Herpes Zoster (Shingles)

A 60 year old man presentes to your GP clinic with a very painful right chest for the past 2 days. He has recently just finished a long course of prednisolone. On examination, you see a well demarcated vesicular rash on one side of his back and side. You suspect it might be shingles, but what are you going to do?

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January 17, 2013 · 1:01 pm

Paediatric Hip Pain

So you have a toddler/child/adolescent complaining of a sore hip and limping in your clinic? What are the different causes, how can you differentiate between them and what do you do from there? Watch on!

Online resources:

Acutely Swollen Joint Flow-chart

RCH guidelines for Acute Hip Pain

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January 14, 2013 · 11:37 am

Erectile Dysfunction

A 60 year old male comes into your practice asking about tests for prostate cancer. He has Type 2 DM and had a heart attack 3 years ago. You sense that there is something else he wants to talk about…..

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January 13, 2013 · 8:17 am

Finger dislocations and auto-irradiation

Doctors are trained to diagnose and treat conditions that patients come to them with. But what happens when the doctor themselves are unwell? Discussions with colleagues often reveal stories of self-prescription and treatment. Usually, this is limited to antibiotics and regular medication use. Recently, I was confronted with a self-treatment situation as a GP registrar in my 2-doctor country town.

Now where was that ureter?

Now where was that ureter?

However, the precedent for medical practitioners treating themselves is not a new one. In 1961, Leonid Rogozov performed surgery on himself as the only doctor on an isolated Russain Antarctic station. He recognised the symptoms of appendicitis and dutifully performed an auto-appendicectomy. Luckily he had the equivalent of surgical interns helping, a driver and meteorologist holding instruments and a mirror.

Alas, my story is not as hardcore.

"just some tape will do"

“just some tape will do”

It was the fourth round of Mid West football in country SA and I was lining up on the wing for the Wudinna United B grade team. Even though the two teams playing were bitter rivals, first quarter went by without incident. However, halfway through the second quarter, I went to punch the ball coming down into a pack of players. As my 2nd finger hit the Sherrin, there was a pop then numbness. Looking down at my right hand it was obvious that I had dislocated the proximal interphalangeal joint. Luckily, I was able to easily reduce the finger as soon as it happened. There was surprisingly little pain, perhaps the adrenaline was covering that? A trainer had seen me holding my fingers and came over. “What do you want to do doc?” And I thought they were the experts! I had seen enough jarred fingers in the city emergency departments to get something started. Some tape did the trick in buddy strapping to my middle finger and I grabbed a couple of ibuprofen. At half time one of the other trainers sidled over and looking at my two fingers strapped together said, “hope you’re not offended if I cancel my rectal exam this week mate.”

Still getting a touch while crippled...

Still getting a touch while crippled…

Better than the iPhone x-ray app

Better than the iPhone x-ray app

Back at the hospital, I took my own x-ray and interpreted the film. No big or intra-articular fractures….that I could see anyway. Perhaps just a slight little chip off the volar aspect of the base of the middle phalanx (left, happy for radiology comment!!). Certainly not enough to warrant anything to drastic as far as surgery went. So I decided that the management should be continued continued as RICE and NSAID-based analgesia. But it made me wonder, if in my post game haze, I had followed proper treatment of finger dislocations for this injury? Certainly I had seen cases in ED where you could always ask for a ortho/plastics opinion. But in the country this isn’t as easy. So what would have been the indications to get my x-rays and finger looked at properly. Next week, I will discuss the equipment and alcohol necessary to take out your own appendix*

Lead shield in place?

Lead shield in place?

Searching around, I found some quick points regarding proximal interphalangeal joint (PIPJ) dislocations:

  • Vast majority are dorsally dislocated
  • Caused by direct blow (usually a ball) to the tip of the finger (axial load)
  • Put in ring block if reducing in ED, but patient can try to self reduce easily as soon as it happens
  • Reduced by slight traction and pressing on the distal end of middle phalanx
  • Murtagh suggests holding onto the distal finger and asking the patient to lean backwards
  • Ortho/plastics referral may be required if
    • Lateral instability
    • Fractures involving base of middle phalanx
    • Extensor mechanism rupture – buttonhole or mallet finger deformity
  • If no worrying signs: buddy strap to adjacent finger for 3-6 weeks to avoid hyperextension

*Fortunately, prospective Antarctic doctors now have a prophylactic appendicectomy.

Ouchy

Ouchy, but not my finger. Same injury

References:

  1. Murtagh’s General Practice
  2. Roberts and Hedges, Clinical Procedures in Emergency Medicine

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Filed under #FOAMed, Emergency Medicine, General Practice, Radiology, Rural GP, xrays

Pityriasis Versicolour

A six minute overview of this common summer month derm presentation.

Online resources:

DermnetNZ: http://www.dermnetnz.org/

Mycology Online: http://www.mycology.adelaide.edu.au/

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January 12, 2013 · 12:12 pm

Choosing a baby name 101

It seems in the past few years that baby names have taken a left turn at the common sense intersection. Those of us working with children (teachers, doctors, nurses, childcare workers) would have certainly noticed this shift in name trends. Of course, popular culture has always influenced the choice of moniker for our offspring. Unfortunately (in my humble opinion), our pop culture now includes such institutions such as Glee, Big Brother and the like. Parents are now naming their children to reflect their (often misplaced) love for these TV shows and movies. In the past, this choice of strange names was limited to the rich and famous: Moon Unit, Pilot Inspektor, Fifi Trixibelle and Sage Moonblood, the list goes on. But the general populous is catching on. Just have a look at the names that are apparently growing in popularity:

Girls                  

  1. Isla
  2. Adalyn
  3. Giuliana
  4. Olive
  5. Kinsley (too close to ‘Kinsey’ for me)
  6. Evangeline
  7. Paisley
  8. Vivienne
  9. Maci
  10. Kinley

Boys

  1. Bentley
  2. Kellan
  3. Kingston
  4. Aarav (clearly just to be at the top of alpha lists)
  5. Ryker
  6. Beckett
  7. Colt
  8. Paxton (as in the star of Twister? Come on)
  9. Jax
  10. Lincoln

A UK study found that 1 in 5 parents experienced resultant disappointment and regret in the different name they chose and wished they had done more research. That or not to have been drunk when choosing.  As clinicians and educators we must also consider the inevitable future Axis 2 diagnosis(es) that the poor child is lumped with.

In light of these poor choices and the future psychiatric consequences, below is a handy reference tool that should help your steer clear of pitfalls in the name game. For our players in ED, you can keep this card and tick off each time you see an example during your shift. The doctor/nurse with the highest score ‘wins’. Enjoy!

Happy to see further examples of names….or additions for the flow chart in the comment section!

What's in a name?

What’s in a name?

References

1. Good or Bad, Baby Names Have Long-lasting Effects. Retrieved February 9, 2011, from Live Science.com: http://www.livescience.com/6569-good-bad-baby-names-long-lasting-effects.html

2. Flora, C. (2004, March 01). Hello, My Name is Unique. Retrieved February 9, 2011, from Psychology Today.

3. http://today.msnbc.msn.com/id/40461260/ns/today-today_celebrates_2010/t/glee-effect-baby-names-reflect-love-tv-movies/#.UOJPee3n00w

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Filed under #FOAMed, Emergency Medicine, General Practice, Humour

Butterflies in the stomach

Swallowed foreign objects in kids

I was called to see a poor young fella up at our country hospital the other week and the case got me thinking about the above topic. As we all know, kids are delightfully inquisitive and adventurous. Of course Freud provided us with the five psychosexual development stages. The oral stage is first and spans from birth to around 21 months of age. Unfortunately this stage coincides with the period in which children become increasingly mobile and can evade the watchful eyes of parents. It follows then that the risk of objects being swallowed also increases. (Interestingly, our ED collueges tend to see many adults stuck on the 2nd and 3rd psychosexual stages presenting with interesting radiological findings….)

However a large observational study in 1999, found that the mean age was 5.2 years (Cheng, Tam; 1999). Although many objects will pass through unobstructed, there are a few cases in which emergent care and/or watchful waiting must be undertaken. Like any medical problem a proper history, examination, investigation and treatment plan is required.

History

The primary objective is to glean what the foreign body is and when it was ingested. Sometimes this isn’t always obvious as the parent was not present at the time. An important strategy is to bring a replica of the object. Especially when dealing with lego, disc batteries or hair clip if possible. Any reports abdominal pain or blood in the stool is important. A history of developmental or intellectual delay can also be associated with major complications given a delay in presentation and vague symptomatology. This extends to adults with such disabilities and should always be considered in any case of abdominal pain in this population.

A list of commonly swallowed objects:

  • Buttons
  • Bones (chicken, fish)
  • Coins
  • Keys
  • Safety pins
  • Drawing pins
  • Lego
  • Glass
  • Soft drink lids
  • USB sticks

Special cases:

  • Large coins (ie 20 and 50 cent pieces)
  • Hair clips
  • Button/disc batteries
  • Magnets

Examination

The demeanour of the child may provide hints as to how far the object has progressed. A child with an oesophageal foreign object may be in distress, vomiting, drooling, and irritable or refusing oral intake. Those with objects in the stomach conversely, may be asymptomatic. However these presentations are not the rule and further investigations sought. Palpation of the abdomen can be normal, but signs of peritonism or localised tenderness point to perforation. Generally, examination will be unremarkable.

Investigation

Plain x-ray (XR) is indicated for any metallic foreign objects. The role of XR is to demonstrate that the foreign object has passed the oesophagus. In this case, the object will be below the diaphragm in the stomach. Mouth to anus imaging is usually required.

Nasty battery, luckily in the stomach (NB fluoro light reflection, not chest tube!)

Treatment

Disc batteries

The alkaline nature of these batteries (used in watches and hearing aides) can erode tissue when in contact with moist mucous membranes. If stuck in the oesophagus as seen on XR, these should be removed urgently or the child retrieved to a centre that can perform endoscopy. The tissue destruction can occur in a matter of hours. On the other hand, asymptomatic children with subdiaphragmatic batteries can be observed at home. The stool must be searched and a repeat XR performed after 3-4 days if it has not passed.

Coins & Hair clips

If the offending currency/clip reaches the stomach, there is usually no treatment or intervention required unless symptoms arise. If the agent is stuck in the proximal or middle oesophagus, then semi-urgent endoscopy is required. Although they lack the chemical effect of disc batteries, they can still cause pressure necrosis and perforate. Distal oesophageal objects can be observed with follow up XR. Check stool for passage.

Magnets

The most important question apart from those covered above are: what sort of magnet and how many were swallowed. Recently, there has been a growing trend of ingested strong magnets causing perforation, obstruction and even fistulae. Fatal attraction indeed. So magnets may need urgent surgical intervention even below the oesophagus.

Humorous stories

A young man that I went to college with had skolled a pint of beer at a pub night that had a dollar coin at the bottom. When he presented to ED that night, the coin was found to be subdiaphragmatic. Palpation over the stomach was performed asking “are we on the money here?” and the patient was sent home to ‘pass the buck.’

Not so shiny anymore…

I saw the poor young girl in ED in late 2011, above, who had on her birthday accidentally swallowed her shiny new hair clip and inadvertently got butterflies in her stomach. I didn’t follow up as to whether she was given a replacement.

Another comes from Dr. Scott, my affable GP supervisor had this gem on hand:

God speed, little pendant

Dear Doctor,
‘James’ was brought into A&E this afternoon after swallowing a St Christopher medallion.  We x-rayed him and confirmed that this had passed the diaphragm. We have reassured the parents that the medallion should pass with time and without complication.  We have, however, advised them to see you or represent here should St Christopher’s own travels be unduly delayed.
Sincerely,
A&E Consultant

Final pearls of wisdom:

  1. Find out what it was and when it was swallowed
  2. Foreign bodies in the stomach or intestine should pass in 99% of cases (with normal anatomy)
  3. Most complications involve foreign bodies in stuck in the oesophagus
  4. Plain x-ray can localise a metallic foreign body and stratify into oesophageal and subdiaphragmatic
  5. Caution with disc batteries!

References: 

Murtagh, J. (2008) John Murtagh’s general practice.  (4th Edition). Sydney: McGraw-Hill Australia.

Cameron P, et al. (2012) Textbook of paediatric emergency medicine. (2nd Edition). Sydney: Elsevier.

Cheng W, Tam PKH. Foreign body ingestion in children: experience with 1266 cases. J Pediatr Surg 1999;34:1472-6.

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Filed under #FOAMed, Emergency Medicine, General Practice, Humour, Radiology, Rural GP, xrays

Riding in harvesters with farmers

Cultivating primary prevention: the mechanised agricultural approach.

 

All aboard the combine harvester

Just the other day I was fortunate enough to visit one of our local grain farmers on their land. All over our corner of the Eyre Peninsula, hard working farmers are driving neat patterns in their combine harvesters (headers) collecting wheat, barley and other crops. Interestingly enough, our patient numbers have fallen steadily during this time. It seems that most of the community is too busy harvesting to be sick! Subsequently one afternoon, I only had two patients right after lunch. An early day! I’d spoken earlier in the year with a patient about visiting his farm and seeing what goes on around harvest time. After half hour driving east of town, I arrived to be greeted by a gargantuan green machine. There had been plenty of them parked in an empty lot next to the medical centre over the year, but when switched on and heading towards you, they are a different beast altogether!

ALL THE WHEAT!

chomp, chomp, chomp

Obviously things have changed a lot since the humble scythe, kyphosis and a headscarf. These days, the operator sits in air-conditioned comfort with a pre determined track and auto steering. The on board computers can tell the farmer the current yield of the crop and let him calculate (with SMS prices popping up continuously) how well they have done for each field. Looking out through the huge unobstructed windshield, you are able to see everything happening. From being plucked from the ground to being stored in the back of the header, a piece of grain has an amazing journey. When the comb at the front cuts the head of wheat, it is fed into the header by some conveyer belts. Inside, the stalk and the head are agitated so that the grain can fall below and be placed in the hopper for further use. The stalk and left over husks are then spat out the back into the field.

It got me thinking. Could we apply this same principle to primary health care and prevention? Watching the header bear down on me first and then seeing the wheat collected into the machine to get sorted gave me an idea. Often general practitioners, community nurses and health promoters have difficulty encouraging the public to connect and participate in health prevention strategies. One simple reason for this reluctance to attend may be that these approaches rely on self-directed changes. Eating less sugars/salt/saturated fats, exercising more, cutting out smoking and reducing alcohol. Stopping all the things that people can enjoy. But these are also all essential elements in reducing serious preventable health issues such as diabetes and CVS disease.

*duelling banjoes*

I propose this. Rather than relying on self-presentation, family members nagging or proactive health workers, we construct a transportable health prevention vehicle. “But Gerry!” I hear you exclaim, “such schemes exist already.” Ah yes they do (Harold et al), but never before like this. The Combine Health Harvester (CHH) will function in a similar way to the headers currently out in the fields surrounding our medical practice. Gathering then triaging the wheat from the chaff. The process by which the harvester can increase health officer access to patients with poor health lifestyles and then do something about it follows:

  1. Unsuspecting patients scooped off the street by scoop
  2. Channelled into the back of the harvester
  3. There, a BMI, blood glucose, blood pressure, and SNAP history taken, nicely.
  4. If enough risk factors exist, the patient will be kept inside the harvester for delivery to the local clinic.
  5. If the patient is healthy, they will be deposited back onto the street. Then left to continue their daily business with a healthy lifestyle pamphlet in hand.

How it works

Once dropped at the clinic, the patients assessed being at high risk can be tested further and referred to specialist care if needed. The technology and policy for the harvesting and patient education are already here. We just, in the words of the machine itself, need to combine them. Now just to pacify those civil libertarians….

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DISCLAIMER: This blog post is intended to be taken entirely as parody and humour. If it has not been, then perhaps you’d better go outside and get some sun. Our capture methods in Wudinna are currently much more crude than stated and will be refined in time. Thank you for your patients (sic).

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Filed under General Practice, Humour, Rural GP

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:

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Molluscum Contagiosum

Useful links:

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Filed under #FOAMed, General Practice, Rural GP

#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?

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Filed under Emergency Medicine, General Practice, Health Policy, Rural GP