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. 🙂


#FOAMed Question of the day: 1 #FOAMedQOTD

Which classic new years injury is shown?


GP CME South 2013 #GPCMEsouth

This week I shot down to Dunedin for the NZ medical associations CME conference.


It was a great event and had a huge variety of talks and informal Q+A sessions.

See programme here:

It was a little lonely on the twittersphere (#GPCMEsouth) but the teams from Canterbury health laboratories and New Zealand Doctor magazine keep me company.

The social media talks were well attended and in the plenary sessions others spoke about the need for doctors to have more information in the public realm. I did have the slight embarrassment of being called out at the #SoMe talk as a “serious tweep” and “blogger” (Thanks Barbara!)

Our wee kiwi GP conference managed to generate 224,403 Impressions! which was quite cool and It was really nice to get lots of messages from those who enjoyed the info flowing onto their timelines. Symplur here

Many of the presenters have been kind enough to let me write about their talks and include a few pearls in a longer format than 140 characters.

So over the next few weeks I should have a few interesting talks to cover and hope to share a few learning points and help solidify my thoughts as well.

The Unofficial Bone Shop House Surgeons Survival Guide

During my time in Christchurch I worked in the bone shop,

There was a book/PDF that was distributed which helped many of us early on and serves as a great refresher.  In the interests of #FOAMed I thought I should share a couple of links.

Before doing this I checked with Chris Cresswell ( @emtutor ) who wrote the original! which has since been edited. Its full of practical advice and worth a read. The word doc is good to have on your smart device of choice. As with all of these sorta things, doesn’t replace your local advice/protocols, If it seems odd check something else!

I decided I should put the first page up so you can get the flavour and practical nature of it.

viva la #FOAMed

  • The Unofficial Bone Shop House Surgeons Survival Guide
  • Welcome to The Bone Shop
  • Don’t try and read the whole of this guide.  Read the introductory paragraphs, then before you see each patient look at the X-rays, read any previous notes, referral, consultant film reading, look the injury up in this guide, talk to the nurse, look up McCrae and decide what you’re going to do before the patient comes in.
  • Everyone expects you to know nothing.  The nurses know everything and will give you lots of help.
  •  For the first few weeks you will feel you are superfluous and are slowing things down.


  • It’s not your fault the waiting room is full: the head of department acknowledges there is a staff shortage and inadequate orientation.
  • What is acceptable angulation/displacement? A lot of the time we don’t know.  If you can get anyone to define “acceptable” for various injuries please add it to this guideline


  • Consider non accidental injuries.  Have a low threshold for discussing with paeds reg.
  • Consider bone strengthening medication for post menopausal women and men over 65 with #s.  We can prescribe calcium (eg calcium carbonate 1.5g bd) and vitamin D (eg calciferol 1.25mg daily for 7 days then once a month).  They need to see their GP to obtain bisphosphonates (eg alendronate).
  • Analgesia/sedation:Bier’s blocks may be performed by an anaesthetic SHO (or above) and are available in “working hours” (d/w duty anaesthetist), or you can do them yourselves provided there are 2 of you – one to do block and manage the cuff – and the other to do the manipulation.  You need to have attended a teaching session on Bier’s block by Anaesthetists prior to being able to perform the blocks yourselves.We do not currently use ketamine/propofol/etomidate in Bone Shop.


  • One alternative is using haematoma blocks (including selected ankles that need manipulating), regional nerve blocks, IV fentanyl eg 100µg, IV midazolam eg 1mg (or 0.5mg in the elderly) and Entonox.
  • For kids consider using 2µg/kg intranasal fentanyl as analgesia.
  • Consider using the 70% nitrous mixer from ED if you’ve been trained to use it. Remember to turn it off.



Text copy on EM tutorials:

Dropbox for word download.





Thoughts on Poker and Medicine

While listening to Simon Carley on risk at #SMACC2013 I had one of those thoughts.

[blackbirdpie id=”311607279076130816″]

First I hope any serious poker players can forgive my over simplifications of a wonderful game. I also hope everyone can forgive my extreme stretching of this metaphor.


So why is medicine like a poker game?
It’s about prediction and probabilities, sometimes we are accurate and can be quite sure of ourselves but sometimes we get caught out by a surprise card or unlikely diagnosis.

In emergency medicine we often concern ourselves with the dangerous diagnoses, most poker players consider these options and likelihood their opponent will draw them. If you have played against a person/disease many times you can be more confident that you will be able to  judge their strength or recognise their tells.

In both luck plays a role that both doctors and card players are uncomfortable with. Everyone will have a “bad beat” where you are confident that you have the correct response or reaction but something unlikely/rare happens and you lose. This leads to both groups having superstitions and sayings which are similar.

“You play the man not his cards” sounds a lot like “It matters more which patient has the disease than which disease the patient has”

Like poker, medicine can be played at a number of stakes. Is it a life and death situation or just trying to rid someone of a minor irritation.

Texas Holdem

Medicine is most like Texas holdem (heads up).
I’ll explain why with an explanation of how it’s played and the similarities.

Heads up poker is played against one other person. You have your own cards and there are a number of communal cards which you make your best hand from. In this way a poker hand reflects a medical consultation information is slowly revealed and you attempt to gauge your position and certainty.

The rounds are as follows:

Pocket cards:

File:Pair of Aces.jpg

Firstly you are given two cards, an initial impression. You know from a glance if this patient is sick or not. Your system 1 is firing on all cylinders. You may get an instant diagnosis from the end of the bed, ?pocket Aces.

But you also know when you don’t have an idea. You know it will be hard or perhaps you just don’t want to play this hand.

Everyone makes their bets, some times this is easy. The patient is dry start some fluids, pain relief/Raise. Other times you don’t want to initiate much treatment until you have more information/Check.
In medicine you can’t really fold. unless you take the next chart (don’t be this person).

 The flop:

Three cards are turned over. This equates well with the history, it’s where the money is. Based on what you know about the patient and you impression most times you can have a very good idea about how you are placed. But there is some difficulty. Many diseases are difficult to tease out, are you being bluffed by your opponent. Previous experience with the opponent/disease can help you here. Are they likely to play passively or do they often show their strength?

The Turn:

This is the physical exam. (might be giving too much credit here)

This adds to what has come before. The reaction to this, tells/focal signs often increase your confidence in your diagnosis. But again it can leave you feeling unsure. But often it makes minimal difference, your impression can remain unchanged based on presence or absence of some signs. This is also often when you take a little time to think of any other possibilities you may have forgotten, a few extra questions whilst examining.

 The River:

 The investigations. Everything is back, all the information you are going to get is there.

This confirms or refutes your previous thoughts. You often know where you stand are you “the nuts” ?

But everything can change and swing based on one investigation/the final card. Is the bloody D-dimer positive? 

Then the final rounds of betting, are you all in for one diagnosis or are you still unsure of yourself? Often you know your badly placed (Pt is sick) but you can’t be certain of why.

 Finally the hands are revealed; in medicine like in poker you may never find out if you were right. Your opponent may never reveal their cards.

The best you can hope for is to learn from your mistakes, minimise your losses and be ready to play again.

But remember, in the end the house always wins.