Tuesday, 4 December 2012



A late post, yet again, but I have been ill so perhaps that goes some way towards an excuse... This was my second (and last) week of paediatrics, so I spent time on the wards and ended up catching an infection from one of the ill little kids... The main thing of interest that happened this week (apart from the really important medical student getting ill) was a fantastic piece of clinical detective work which came from one of the doctors on the ward; something House MD would have been proud of.

Me being ill isn't really blog-worthy, so I will brush over it. There are a lot of sick children in paediatrics, especially babies with bronchiolitis around this time of year. I think one infected me with a virus (perhaps RSV, who knows) and I had to take the last day and half off last week with general coryzal symptoms, generalised myalgia and headache... Or man-flu... whichever you think fits best. I am feeling a lot better now, though.

It is a terrible disease... Honest...

Back on track, I spent most of the week when I was in hospital in a variety of different ward rounds and clinics with the nasty children which then went to make me ill. The best part was during a handover, when all of the patients are discussed between the day and night team, to make sure everyone knows what is happening with each patient at that moment in time. One of the patients, lets call him Billy, had been in the ward for the last few weeks, and was receiving chemotherapy for a rare type of cancer that had started in his tummy, but spread out across his body. The subsequent scans had suggested that this treatment was being very effective in controlling the cancer, and it was all shrinking, but overnight the night team had noticed that one of his pupils had become fixed and dilated (a blown pupil).

Blown pupil seen here in the patient's left eye

This raised a lot of worries, most importantly the worry that the cancer had spread to the brain, and was growing there, affecting the nerves coming out of the brain by pressing on them and creating this symptom. The night team had arranged a whole host of brain scans and investigations to be carried out this day to find out what was happening. One of the paediatric consultants, who always dresses pretty shambolically and behaves a little like a crazed professor started asking the night team questions

"Is the patient on hyoscine for the chemotherapy?"

Yes he is, they answered, he has a patch on at the moment

"Where is this patch, is it on his neck perchance?"

Why yes, its on the left of his neck, a bit above the clavicle"

"Well that is the answer, then. Hyoscine is an antimuscarinic, and the drug is passing through the skin into the blood vessels which then feed into the eye, dilating the pupil. Change the position of the patch."

And hey-presto, the patch position was changed to the other side of the neck, and the eye slowly went back to normal. A lot of stress for Billy and his parents avoided, and a lot of expensive (and radiation-filled) scans avoided. A simple diagnosis made without any fancy hospital tests, just a brain. That is the way medicine should be done!

To wrap up, the boy who was hallucinating snakes was discharged this week, with no medical cause found for these sightings. This is good, as it means he hadn't accidentally eaten some illegal/legal drugs, and he didn't have a brain tumour, but it did leave a question mark over the diagnosis. The children's psychiatric team were involved, who decided he seemed he may be slightly on the autistic spectrum (and wanted to follow him up), but they were not sure where these hallucinations came from either. The final decision was it must have been a nightmare which had started this off, and the psychological trauma which this nightmare (i suppose about snakes) had caused had lead to these hallucinations. This has been documented before. Not a perfect answer like I was hoping for, but it is the best we could get... A little like the finale of lost.


  1. What a kickass consultant, I'm definitely going to have to remember that interesting bit of pharmacology/physiology in case I ever see it in action. Must have been such a relief for everyone involved in the child's care too.

    Hope you make a speedy recovery from the RSV/manflu dude!

  2. Thank you - recovered with plenty of time to spare to the Christmas holidays, and that is what matters most!

    If you manage to spot something like that I would hope your medical school would be so impressed they would graduate you on the spot :P

  3. House MD moment for sure.

    1. My thought exactly. :)