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?

 

 

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/

The other side of the coin.

I was recently reading the post “Are you really a doctor” from Penny Wilson. This got me thinking about what its like to be on the other side. I’ll get onto my thoughts but first  a story which set the tone for my medical career.

During my 4th year of medical school (first clinical time) on my 2nd day on general medicine.
Post take ward round, desperately trying to keep up with the team as I wasn’t sure which room was which etc.
They were seeing a moderately confused woman in her 80s. The patient had been seen by a female registrar in ED then clerked by the female house surgeon and reviewed by the female registrar.
As I was still trying to find the notes (who hides these!) I was late and missed the consultant reviewing the history and as I nipped through the curtain the female consultant who held not one but two fellowships was examining the patient.
As soon as the patient locked eyes on me she let out a loud sigh and said “thank God! finally I get to see a doctor!” I tried in vain to push the patients attention back to the consultant but was unsuccessful. Each answer the consultant gave was painfully checked with me. Finally after what seems like a lifetime the consultant explained what we would be doing next. the patient replied “If that’s what the doctor thinks is best”

The team took it pretty well and I was the recipient of my fair share of jokes over the run. They had all heard it before but not as clearly as this time.

Very occasionally my gender leads to trouble. I am usually sent to see the trouble makers in ED (fair enough but they are more likely to take a swing at me) I was recently told by a medical protection society worker that a chaperone should be present when listening to female patients heart sounds. They didn’t appreciate “I can understand that when I forget my stethoscope”

Being a bloke leads to the reduction in the number of groping incidents but doesn’t completely stop them. Comments are pretty frequent. Whilst on geriatrics it was considered a pretty accurate assessment of patients frontal lobe status if they suggested my slippers might be welcome under their bed.

I remember hanging out on the labour ward for days trying to get involved with births as people were uncomfortable about a bloke being present. In general practice the split is clearer most women see a female GP for their “women’s issues” I have never had a patient present for a cervical smear (makes a mockery of Fears, Smears and Tears).

And finally I thought I Would finish with a little Margaret  Thatcher.

“If  you want something said, ask a man; if you want something done, ask a  woman.”

 

 

 

 

Offline resources for remote practice.

 A good friend and mentor who has a few grey hairs carries this with him everywhere.

This contains the distilled wisdom of many years of general practice.

Saw Prof Murtagh had a similar tome from his interview with Gerry over at rural flying doc.

 

Many pages have fold outs with articles or further information. This portable brain is regularly updated and every few years metamorphoses to a new book dropping some bulk before growing in size again.

He is considering trying an online resource for this next edition but “might be a bit long in the tooth for that”

Anyone else seen a tome of reference or have their own?

A wee ditty for those at #USANZ

Was told this rhyme by an elderly patient today. He learnt it as a boy. This ones for the urologists.

 

“When a man grows old and his balls turn cold,

and the end of his prick turns blue,

and the hole in the middle refuses to piddle,

I’d say he’s stuffed wouldn’t you?”