PODCAST: Really Rural Surgery with Dr. Bret Batchelor

Dr Bret Batchelor is a Canadian GP working in rural British Columbia.  He is also a part-time surgeon practicing his “Extended Surgical Skills” in a small town.

Over the last year Bret has been podcasting at “Really Rural Surgery“.  The podcast is a heavily evidence-based look at the practice of Surgery & procedural Obstetrics with a focus on doing common procedures in the small towns.  There is a strong flavour of “medical myth busting” which we love!

Bret was kind enough to spend half an hour chatting with me about his practice, the ethos of rural procedural work and how to train in the field.

If you are interested in Rural Surgery or EBM check out the podcast and site here.

Bret is on Twitter @ReallyRuralSurg  – he is a super smart guy and keen to spread the word – so ask him some questions and send some comments to the site.  Are there any questions you want answered about everyday Surgery?

Here is the podcast:

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Casey

Clinical Case 110: Sepsis, Scans and Surgeons

Here is a case that may keep you guessing.  One for the US nerds.  Here we go:

25 year old tourist – visiting the town, she has been backpacking for 6 months and the history is a little vague… but basically she thinks she may have had a miscarriage about 5 months ago.

She had a positive pregnancy test and two weeks later developed pain and PV bleeding.  Didn’t see a doctor as she had no travel insurance…  the pain settled and she thinks she may have passed some large clots  – anyway the symptoms settled and she carried on her travels.  No imaging was done.

Fast forward to now – 5 months later.

The history is of 24 hours of lower ado pain. The pain started in the left iliac fossa.  Was well localised but has since become more generalised – on examination she is guarding and has clear peritonism across the lower belly.  Certainly she is more tender on the left.  She is febrile (39.8 C = 103.6 F), tachycardia 110 and has a BP of 90/60.  She denies any recent PV loss, discharge or urinary symptoms.  Her bowels were OK until yesterday – no motion since the pain started.  A VBG shows a mild, compensated metabolic acidosis, normal lactate.

He UA shows some pyuria but no nitrites.  And the B-hCG is…..   [drum roll] .. negative.

So in summary – a 25 yo lady who may have had a spontaneous miscarriage 5 months ago now presents with a sepsis picture, left iliac fossa pain and peritonism.  We need a scan!  So I will show you a series of 6 TV US images now and let you interpret them…  here we go.   [I have added captions to orient you if you are not familiar with TV scan which can look a bit weird to the uninitiated ]

I think I will let this case linger here for a few days.  Would really love to hear your thoughts on these images, the possible diagnoses and where to next!

Of course I will tell you what the final outcome and diagnosis was – but first lets see what you think of these images in this scenario.

Comments please.  Are you a super sleuth with a scanner?

Casey

Right ovary on TV

Right ovary on TV

Longitudinal pelvis view

Longitudinal pelvis view

Left pelvis adnexa

Left pelvis / adnexa

Left ovary

Left ovary

Left pelvis mass long.

Another look at the left pelvic mass

And so what happened in this case? What was the diagnosis?

After some fluid resuscitation and empirical antibiotics we headed off to the OT. Gynae started with a laparoscope – which showed: – a lot of purulent fluid – a long inflamed appendix which was adherent to theft anterior pelvic peritoneum, wrapped in omentum. – the appendix had a terminal abscess which contained a sac of frank pus in a strange casing! – Presumably a partially walled off appendix abscess in an odd location. Moral of the story: an unusual appearance of a common disease is commoner than the usual appearance of a rare disease ! The pregnancy was “noise” unhelpful clinical data

Dr Penny: Podcast on Polycystic Ovarian Syndrome

The nomadic GP – Dr Penny Wilson – has just finished up a stint in our cozy little hospital here in Broome.

So amid the births & beaching I managed to record this podcast live in person with our favourite Gynae guru.

Penny knows about a thousand times more than I do about polycystic ovarian syndrome – so I took the opportunity to get schooled in the many aspects of this common and challenging problem.

So – here we go.  Have a listen and check out the links to useful resources and references below:

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Here is a great patient education resource from the Jean Hailes website

Here is a review article from the Medical Journal of Australia 2011 – lots of good evidence discussion

There is also a recent NICE guideline from the UK (Feb 2013)

There is also a set of evidence-based guidelines from the RACGP which are pretty long but like all of these things – it does have summary points if you are in a rush.

Thanks again to Penny – another sterling job – we will likely be hearing more from Dr Wilson in the near future!

Casey

Lessons Hard Learned: Dr Domhnall Brannigan

After a bit of a break – the Lessons Hard Learned series is back.

Today I am chatting with Dr Domhnall Brannigan from Tasmania / Ireland.  He tells me about a really sad case he saw and we discuss the biases we all carry in medicine, communication and some Resus stuff you won’t read in the textbooks.

You can check out Domhnall’s blog over at underneathem.com , follow his Twitter rants @dreapadoirtas

OR you can hear his excellent SMACC 2013 lecture over at the ICN website here.

But for now lets hear from the big guy himself – take it away mate…

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Contraception: Commonsense and controversy

Welcome back.  I have had a few weeks off and this is the first podcast for a while.

I have invited Dr Penny Wilson – our resident GP / Gynae / Women’s health expert back onto the podcast to discuss her approach to the common presentation of contraception counselling.  We also discuss the recent controversy around the risk of DVT or PE with some of the newer combined OCPs.

This is really aimed at the GPs in training or those who occasionally get involved in contraceptive counselling.

Penny mentions a number of trials and online resources to aid your learning or discussions with patients.  I have listed them below for you to follow along.  Please feel free to share any other contraception resources you might have.

The World Health Organisation has some cool resources:  a Smartphone App,  an “online wheel”.  These are the “Medical Eligibility Criteria” that Penny mentions.

The US Centre for Disease Control (CDC) has a similar online “Eligibility Criteria” decision tool.

Most common OCPs are here:OCP summ chart

The American College of O&G’s position on the relative risk of VTE with OCPs.

The Australian – National Prescribing Service (NPS) published this summation of the data and tips for prescribing.

The TGA (therapeutics goods administration) – the Aussie version of the FDA put out this statement. about VTE on the newer pills.

The FSRH – from the UK’s RCOG completed this met analysis in September 2013.

They also have a really comprehensive resource for clinical guidance around all sorts of reproductive health issues for doctors HERE.

OK – Onto the podcast.

 

BREAKING NEWS:

A new paper out just recently.  Big data – more than 200,000 woman years of COCP – with prospective capture.  Published in Contraception, April 2014

Comparison of drospirenone-containing pills to others showed no difference in VTE outcomes.

So, as we said in the podcast.  The numbers are not really as scary as the headlines would have you believe.  So stay rational!

CASEY

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