12 days of Christmas in the ED

Working in A&E brings plenty of different experiences, here is a selection of true stories from the 12 days run up to Christmas.


On the first day of Christmas, the ED gave to me: a cockroach infestation in resus bay 3

On the second day of Christmas, the ED gave to me: a patient with a baseball bat to the face, and the chance to assist in a lateral canthotomy

On the third day of Christmas, the ED gave to me, a psychotic gentleman after losing a loved one in hospital , the questionable choice to bring the body to A&E due to a flooded morgue to help the patient come to terms, and the dire mistake and consequences of bringing the wrong body up to the ED.

On the fourth day of Christmas, the ED gave to me, many giggling nurses, several confusing PA calls, my name changed on the computer system to 'Bieber', and in inability to change it back until three

On the fifth day of Christmas, the ED gave to me: A patient who had been hit by a bike, a swollen and painful hand, an X-ray showing a dislocated trapezium bone, a referral to a surgeon who wasn't sure what the trapezium bone was, and the feeling that the MRCS must be pretty crappy. 

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I am now, as you can tell, struggling, to keep fitting my recent experiences into this ridiculous format, and will just list the rest. This was a terrible idea to try and do this!
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On the sixth day of Christmas, a patient presented having electrocuted himself with an iron, wearing a T-shirt emblazoned with 'what doesn't kill you makes you stronger'. The irony was lost on him. Perhaps he was going to turn into a superhero, with a super power of resisting the power of resisting literary techniques.

The seventh day of Christmas was not a good shift. I was called a 'dirty fingering heterosexual' by a furious patient, a very anxious man presented who thought he had cyanide poisoning from eating a bag of apricot seeds from a health food shop and refused to leave, and a patient snuck into the A&E toilet and cut her wrists, barricading herself inside.

The eighth day of Christmas started of promisingly with the ambulance service bringing in a patient coded as 'shooting/stabbing/penetrating wound', exciting the department to prepare for a trauma call, until it turned out it was a man who had dropped a kitchen knife on his foot.

On the ninth day of Christmas, a patient with dementia was bought in due to pneumonia. We were transferring them from the ambulance trolley onto one of the A&E beds, when the patient started taking a poo. The carer, who had come in from the nursing home, shouted 'catch it' and the nurse managed to grab the stick of stool mid-air out if instinct. With her bare hands. Merry Christmas...

The tenth day of Christmas was more positive, with a patient telling me they had named the pulmonary embolism they had developed after surgery 'Jeremy Hunt' as it was a "potentially fatal clot" and a drag queen attended with mallet finger after getting their fingers stuck together while gluing on their eyelashes.

They eleventh day of Christmas was a day of detective work.  A child presented having eaten berries from the garden of an unknown origin, but the mum had bought in the leaves from the plant (if only I had a botany degree as well, but good ol' google has the answers as always if you look hard enough). There was also the interesting conundrum of a patient presenting in acute alcohol withdrawal which can be very dangerous and even fatal unless the patient continues drinking, but with the added problem that she had been given a bail condition that she couldn't drink any alcohol, due to an assault, and if she did she would go back to prison. 

The twelfth day of Christmas started well, with plenty of gifts to the department of tasty food from the local Jewish ambulance service (Hatzola) and Muslim communities (interestingly we had many more gifts from groups that were not Christian), but then was ruined when I mistook the medical consultant for a patient who had come in with solvent abuse induced hallucinations, and told her that she needed to pull her act together and that we were not going to give her the glue back that we had confiscated... I am going to have to keep my head down until the New Year!

Procedures and nights

Hi,

Sorry for the poor rate of posting - I have been very busy but that is always my excuse. I am now in a training post as an emergency medicine trainee. The hours are pretty rubbish, and I am working every weekend this month, but I love the job. I get to see a complete range of diseases and people every day and get to do a lot of different things.

I am on nights this weekend, but over the last week and this weekend I have seen people ranging from a 45 year old woman with vaginal bleeding 4 weeks following her last period (quickly diagnosed as her next period and discharged) to people in cardiac arrest and with severe burns and explosion injuries following bonfire night mishaps. 

I really like the procedural side of A&E, and the chance to get away from the constant push to see and discharge people before they 'breach' the 4 hour wait and sit in a room for 20 minutes and do some suturing or put a joint or broken bone back in place. Yesterday night (or this morning more accurately) someone came in with eye pain for 3 days following angle grinding some metal without eye protection. I am not an expert with the equipment needed to examine eyes (called the slit lamp, and often seen at opticians) but I could see a small piece of metal just over the iris (similar to the picture below)

Metal piece in eye, picture taken from Opthobook.com

I have not taken things out of the eye before, but remember being taught how to back at medical school. The registrar on had also not done this procedure before and was caught up with a sick person which we couldn't get venous access on, and was trying to gain access with the ultrasound machine. I thought I would have a gentle try and if failed, would have to get the person to come back to see the specialist tomorrow. I bent the end of a needle and managed to use that to get the metal out of the eye. Very rewarding, but nerve-racking, poking the end of a long needle towards someone's eye and repeatedly telling them they have to hold very still!!

I also had a patient last night/this morning who had abdominal pain and a large mass at the lower part which felt like it could be the bladder. I have not had any ultrasound training but am always in awe of the more senior A&E doctors who can rock up with the ultrasound probe and diagnose heart failure, PE, pneumothorax and so on in seconds at the bedside. I thought I would have a go with the ultrasound (no radiation, nothing to loose) to see if I could see if this was the bladder.We normally have a special machine called the bladder scanner to measure for bladder volume but our department's one broke 6 weeks ago and is still apparently being repaired... Positioning the probe over the bottom of the abdomen I could see the large circular bladder, and using the measuring tools on the USS it was massive. We put in a catheter and 1 1/2 litres drained out. Although this is a very simple thing, it was very rewarding to be able to work out how to do something, make a diagnosis and be able to make a clinical difference to that patient.

I also managed to do a special nerve block to the femoral nerve for a lovely 90+ year old lady with a hip fracture last night/this morning as well! 

As you can see I have been doing loads with my shifts, and feel like I am learning lots of new useful skills. Sadly I have one of my professional exams coming up and having sunk over £300 into it I now need to spend much of my free time revising, as it is coming up next month! It seems there is no rest for the wicked.

Finally, I really hope that as junior doctors we do not need to strike, and the BMA and the government manage to re-enter negotiations, but given all of the poisonous rhetoric being put out but Jeremy Hunt, and the hatchet jobs appearing in news papers (most recently today in the Mail on Sunday) I think that it may well come to that. This is a huge shame, but a small price for us as a country and profession to pay for continuing the good work that the NHS can provide and preventing the destruction of the NHS and many doctor's lives.

Politics

Hi,

I haven't usually bought up politics on this blog, but that definitely doesn't mean I am not interested. The current government stance and rhetoric on the NHS and doctors contracts is very frustrating. I could go on about it for paragraphs as many (much more eloquent) people have done, but I will just recommend this blog by juniordoctorblog.wordpress.com which I feels summarises the governments response well, and critically analysis it (with referencing). I cannot thank the blog's creator enough for putting the time and effort into creating a much better thought out, and much more thoroughly researched piece than the current government.

God's balls

Hi,

Wow, it has been a long time since I last posted. This job is quite busy, but isn't busy enough to give me an excuse. I suppose I have just been distracted by other things going on in life.

I am on paediatric surgery at the moment, which is a big change to anything I have done before. I was pretty scared when I came into this rotation as I didn't have any paediatric experience previously, and it has taken me a little time to get my head around things. On surgery I am the only F2/SHO and there is usually a registrar and consultant on at the same time. As with most surgical specialities, they spend much of their time in theatre so I am left on the ward trying to work out what to do with my patients. Fortunately at the start of the rotation the general paeds team, who share the paediatric hospital with us, were very helpful. Sadly in the last month or so, due to politics which is well above my paygrade, they have been distancing themselves from my team so I have had to make do much of the time, but fortunately are still around in case one of my patients is genuinely ill. I am getting to spend some time in theatre as well, though, which is quite interesting, but I don't think surgery is the profession for me. The initial cutting is exciting but then all the searching around and stitching up layers is not!

The reason for coming to post today was an absurd situation I found myself in, and I felt I should share it. A 9 year old patient had come in yesterday with an acutely painful testicle. We were worried that this was testicular torsion - a surgical emergency which results from, surprisingly, your testicles getting in a twist. His mother was not keen on him having the surgery and it took about an hour and a half to persuade her that this was necessary. The surgery was performed overnight and found a torted hydatid - a little extra bit on the testicle which is the remains of the female reproductive organs (from when the boy was a foetus). This has no known function and is not important, and doesn't need surgery if it is diagnosed before the operation. The problem is, having a twisted testicle is an emergency and you don't want to faff about trying to work out which one it is with ultrasounds and the like if you are unsure - leaving the testicle twisted for too long will result in it dying permanently. In fact there is a surgical 'saying' - ""Testicular pain - don't engage brain"

The next day, the child was well and happy to go home, but the mum was not happy. I had been left to review this child, as the consultant and registrar had gone to theatre for a different case. The mum was upset that we had operated on the child and found nothing wrong, and upset that we had removed the dead hydatid of Morgagni which had been causing the pain. The reasons for this were that she knew that there was no problem with her child's testicle (hence why she was initially refusing the operation) because she was very religious, and she knew that God wouldn't want to harm her baby; she was upset that we had carried out the operation as she felt that God had been testing her faith and she had failed, showing she didn't trust in him to provide for her; and she was upset that we had removed the dead twisted tissue (why did God put it there if it has no use).

A picture found from the internet of an ultrasound of someone's testicle with the face of the Egyptian god of male virility in it

First, I was glad that the consultant was not around, as I would probably not hear the last of  him being compared to God in 'providing' for this woman. I wasn't too sure how to address her concerns though. I tried to explain that bad things did happen to kids (a point helped by being in the middle of a ward full of sick and disabled children); I tried to point out that perhaps the presence of the hospital was a way for God to provide for this woman in her time of need; and tried to convince her that we had no known function for this tissue, and its removal shouldn't affect her son in any way. She was not amused by my attempts at explaining things and kept trying to drag me into a theological argument. All of this was watched by the husband who was clearly on 'my' or the medical establishments side with regards to the need for the operation, but not keen on speaking up. I feel a lot of the passionate arguments the mum was giving were more for his benefit than mine. I am not a religious person by any means and was trying to keep things civil, but it took me an hour and a half to escape.

An hour and a half!

I was called back twice for questions about wound management by the nurses, which just turned out to be more theological arguments over why God wouldn't want to hurt this boy, and how he must have a special plan for the hydatid of Morgagni, if only we would wait and see. I felt that these recalls were likely due to the husband arguing things with the wife, so she would bring me back and argue them with me. Not ideal given we have about 20 other patients in the hospital at the moment to look after. The third time the nurses called me telling me she just had a couple more questions before she left, I asked them to tell her that I would happily come down if she promised not to talk about God anymore, and if she had any more questions of this nature then perhaps she should take them up with the hospital chaplaincy service. Unsurprisingly, she changed her mind and decided that she didn't need to speak to me any more. I will have to go back tomorrow and ask the nurse if they had to call the chaplain as an emergency to explain the reasoning behind an omnipresent, omnipotent, omniscient, benevolent God.

PornBomb

Hi,

Changing jobs today, and I am pleased to be moving on. As ChocolateAndCream said on the previous post, GP seems pretty love or hate, and I really don't think I liked it. This could be in part to the practice, which I felt abused its junior members and made us perform most of the work, having to stay late, but even without this I still don't think I would have really enjoyed it that much. The last day was hilarious, though. I had gone to hang out with the admin staff over my lunch break to say goodbye to everyone, and was helping one of the admin people open up letters to the GP. They get hundreds a day, as despite it being the 21st century email doesn't seem to have caught on (but fax has become quite popular).

One of these letters was suspiciously bulky, and addressed personally to one of our partners rather than just to 'GP'. Most are thin and typed, as they contain a few sheets of paper about a patient's hospital appointment, but this one was handwritten. I opened it cautiously, half considering that it may be full of anthrax, or some kind of bomb from a slighted patient. Inside I found an A4 sheet with both sides filled with scrawled handwriting, and about 100 pieces of pornography cut out from magazines and papers. The handwritten scrawl was difficult to understand, but seemed to say, in summary, that the patient was very happy with the care he had received from this one of our partners, and was enclosing a selection of 'presents' to thank him inside.

A strange goodbye to GP, it wasn't all bad, but I am going onto paediatrics now and am looking forward to the challenge! 

Open the floodgates

Hi,

I often see a lot of unusual presenting problems on GP, and having watched a couple of those Channel 5 programmes "GPs: Behind Closed Doors" I can certainly say that there doesn't seem to be much exaggeration...

On Friday I had a very strange day. The roof was leaking a strange yellow coloured fluid quite heavily for the morning, and I couldn't be moved to another room as there were no others available. We are part of a multi story complex, so I was worried it might be urine, but I definitely hope it wasn't! It certainly didn't have the smell at least. Either way, trying to explain the hodgepodge of buckets I had created on the floor to try and collect as much of the (large) quantity of water which whooshed down every 5-10 minutes, and all the paper towels I was (unsuccessfully) trying to use to dam the errant fluid from the patient's shoes. 

In this ridiculous situation I had to consult all morning until I got to move room (when one came free) in the afternoon. Among the other patients, I had a lady who was convinced that she had high blood pressure because every time she touched something after walking for a while at home she got a shock (feeling all the high pressure coming out of her body). It took all my persuasive powers to convince her that her new carpet (Sherlock Holmes right here!) and the phenomenon of static electricity was to blame. This consult was followed by a lady who was concerned as sometimes she woke up and her arm felt as though it was 'dead' and she was worried it would fall off. She had recently come to the UK from another country, so trying to explain that this was a normal phenomenon was complicated by trying to use a telephone translation service.

I was getting quite frustrated throughout the morning, mostly due to the roof leaking all over me and my patients rather than due to the patients coming in, and my final patient must have sensed this. After talking about their problems they asked me if I had ever considered Islam as a religion as I was a very good listener. I didn't really want to get into a religious discussion and tried to deflect the question, as I wanted to get off to lunch by this point. Stranger still, in the afternoon after dealing with another patient's issues (a ganglion of the wrist)  she handed be a leaflet on Christianity and asked me if I had accepted Jesus into my life. Perhaps it was the weather, or the time of year, but you couldn't have written a better script for an absurd day!

Either way, I only have a few more days of GP life left, and then I am onto my next placement. I am looking forward to a change in scenery and pace!

In other news I have been offered a training post in Emergency Medicine for the next years, which is very exciting. This is what I think I want to do with my career in the future, and I am looking forward to getting back to the exciting hospital medicine!!!

Pregnant but you don't know it

Hi,

Had a patient present a few weeks ago who reported she had not had a period this month. On questioning she was adamant she couldn't be pregnant as hadn't had sex recently, but agreed to do a pregnancy test for me. Unsurprisingly this test was positive. This left her in a difficult situation - she wanted to complete her education and her religion advised her against abortion, but she really didn't want to complete the pregnancy. After talking through the options I gave her referral details for the midwives and the abortion clinic, so she could choose which option she wanted to refer herself to after discussing with her family.

Today she came back, even more upset. She had decided that she didn't want to continue with the pregnancy and had attended the abortion clinic. As part of their work up they performed an ultrasound scan which revealed a 7 month old foetus (thank god for the scan!!)! This effectively took the choice as to what to do with the pregnancy away from the girl as this is far too old to consider abortion. We talked for a long time, and it turned out that she hadn't actually had periods for all this time, and had had unprotected sexual intercourse while on holiday in Europe at about the correct time. Eventually she came to terms with the situation.

3 main points from this:

1) This apparent virgin pregnancy was sadly not what it seemed

2) Some poor European man has a child he will never know about

3) Always examine the abdomen! If I had examined her I would have felt the baby!


As the streets might have said "You're pregnant but my gosh you don't know it" - and evidently neither did I! [Apologies for linking to terrible piece of music]

Heart block and the breakdown of marriage

Hi,

Another little hiatus to blogging as I was on holiday! Coming back, I want to share an explanation of the different types of heart block using the breakdown of a marriage as a metaphor. I heard this explanation recently and want to share it with you mainly because I found it funny! 

Science stuff - heart block is a problem with the electrical conduction of the heart, which delays (or blocks) the normal signals progression through the heart muscle. Depending on the degree of this blockage you get different appearances on ECG, which are 'graded' into different types of heart block. Simplistically, the greater the level of heart block the more dangerous it is. Heart block is measured by the relation between the 'P' wave of the ECG and the 'QRS' complex of the ECG - see image below

P wave comes before QRS complex as shown here

The metaphor is a marriage and the washing up leading to the breakdown of this marriage.

Normal heart:

A good marriage with a slightly lazy husband. In this he sadly needs to be reminded to do the washing up every day. The P wave shows the wife having to remind him to do the washing up, and the QRS is him doing the washing up. At the early states of marriage he is good and does it every time promptly when asked. See normal ECG below:

Nice short regular spaces between P and QRS. Not much nagging needed!

First degree heart block:

Now comes the start of the marital breakdown. First degree heart block has a regularly prolonged period of time between the P and QRS waves. Here the hubby is getting a bit more lazy - every time he is nagged to do the washing up he delays it before doing it, perhaps leaving it overnight until the morning before doing it. This is due to poor conductivity of the electrical impulse in the heart slowing things down.

Look at those big gaps between the P and QRS. Leaving it to soak all night is not a valid excuse!

Second degree heart block - Mobitz type I (also known as Wenckebach): 

As things start getting worse in the marriage the husband now sometimes misses doing the washing up all together! In this situation the ECG shows a prolongation of the interval between the P wave and QRS complex each beat until it gets so long there is no QRS complex following the P wave at all. After this missed beat, the interval becomes short again and the process repeats. This is the husband becoming lazier and lazier, leaving the washing up longer and longer until he just cannot be bothered to do it. This obviously leads to an argument and then he has to buck up and he gets on with doing it properly again, but then becomes lazier and lazier until he misses another washing up. See ECG below

See the interval between P wave and QRS complex getting bigger until the whole QRS is missed, then repeating

Second degree heart block - Mobitz type II:

Here the husband just misses doing the washing up every so often because he is out of the house (with friends, with a mistress, we will never know). Here the interval between P wave and QRS complex is kept the same (perhaps due to guilt) but there is a regularly absent QRS complex. ECG is below

Intermittently the P wave is not followed by a QRS wave as it should be

Third degree heart block (complete heart block):

Here there is no association between the P wave and QRS complex at all - P waves are happening and QRS complexes are happening but they are not linked. The wife has become fed up with the husband and has left him - they are both doing their own washing up independent of one another in different houses.

Here you can see regular QRS but no relation to the P wave - some P waves fall before, after, or on other parts of the ECG.

That's the stages of heart block explained as though through marital breakdown. I thought it was quite funny and helpful to help remembering which is which. I hope you find them helpful too!

Definitely not pregnant

Hi,

Had a flummoxed patient come in to see me today after she had been started on the progesterone only contraceptive pill (or mini-pill) three months ago. She had been asked to come back in to assess how she had been coming along with this medication and to prescribe her more. After talking about how things were going with the pill, I offered to prescribe her a years worth, so she didn't keep to have coming back

"Oh, don't worry about that doctor, I've got plenty"

Confused, I asked what she meant, as her three month period was almost up

"Oh, I have lots left thanks. They gave me all of the stock the pharmacy had - they even had to get me to come back later as there wasn't enough to give me. I have a whole bag of packets left"

I was confused as to what had happened, but on further probing it turned out that there had been confusion and the script which had been issued by us for 84 pills (3 lots of 28 = about 3 months) had been cashed in by the pharmacist for 84 packets.

~6.5 years worth of contraception.

Mammaries

Hi,

Awkward consultation today where a middle aged women wanted to have a breast reduction. This is something difficult to negotiate at the best of times, as it is all about finding where that line between health benefits and cosmetic lies, but it was made so much more difficult by the fact that when she wasn't referring to her breasts as 'the twins' she was referring to her 'mammoth mammaries'. Her pointed enunciation of the letter 'm' throughout  these words, and the serious note she was clearly trying to portray by using this clearly medical phrase made it difficult to complete the consultation with a straight face.

In the end we decided that it would be quicker and easier if her boyfriend paid for the surgery

The Great Cholesterol Con?

Hi,

Had a recurrent difficult consultation over the last few weeks - a lady had had routine blood tests done as part of her NHS health check which had shown a raised cholesterol. It is generally accepted (and pretty widely known) that high cholesterol levels lead to an increased risk of diseases such as heart attacks. This is based on a wide body of evidence from multiple studies and meta-studies backed up by government organisations such as NICE and mostly by the most important source of all - Wikipedia.

This lady had read a book called "The Great Cholesterol Con" which suggests that cholesterol is not linked to heart disease at all, and there is nothing to gain from lowering it at all. For this purpose she had started a "sausage diet" where she ate 1-2 sausages every meal, breakfast, lunch and dinner, along with the rest of her food. Predictably her cholesterol was crazy high. I tried to talk her through the evidence behind the ideas of lowering cholesterol, but I hadn't read the book so couldn't do this very effectively. I asked her to come back the next week so I could have some time to do some research. She was a little bit annoyed about this - she felt as a doctor I should know all this already, but agreed to return.

I read up on the arguments in the cholesterol book, which are based around inconsistencies in the Framingham Heart Study which suggested that as your cholesterol dropped, your risk of heart disease rose. It seemed as though this book was very selective in the data which it displayed to portray its arguments (well summed up by this review of a similar book) and ignored huge swathes of evidence which did indeed suggest high cholesterol levels (rather than just all cholesterol) are bad for you. You obviously need some cholesterol (and some salt, sugar, etc) but having too much can be a problem.

I collected up all of my research and information and bought it back to the next consultation with this lady. She was having none of it, and told me I had been taking backhanders from the statin producing pharmaceutical companies to peddle their wares. I tried to explain that as the patents on drugs such as Simvastatin had expired there would be no specific drugs company to try and pay me off, but the more I tried to disagree with her the more angry I made her. 

This was a loosing battle - I guess all we can do is display the evidence to the best of our ability and let people make decisions for their own health based on that. It was just upsetting that this wasn't a concious decision to damage her own health (like someone who smokes 40 a day, knowing full well it is bad for them) but a misinformed decision to try and help her own health, possibly guided by someone more interested in book sales than helping people. That said, she is coming back next week for another round of discussion, so wish me luck!

Mistakes

Hi,

Awkward moment with a patient on Friday. He had come in with a strange looking rash on his hands and face. It was strange looking and I wasn't too sure what it was, and told him it might be a non-specific viral rash and I wanted to get one of my seniors to look at it. He replied that he thought it was hand, foot and mouth disease after searching on the internet. I assured him that this was rare in adults, and went off to ask one of the GP partners to have a look. 

A cursory glance later, the GP told the patient that it was definitely hand, foot and mouth, a viral infection which will resolve itself, and isn't anything to worry about and left. The patient gave me a look of scorn and then followed the partner out of the door

I guess that makes us 1-1 Dr Google...

Nuclear war

Hi,

Today I saw a lady who had become obsessed with the fear that we might have a nuclear holocaust this year. What do you do with this situation? I tried to explain that it is unlikely, but I couldn't say that it certainly won't happen. What with all these problems in Ukraine and the Middle East, she told me that perhaps I should be more worried and left.

Perhaps she is right!

Fertility

Hi,

Really tough consultation today. A 44 year old lady had been coming to our practice for a few years trying to get pregnant. She had got a text asking her to make an appointment with a doctor about her recent blood test results, and came in to see me

Due to her age, she wasn't eligible for NHS assisted contraception during the last few years, and had been in and out of the surgery getting blood tests, trying to stop smoking and reduce her weight in order to improve her fertility. The blood results she had come in to hear about from me showed that she was going through the menopause and couldn't have children now. 

This was terrible news to break to her, as she really wanted a child. I think she had been in denial for some time, though, as she hadn't had a period in about 6 months. I spent over an hour talking with her while she alternated between crying and shouting at me - she felt that we had let her down and let her time run out. Being exposed to that raw emotion was scary, and I was aware that towards the end I had 5 people waiting to see me in the waiting room who could hear all the shouting and sobbing coming from the room. 

Being a GP can be emotionally draining, especially when you are questioning whether your team may be in the wrong...

CBBC skills

Hi,

On Friday one of my patients was a 3 year old kid who had come in with an ear infection. After having a chat with the parents and a playful examination of the kid I reassured them and went to send them home. The mum was really impressed - she told me that her child was usually really shy of the doctors and wouldn't let them examine hum at all.

For a moment, I was secretly smug. I am the child whisperer! She quickly deflated my bubble and explained that it was probably because I looked like one of the 'silly CBBC presenters' and wasn't scary like those 'other older strict doctors'...

Well, as long as the kid doesn't vomit on me, I will take it...

Dr google

Hi,

A patient came in today with calf pain he had had for a week after falling off of his bike. After a google to come up with the possible causes for this, he was adamant that he had acute compartment syndrome. This is a medical emergency where the trauma to the limb causes so much swelling it cuts off the blood supply, meaning the tissue becomes more damaged and inflamed due to to the lack of blood. A vicious circle. His leg looked completely normal.

It took me a very long time to try and convince him that Dr google was not in an ideal position to assess his leg, and if he did have acute compartment syndrome his leg would have destroyed itself by now. After 30 minutes of my time he left to try some paracetamol and rest.

Benign Paroxysmal Positional Vertigo

Hi, 

Had a rewarding experience today in GP world - a lady came in complaining of severe dizziness for the last month or so, and I managed to diagnose and treat the condition in about 10 minutes, leaving a very satisfied and surprised patient!

When patients complain of dizziness, it is important to find out what they mean by this - importantly separating out the symptoms of vertigo (feeling like the world is whirling around, like you have just stepped off of a fast merry-go-round)

Not all fun and games

She had these vertigo symptoms when looking up to do her mascara, and when turning over in bed. This is very suggestive of a disease called Benign Paroxysmal Positional Vertigo (BPPV) where there are little crystals in your ears which keep the fluid moving after you stop your head from turning, making it feel as though you are still moving/spinning.

A simple test for this is known as the Dix-Hallpike test, and simple involves having them sit on a couch looking at 45 degrees to one side, then rapidly lying them down - this makes them feel very dizzy and makes their eyes spin in circles (rotational nystagmus). A potential risk of this manoeuvre is you make the patient feel so poorly that they then vomit on you. fortunately this did not happen here!

Because this condition is due to the crystals in the inner ear, it can easily be cured by putting the patients head through a series of different positions (known as Eply manoeuvre). This basically shakes the crystals out of the inner ear and cures the problem.

This is exactly what I did - aided in part by good ol' Wikipedia on my phone by the bedside as I had never done these moves before. It worked wonderfully, these problems which had ruined this patients life for a month were gone after a few minutes of turning around and about. She was able to walk out of the practice cured and happy, very grateful for what I had done. It made my day, being able to cure someone with your bare hands (and the not-insignificant power of Wikipedia!) 

Time out

Hi, 


I know it has been a very long time since my last post - (months!) but I have been mulling over this GMC situation I mentioned in my last post. I have decided that instead of posting long detailed posts as I have been before I will just post a little story of bit of information that I have been thinking about without background, adding to the anonymous person-and-situation-changing that happens already. I don't want to stop writing things down...

That being said, finding time for writing things down is tough! When I last posted I had just finished my F1 and was starting a rotation in A&E as an F2. I now just completed the 4 month rotation in A&E and am working as a GP now for the next four months. 

A&E was amazing. The breadth of different conditions, learning different skills, and all the crazy reasons for people coming in was great. I looked forward to going into work each day, and perversely, while all the nights and weekends were a bit rubbish, having time off during the week was really nice. Lots of very sick people, exciting trauma situations, people with odd things in odd places and so on. I am now applying for A&E speciality training and have my interview soon. Hoping that this goes well!

Despite all of the 4 hour target pressure and the news about A&E being swamped (it is) I think I am finding my new rotation on GP more stressful. In A&E there is great banter with the other staff, always people to ask to help out, and the sense you are all in it together. In GP I am stuck in my own room, trying to see people every 15 minutes who usually have little wrong with them, but occasionally can be very complex. Trying to pick the complex ill patients from the rest is difficult without any investigations, and trying to manage time to see each patient in about 10 mins (leaving time to do paperwork, referrals, etc) is very difficult. The simple patients who have colds and want antibiotics should be able to be seen in 3-4 minutes, but usually take 10-20 due to all the arguing over the fact that they want drugs. They patient who is suicidal and depressed cannot be condensed down to 10 minutes, and makes everything run late. At least in A&E if you need to spend more time with a sick patient or difficult case you can, in GP it is a real struggle. As you get more experienced working as a GP I am sure this gets easier, but is still a crazy idea.

I think most of the difficulties with being a GP isn't around making complex diagnoses or performing complicated procedures (though there is a lot of scope for these), but it is mainly around communication with patients. I thought I was good at communicating - had dozens of lectures on it at medical school and 'practice' it plenty with friends/at the pub/all the time but this can be a real struggle! 

Either way - I am now applying for A&E, hoping that this crisis in UK hospitals gets better (some good comments on the problems places like this) and now on GP which is much less relaxing than I hoped!