Monday, 18 April 2016

Consultant

I'm neither a primary doctor nor a general practitioner.  I don't pretend to be one, I don't want to be one, and I can't imagine being one.  To me, seeing the same people over and over again for the same problems over and over that may or may not be getting better over and over sounds worse than having hot pokers stuck in my eye over and over.  Thankfully people who enjoy that particular flavour of torture exist, and I respect the hell out of them for it.  I just couldn't do it - I think I'd rather sell used cars for a living.

As a result, I'm a consultant.  Very few people refer themselves to a surgeon, so the aforementioned torture victims I mean primary doctors do that for me.  If they find a breast lump during a routine visit, they refer her to me.  If they're having abdominal pain and an ultrasound shows gallstones, they are sent to me.  If a patient goes to the emergency room/A&E and has appendicitis, they call me.  The system mostly goes very smoothly, and the calls I get are mostly appropriate.

Mostly.

Every now and then, however, something slips through, mistakes happen, calls are made . . . something happens that makes me wonder how certain doctors had the mental capacity to graduate from primary school, let alone medical school.

Charlie (not his real name™) was a very nice 18-year-old kid who was sent to me by his primary doctor due to right groin pain.  He'd been having the pain for several days, localised to the right groin, and worse when he would bear down (read: poop).  It seemed a fairly straightforward presentation, and his doctor felt it was likely a hernia (though I'm quite certain he never examined him for reasons that will become crystal clear later), so he sent him for a CT scan which confirmed a small left inguinal hernia.

Those of you who are reading carefully have already discovered the problem.  What, you haven't found it yet?  Stay with me.  I'll get you there.

When Charlie came to see me, he was clearly in pain, clutching his right groin.  I looked over the radiologist's reading of the CT scan ("small left inguinal hernia) as Charlie said "It hurts over here, Doc", pointing to his right groin.

Right groin.  Left hernia.

I looked at the CT scan itself which definitely showed a left-sided hernia, and my Inner Pessimist started yelling at me.  "He's at the wrong doctor, stupid!"  Trying my best to ignore Inner Pessimist (though I suspected he was absolutely correct), I decided to do something silly: examine the patient.

Charlie pulled his pants down gingerly, taking care to avoid his scrotum.  I did the usual Turn Your Head And Cough routine, and while there was definitely a hernia on the left (which was tiny and completely painless), there definitely was not one on the right.  His right testicle, on the other hand, was exquisitely tender, mainly on the back side.

"I told you!" my Inner Pessimist started laughing.

"Are you sexually active?" I asked him.  He turned sheepishly to his father before muttering "yes" under his breath.  "More than one partner?" I continued.  The beet red colour he turned and the silence that ensued was exactly the affirmative I expected.

I explained to him that his pain was not due to a hernia on the opposite side (heh), but rather to epididymitis, an infection of the epididymis which stores sperm and sits just behind the testicle.  It's usually caused by chlamydia or gonorrhoea and is easily treated with a few doses of antibiotics.  A 2-minute exam (and asking the right questions, of course) is all it would have taken his primary doctor to save Charlie a CT scan and an unnecessary trip to a general surgeon, who has no business diagnosing an infectious urological infection anyway.  I sent Charlie back to his primary doctor to get the appropriate antibiotics.

If you think that's bad, it gets worse.

Two days later (while this little episode was still fresh in my mind but I hadn't yet had a chance to write it down for you fine people), I was called at 8 AM (at least it wasn't 2 AM) by one of the hospital's gynaecologists.  I get these calls with some frequency, usually due to a pregnant woman with suspected gallstones or appendicitis or some kind of surgical misadventure in the operating theatre where they need help.  Those can be very difficult cases to diagnose, and even more difficult to manage.

But not this time.  I wish it had been something that simple.  The conversation went a little something like this:

GYN: Hi, yeah, um, we have this lady here."
Me (under my breath): Well I hope you have a lady, because if you're seeing a man then something is askew in the universe.
GYN: What?  Oh, well she has a big labial abscess and is in diabetic ketoacidosis."
Me: . . .
GYN: . . .
Me: I'm waiting for the punchline.
GYN: What?

The woman was acutely and severely ill due to a raging infection in one of her Girl Parts.  In case you forgot, I don't do Girl Parts.  Fortunately for me there are specialists who manage these exact types of Girl Part Problems, namely gynaecologists.  Which she was.

Hence my confusion.

It sounded like an isolated gynaecological problem (apart from the diabetic ketoacidosis, which is a medical problem that I also don't treat), so I waited for her to tell me what exactly I could do to help.  She seemed entirely shocked that I expected her, a gynaecologist, to deal with a gynaecological problem.  She expected me to do . . . something.  However, being the conscientious bastard I am (and because I was already in the hospital seeing another patient), I went to see her to make sure they weren't missing anything.

And . . . they weren't.  It was an isolated abscess involving the entire left labia majora, but nothing else.  I went back and told the gynaecologist that this was a gynaecological problem and that she, a gynaecologist, should take care of it.  Right now.  Reluctantly, she agreed to do her job and took her to the operating theatre where she encountered and drained a large labial abscess (which everyone, including the janitor, I suspect) already knew about.

It shouldn't take a general surgeon to diagnose or manage these problems, just like my skills should not have been required to diagnose shingles.  And just like I shouldn't expect a nephrologist to remind me how to take out a gall bladder.  There are certain things that are easy to miss, difficult to diagnose, or complicated to treat, and I'm always happy to lend my expertise.

These two cases were none of those things.

46 comments:

  1. Left or right, neither of these poor saps was having a good time.

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  2. of course, if all doctors were smart, intelligent, observant, and competent, we wouldn't get these stories, would we?

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  3. Yummy...yummy...yellow pus when you drain them. Can you imagine the smell when draining the abscess on the labial wall? It makes you want to puke. Draining the wall actually involves cutting and taking out part of the walls tissue. Let the pus come out, instill N/S with syringe in the hole continuously, make sure all that pus are out, then suture them.

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    1. You can suture the inner wall.

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    2. No. Abscesses should never be sutured. NEVER.

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    3. You misunderstood me. The idea is to open the abscess, drain them' and stitch its walls to the surrounding skin so it stays open. I didn't mean closing them completely.

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    4. Hey Doc, could you explain why? Just curious.

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    5. Anon - I see. You're referring to marsupialisation, which is rarely necessary.

      SoWeird - Suturing an abscess closed re-establishes an ideal environment that was present for the original abscess and allowed it to flourish. They are left open, sometimes packed with gauze to ensure that it doesn't close up too early. This allows any residual infection to drain.

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    6. In my experience, most abscesses, especially Bartholin Gland abcesses or cysts do not smell bad. Most are sterile or culture normal skin flora. Anon read online how to do an I&D?

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    7. It depends on the type of bacteria that is causing the infection.

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    8. .....well there goes my appetite for the next month. Seriously i was thinking about going and getting some food then i read your comment.
      Guess that options now gone.
      Connor

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    9. @Amy; it sounds kind of like a Google Universiy medical directive to me.

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    10. @ Ken...I had the same thought. An abscess is a collection of pus that has accumulated *somewhere* in the body because *something* got infected *somehow.* Might be small, might be large. Might be just under the skin. Might be further inside, deep in the tissue. Might be resolved with simple I&D, might need something more. Can't know what's really required in a specific case without actually examining the patient. Google U. is no substitute for first-hand observation.

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    11. "not suturing" makes sense to me. Whenever one of my less intelligent cats gets an abscess (from being bitten), the vet cleans it out and sutures in place a piece of tubing that pokes out either end of the bite. That stays in for about a week, and it drains and drains and DRAINS.

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    12. yep, I've had cats with those, too.
      but cat abscesses ALWAYS stink. those critters are rotten, inside.

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    13. The only time you want stitches down there is if you have a tear or episiotomy while giving birth.

      Source: Has girl parts.

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    14. @Ken as rotten as their personalities. (Note: I have cats)
      Connor

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    15. Careful you two. I like cats and will ban you both like I did with JB.

      Not really. I do like cats though.

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    16. When I was a kid, bro brought home a kitten with an abscess. It was MY job to treat that and slowly, slowly coax it closed from the bottom up (they will heal over the top if you so much as turn your back, and then you have to start over). Took a good month. No one else would go NEAR the poor thing, which then lived to be about 16. At least he was a nice cat.

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    17. one of mine is currently on heart and thyroid medication. surprisingly, she is a lot less grumpy than she was when she was healthy.

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    18. Cat fan here too, Doc! :)

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  4. Reading this made my lady bits hurt lol! I truly enjoy your blog!

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  5. Your alternate headline should be, Lazy doctor stories or why the heck did you call me?

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  6. "abscess involving the entire left labia majora" having had a big abscess (though thankfully not in my lady bits) I'm crossing my legs over here.

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  7. Suddenly, my mastectomy doesn't strike me as having been such a big deal. *abscess involving the entire left labia majora* is a phrase I hope to never hear used about such a delicate area of my anatomy.

    The mastectomy went very well. I occasionally annoyed the nurses by being an active busy patient, intent upon escape. At least they weren't having to prod me out of bed to get exercise.

    Wednesday

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    Replies
    1. Wednesday - I'm very glad to hear your surgery went well. I hope your recovery goes as smoothly.

      While you're recovering, you should have plenty of time to MAKE A DAMNED GOOGLE PROFILE ALREADY. I think you're well enough established here to deserve one.

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    2. Thank you, Doc. Yes, I'm recovering nicely and enjoying full range of motion. I'm behaving myself well enough not to go clean the gutters though. They do need a spring cleaning.

      Okay, I set up a Google account, let's see if this works.

      Wednesday

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    3. Well done! Yes, it works. I deleted your double post.

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    4. Hi, Wednesday! Glad everything went well for this big step forward on your journey to good health! :) And, welcome to the "non-anonymous" side of the SFTTB neighborhood.

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  8. It's totally mind-boggling to know that Charlie's doctor didn't bother to either examine him or even *listen* attentively to his actual complaint. :(

    In addition to subjecting Charlie to an unnecessary surgical referral appointment and CT scan, it's likely this also caused Charlie to suffer discomfort for some additional period of time, while he *waited* for these things to happen. If he'd gotten the correct diagnosis and prescription when he first saw his PCP, he could have filled the prescription on the way home, started on the meds, and would have been feeling better much sooner.

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  9. So were she and Charlie dating?

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  10. Hey Doc, been following you for a good wee while now, since FML brought you to my attention. I've been meaning to ask or comment on a few of your posts but I'm not particularly productive.
    I have no medical history, but must ask - is an abscess essentially a giant pluke?

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    Replies
    1. An abscess is a collection of pus.

      Feel free to comment on whatever you like.

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  11. This comment has been removed by a blog administrator.

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    1. Please allow me to be the first to say...what?

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    2. last I checked, I don't possess the proper equipment to deliver a baby. but I could probably muddle through assisting someone who DOES have the proper equipment if I needed to.

      and probably without google video search. I suspect most of the intelligent posters here are similarly qualified.

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    4. google U apparently left a very large gap in your education.

      but then, we already know you're dense.

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    5. addendum: I'd guess most of the women here could deliver a baby all by themselves, though.

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    6. Anon: Ken means he's a man, which limits his involvement to a secondary role on the delivering babies front. Medical science has not yet progressed to the point where men can deliver babies "on their own" without, for example, a woman involved.

      If you mean "assist" then many women through the ages have given birth without any assistance and any man (or indeed woman) who has been present at a birth could probably provide reasonable assistance for a straight-forward case. If there are complications then it's blue-light time, however many videos you have watched.

      Ugi

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    7. This comment has been removed by a blog administrator.

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  12. When you say you don't handle girly bits, does that include ectopic tubal ruptures? I apologize if I sound idiotic. I am just attempting to understand where that line is.

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