The Day of the Beating Heart Donor

24/08/17

I observed an eye-opening and mind-boggling event today – something I had heard of a thousand times before, and I knew was commonplace and such a great, great gift to give to someone – yet you never think things through and the details and the minutiae and the step-wise journey that gets you to a certain result sometimes just doesn’t register till you are actually on the other side of the coin. Today I observed an anaesthetist keep a clinically braindead patient comfortable on his journey to giving the greatest gift to a multitude of individuals – through his organs that he donated, the gift of life. I am still reeling, and literally have no words to express how chaotic and inexplicably sad I felt on the inside, and what the whole process entailed and how I came to realise and came to terms with what I bore witness to today – I will surely like to revisit this topic at a later point for a much-needed debrief. But not today. I just felt like I had to share something about this day, and I will. But not today.

RIP.

26/08/17

OK – so here I am, it is the following weekend – and I finally have enough time to do justice to this post
the day began with a pain clinic round – for those of you just joining us, I am now in a anaesthetics placement currently, and aside from all the wonderful cases we are meant to preside over anaesthetics-wise in theatres during various surgeries, we are also required to oversee patients in acute painful crises of any sort, and make a pertinent plan for adequate analgesia, whether it be a PCA pump or varying doses of different drug regimens. It was a cheerful day – not because we saw patients in pain, but because we saw the aftermath of what adequate analgesia does – happy, comfortable, asleep patients – patients with broken vertebrae from falling off horses and post surgery patients and patients with chronic pain issues who had become acutely unwell – all were magically comfortable with the various cocktails measured out to them in various dispensers (epidurals, blocks, PCAs, oral/iv/subcut/intramusc meds) – and to top it off, my consultant was a particularly cheerful, fun person; the ward round was informative and collaborative, and we struck up a dynamic where we bounced ideas off of one another, and she made sure I felt included and did not feel as alienated with the whole deal of being new to the idea of a pain clinic as I thought I would be.
Fast forward to 3 hours later and my consultant gets bleeped about being roped in to performing the anaesthetic for a donor extraction surgery – a team from the nearby major transplant centre were coming in to perform the surgery, and to harvest the organ(s) from a patient currently admitted in our hospital. My consultant asked me if I wanted to continue with the day’s pain rounds or would I like to join her in the theater to see this procedure? I excitedly said yes, thinking I would get to see the miracle of someone donating their kidney to their loved one and both donor and recipient ending up side by side on adjacent beds in the ITU. The reality was far from this very romantic notion.
As I changed into theater-appropriate attire – I realised what was going on as the team from the other hospital introduced themselves and told us the story – this was a 50-something male patient, who had suddenly had a massive stroke, and had been declared clinically brain dead the evening before. He was being kept artificially alive on a ventilator, and the family had said their goodbyes and understood the terminal nature of his condition. All of this however did not prepare me for what this procedure actually entailed: We would be providing anaesthetic to a brain dead patient, in order for him to be as comfortable as possible during the procedure which would entail the team of surgeons harvesting whatever organs had been consented for donation (in this case both kidneys, liver and pancreas) and for us to keep his organs as adequately perfused and optimum physiology as possible till the last possible minute, and at the point of removal of the organs, the blood exsanguinated from his body, at which point we were told ‘your services would no longer be required’ meaning to say the patient would then have been declared officially dead. So we wheeled this patient into the operating theater for what were to be his last few hours of life (albeit artificial due to the ventilator). It doesn’t get any sadder than this does it? It does, in fact. Not with anything else that happened during the procedure – but with the multitude of realisations I had over the next few hours.

I have seen asystole many hundreds of times (I am not proud of it, just the nature of my job) but I have never seen a beating heart become…just a heart. It literally was beating enthusiastically one second right in front of me and then it…wasn’t.

I have attended many surgical procedures which involve trying to get the patient to improve – never to mark the end of their life.

I have seen a heart being jump-started by electric paddles to kickstart it to life – never have I experienced the opposite, cardiac activity ceasing as a result of the drainage of blood from the major vessels entering the heart, and therefore from the rest of the body.

I have heard of so many organs that are transplanted into deserving human beings whose very life depends on the organ(s) being amazingly gifted by someone else who no longer requires their use – but I have never quite registered what it means to actually remove tissue of any sort from a ‘alive-till-the-organs-are-removed’ body so that once these viable tissue are removed, the body will essentially very quickly shutdown.

But I also had one other, very major overwhelming realisation: there is no precedence and no other example I feel of such an amazing, voluntary gift, either on the part of the donor, or on the part of the family who consent to the donation – a gift that may well mean (quite literally) the difference between life and assuredly painful death for so many individuals. While I may have initially felt that the procedure meant the end of a life, I was wrong. The procedure that I witnessed did not just mean the start of a new lease of life for the individual(s) who got those organs, but also their families and friends and loved ones and all the lives in turn they will interact with and influence and touch just by being alive – they may go on to teach, to lend, to help, to protect, to heal, to donate; they may go on to hold someone’s hand, walk someone down the aisle, attend a graduation, a christening or a birthday. They all owe every moment from here onwards to this, the procedure that started it all – thanks to the beating heart donor.

ECT – the conflict within

DISCLAIMER 1 – EXTRA-LONG POST. You have been warned.
DISCLAIMER 2 – More importantly – this is in no way supposed to be a ‘for’ or ‘against’ type of post regarding any particular therapy/treatment – it is just my opinion and my own feelings about this experience which was very new to me. Bear with me, before rushing to judgement or conclusion – and if you already have formed an opinion without prior knowledge/experience then please stop reading further!)

For those of you who do not know, I have recently started my 6 month rotation in Anesthesia as part of my emergency medicine training, and it has introduced me to a whole new weird and wonderful world that is equal parts unexpected and fun and slightly scary but mostly awesome. But more about that later. Today (and for the past few days) I have been wrestling with some inner demons (wow, that’s not melodramatic at all!) about a recent experience and the ensuing internal conflict broiling inside me. I will try to explain things in my usual way, which is to take you on that journey with me.

So the day usually starts at 7:30 AM, and the rota tells you it’s a different theater every morning – I checked the night before and all it said was that I was assigned to a particular consultant to shadow (read badger/annoy for the rest of the day!) and that we were supposed to be in the “ECT” area (theater?) in a completely different building from the one I had been going to for operations/procedures requiring anaesthetics in the past week. My first thought was ECT? It can’t be electroconvulsive therapy? That’s not still being done in this day and age? But I texted one of my friends in the same rotation as I am, and he said this area was in the building that houses the maternity block, and I thought it was probably some sort of gynaecological/obstetric procedure requiring anaesthesia which is why I am being assigned to this and I am sure I thought of ECV – external cephalic version! I reassured myself and went to bed, woke up the next day bright and early and headed to whatever this amazing day heralded. It was not amazing. Atleast, not initially.

ECT, as it turned out, did mean electroconvulsive therapy – a treatment for drug-resistant psychiatric conditions (please excuse the rough/non-medical language) – and I found out that what I was assigned to today was in fact the ECT suite, a separate entity from the rest of the hospital- where I was shown around while I was waiting for the consultant. There was a procedure room, with anaesthetic stuff and an OT table, and a separate recovery area. There were 4 nurses, a head nurse, 2 health care assistants and 1 psychiatrist/consultant – aside from my anaesthetics consultant and absolute-novice-baby me! The whole area was very peaceful and calm, and the staff were very friendly and spoke in calm, reassuring voices even when they asked me if I would like a cup of tea. I felt myself calm down a bit (I was nervous because A- I had no idea what to expect and B- I HAD NO IDEA WHAT TO EXPECT!)

There were 4 patients on the list for today. 3 of them (the first 2 and the last one) were regulars, here for their 7th, 3rd and 11th treatments, so they did not need pre-assessments doing from an anaesthetics point of view – just a confirmation of their consent for the current procedure (consent did not mean a blanket consent for all treatments, you could consent to the first treatment and revoke consent at any later treatment session, if you were deemed to have capacity. All 4 patients today had capacity) The 4th one had completed 12 sessions of the ECT previously and that usually meant their treatment was over. But their doctor had assessed them and had thought that despite the improvement the patient could benefit from further sessions, and so they had to give another detailed informed consent – because initially they had consented to the 12 sessions, and this was adding on to what they had initially consented for. But I digress – there was just so much to take in and learn that I do not want to miss out on any of the details/finer points that I came across.

So anyway – while we waited for the first patient to turn up, my consultant took pity on the incredulous expression that I had on my face (this was without me realising it) and explained a few things to me, and looked up a very good paper for me to read about ECT. He broke down what we needed to do here, which basically entailed: introducing ourselves; confirming patient details; confirming no changes to medical/pre-assessment history had taken place in the last week since last treatment; putting a cannula in; hooking them up to some monitoring (continuous ECG trace, pulse oximeter, blood pressure, an initial temperature reading) and also hooking them to an EEG machine which is basically just like an ECG of the brain – mapping the electrical activity of the brain; administering the induction agent (usually propofol) and/or a sedative, and supporting the patients breathing before, during and after the procedure till the anaesthetic wears off.  ECT is basically electric current that is run via two ports/electrodes placed at both temples while the patient is unconscious. The current causes your neutrons to fire in a way to cause a generalised toniclonic seizure, and your brain activity is mapped continuously to make sure it has worked, and that the seizure lasts a certain length of time (usually greater than 10 seconds but on average about 30seconds in duration). It is essentially equivalent to being ‘under’ for a surgical procedure, just like you don’t feel the surgeons scalpel or drill, you do not feel the actual shock. Your heart rate and oxygen levels and blood pressure and all that jazz is continuously monitored and in the event of any fluctuations, it is handled by the team of extremely qualified individuals in attendance, as it would be in any surgical procedure. But the actual procedure was what caused me to be so incredulous. Why, you may ask? I will explain, but first let me take you through the first patient’s treatment.

This was a 50-something female, with a history of depression, and she had become so depressed that she had stopped eating and drinking, and none of the medication or combinations of medications had seemed to work on her. I had all this information from her history sheet, and chatting with the consultant psychiatrist made it clear that this was sort of a last resort. She had become anorexic to the point that she didn’t really have the strength to lift up her head from where she lay in bed, to take a sip of water. She was initially medically rehabilitated, her caloric intake monitored and her strength returned, and while she had become medically fit, her depression was still strong. She began this prescribed treatment, and today was coming in for her 7th session. She had been almost a complete mute prior to the first treatment, and was markedly different today. She walked in to the room unsupported (I thought she would atleast be in a wheelchair). She made eye contact with all of us. She smiled at me when I said good morning, and replied shyly that it was indeed a good morning. As they hooked her up to the various monitors she looked around with that smile her face, and gave adequate responses to the questions and requests from the staff members, such as May I put these ECG stickers on you?, and can I put a cannula into the back of your hand? We walked her through the procedure, put her under and after she had drifted off to sleep and we were monitoring her airway and breathing, we put a rubber/foam type thing between her teeth so she wouldn’t end up biting her tongue or lips, and then they placed those electrodes on her temples and …I don’t know what I expected, probably that the patients arms would flail around and her legs would jerk up off the table and it would all be very violent and gruesome. It was certainly difficult to see, but nothing quite as dramatic as that. She just straightened out a bit, feet became a bit rigid and there was a generalise trembling, followed by some twitching. The continuous EEG trace showed she had had a seizure that lasted 34 seconds, and while she became tachycardiac during it, she settled down almost at once after the seizure ended. She began breathing spontaneously after a few minutes and was taken to recovery as she regained consciousness. And now for the crux of this post – the reason why I was so conflicted.

All my life, or at least the last 10 years when I have been a doctor (15 if you count medical school) I have been working with the idea that we need to minimize seizures and we work very hard to figure why someone may have had their first fit, to try and prevent it from happening again, and I have been involved in extensively counselling and reassuring family and patients and parents of toddlers etc on the subject – so the ‘inducing’ of a seizure as a treatment was a bit of a shock – no pun intended! I knew the patient came to no harm from the immediate procedure, the electric current and the anaesthesia, and they actually did not feel anything, much like any surgical procedure (with the added benefit of amnesia as a known side effect of propofol!) and much more importantly, the patients reportedly feel better and they don’t have memory of it etc etc. But having never actually witnessed it before, I had quite mixed feelings about it because it conflicted with my mindset of ‘how to manage a seizing patient’ – as opposed to this current situation – once again, no pun intended! The conflict I speak about is not of the “ohmygod I do not agree with this practise how dare they?!” type of reflection, and I apologise if it sounded that way. Rather it is more of a “everything I feel inherently about this situation is basically not true!” and I had to actively try and work towards not panicking when I saw this patient seize. And the one after that. And the one after that. It didn’t get any easier, and I didn’t get used to it and it really bothered me. I didn’t know what really was most bothersome for me. Was it the fact that I pride myself in being completely professional and see all sorts of unexpected medical scenarios and presentations as an emergency medicine trainee with the calm and focussed approach that is taught and cultivated in my specialty, but that in my almost 6 or so years of emergency medicine experience, I have never been this affected by any procedure or situation? In other words, was it the procedure that had bothered me, or my own reaction to it?

A few positive notes/observations from the day –
*Any patient who can consent because they are deemed to have capacity will be asked for their explicit consent for the treatment, and they will be given the full information regarding it. Out of the 4 patients scheduled for the day, the 3rd one who was coming in for her 13th treatment (having completed 12 previous ones and deemed to still be in requirement of a few further sessions) came in and then declined to give consent for the next one. And, even though she had consented for 12 sessions and had had them, AND she had the capacity to refuse at any time, we respected her decision and she went home. We didn’t just strap her down like a bunch of frankenstein-y mad doctors while cackling in high pitched laughter to administer jolts of voltage against her will – though I will be the first to admit this is what I thought when I first found out I was in the ECT suite, that this was my unfortunate concept of ECT, based on nothing but my (very vivid, it turns out) imagination.
*Also, it has been around since 1938 – there is tons of research on this topic and while it is all shrouded in controversy mostly due to preconceived notions and ideas, there is no denying the absolute faith people have in this treatment.
*The sons of the first patient who’s treatment I detailed earlier were sat outside in the relatives’ room and while the patient was being wheeled to recovery, I went and asked them how they felt the treatment was affecting their mum. They both agreed there was a distinct difference in Mum, that she had begun enjoying her meals – looking forward to what was on the menu for the day,  offering to go to the park with the grandchildren and making plans for one of the sons’ wedding that was supposed to be an out of country type thing. This was in stark contrast to her being in the throes of progressively worsening depression since their father had passed away a few years ago.
*They don’t just administer this treatment without trying anything else.
*It is not like touching a live wire; you don’t feel anything – you aren’t zapped like a Tom&Jerry cartoon situation. In fact, the voltage is so low that I was surprised that while the current was being administered, one of the nurses had their hands on the patient’s chin as a reinforcing/reassuring measure. They were clearly not feeling the effects of a transmitted significant voltage, unlike in a cardiac arrest situation if you administer an electrical shock, you have to be clear and not touching any part of the patient’s body lest you get a shock as well. It is all very professional and clean and protocol-oriented.
*There are a lot of good people working very hard to make the experience as comfortable and easy for the patient as possible.

At some point I will probably do some research into the subject. It has certainly piqued my interest – but I am ashamed to admit I won’t be looking forward to the next time I get assigned to this area, and I dread looking at the rota announcing when I am going to go there next. And at some point I may actually grow to appreciate the whole process. And look beyond the obvious conflict. But today is not that day. Sigh.

A Catheterisation Conundrum

Hmm…I gave much thought to how I wanted to go about posting about this experience I had the other day, and I decided to just lay into it. So here it is: I have probably done dozens of urinary catheterizations in my almost decade of being a doctor – male, female and ranging in difficulty level from easy to ‘I-give-up-lets-call-urology – but what I learnt this time was a truly unique experience, atleast it was for me. It really reiterates my motto of ‘learn something new everyday’.

My patient was in his 70s, had just recently been discharged from hospital after suffering from a myocardial infarction x 4 weeks back. He had come in with abdominal pain, so everyone at triage was understandably freaked out because they thought it may be related to a cardiac situation. I went in to see him and he was writhing in agony, it was clear this pain was not cardiac in origin, and it was localised to the lower part of his abdomen, which was very distended. One hand on the suprapubic area confirmed the firm mass which was quite tender and dull to percussion was in fact his bladder – he had not been able to pass urine for the past 15 hours! Currently under treatment for a UTI x 2 days, which was diagnosed when he began to have first pinkish and then dark red, painless hematuria. It was very likely that a clot had obstructed the bladder outflow tract, and caused him to go into retention. Simple solution, pass a 14 or 16 French catheter into the urethra, and relieve the obstruction.

And I began prepping for it: catheterization trolley, catheter set, catheter itself, instillagel, water for injection, cleanie wipes, some saline solution and gauze. I took consent, which he almost yelled out in agreement. I walked him through the steps of the procedure, and he declined my offer of a chaperone. I requested him to expose himself from the waist down. I cleaned the genitalia with some saline soaked gauze, and cleaned around the foreskin. As I tried to retract the foreskin back to bring the glans out to put the catheter tip in, I realised I had run into a problem that I had never encountered before. The foreskin had shrivelled up and had a minuscule opening at its tip, but there was no way the head of the penis was going to protrude itself from under it – it just would not retract. I asked him when was the last time his foreskin had retracted and he replied that that had not happened for atleast 5 years! I could not see how I was going to insert a catheter into the tip of the penis if I could not see where the tip was. I ungloved myself and went to seek counsel of my elders – which in this case was my consultant who was very busy almost elbow deep in resus – I briefly described my situation. He very nonchalantly informed me that I should attempt going in blind, and should it by unsuccessful, to inform Urology. I had serious doubts and considerable reservations of blindly pushing a catheter in where I could not be sure was an orifice – but he reassured me saying that the hole was there ‘somewhere’ I just had to…look around for it a bit. Well, maybe feel would be a better word.

Anyway, so I went back in, regloved myself, and took a deep breath, before explaining to the patient what had transpired and what I was going to now attempt. I then took another deep breath and tried poking the catheter in through the opening in the foreskin, and it almost atonce met with resistance – the head of the penis presumably. I tried coaxing the catheter in further, but it wouldn’t budge. I pulled out and tried a different direction slightly angled differently. No luck. I tried a seventh time. Still nothing. I was literally feeling beads of sweat form on my brow. I was very aware of how uncomfortable the patient was feeling, and of how traumatic a catheterization can be, even when you can see the penile head. Added to that the fact that this patient had recently had a heart attack and was on oodles of blood thinners, I did not want him to bleed out through a urethral injury of my doing. I decided to try one last time, a deep breath and it went in, the patient yelled and then bit his lip and this very VERY murky, dark brown coloured urine tarted pouring out through the tip of the catheter into the kidney dish I had in front of it – at first I thought I had injured him and it was blood coming out, but I was reassured when it started collecting in the bag – though very dark, brownish, it was very old blood, definitely not fresh and definitely, reassuringly, not my doing. I cleaned up and went off to bleep the urology team. The patient kept thanking me, with look of content on his face as he lay back and let the catheter relieve him of his obstruction of 15+ hours. I left the room feeling very good about myself (catheterisation is one of those procedures that can make a sudden distinct difference in your patient’s situation, for the better) not only because the patient was very happy and comfortable and no longer writhing around in pain, but also because I had learnt something new today, and I couldn’t shake the feeling that even after doing a procedure hundreds of times (OK I may have exaggerated a little bit) you could still be surprised and be presented with something that may require a bit of out-of-the-box thinking.

Excuse me while I go pee.

The Intestinal Obstruction That Wasn’t

84 year old male – known to have chronic constipation, and on warfarin for atrial fibrillation – referred in by his GP for ‘inability to open bowels for 2 weeks’ – yes you read that right folks, T-W-O W-E-E-K-S! – ‘increasing abdominal distension and abdominal pain, along with decreased appetite and a possible mass in the pelvis/abdomen going above the umbilical area’.
The nurse triaging him came to me, asking for some pain relief for the patient ‘and an enema because that’s what he usually has for his constipation’ – I decided to go see the patient myself. I stepped into the cubicle and the gentleman seemed to be in some discomfort, but he kept saying that he was in an uncomfortable position/posture rather than anything else causing him discomfort. I introduced myself and asked him what had brought him to ED – he replied by telling me he had not opened his bowels for 2 weeks now, and though was still passing wind and had passed some today, he was drinking very little and felt nauseous and omitted a few times in the past 3 days. I asked him if he had been passing urine normally, and he reported that yes he was peeing fine, but that he was drinking so less due to the nausea that only small amounts were trickling when he needed to go. I took that statement at face value and moved on. He was lying in a trolley, awake but lethargic and completely oriented. His observations were all within normal limits except for a systolic BP of 89, and his GP notes reported a background of chronically low blood pressure. I examine him, of particular note is his visibly very distended tummy – which assort but distended, feels like gaseous distention from the percussion notes, and with tinkling infrequent bowel sounds – and is quite sore particularly in the lower half of the abdomen, and I can also palpate a mass in the lower part of the abdomen – the patient reports that’s been going on for atleast 3-5 days, possibly when the vomitting began as well. This seemed very much to me to be a classic case of intestinal obstruction – and the management plan is – do baseline bloods (already very kindly done by the triage nurse), get venous access (also done), start some fluids, abdominal X-rays, nasogastric tube and surgical referral, and also catheterise patient, to monitor intake and output.
I speak to my registrar who agrees with said plan of action and while I request the X-rays and take the patient down for it, the lab apparently calls back and my registrar takes the call – the patient’s urea is 44, and the creatinine is 469, last creatinine 3 weeks ago was 141 – so he is going into renal failure, if not there already. While I seemingly faff around with the surgical consult, my registrar gets an ultrasound machine, and I assume it is to rule out a AAA, so I walk into the cubicle with him. And he explains to me a great pearl of wisdom that clearly comes with experience but is such a simple thing that I am left berating myself for not thinking about it earlier. He told me that if someone comes in with such significant renal function decline so acutely, always think of and rule out an obstructive cause for this presentation before moving on to other more sinister things. He was doing an ultrasound to look for hydronephrosis or hydroureter, which is basically the dilated urine collection channels in the kidney downwards and the reason they are dilated is due to an obstruction further down the channel. And that is exactly what he found. The left kidney was moderately enlarged but the right kidney was massive and its ureter was like a fire hydrant pipe rather than the small thin tube – and the mass in the lower part of the abdomen, going from pelvis and extending up from the umbilical area? His urinary bladder!!! I was in shock – as my registrar then gave me the second pearl of wisdom: never believe anything you are told, do not take it for granted until you have objective evidence. The patient felt he was peeing less and less because he wasn’t drinking enough. Yet he was peeing less because the channels beyond his bladder were so narrowed and obstructed that they did not allow emptying of the bladder and it just kept filling up till it was a massive huge thing floating in his belly. I at once made arrangement to catheterise the patient, whereby 2000 ml (that’s 2 litres!!!) of dark brownish urine poured forth out of him.

He had been in urinary retention for the better part of 3-4 days, possibly due to an enlarged prostate that had just gotten worse, and his constipation (though being chronic) was either a factor of his massive bladder pressing on his rectum/colon and not allowing the contents to move ahead; or (a bit like the chicken and egg thing, of which came first?) he was constipated, which gave him some abdominal pain (expected) and that pain had the added effect of causing urinary retention – anyways, after passing the catheter and draining all that urine the patient felt quite comfortable, and the surgeons took him away to do their wonderful things.

Rat-Bite Fever

You really do learn something new everyday!

So today I had a patient – 4 year old male with a 24 hour history of abdominal pain which woke him up in the middle of the previous night (he kept crying and pointing to his tummy, saying ‘ouch’ over and over again), associated with 1 episode of vomiting, and this morning when he woke up he had a fever (40 degrees) and was off his food and drink – Mum took him to the doctors, who diagnosed him (provisionally, I guess) with tonsillitis and sent him home with oral antibiotics (phenoxymethylpenicillin) the child had as yet only had 1 dose od this antibiotic but Mum felt he was being very difficult to feed/keep fluids down so was concerned, child still had an ongoing fever of 39.4. There was no history of any rashes, no cough but had a sniffly nose the last couple of days. Wetting nappies as per usual (a sure sign he was taking in enough fluids) but no dirty nappies today (not unusual for this patient to go x2 days without pooing) Upon my review he was a bit upset, and seemed to be in discomfort, despite having had some sickly sweet paracetamol a while ago to counter the fever.

He had a background of some degree of developmental delay due to a disorder that I do not want to disclose here, for patient confidentiality so this story is untraceable back to them. There were no other comorbidities.

On examination, the child was sitting in Mum’s lap, crying but was settling down when soothed. ENT exam revealed a slightly hyperaemic throat with enlarged tonsils, no exudate or discharge. He kept sticking his tongue out and wincing when he swallowed – pointing towards the possibility of odynophagia or painful swallowing. May explain the ‘off food and drink’ as may be too painful for him to swallow. The mother was giving him regular round the clock calpol though, so difficult to say. Ears were wax-laden and I could not visualise a tympanic membrane in either. Chest was clear to auscultation, no heart murmurs or other weird sounds on listening to the chest. Tummy was nice and soft with no palpable masses and child did not appear to be in discomfort when tummy was examined. He was moving all four limbs, neck seemed soft and his observations (vitals – heart rate, capillary refill/BP, respiratory rate, oxygen saturation on room air – were all within normal limits; all except the temperature, which was still high despite the calpol. I prescribed some ibuprofen. There were no rashes (did I already say that? Yes, that was history, this is examination) – Moving on…

I asked mum if he had been unwell prior to the waking up with the ‘ouches’ in the abdomen? She reported he had spent the weekend with Dad, where he had been bitten by a rat (!!!) on the right index finger – sure enough, on examining, his right index finger had a blackened almost shiny minuscule raised bit – an unmistakeable bite mark, on the distal end of the finger. Surrounding area was a bit reddened and slightly inflamed looking. On movement of the finger, hand, wrist etc, he did not seem to be in a lot of discomfort, though he wasn’t exactly happy I was poking and prodding him so much. There were no palpable axillary etc lymph nodes either – but he was a bit warm to the touch still, and when the temperature was rechecked it was 40 again! We quickly started some antipyretic measures while I quickly listed the differentials in my mind. A) It seemed very likely that the tonsillitis was not bacterial (probably) as a sniffly nose and the acuity and high grade of the fever pointed towards a viral upper respiratory tract infection. It could still be a bacterial infection, though, so I wasn’t going to stop the antibiotics. B) I could potentially/probably send the patient home, as even though they did not seem to be drinking too much, they seemed to be weeing as per usual, according to their wet nappies frequency, with advice to sort of force fluids, along with some adequate antipyretic advice and analgesia advice, with followup in the GP surgery, and that if situation worsens or any of the red flag signs appears, to come to A&E instead. C) could it be an infection spread by the bite of the rat? This last bit I honestly did not know – I had heard and studied about (and mcqsed!) about cat scratch disease and dog bites and human bites and tick bites, but I had never in the course of my 5 year study or almost 10 years as a doctor come across a rat bite – my curiosity piqued. I did what everyone does when they are confused about something – I want to say something impressive like ‘I discussed it with my seniors etc etc’ but in reality I … googled it! (I discussed it with my seniors after that, though, who very kindly reviewed the patient, and discussed it with the paeds registrar and admitted this patient to the hospital – the rationale being they still had a fever despite significant attempts by Mum and A&E staff.) But my google search was very fruitful, and I present to you a few bits and pieces about RAT-BITE FEVER (yes, sounds very impressive and a little icky, and it is!): (this information is courtesy of the CDC website, which is probably the most reliable and authentic information out there as it is so aptly named the Centres for Disease Control and Prevention!)

It is a bacterial infection, has two types of bacteria implicated in it: the spirilary (spirillum minus bacteria) type and the streptobacillary (caused by streptobacillus moniliformis) type. It is transmitted by either being bitten or scratched by infected rodents, or with regular handling of infected rodents even without being bitten, or due to ingestion of the pathogens in food/water that is laced with rat urine/feces. It is not contagious. Symptoms include invariably a combination of any or all of the following: fever, vomiting, headache, joint pains, muscle aches, headache, rash, ulcer at bite wound, swelling around the wound and swollen lymph nodes. Can we agree we are ticking off a lot of the boxes for rat-bite fever? Symptoms may begin within a few days of being bitten by a rodent, or may present a few weeks after the bite. Rash is usually maculopapular. There are certain people at risk – like if you have a rat fetish or handle them or keep them as pets or if your local rat population lives alongside your local human population. Penicillin is the treatment of choice – don’t ask me what it is when you are allergic to penicillin! Complications include meningitis, myocarditis, pneumonia and rarely death. *cue ominous music* Prevention is a) avoid rats! duh b)practise good hygiene c) do not put infected fingers into the mouth.

AND THIS IS WHERE IT ALL CLICKED FOR ME WITH REGARD TO THIS PATIENT – HE PROBABLY PUT HIS INFECTED RAT-BITTEN FINGER INTO HIS MOUTH – AND INGESTED SOME OF THE PATHOGENS – AND HE WAS CURRENTLY AN IDEAL CANDIDATE FOR TREATMENT FOR RAT BITE FEVER! Fortunately he was already on the treatment for it – the Paeds registrar concurred with our assessment and the patient was moved to the pads unit.

I reiterate: Learn something new everyday!