Fourteen-twenty

I ask most clinicians the same question. 'Tell me about the last patient who taught you something'.  RH smiles a wry smile. Man hands on experience to man. He draws up a patient's notes, and together we read through the letters. The story emerges of a otherwise healthy middle-aged man who is fitted with a pacemaker. Every year thereafter we find a letter that reads; Pacemaker checked - normal operation The list continues for several years without excitement. Suddenly there is an aberration; frank, in black and white;  Out of hours service. Your patient has died The next letter is the pathologist's report.  Cause of death: tuberculous myocarditis I suck my teeth. 'So what do you think is the lesson here?' he asks. Turning the question around; an old trick. I smile a wry smile. 'Always be on the lookout for tuberculous myocarditis.' He says no, firmly but politely. He is right. The lesson is finer than that. We can no more be on the lookout for tuberculous...

 Men who roll their own cigarettes (and they are invariably men) sometimes develop a curious automatism of the hands, whereby they continually mime the action of rolling the paper. This may at first glance mimic a 'pill-rolling' tremor.

 'Was she comfortable, doctor?' I looked into his eyes. It had been a prolonged cardiac arrest. My wrists ached. I could still feel the crack of her ribs. We had got her back twice and she had gagged on the tube, choking and vomiting, before we finally called it after an hour. I looked into her husband's eyes, and I lied to his face.  'Yes, she was comfortable. She was asleep the whole time.' I felt sick. That's one of a hundred memories I don't want. 

 It is a truth universally acknowledged, but not often stated, that clinical judgement is insufficient to exclude subarachnoid haemorrhage with acceptable certainty. Why wax lyrical about the minutiae of the clinical assessment? Perhaps the neck was slightly stiff. Perhaps one pupil was slightly sluggish. What of it? Ultimately, when the patient came in complaining of a first episode of acute severe headache, we all knew that a CT was inevitable. And, to boot, since we were sufficiently suspicious of subarachnoid haemorrhage to perform a CT, and in the absence of a compelling alternative explanation, we would be negligent not to then follow-up the normal scan with a lumbar puncture after 12 hours to look for xanthochromia.  Is this intellectual bankruptcy? Wise heads on the post-take ward round will cluck knowingly. 'Ah, rushed in with a scan, did we?' How infuriating! The luxury of the normal CT scan report is enabling of maddening arrogance. The same is true of troponin. A 6...

It was a busy shift, fighting fires, physically and psychologically tiring. I was dealing with two unwell patients in A&E when a house officer from the surgical ward called. He was worried about Mr X’s blood pressure. The numbers didn’t sound too worrisome to me, at least not compared to the patients in front of me. ‘Give him some fluids,’ I said, ‘I’ll be there when I can’. I thought but didn’t say ‘Not for several hours mate’. I continued seeing the patients in A&E. He called again. I tried to buy time with more fluids. Even in hindsight, I don’t know if on the basis of the information available I made the right prioritisation. The crash bleep went off, rudely monopolising attention and trivialising all previously-prioritised thoughts. I raced to the surgical ward, to find an ashen-faced Mr X, in the throes of CPR, and an equally ashen-faced house officer. Pink froth was bubbling from Mr X’s mouth. Pulmonary oedema. He had had too much fluids. The blood gas came back. Lactate...

Our ward round was brought to a halt by a Portuguese patient who spoke no English. The interpreter would not be available until tomorrow, and we tried in vain to explain to him that he would need a coronary angiogram (a challenging mime). The consultant produced his smartphone and proudly declared that his translator app would save the day.  ' Do you have any pain? ' he asked the machine. ' Do you have any pain? ' it asked the patient, in flawless Portuguese.  ' You'll need a test called an angiogram ,' he told the machine.  ' You'll need a testicular angiogram ,' it told the patient, without so much as a blush. 

Clasp your hands together with fingers interlaced. Notice which thumb is on top. Now relax, and re-clasp your hands, but this time with the other thumb on top. Sit back and enjoy.

Some call it the photic sneeze. Others call it the ACHOO (Autosomal-dominant Compelling Helio-Ophthalmic Outburst) syndrome. We all know it - sometimes you look at a bright light and it makes you sneeze. Or maybe it doesn't happen to you, but you know someone who does get it. Well, apparently it could be down to a mutation on the long arm of chromosome 2, region 2, band 2, sub-band 3.  Quite a specific address.

The reported associations of vitamin D deficiency never cease to amaze. A study  published in 2013 examined possible indicators of deficiency in the characters of the The Hobbit, and concluded that 'the triumph of good over evil may be assisted to some extent by the poor diet and lack of sunlight experienced by the evil characters.' A sound bit of advice for anyone hoping to reach their eleventy-first birthday.

Many diseases that have names don't deserve them. And some that don't have names deserve them. Can you give it to them? Then do not be to eager to deal out diagnoses in judgement. For even the very wise cannot see all ends. [apologies to JRR Tolkien] I find it a useful and humbling exercise to think of diseases that don't currently 'exist' (in our awareness) but easily could. Here is a simple three-step process. 1. Think of a pathological process which is well-understood and operates across multiple organ systems. e.g. transient vascular occlusion resulting in symptoms from downstream ischaemia. Think claudication (leg), angina (heart), TIA (brain). 2. Think of an organ system in which this pathological process could operate but which is not currently recognised. e.g. thyroid gland. 3. Imagine what symptoms would result from the process in the organ. e.g. transient attacks of fatigue and depression. There are more things in heaven and earth, Horatio, Than are dreamt...