PODCAST: Dr Airell Hodgkinson

Gday and welcome back to the podcast after a short hiatus as I checked out the fish in Fiji…  Ahhh.

Today’s podcast is a conversation I had with my former colleague and mentor Dr Airell Hodgkinson.  Airell is a rural GP Anesthetist based in Albany – the southern end of WA.

He is a real thinker and has similar interests in trying to ensure our rural patients get the best quality care which they deserve.  Airell has recently concluded an audit of the local Albany cohort of “fractured NOF” patients.  He has collected the data to see how this group of high risk patients fare in Albany and compared it to those whom were transferred to a metropolitan hospital for surgery / anaesthesia etc.

The data is quite interesting – but not yet published… so watch this space.

Although it is an audit of older people with NOFs – there is a lot we can learn from this review – particualry when it comes to the decsion-making around transferring rural patients to tertiary care for serious illness.  Although it seems like a good idea on first thought – one has to consider a lot of factors when making these decisions with our patients.  As there are a lot of problems associated with transfer – especially for conditions with a time-critical course and where the rate of bad outcomes can be high.

From the outset – the Broome Docs motto has been: “delivering great care, out there!”  And it is something that I think about a lot – are we doing the best thing by this patient by keeping them in a small rural cetre – or could they get better care in the city?  This is a really tough call – especially when the patient wants to stay in the bush and for you to do “your best”.

In Broome, our capacity to provide great care has increased in recent years for conditions like sepsis, mental health clients, trauma and other medical emergencies.  As such the lines have moved in terms of who we keep or whom we send “south” (or east!)  Most of my practice is shaped by anecdote and receny bias – so it is really nice to see Airell has managed to collect some hard data around a group of patients where there is no good answer often.  This is a dynamic and wicked problem – one where there are many unknowns. BUt now we have a bit of data to have htat important discussion with our patients before deciding on the best place for their care.

OK – onto the podcast!
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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

Renal Colic Scans with Dr Adrian Goudie

Patients presenting to the GP or ED with flank pain, colicky pain or pain with haematuria are pretty common.  We know that a lot of these folk will turn out to have the dreaded kidney stones.  We all have our own ways of deciding how to treat these patients.  You may be aware that in September  a big paper was released in the NEJM titled Ultrasound vs. CT for Suspected Nephrolitiasis.  For many ED docs this paper just might be a game-changer.  This was the first really big trial which looked at the bedside US vs. formal US vs. CT for the initial workup of this group of patients.  And it seems to suggest that bedside US is a valid first test for most patients.

As a GP I think this is potentially a big change – if we can scan at the bedside in our clinic with the modern machines – we just might be able to do a pretty fair job of managing simple, uncomplicated renal stone disease without ever needing a hospital – that would be nice!

Anyway – I have been wanting to pick the brain of a much smarter ultrasonically-enhanced doctor about how this changes our practice in 2014 – so I managed to enlist the help of Dr Adrian Goudie [ED Physician, Ultrasound Village teacher, SMACC Sonowars combatant, Ultrasound Leadership Academy Professor and immediate past President of the Australasian Society of US in Medicine…  and great bloke! ]

We had a natter about the paper, his practice and the pragmatic approach to patients with potential stones in the ED (or GP clinic).

Here is the podcast:

DIRECT DOWNLOAD HERE

Adrian has a really nice set of “rules” to guide us when working up suspected renal colic patients.  It goes something like this:

  1. Treat the following groups with caution – you may want to be more aggressive with your imaging if the patient has:
    • Known renal failure, or new renal failure
    • Known congenital anomaly or single (transplanted etc.) kidney
    • Signs of infection / sepsis / obstructed pus is bad.
    • Extremes of age – you are just more likely to find other pathology that you don’t want to miss
  2. As a routine have a look at the aorta – this is low-hanging fruit and an important one to not “miss”.
    • You should also consider the gallbladder, uterus, ovaries, testes and even the appendix if the clinical picture fits.
    • Think outside the KIDNEY BOX – particularly if your renal scan is normal.

You can also check out an older Broome Docs Case [To Frolic with Colic: Case 035]  where we looked at the value of “haematuria” in the investigation for renal colic.  It is interesting to go back a few years and see the smart docs who anticipated this research with their comments- Dr Goudie was one of them!

Also check out the Renal Ultrasound talk from Matt Dawson at Castlefest a while back. So you can see what stones etc look like.

There is a great “Cheat sheet” for reference when scanning from my friends at the Sonocavge HERE – Thanks Dr Goudie and Dr Rippey.

Let me know if this will change your practice…. or not.

Casey

Clinical Case 108: Planes, Drains and Pneumothoraces

Another case inspired by a Twitter debate today.

A Tweet Case was put forward by @FlyingDrBen  (Ben Darwent) who is based in Perth WA – home of LITFL. My friends Minh le Cong, Karim Brohi and Tim Leeuwenburg started a discussion around the case.  Fair to say it got way too big for twitter!  So I am posting this case to get you all thinking and source expertise on the topic.  Here we go…

Rodknee is a 27 yo. man who has presented to a remote hospital following an “incident” in which his girlfriend stabbed him in the right lateral chest with a small kitchen knife ( ~ 12 cm blade).  She apparently found out he had been sleeping with his wife despite his assurances to the contrary.  The oldest story in the book!

Rodknee is a stoic individual and managed to sober up and have a sleep before presenting to the ED about 3 hours after the injury.  There was not much blood loss at the scene and he managed to patch things up with his +1 in the meantime.

On arrival his Obs are all normal ( P = 70, BP = 125/80, RR 14, SpO2 = 99% RA, he is well perfused and alert.  He does complain of some pleuritic pain on inspiration over the site of the wound.  On inspection he has a very neat stab wound ~ 2cm long at the anterior axillary line – 6th intercostal space.  There wis no active bleeding or bubbling.

The attending Doctor is a semi-retired GP from an affluent Sydney suburb who is doing a few locums “for fun” to round out his career.  He has asked for your advice – fortunately you have a High-def VC link up to their ED which is about 250 km away.   So you have a virtual look at the patient.  He is as advertised.

Being an ultrasound enthusiast – you talk the locum through a FAST scan and look for a pneumothorax / haemothorax.  The very rough and ready images reveal a tiny right pleural fluid collection (less than a centimetre) and no clear pneumothorax – although it is hard to exclude in a mobile vertical patient who is 250 km away!  So we think he has a small haemothorax and either no pneumothorax – or a very small pneumo we have not been able to find on US.  He remains haemodynamically stable.

The locum is super keen to get Rodknee transferred out to your bigger ED ASAP – he is the solo cover and has been up all night already.  Fair call – lets get the aeromedical team in to swoop and run.  But……   what about the potential pneumothorax?  Does it need a drain before we put this chap on a small plane?  The textbook says it will expand and might cause tension effect if it does.

Just out of interest – you ask the locum if he is comfortable with placing an ICC if required…  he tells you that he last did one in 1979.  Then he starts waving a metal trocar around like the Swedish chef from the Muppets!  Hmmm, maybe not so soon!

So here is the question – is it better to perform a prophylactic intercostal catheter in a well lit ED under sterile conditions, OR should we fly him without an ICC.  What is the risk of his developing a tension pneumothorax or becoming hypoxic is his possible pneumo expands?

Is a drain mandatory for a 30 minute flight in a small aircraft that will be going to altitude?

Controversial!  Lets hear your thoughts.

Casey

Here is a nice physiology experiment from the Journ of Trauma & Acute Surgery Nov 2014 – small pneumothoraces did expand – but not with any clinical implications at cabin pressure up there.

 

Clinical Case 104: FAST Thinking

This is a trauma case.  I want to use this case to illustrate something about the way we think about trauma when it comes to making calls using ultrasound – specifically the FAST exam.  FAST exams are ubiquitous in modern ED practice – but if executed and interpreted poorly – they are potentially a source of error.

Now you may be aware that I am an US tragic – and when it comes to trauma I have been seriously drinking from the gel fountain.  OK – onto the case.

Typical Broome case:  a lot of unknown unknowns.  30 y.o male who is brought in by the Ambos after being found on the roadside.  Appears to be very drunk.  There wis a vague history from the Ambos that a few “innocent bystanders” saw our patient getting a “proper flogging” [being kicked and punched by a group of fellows].

On initial assessment there is not much to find externally – no bruises or lacerations .  His Obs are really very normal [BP 110/70,  pulse 80, RR = 12, breath alcohol level 0.3%…. normal for Broome].  He has a normal neurological examination [ which is of course the bluntest test in Medicine! ] And equally reassuringly has equal and reactive pupil responses.

Now it is a few hours since the injury and his belly is sore.  Despite his relatively pickled state he is really not wanting you to examine his belly at all.  He seems very tender though there is no distension or bruising.

So being me – it is time to get some gel onto the patient and find the badness.  The scan is basically negative, well almost.  The LUQ, pelvis and subxiphoid views are all normal… but. The RUQ view is just not quite right. Take a look and think – is this a positive, a tiny bit of free fluid? Or is it OK?  This is the sort of call you need to be really sure about when doing these bedside scans.

Because it would be easy to look at this and say – “it is OK” and move on, but if you cannot convince yourself of normality – then you need to act.  So what is it going to be?
RUQ FAST view
So – here is the summary: a Very drunk man with normal obs.  Not a clear mechanism of injury – but we think he has been “flogged”.  Not much to find on examination.  And his FAST exam looks pretty good – but is that RUQ view as it ought to be?  It all hinges on this!

OK I ma going to leave it hanging there and wrap up the case in a few days.

Let me know – what will you do next?

If you are interested in the finer points of the FAST exam then I highly recommend Dr Laleh Gharabaghian’s Sonospot website, or check out her podcast with Scott Weingart on “Don’t Half Ass your FAST”

OK, after a few days to consider the FAST  – here is the conclusion to the case.  But first a rant about “half-arsing the FAST” [Love that line from Dr Laleh]

Obviously it would be a bad idea to make a call on a single still image from a FAST protocol – and yet I see this a lot!  I see a lot of Docs getting a little too focussed on getting a “text book picture” on the screen.  I think we should be exploring the area, as Laleh says: fanning through the whole potential space around Morison’s pouch and into he paracolic gutter if the gas allows.

Lots of folk use a single angle of attack – this often gives a nice image – but to be sure that you are not missing something down at the inferior edge of the liver – you need to look at it from a few sides.  This requires one to have a few tricks in the quiver – not just 4 “standard” points to cover.

Now – point number 2.  FAST (and a lot of bedside US) is not the most sensitive test – it requires a decent volume of haemoperitoneum to be present before you notice it.  So what does that mean in practical terms?  Well I looked at the image above – and thought: “it is nearly normal”.  There just might be a slip of blood there anterior to the kidney.  On a second fan through – I was convinced that there was something “not right”.  It was not clearly NEGATIVE.  Now human nature makes us want to think like this:  ‘if it is close to normal – it can’t be too bad.  Could it?’  But that is wrong – FAST is insensitive, so any subtle abnormality could potentially mean serious pathology.  When you interpret a FAST – you need to be certain of normality.  There is no room for “close enough” here.  And when I rescanned this patient – I was not certain.  So I decided to go onto CT.

A slice from the CT

liver cT

Liver laceration with associated pancreatic contusion. No fresh blush of contrast

So – as you can see.  A small anomaly on the FAST can bely serious injury.

So – our patient remained stable and was managed conservatively.  HE did have a lipase bum and went onto develop some traumatic pancreatitis.  [ we would never blame the alcohol! ]

And for the record he had serial FAST scans which become more obviously positive over time.  One could even see the laceration with the aid of the CT!.  But that is not what FAST is about – you should not be looking for solid organ injury.

And here is the liver lesion on the subsequent UltrasoundLiver laceration

So remember – DON’T HALF_ASS YOUR FAST

Have a low threshold to call it “not normal”.

Scan like you are hunting for blood – not just taking a snapshot!

Repeat the scan if in doubt.  And remember to interpret in the clinical context – i.e.. a NORMAL FAST in a crashing patient means little.  You need to find the badness when the pressure is dropping – either in CT or the operating room!

Happy scanning – Casey