, but it aint working!
Here is the background info:
PMHx: Diabetic (type 2 – is there any other kind?)
Meds: metformin 2 g/day SR, Gliclazide 120 mg MR, Quinapril 20 mg, aspirin 150 mg/d. No Allergies
She is overweight with a BMI of 39. Central adiposity. Malodourous slough coming off the foot. She has a good dorsalis pedis and posterior tibial pulse to feel
Obs: T = 38.4, pulse = 98 SR, BP = 166/102, RR 14, Sats 97% RA. Her BSL is 29 mmol (~ 520 in USA)
This is bread and butter for the remote area docs, so i am going to ask 3 questions for you to ponder and comment upon…
Q1: Antibiotics in this scenario – what are you going to use? Any particular pathogens to keep in mind?
Q2: Imaging – what do you do? Are plain films worthwhile?
Q3: Management of her hyperglycemia (assume she is admitted) – what targets and what to use to achieve this?
….. OK, bonus question… #4 : Maggots…. good, bad or indifferent?
Get your thinking caps on. Especially you Dr Dorr – I am gonna quiz you on this this week!