Hot pool Horrors.

Whilst on holiday at Hanmer Springs I couldn’t help but notice the signage.

“Keep head above water!” “No diving or splashing!”

With a 3yo whos idea of not splashing involves a small tsunami each time he hits the water I wondered about the risk and history of these signs.

So what is everyone so worried about?

PAM (Primary amoebic meningitis.)

Caused by Naegleria fowleri a nasty little amoeba which lives in warm soil and can survive for long periods in inadequately chlorinated or filtered warm water. After being “forced” into peoples nasal passages it migrates to their brain and causes an almost always fatal meningitis. (1)

(Hanmer looking lovely below)

The first recorded New Zealand outbreak of amoebic meningitis was in 1968-1978 (8 cases) which lead to the implementation of standards to reduce the risk of infection. (2)

Now pools are classified as naturally occurring pools which are considered high risk and lower risk commercial pools which are required to meet a standard. These pools which usually have a constant flow of water, are filtered and chlorinated. Other important techniques to reduce the incidence of N. Fowleri in the water are foot washes and having no bare soil near the pools themselves. (3)

New Zealand has a large number of geothermal areas and many of these are considered high risk as they are pools which may be dug from the side of a river bank or in some cases out of the earth. (Eg: Welcome Flat hot pools below)

In recent times in 2010 there was another 2 cases in the central north island. (2) Which again lead to improvements in a number of bathing areas.

Quantifying risk is very difficult but some epidemiologists have had a go!

“French epidemiologists estimate that given 10 N. fowleri amoebae per litre of water and a likely inhalation or ingestion of 10 ml of water during swimming, the risk of human infection for a swimmer is 8.5 x 10-8!5” (2)

So clearly pretty low risk but as the diagnosis is often elusive. Eg: unwell male in his 50s with no fever just feeling terrible and no meningeal signs. (4) This often which leads to late treatment which is not very effective with only occasional case reports of survivors (5)

Treatment is usually with IV +/- intrathecal amphotericin  but most patients have had multiple other drugs including standard meningitis therapy (here: ceftriaxone) by the time a diagnosis of PAM is suggested. (2)

Thanks to good public health measures PAM has been reduced to only occasional case reports. It seems that an ounce of prevention really is worth a pound of cure.

Might try keep the lad from dive bombing the sulfur pools next time we are there.

Jump into swimming pool




1)The epidemiology of primary amoebic meningoencephalitis in the USA, 1962-2008.       Yoder et al.

2) A case of primary amoebic meningoencephalitis North Island New Zealand.

3) NZ Ministry of health PDF:

4) N Z Med J. 2004 Feb 20;117(1189):U783; author reply U783.
Primary amoebic meningoencephalitis presenting without fever.
Bond B. (GP discussion)

5)A rare case of survival from primary amebic meningoencephalitis Gautam et al

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?”


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.

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.



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



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.


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:

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. 🙂


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.


SMO Average  Age

Vocational Trainees /# SMO

Musculoskeletal Medicine


Medical Administration


Palliative Medicine



Occupational Medicine


Sexual Health Medicine



Rehabilitation Medicine



Paediatric Surgery



Pain Medicine


Cardiothoracic Surgery



Otolaryngology/Head & Neck Surgery



General Practice



Vascular Surgery



Family Planning and Reproductive Health








Obstetrics & Gynaecology






General Surgery



Orthopaedic Surgery



Internal Medicine



Oral & Maxillofacial Surgery



Public Health Medicine






Accident & Medical Practice/Urgent Care









Radiation Oncology



Rural Hospital Medicine



Plastics & Reconstructive Surgery



Diagnostic & Interventional Radiology



Intensive Care Medicine



Paediatrics (General Paediatric)






Sports Medicine


Clinical Genetics



Emergency Medicine




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