One Page Paeds – Dermatology

Way back in 2008, I was studying 3rd year medicine and decided that my study for final paediatric exams would be aided by one-page summaries. I wanted these to cover simple GP-type presentations and to cover the core of each topic. I have updated them and will continue to add and refine as management changes. In the meantime, please feel free to use for study or just a quick refresh as I still do as a GP registrar now! Comments welcome.

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Impetigo

Useful links:

• DermnetNZ
• PubMedHealth
• RCH fact sheet
• Murtagh’s patient info

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Molluscum Contagiosum

Useful links:

• DermnetNZ: http://dermnetnz.org/viral/molluscum-contagiosum.html
• PubMedHealth: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001829/
• RCH fact sheet: http://www.rch.org.au/kidsinfo/fact_sheets/Molluscum/
• Murtagh’s patient info:

#interncrisis

Scrubs Protest – Sat Oct 20th

Over the last few days you may have become tiresome of my tweets and re-tweets that contain a certain hashtag. ‘#interncrisis’ refers to the current shortage of jobs for newly qualified, first year doctors (i.e. that have just graduated). In Australia, these ‘interns’ shoulder a large responsibility in our public hospitals. They take bloods, write in notes, explain decisions with patients and compile discharge summaries (sometimes within a week of discharge!). Without them, our system fails. So why are we so interested in these P-plater doctors?

During intern allocations this year, it became apparent that close to 182 interns would have no hospital employment in 2013. This is not an unexpected or new issue. Since the mid-2000s, the number of medical student places has increased dramatically to address the shortage of doctors in the workforce. However, the downstream effect of this move wasn’t and still hasn’t been addressed. Even going back in 2009, NSW found that their hospitals were ‘buckling in tsunami of interns’.

Is there an #internsolution? 

So what then is the #internsolution you may ask? As many people already realise, there is a large imbalance in the doctor workforce. Rural communities and hospitals are often short staffed and rely on locums to fill vacant positions. For many years, governments have relied on this expensive option to plug these gaps. Often, this has meant an abuse of many international medical graduates (IMGs). But with the current oversupply of interns in our metropolitan hospitals and a need for medical services in the country, it should be a case of simple diffusion.

Already the Prevocational GP Placement Program (PGPPP) exists to enable interns and junior doctors gain experience in a general practice setting. Even for those not interested in a career in GP, it can provide all junior doctors a better understanding of how primary health care works. All of our patients have contact with GPs, so too should our junior doctors. A call for mandatory intern GP terms was made back in 2010, but has yet to be implemented.

PGPPP – GP Synergy banner

To many, it seems that PGPPP may be the answer to our intern crisis. It is therefore unfortunate that in a knee-jerk, myopic decision, the federal Health Minister has decided to pay for an extra 100 intern places by taking funding away from the PGPPP initiative. A single year stop gap measure that degrades for what many junior docs, a valuable entry point into general practice. A faceless spokesperson for Mrs Plibersek responded to Medical Observer, stating that the PGPPP has previously been undersubscribed. I find this hard to believe and will have to check with AGPT. In any case, a move to make intern GP placements mandatory would solve any under subscription issues! I would also be very wary of falling back on using private hospitals and corporations to accommodate interns. Yes they would be employed, but would the level of supervision and ongoing education meet the national curriculum framework?

For the states part, extra intern spots can be created in some of our larger regional centres. These communities have sufficiently sized hospitals so that interns cover the required ED, medical and surgical terms. In fact Broken Hill will host three interns in 2013 to help solve the crisis. Already in South Australia, the town of Mt Gambier currently hosts 6 interns and has done so for the past few years. SA has the ability to fund additional intern positions in towns like Whyalla, Port Augusta and Port Lincoln. There are plenty of other such towns in rural and remote Australia. Of course with any scheme such as this, adequate supervision and training is paramount.

So, what now?

Simple maths…

In the meantime we may well have to sit and watch the political hot potato been thrown between state and federal governments. In my view both need to come to the table. On one hand, the federal government is able to fund more PGPPP placements and help free up further hospital placements by also offering additional GP spots. Of course this will cost money, but manageable with a generous surplus handed down by Mr Swan. On the other, state governments can provide additional intern positions in some of our larger regional centres as seen in Broken Hill and Mt Gambier.

These changes need to happen now, before larger numbers of interns are without places. We are talking about 182 missing out in 2013, in 2014 it may be hundreds more. The next step will then be to increase training positions for the different specialities. As it stands, general practice is already oversubscribed with many taking multiple years to enter. If this second step is not addressed, we will be left with a generation of continuing medical officers without career progression staffing our already bursting hospital system. Our very own registrar crisis could be just around the corner.

The key to lowering health spending is in primary health care and it seems that creating more GP placements for junior docs and then increasing GP training spots will solve not one, but two problems.

What can you do to help?

• Like this page: http://www.facebook.com/MedicalStudentActionOnTraining
• Tweet your thoughts: #interncrisis, @Tanya_Plibersek and your local member
• Snail mail: federal and state Health Ministers and your local member
• Discuss: let your family, friends and patients know that this is a real problem and may only get worse if nothing is done.

Situs Inversus

A 50 year old lady presented to our tertiary hospital with abdominal pain of a non-specific origin. It was decided by the ED consultant to order an abdominal CT scan (otherwise known as a ‘grope-a-gram’). Although there was no obvious pathology detected to explain her symptoms, I was still showed the abdominal slices to look for an interesting finding:

“Who is the fairest of them all?”

I will post a short precis on this condition (and its classification) in a few hours leaving some for the Twitterverseto have a gander. I wonder how long it takes you to find it, I remember it being well over 30 seconds for me!! ===============================================================

So after my almost minute of searching through the above grey/white/black image for subtle fat stranding, flaps of aortic lining and pancreatic abscess, it hit me. “Oh s**t. The liver isn’t supposed to be on that side.” My heart sank when a medical student came up and said straight away “this CT looks weird” and without missing a beat exclaimed “everything’s on the wrong side.” A few terms of colorectal surgery and general medicine had me looking for minutia. I’d failed to see the forest for the trees, or leaves even! The more thoracic slices were easier to pick:

Put your hand on your heart….other side please

What we had was a case of situs inversus. This condition can also be known as situs transversus, situs oppositus or situs organsaroundthewrongwayus*. Their internal organs are mirrored across the sagittal plane, or more simply: things usually on the right side of the body (liver, gall bladder, caecum) are found on the left and vice versa.

*Term made up by me, just now.

So what is the first thing you should think of when you see a CT like this? No the answer shouldn’t be situs inversus. Common things happen commonly. Mislabelling or image mirroring of the CT may be to blame. Then if you are confident this is not the case, time to delve into the rarefied air of such genetic abnormalities. Rare, yes. But the classification of position of internal organs is quite simple. It is not clearly essential knowledge, however very good for impressing cerebral physicians…

Total flips of the heart

• Situs solitus (‘normal’) – How most of us and the anatomy text books are put together/drawn

• Situs inversus with dextrocardia (situs inversus totalis) – Most common form of inversus which has a right sided heart, in keeping with the switch

• Situs inversus with levocardia (situs inversus incompletus) – A much more rare form of an already rare condition in which the heart remains on the left (normal) side of the thorax

• Situs ambiguous (heterotaxy syndrome) – Any combination of the above that does not fit a pattern of complete solitus or inversus. Calling it ‘incomplete’ situs inversus probably explains it better, but sounds too much like the latter.

Basically your insides are all topsy-turvey…

Situs inversus is thought to have a prevalence of 1 in 10,000 people. It is inherited in an autosomal recessive manner and is usally associated with other congenital heart defects (most commonly transposition of great vessels, TGV). Interestingly, although Leonardo Da Vinci was the first to describe dextrocardia, it was Matthew Baillie who described situs inversus and TGV. He was a Scottish physician who in 1793 wrote the best titled text I have come across: The Morbid Anatomy of Some of the Most Important Parts of the Human Body.

Interestingly 25% of patients with situs inversus have an underlying diseased called Primary Cilia Dyskinesia (PCD). Cilia are tasked with placing organs in their appropriate positions during embryogenesis and this is where things can go wrong. If patients have the triad of chronic sinusitis, bronchiectasis and situs inversus, then this is known as Kartaneger syndrome. Perhaps its worth conducting a thorough listen to the chest (or ECG) for those patients with recurrent sinusitis and mucousy coughing?! These conditions pose interesting anomalies, but what are the practical consequences for the patient sitting across from you?

• ECG interpretation: If you attach the leads (correctly!!) and see strange axis deviation, p-waves inversions and a decrease in QRS voltage across to V6, then there may be inversus. To confirm this, swap all of the leads across to the right chest, including limb leads. The lesson though, is always double check lead placement lest you end up diagnosing ‘technical dextrocardia’

RA lead goes on the left lower limb?

• 

  General surgery 101

  Pain/Tenderness: We are taught in surgical training to know that for pain or tenderness in the abdomen, think about the underlying structures to help differentiate causes. Clearly if things are mirrored it will change your thinking. LIF pain could be appendicitis, RIF pain could be sigmoid diverticulitis and LUQ pain could be gall bladder related. Bruising over the right flank might mean you are worried about a splenic rupture.

• Organ transplantation: The vast majority of organ donors will have anatomy orientated in the usual way. However if a patient with situs inversus needs a transplant, problems arise. Not only are arteries and veins in different positions, but the physical shape of the organs will not match up. In fact, an American patient with situs inversus underwent a heart transplant in 2007. The six-hour long operation was likened to solving a “three dimensional Rubix cube” (actually not sure what other dimensions Rubix cubes come in…but here is one solved in 30 seconds)

Thanks for reading and contributing. Clearly this is not a common presentation or finding, but hopefully if you happen across an interesting CT, CXR or ECG, you will have some background knowledge of these rare and fascinating disorders.

Bow-ties in medicine

“I have an opinion about men who wear bowties. They are mavericks; truly adventurous dressers who live on the sartorial edge. They are nonconformists and often seen as threatening to the establishment. Yes, look out for the man who sports a bowtie – he probably has an attitude.” – Chris Hogan, 2008.

Revenge of the Ner..Doctors

So I’ve been busying myself this year by watching online lectures as part of the Diploma of Child Health. This is run out of the Children’s Hospital at Westmead in the outer suburbs of Sydney. Throughout these lectures, I have noticed many of the doctors sporting natty bow-ties. During my time at Flinders Medical Centre and in GP land, I could probably count the number of docs setting this trend on one hand (free from polydactyly). But it seems every second professor or head of department on these web-based lectures are wearing them! What is going on? I propose this hypothesis: As one delves deeper and deeper into the sub-speciality crevasse, silent pressures force a required dress code. The most obvious and classic of these, the humble bow-tie. The graph below summarises my findings. Unfortunately elbow patches, jumpers tied across chests, pocket protectors, grubby white coats and mad scientist hair variables have not been investigated, but pose areas for future study.

Figure 1: Bowties verses subspecialty

Neurons or shooting stars?

Additionally, my off the cuff choice of neurologists at the pinnacle of this fashion statement seems to be rather accurate. In an article published in 2010, an American medical news outlet outlined neurologists penchant for wearing bow-ties. The American Academy of Neurology’s self-appointed spokesman on neckwear, John C. Kincaid, MD states that “Bowties suggest the wearer is ‘on the precise side,’ which describes many neurologists.” Yes it also describes the majority of people diagnosed with OCD. Perhaps suggesting a slight overlap in populations? The Academy is pretty serious about this caper, so much so that they even have an official bow-tie festooned with miniature neurons. But you are a renegade infectious diseases consultant, you want something slightly more relevant adorning your small piece of tied fabric. Well never fear. This website makes and sells bow-ties featuring microscopic lovelies such as: Anthrax, E.coli, Swine flu and Rhinovirus. Just don’t get any Syphilis on your neck….

E.coli (not to scale)

But this lighthearted choice of bow-tie material brings us to an important point in medicine. Infection control. Millions of healthcare dollars are spent around the world trying to reduce the number of hospital acquired diseases. Instead of regular neck ties dangling around in purulent exudate or hospital food (equally as nauseating) ready to be transfered to the next vicitim/patient, bow-ties remain high above strangling the neck of the treating physician. Neck ties have been shown to carry nasty bugs such as Staph aureus, Klebseilla and Pseudomonas as shown by a study of New York doctors in 2004. But obviously it depends on the specialty of the wearer, as you wont see much patient/doctor interaction from a radiologist. On a recent Twitter discussion it seems that along with neurologists, gynaecology and urology have higher proportions of bow-tie wearers. Whereas neurologists may be keen to avoid a long tie tickling a patients face during cranial nerve examination (albeit a nice quick way to check CNV sensation), our friends working below the umbilicus may well be avoiding ‘bits’ on their attire. (I chose the word ‘bits’ as the alternatives have been getting too much coverage in the media of recent days and I thought it rude of me to slipper them in.)

White is the colour of purity….

I can also see the benefit of bow-ties in paediatric populations as a way of breaking the ice. Whether the use of novelty ties that spin or flash lights would entertain the children as much as the wearer remains to be seen. Another avenue of research that may be followed. Until then, myself like many rural docs are happy with rolled up sleeves and the occasional boardshort/thongs combo. US readers should note the Australian use of the word ‘thong’ unless you have a confession KI Doc?