Monday, May 19, 2008

SurgeXperiences Carnival 122

It’s been eye-opening to read submissions from all over the medical blogosphere this fortnight. This is the first blog carnival I have hosted, and I now appreciate the amount of effort that previous hosts have put into it.

A few weeks ago, a young man presented with a chicken bone lodged transversely in his distal rectum. After the ED registrar and consultant had spent over an hour trying to remove it, I thought it would be easiest to cut it in half. Dr Wes felt that he had a similar epiphany in MacGyver Moments in Medicine.

I’m not sure whether this qualifies as pornography or a fetish post, but Make Mine Trauma at IntraopOrate describes in Oh Say Can You See her secret fantasy of seeing her internal organs. Hey, anything that gets your rocks off, baby. ;-)

MB Herrera at Life, Money & Development describes in Natural Recipe for a Healthy Prostate some Level 6 evidence for relieving BPH. Personally, I think it is the result of too much masturbation... but you can't stop human nature, can you?

When I first read Øystein’s blog I thought: “This guy has too much time on his hands.” I quickly realised that he is not just a voyeur, but films operations for a living. His submission was "Filming surgery with camcorders". My tip - never let a sound recordist into your theatre, and if they do, insist that they remove that hairy dog from their microphone, unless you are happy for your patient to have their wound infected with bizarre and rare bacteria or fungi.

In a post reminiscent of poor Otto in Helen Palmer's "A Fish Out Of Water", TherapyDoc submitted "The End Stage" where she seems to have reached a zen moment with her fishy charge.

Bongi almost didn't make it in with Surgical Ego because he didn't flatter me enough, but I felt that I had to prove him wrong. Therefore I'm also listing his other submission No Wining about the trials and tribulations of being berated in a unit meeting. Don't worry, I once had the same experience (and criticism) after doing a trauma thoracotomy in ED. May I refer you to this article? It has helped me enormously.

Dr Deb writes about a man who apparently underwent hand surgery without any anaesthesia, placing himself into a trance only. Honestly, I didn’t find this very interesting. It left me feeling rather numb.

Suthacha_Xiang Mei writes about her first surgical rotation. It's always good to see some enthusiasm in our medical students, locally and globally.

Thanks everyone for a great range of submissions, and I wish you all the best in your blogging lives – and please keep reading my blog, too! Please keep reading SurgeXperiences and the next carnival will be hosted in a fortnight at The Sandman. Post submissions here.

Sunday, May 11, 2008

SurgeXperiences Carnival Submissions

As I am hosting the next SurgeXperiences Blog Carnival on May 25, I guess I better read some blog entries.

I have no rules - just go ahead and make your submission and then I'll read them. I'm not one to post everything that gets submitted - but don't take any omission as a personal rejection... It's most likely I just didn't get around to reading it!

Thursday, May 08, 2008

Storm Clouds Gather

Mrs Hodge walks in with her wheelie frame. She is not happy. Neither is her daughter.

"I'm sorry about the wait," I say as I usher them into the cramped, drab Outpatients cubicle. "As you can see, we have been very busy and are a bit behind".

"So you should be," she snaps. "I've been out there for an hour and a half. This is pathetic. You better fix me or I'm walking out of here now."

I already get the feeling that this will be a difficult consultation, as both women scowl at me.

"So could you tell me what the problem is, Mrs Hodge?"

"You tell me, you're the doctor!"

I scan the GP letter again.
Dear Dr Sheepish:

Thankyou for reviewing this 68 year old woman. Please assess, investigate and manage as appropriate.

Kind regards,

Dr GP.

Oh dear. I could think of quite a few reasons why the GP had no referring details - but the real reason was becoming quite obvious.

"Unfortunately the GP has not given me much information. I'm relying on you to give me some idea. What have you noticed that has been wrong recently?"

"I have stomach problems."

"What kind of stomach problems?" I enquire - now we are getting somewhere.

"It hurts sometimes. Some times I feel sick."

"How long has this been going on for?"

"A while."


"Well, are we talking a few days, a few months, years?"


"5, 10, 20? All your life?"

"At least 5 years." The scowl has not moved since the consultation started. I know things are going badly when I degenerate into closed questioning within the first 30 seconds.

"So less than 10?"

"That's what I said. At least 5." The patient is getting agitated. "Aren't you listening? I said 5 years. What kind of doctor are you?"

"OK, where do you feel this discomfort? Does it happen at any specific time? After meals? Does it last long? What do you do to make it better? Is it worse when you lie down? Do you ever vomit or feel like vomiting?" There is no way that open questioning will do any good here.

"Sometimes in my chest, sometimes in my tummy. Sometimes it happens with food. Sometimes I just get it. It goes away after a while. Usually I feel sick but I don't vomit."

The consultation is stalling, so I move the patient into the examination bay, and find some mild right upper quadrant tenderness, and some epigastric tenderness. My money is on gallstones, but there is also a small umbilical hernia.

"So when you get this discomfort, is it mainly in your chest or in your tummy? Can you point to where it is? Have you ever had pain in your shoulder?"

"Haven't we been here before?" Her daughter interjects, as the patient starts waving her hand around her torso. "What kind of question is that? Don't you listen? Why are you asking about her chest and shoulder? She said it was her stomach." I start wishing I hadn't invited her in.

"Firstly, I need to ask these questions because it could be a number of problems. Clearly your situation is not straightforward, and I'm trying to establish what the main issue is. What bothers you most: stomach pain, or nausea?"

It's the patient's turn to chime in. "I told you it was my stomach. What's wrong with you? I came here because of my stomach - 6 years of medicine and you think you're all high and mighty. Why ask me what the problem is? I don't have a medical degree. It's people like you that really disgust me." She all but spits on the floor.

"I'm here to try to work out what is going on. Obviously you don't approve of what I am doing, and we aren't making a great deal of progress with your symptoms." It has already taken 20 minutes of tense negotiation to get the information that I have. Like drawing blood from a stone. "I have other patients waiting, but at the moment I'm prepared to offer you an ultrasound and some antacid tablets to start with, and an ECG. I can see you in 2 weeks with the results or, if you don't wish to see me, you can make an appointment to see one of the other surgeons at the hospital."

"Hang on a minute." Storm clouds start gathering as I hear thunder in the background. "I didn't say anything about not wanting to see you. You're just trying to get rid of me. Go on, close my file, you sick bastard."

"Mrs Hodge, it's clear that this consultation is not working for either of us. I am still prepared to organise your tests and send a letter to your GP, but clearly you are too agitated to continue. If you wish to come back we can discuss the results in two weeks."

"You can take your tests and shove it up your arse. I'm leaving. Where do you get off treating me like a dog?" She and her daughter storm out of the cubicle. I can hear them loudly complaining outside as I pick up the telephone and let the Patient Liaison Officer know that she will be meeting some very upset people soon.