Archive for September, 2008

8.5meters of differential diagnosis.

Posted on September 26, 2008. Filed under: Journal from behind the desk... |

I saw a patient this week (well actually I saw lots of them, but this one in particular caused me more irritation than a fat woman’s thong on a perianal abscess) and I had a student in with me, so consequently I was running late.

This particular patient came in for a prescription for their eczema, no real problem – under control with emollient, ran out of emollient…a real no brainer.  Done and dusted….but on leaving the room she said something along the lines of:

“Last time we saw you, you told me I had indigestion, I thought you should know it turned out to be ovarian cancer, but it’s OK I’ve had it treated”.

She left the room and left me stunned…

So I obviously have a rummage through the notes. It turns out that six months ago I saw her with some chest pains, increased burping, worse on laying down, and felt like food was sticking. No weight loss… 

“Hmmm”, me thinks, “Sounds like indigestion symptoms. What happened next???”

I prescribed some Omeprazole, gave dietary advice and said to return and see me if there were any problems or if it wasn’t resolving.

Then what???

TWO MONTHS LATER….she returns to see her Doctor with a small suprapubic abdominal mass, which turns out to be ovarian cancer.

So presumably in the 2 months the Omeprazole had resolved her indigestion symptoms, and yet she has it in her head that thess two events were interlinked.  Did she have cancer when she came to see me?…well probably yes, but I’m pretty damn sure she had indigestion and this was nothing to do with the cancer. 

So in my 10 minute appointments I’m supposed to ignore the obvious symptoms and management and look for the asymptomatic and not at all obvious problems.

I felt like running through the car park and grabbing here back in,

to say something like…

“The indigestion was just indigestion, could you go and tell anyone that you’ve told I misdiagnosed your cancer, that in fact it was a coincidental illness please?”

or

“There was 7meters of small intestine, and 1.5 meters of large intestine between my correct diagnosis and your other diagnosis. Not to mention that presumably my prescription resolved the problem you presented with, as you didn’t return to the surgery as advised to if the tablets didn’t help!”

OK so I shouldn’t be too harsh. The poor woman has cancer. BUT PLEASE be realistic I can’t give full body MRI scans to everyone with everyday problems incase there is also a nasty tumour growing somewhere.

Robotic Polo’s take revenge on humans for the years of eating their non- robotic children.

OK I feel better now…

I think I deserve a holiday…so check out the blog roll for a read next week, and I’ll come back all refreshed.

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OK it’s my own fault…

Posted on September 18, 2008. Filed under: Uncategorized |

I should know better but last week I said it was “Quiet”.

I’ve worked in health care long enough to know that this means there will be an impending disaster.  In the Emergency Department, staff would be disciplined for even using the Q word. The use of this word or similar normally meant that the “hot phone” was about to ring, (and no it wasn’t “The banker”)

If a butterfly flaps it’s wings in China the repercussion will be a tornado somewhere else in the world. (Trust me Emergency nurses know all about Chaos theory…)

Whereas if a Nurse says the Q word in hospital the subsequent repercussions will include a multi-car pile up and 5 cardiac arrests before the next shift starts.

So yes…I should know better, I’ve even discussed the topic before in P=Q-D/C/BM (and you thought chaos theory was confusing).

Anyhow the short and curlies of it are this…it’s been busy, I’ve got myself paperwork and chores and precious little time to do much else….alas here endeth the blog for this week….but if you want a giggle and some education I particularly liked this post from Rob this week…so if you are quie…..not too busy, have a read…

or nose through the archives…how about “Do no Harm!”

Enjoy…

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Un-nervingly quiet….

Posted on September 10, 2008. Filed under: Journal from behind the desk... |

It freaks me out when this happens….

Empty appointment slots…Not just one or two, but 10’s and 20’s.

Just the tumbleweed blowing through the surgery.

Thankfully it isn’t just me, my colleagues are also peaceful. (Otherwise I’d get a little paranoid and think the rumours were out about me writing sarcastic comments about my patients on the internet!!)

I don’t get bored. There is always things I can read, write or just fiddle with to entertain me (don’t be smutty)… but I do get anxious.

Anxious that there is always a calm before the storm.  So I take the opportunity to tidy, stock and generally be ready for the impending disaster about to hit the surgery. The next big outbreak.

When I used to work the Emergency department, on the odd opportunity it was a little empty…

…we used to play cricket with a leg splint for a bat, and a rubber glove stuffed with paper towels for a ball!  Or we’d be particularly evil and prepare the department for the early shift with a fake busy department. Mr T. D. Bear in cubicle one with nebuliser running, Resus Doll in two with the buzzer ringing etcetera. So as the early staff came in, one of the night staff would sprint passed with the defib.   Oooh, how you could see their fresh little faces crumble, their already battered morale take that final plunge.  But we did it with love and affection.

Oh how terrible for you…bye…

The incoming early staff were always easy targets for night staff pranks.  My personal favourite was to put diluted orange juice in urine pot, then let them watch as I did a pregnancy test, say “no she’s not pregnant, but I think she has diabetes” sniff the bottle and then take a big swig out of it, before saying “Hmmm, yep Diabetic”.  Ohh, how the used to gag on their freshly digested cornflakes.

I digress…As I have mentioned in the past I work in an area where tourism is big business. I think it is a little on the quiet side as most of the tourists have gone home, and the people who have spent the summer working their butts off to entertain and accomodate the tourists have themselves gone on holiday.  The few holiday makers that come in confirm this, as they are owners of Bed and Breakfast’s in other tourism areas and have come here to have a holiday themselves!  So I think we have just swapped our tourism staff, for Bogner Regis tourism staff.

But don’t panic…doom and gloom is just around the corner. It always is…

So I’m off to stock up the blue lidded sample bottle with those cute little plastic spades for the next bout of diarrhoea and vomiting. Clean my stethescope and stock up on tongue depressors for the next bout of colds…(“No! It’s the flu!!”).  Get some new reward stickers for the next chicken pox outbreak and stock up on K-Y jelly for…..well, hopefully someone else to use!!

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Stay black!

Posted on September 3, 2008. Filed under: Apply topically, Journal from behind the desk... |

Following on from my rather random post about traffic signs last week, this week I’m going to be ranting about traffic lights, this is slightly more related to my work than last week – I promise!

I feel a little bit rotten picking on this subject having been on both sides of it now, but it just winds me up and thus I shall get it off my chesticles.

On fairly regular occasions the (not so) local hospital has what we used to call a “Bed crisis!”  This is not as the name suggests a bed having a nervous breakdown… but in fact a hospital admissions crisis.  In the most biblical sense there is “no room at the in- patients”.

From my Accident and Emergency (A&E) days this meant we would have a patient in the department for 48 hrs +, as there was no-where else for them to go.  The whole reason I worked in A&E was so that I wouldn’t have to do “drug rounds”, and yet bed crisis meant I had to, as well as cope with all the usual A&E goings on. 

There were days when we had the “Plaster room” and corridors full of patients and yet still more patients arriving. This was a time before “Admissions Units”, so every emergency patient admitted whether from a GP surgery or self referred came via A&E.  Very occasionally we’d shut the hospital to new admissions, meaning that patients had to go to the neighbouring hospitals, which were themselves bordering on having a crisis.

But now I am out of all that, and the hospital (not the same one I used to haunt) has a traffic light system which reflects it bed status.  This is what gets on my dematones!

It used to be that:

Green” meant “Find a bed you like, it’s your’s! Would you like a nurse to help you with the crossword sir!”

Amber” meant “it’s a little cosy, the staff will do there best to attend to you”,

Red” meant “you get a nice view of the car park from the corridor and once a day the cleaner will say “hello””. 

But this wasn’t good enough, so they introduced “BLACK“.  So red is inflammed and infected and Black is necrotic – the walls have gone to slough and the hospital is falling down around our ears!!!

So that kind of makes sense.  It does beg the question of “Why bother?”

What effect does this colour coding have on the hospital??

Is it so the hospital staff can come for a day at work, check the bed status, identify that it is red or black, and then go into the drug cupboard and medicate themselves to the appropriate level?  Hmmmm, I doubt it helps staff morale.

Is it so that the bods sitting in a board meeting have something to  demonstrate the extent of trouble the hospital is in, using simple colours that dumb ass chief executives will understand?  Well maybe.

Is it so the hospital can send messages to the primary care clinicians saying “we are on black alert…don’t admit anyone, and if you do it’s all your fault… we warned you!!!” Hmmm, yep I think so, and this is what gets on my nougats.

Do the hospital managers sit in their nice excutive offices on the umpteenth floor and look out across the county, thinking that the clinician in the various surgeries scattered all around the local countryside sit their telling their patients…..

“Hmmm, the hospitals Green today, well Ms Jones you’ve had that ingrown toe nail for a full 24hours, lets call an ambulance and get the surgeons to see you urgently”

Or….

“Well Mr Smith, it sounds like your Aorta is leaking into your abdomen, unfortunately the hospital is on black alert, so pop down to the staff room, I’ll get the cutlery out the drawer, cut you open and see if we can’t put a nice plaster on it for you”.   

Well…do they????

Quite frankly I, as with everyone else in the surgery, don’t want to admit patients, and we will do everything we can to keep them out of hospital. But whether the hospital is on indigo alert and ultra violet, if patients need admitting – they are going in…  I am not being accountable for my patients demise because the beds are full, and I’m not neglecting my patients needs, and no sweety, you can’t come home with me so I can monitor you…. (and no, I didn’t shut the community hospitals to fund a super-dooper centralised hospital with less beds).

Deep breathes dude….deep breathes!

And there endth my 80th post!!

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