I enlisted Dr Penny Wilson once again to chat (teach me) all about infertility in the GP office.  DIRECT DOWNLOAD here

Enjoy
Casey

In WA we have a wonderful service based at King Edwards Memorial Hospital for Women – it is SARC [Sexual Assault Referral Service ].  When I was a trainee in the metro area we were lucky to be able to refer victims to this service 24/7.  However, in the rural areas this is not usually possible.

So I thought I would put together the basic approach and a few tips I have learned over the years for a podcast.  I am definitely not an expert, so I am really hoping there are some pearls from the listeners to help us out on this one.

Have a listen and let me know if you have any resources, experience  or pearls you can share. DIRECT DOWNLOAD here

Casey

As a bloke GP mainly doing ED stuff, I rarely have to treat it beyond suggesting some OTC NSAIDs and a hot pack.

So I have teamed up with Dr Penny Wilson (@nomadicgp) who writes the Nomadic GP blog about her experiences as a roving rural GP trainee and now locum in all parts of the country.  I could particularly relate to this recent story where she failed to locate a cervix on speculum exam (though in her defence it wasn’t actually there! ;-) ).

Penny is a bit of a gun when it comes to ladies health – so I asked her about some really dumb stuff and I hope you can learn as much as I did.

DIRECT DOWNLOAD - or get it from iTunes

You turn up to work your day shift and see you have been assigned to the Obs ward for the morning.  It is your task to see the dozen or so patients sleeping off the evils of the night before in the small ward out back of the ED.  You know the drill – a few minor tox cases, a Psych sedation, maybe an old guy with a bump to the head etc….

As you look at the list of patients under your care – you have a heart-sink moment as you recognise Phineas’ moniker.

Phineas.  Well Phineas is a well known individual.  He is about 50, and you have seen him many times over your tenure in this ED.

Phineas was a successful independent builder, running his own small company and living in a well-healed suburb with his wife and 3 kids until he had his accident.

About ten years ago Phineas had a few too many drinks and drove into a wall.  He suffered a nasty frontal brain injury and spent a month in ICU, a craniotomy and a prolonged rehab saw him back to full physical function. But…. his brain injury left him with seizures and “Phineas Gage” persona.  Phineas became impulsive, disinhibited, drank to excess and had trouble organizing his life.  His marriage had disintegrated over a few years and he couldn’t hold any sort of job.  Phineas doesn’t have a diagnosable primary mental illness and he has seen a number of Psychiatrists who have all agreed – he does not need their help.

Over the last few years he has been living in a series of supported housing units, but he tends to get into a lot of fights and never stays anywhere longer than a few months.  However, the ED is one of the few permanent fixtures in Phineas’ life.  He frequently presents via ambulance after experiencing secondarily generalised seizures in public.  He is prescribed phenytoin but whenever he gets a level done in ED it is close to ZERO.

You read through the chart from the night before – same old story.  He was drinking in a local park, when he had a convulsion.  A passerby called 000 and the Ambos brought him in.  He was GCS 14/15 on arrival and blew 0.09 on the BAL analyser.  All his obs and examination were “normal for Phineas”.  He received an IV load of phenytoin 1000 mg over an hour, some thiamine and a hot meal.  He required a few doses of diazepam after this for “twitches”.

The resident decided to admit him for “Neuro obs and  Neurologist review in the AM”  This brings a momentary smile to your face!  This is Phineas’ 23rd admission in 3 years.

You wander into his cubicle, and he greets you with a knowing smile.  ”Gday Doc!  I’m glad it is you on today.  That young guy last night seemed very serious!”  Phineas is his usual, jovial self.  

After you check him out and talk about the footy for a while Phineas is keen to leave.  He tells you he is staying in a nice flat with a few other “mental defectives” and plans to head back there for a rest and to make sure they have not knocked off his stash of Bundy rum.

So here we are.  The point of the exercise today is to explore a few issues that this sort of patient can present to us, Emergency Physicians who are sometimes by default the primary carers for some patients.  SO have a ponder on these questions;

Q1:  Would you load Phineas with phenytoin each time he presents “post-ictal”?  If so, would you give him IV phenytoin, or something else?

Here is a post from Dr Bryan Hayes of the Academic life in EM blog on oral Phenytoin loading in ED

Q2:  Clearly compliance is a problem. You are an ED doc.  How far do you go to try and get Phineas to take the meds he needs?  Do you give him a prescription?  Hand him a bottle of pills with instructions?  Get a blister pack made up.  Get a Social worker / community health worker involved?  Do you go round to his flat and check on him?  OR is it ethical to accept that Phineas will not take anything you give him and not bother with the meds?

Q3:  Is this a competence question?  That is – is this man competent to make his own health decisions?  Given the facts:   he has clearly and repeatedly put himself in harms way, has a brain injury yet seems insightful enough when you talk to him.  How do we go about deciding on competence in this situation?

OK.  Enough clinical and ethical food for thought there.  Hit me on the comments page or twitter @broomedocs with your thoughts.

Casey

PS: in a modern version of the Phineas Gage story – here is one from Brazil (thanks Dr Tim for sending it in.)  A lucky man indeed.

The pain felt almost metallic in nature, which didn’t mean anything to me at the time. He had returned from Thailand with a strange rash over his flank that two other experienced GP’s at my practice could not identify when I sought their help.

 Just then a still small voice flashed into my consciousness about using my iPhone to take a picture and submit this unto the TeleDerm website. To my surprise within 30 minutes I received a text message saying that Dr. Jim Muir had reviewed the case and posted a reply. The rash in question was Cutaneous Larva Migrans!

 This was case was submitted and published in the Australian Family Physician last year.

This encounter is echoed across Australia with similar consultations and enquiries being made of the TeleDerm service everyday.

The word has powerfully spread through Australian medical circles via twitter and multiple blog posts highlighting the outcry that this essential service may lose its federal funding from the Department of Health and Ageing.

TeleDerm addresses the lack of access rural patients have to specialist dermatology services and recognises the vast distances they may need  travel to seek specialist dermtatological review.

To lose this service would be significant to the landscape of rural and remote medicine and again deepen the disadvantage felt by our rural patients.

Here at BroomeDocs both Casey and I would like to throw our support behind the #SaveTeleDerm campaign and encourage all doctors to unite in taking this cause straight to the Department of Health and Ageing.

So how can you help?

1)   Sign the petition which will send an email to the Health minister alerting her to the dire consequences of losing TeleDerm

2)   Tweet #savetelederm and tell everyone your story!