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!