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!

 

Going back to school.

While most of the #FOAMed world descended on the Gold Coast for #SMACCgold I was off to school with Ms 5. Going back to school was an interesting experience and reinforced the models used for teaching. As training CC doctors are pretty similar to five-year olds (see: attention spans.) I think many of them are directly applicable to our departmental training/teaching.

school 1st day

The first thing that you notice when you enter the class is the structure. Both in terms of location and routine. The day starts with mat-time where the days activities are discussed. After this follows news when those with something interesting to say have a turn to do so. Then a short break and some physical activity to burn off some energy. The day continues in this structured manner, with group activities alternating with independent work and regular breaks.

If a child does something that is considered bad behaviour they are not immediately punished. Often the first comment is distraction or a reminder to think about their actions. If they persist they are  moved from any distractions around them. Behaviour is defined by good and bad choices/decisions. Children are responsible for their own decisions but it’s also made acknowledged that the actions of others can impact this.

Role modelling is used to allow the smooth transition of children into the class room. You often hear “If you are not sure what to do look to one of the older children and follow their example” This extends to the playground. Older children are empowered to problem solve on the playground and not involve teachers unless they feel it is required.

Sessions in the classroom are explained in simple terms. Children are explained why they are doing activities as well as the practicalities. If unsure they are encouraged to ask questions of the teacher or their peers.

albert_einstein

These concepts seem very simple and straightforward we sometimes struggle with them in hospital departments. How often do we hear  “do as I say not as I do…”   Whilst Shame based teaching is less common than previously, people are still singled out for attention without the context of the actions being taken into account. Another important factor is teaching they reasons for procedures or investigations rather than discussing the technique. This is even more important in heavily protocol driven areas.

After spending time in a class full of 5 year olds I will be going back to basics when it comes to departmental teaching.

Well done Crusaders!

Good to see the Crusaders medical team giving their player time to properly recover from concussion. Sadly some conversations about “rugby becoming soft” ect. Hopefully this culture can be changed. 

Keep your eyes peeled for the LITFL team current series on concussions and sports medicine.

See link: http://www.stuff.co.nz/sport/rugby/super-rugby/10020709/Kieran-Read-concussion-issues-not-cumulative

Refs:

http://lifeinthefastlane.com/pitch-side-management/

http://lifeinthefastlane.com/about-sports-concussion/

“Dad’s acting like a goldfish.”

55 year old man presents to ED in the presence of his son after becoming confused at the supermarket whilst doing his morning shopping.

No memory of why he was shopping, no memory of being in the supermarket or how he arrived there.

shopping trolley

Unable to remember drive to the hospital, unable to recall names of team.

repeated attempts to orientate to time and place. “whats going on bro?”

no other change in cognition. preservation of longer term memory.

denies drug use, no History of epilepsy, migraines, head injury.

 Normal neurological exam.

Throughout the time in the department the patient would catch the eye of staff who they knew before the episode wave and say “bro, whats going on?”

Bloods showed no abnormalities.

This constellation of symptoms is consistent with a diagnosis of:

 Pivot_Wave

 Transient global amnesia.

Diagnosis of exclusion.

Features:

Rapid lost of antegrade memory.

Repeated attempts to orientate themselves. often with a repetitive manner.

No change in level of consciousness.

lasting less than 24 hours.

Clinicians report perseveration as the predominant feature. Many can remember the specific mannerism of the TGA patients they have seen.

Rare condition: incidence in those over the age of 50 being: 20-30/100,000 per year

The cause of TGA is unknown but a number of hypotheses exist with migraines, epilepsy being initially linked but then more recently discounted. A vascular hypothesis is another disputed possible cause. With this number of possible causes being postulated it’s pretty clear we are unsure of the cause. This is likely due to TGA being a syndrome with multiple causes leading to hippocampal dysfunction.

The most comforting feature of TGA is that patients with “pure” TGA eg: only memory impairment which resolves they have a normal mortality and morbidity and a low chance of further events.

Follow-up:

Patient was admitted to the ward for observation, symptoms improved with return of normal memory within 8 hours at which time he stopped waving. No memory of events of the day.

 Ref: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600033/

http://www.uptodate.com/contents/transient-global-amnesia