Babies, bilirubin and bullshit?!

Time for a bit of a yarn.

During my Trainee Intern year a few years back I worked at the Sophia Kinderziekenhuis at Erasmus MC in Rotterdam. Whilst there I was told the tale of the invention of ultraviolet therapy for neonatal jaundice. There are a number of different versions but like many stories I like the one I was told first best.

Most midwives will tell you that for many generations people have placed young infants in the sunshine to help them lose their yellow tinge. But it wasn’t until the 1950 and more so the 1970’s that medicine started using phototherapy widely.

Phototherapy baby

The story I was told goes “One day a young paediatrician was walking his dog in the park. Being a beautiful sunny day (when presumably he wasn’t on call) He was enjoying letting his mind wander and the fresh air. Then splat! he stood right in a dog shit and slipped to the ground. Whilst lying on the ground likely in a less stellar mood than he had previously been he noticed something. The dog turd which he had fallen on had been there for sometime and the outer-layer had turned white. He wondered if this was due to the sunshine breaking down the bile and other compounds. This set in motion a further thought about the potential for other compounds to react with sunlight and be broken down perhaps even in the skin?”

white-dog-shit

Since being told this tale I have chased up the origins of UV phototherapy and sadly no excrement was involved in its discovery. A number of observations including the breakdown of bilirubin in test-tubes exposed to sunlight and improvements in infants treated with natural sunlight lead to Dr. Cremer making the first study and then after the Yanks followed up it was more widely used.

Its interesting the stories which you are told during your medical training and the ones that stick. Anyone got a good yarn they remember from their med school days?

 

 

Kicking it.

 Young bloke presents after footy practice last week. Kicking when had sudden pain in his right groin. Did what most do and ignored but still painful and has not improved with rest.

He had been reviewed by the team physio and given a diagnosis of a sprain and persisted playing through his pain.

O/E
Fit young man.
Tender on even passive motion at the hip. Power of hip flexion and knee extension both reduced due to pain.

Clinical suspicion leads you to order a pelvic X-ray.

HIP

 

HIP 2
The above films show an avulsion fracture of the Anterior inferior iliac spine. with minor separation.

 

Avulsion fractures of the pelvis.

Points to remember:

Pelvic avulsion fractures are seen in patients aged 14 to 25.

This fracture is due to forced hip flexion often eccentric breaking the physis.

Most common are Ischial tuberostiy approx 50% (sprinters/tennis players)

Anterior inferior iliac spine (15-20%) (kicking as above)

Anterior superior iliac spine (15-20%) (also sprinting)

Treatment is conservative unless significant (1.5cm+) seperation has occured. very important to slowly return to activity as re-injury is common.

I have a low threshold for imaging young atheletes with injuries sustained at times of maximum effort as these fractures are common and do follow a different course to a standard sprain. (slower and more painful generally)

A beautiful summary image of these fractures from learning radiology

IMG_0273-0.JPG

Refs: http://www.learningradiology.com/archives06/COW%20205-Ischial%20Avulsion%20Fx/avulseischiumcorrect.htm

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2465275/

An Awful case and pun.

A 70yo woman presents to ED with the following lesions which have been present for 2 weeks now and have steadily progressed from small raised areas into the large, painful areas seen below with moderate amounts of necrosis.

The patient had presented to ED a week earlier and was given a presumptive diagnosis despite the lack of obvious exposure. some antibiotics given for probable secondary infection at that time.

She has no history of major diseases of any kind other than well controlled hypertension (on metoprolol)

 No allergies.

photo_1

She is a keen gardener who has a pet dog. She has not visited any farms or abattoirs in the recent past.

 

photo_2   photo_5 photo_4

Further advice was sought from dermatology (email photos sent) which received the following reply:

“Hi
Thanks for these excellent photos of Orf, probably acquired via contact with a sheep, goat or other animal. Symptomatic management with a topical antiseptic such as Betadine dressings and analgesics is correct.”

Orf is a parapox virus which is passed amongst sheep, goats and a number of other animals (including red squirrels apparently)

It causes lesions like those shown but often much less impressive with papules which often burst releasing purulent (and infective) material.

Most people effected by orf are shearers, farmers and of concern to myself is children with pet lambs.

 kids feeding the lambs

Orf is something that presents reasonably frequently to GP land here in rural(ish) NZ. Many of the people most at risk for orf often treat themselves. Stories of shearers curetting their own lesions abound.

Follow up (2 weeks later)

As you can see most of the lesions have improved significantly with almost complete resolution of some of the later lesions which never ruptured.

photo_4 b photo_3 b photo_1 b

Final  follow-up 8-10 weeks post initial presentation:

I’ve since seen the patient at the supermarket and can confirm complete resolution without any scarring of all of the lesions. She now gardens with gloves on and thinks the only possible exposure was something her dog must have rolled in.

One of the best going cases of Orf I have seen. It can be much more aggressive in those with immunocompromised but as mentioned earlier the patient is very fit and well with no major health issues.

So there you have it one Orful case… *drops mic*

PS. Sorry I Haven’t posted in ages. Will do better in future. :)

References: 

http://lifeinthefastlane.com/what-is-orf/

NZ medical workforce data.

The latest NZ residents doctors association newsletter included some interesting statistics regarding the current medical workforce.

Of interest are the average age of the SMOs/Consultants/Attendings working in the various fields. The Muscloskeletal medical docs being the oldest of the bunch and NZ EM doctors coming out as the relative whippersnappers.

The table also includes the number of trainees to SMOs. This is affected by a number of factors. Many fields simply do not have very many training positions within New Zealand. Others are very popular such as EM/Paeds and Urgent care and have capacity for larger numbers of trainees. This is often due to the service provision that trainees are able to provide to District health boards and private employers whilst completing their training.

Discipline

SMO Average  Age

Vocational Trainees /# SMO

Musculoskeletal Medicine

59.59

-

Medical Administration

57.50

-

Palliative Medicine

57.07

0.13

Occupational Medicine

54.67

-

Sexual Health Medicine

54.44

0.22

Rehabilitation Medicine

53.95

0.23

Paediatric Surgery

53.78

0.11

Pain Medicine

53.69

-

Cardiothoracic Surgery

53.32

0.32

Otolaryngology/Head & Neck Surgery

53.11

0.15

General Practice

52.96

0.23

Vascular Surgery

52.55

0.23

Family Planning and Reproductive Health

52.50

-

Neurosurgery

52.50

0.20

Dermatology

52.22

0.07

Obstetrics & Gynaecology

52.22

0.40

Psychiatry

52.08

0.26

General Surgery

51.57

0.03

Orthopaedic Surgery

51.05

0.23

Internal Medicine

51.00

0.46

Oral & Maxillofacial Surgery

51.00

0.26

Public Health Medicine

50.93

0.02

Pathology

50.88

0.18

Accident & Medical Practice/Urgent Care

50.81

0.98

Urology

50.73

0.17

Ophthalmology

50.64

0.17

Radiation Oncology

49.62

0.40

Rural Hospital Medicine

49.28

0.18

Plastics & Reconstructive Surgery

49.27

0.29

Diagnostic & Interventional Radiology

49.24

0.19

Intensive Care Medicine

49.16

0.22

Paediatrics (General Paediatric)

49.13

0.44

Anaesthesia

48.97

0.31

Sports Medicine

48.61

-

Clinical Genetics

45.33

0.17

Emergency Medicine

45.04

0.74

 

 Perhaps our SMOs could continue their careers a little longer like Leila Denmark who practiced until she was 104 years old!

 

Assault in hospital.

Sadly assaults both verbal and physical  are a common occurance in hospitals around the world. A recent survey in the NZMJ confirms the amazing prevelance. Nurses are more at risk than doctors as they spend more time in promixity to patients. With those working in psychiatry and in emergency departments being at the highest risk.

Despite these rates it seems to be an accepted part of the job that the odd patient will attempt to punch/hit/kick/spit on you or more commonly verbally abuse you for any number of reasons. In my experience it is very rare that a patient is prosecuted for their behaviour. Often colleagues are dissuaded from taking matters further even after being assaulted.

Perhaps a police liaison such as those being introduced at Blackburn hospital would make a change. Having the local constabulary visit the department and offering the patient the choice between settling down or visiting the cells has been almost universally effective in getting patients to comply with requested standards of behaviour.

The last word i will leave to Paul Quigley from Wellington Hospital ED:

“There are mentally ill patients, others are under the influence, and some people are just arseholes”

Refs:

NZMJ article http://journal.nzma.org.nz/journal/127-1394/6125/

Thoughts from mike ardargh http://www.stuff.co.nz/national/health/10074792/Hospital-staff-under-attack

Blackburn (WARNING Daily mail link) http://www.dailymail.co.uk/news/article-2591479/Hospital-A-amp-E-unit-gets-time-POLICE-station-patients-violent-abusive.html