The case of the Valentine’s Finger – a confusion about management plans

62 year old male, known to have rheumatoid arthritis, on naproxen for it regularly, attended ED with the complaint of discoloration and numbness of the right ring finger; he turned out to be a lesson in management.

Upon my review at 7AM, the patient had been in the department about 2.5 hours. He reported that he wore heavy gloves (his usual) at work (works in the produce section of Tesco’s) and he removed his gloves at around 1AM and noticed the ring finger of his right hand to be darker coloured than the rest of his hands. It was painless and he didn’t recall bruising or injuring it in any way. He thought nothing of it, and put it down to his glove having rubbed off some color on to his finger. 3 hours later, his manager examined his finger and noticed it was colder than the rest of his hands. He was then advised to attend ED. When I saw him, a good 6+ hours had passed since he first noticed the discoloration. There was absolutely no pain, no history of trauma, on examination, there was a significantly darker discoloration of his ring finger, isolated, also appeared slightly swollen, had full range of motion, and capillary refill could not be assessed because the finger did not blanch on pressure. Radial and ulnar pulse were palpable of the affected arm. There was no sensation loss at the ring finger. There wasn’t any tourniquet effect of anything like a tight glove or a ring. He denied any drugs of abuse, had never smoked in his life and was not allergic to anything. He had no prior history of any such symptom, no prior personal or family history of any clots or bleeding or vascular disorders. To make matters slightly worse, he had injured himself in some accident, causing a deformity of the distal phalynx of this finger, with a rudimentary distorted nail bed.
All his observations were within normal limits. There wasn’t much else of note per examination. Are you on board this thought process with me?

I was at a loss to figure out what was going on and what was causing this patient his symptoms. He felt fine within himself. He actually found it quite funny that I couldn’t figure out what was going on. I went through all differentials of this sort of symptoms, but it didn’t fulfil any criteria for …anything. It didn’t look like an arterial ischemia, because it wasn’t pale, nor painful. It did look like venous congestion, but I could not for the life of me figure out why he would suddenly have an isolated venous congestion of just a single digit. And also, since it had been 6-8 hours since symptoms started, was there anything else I could do? I Decided to seek senior advice.

I excused myself, and went to ask for senior support. I discussed it with a register, who kindly came in, examined the patient, spoke to them, excused themselves and…asked a second registrar (there were no consultants available at that time) He also came in, spoke to the patient,  etc etc… and to the mirth of the patient, all FOUR of the doctors who came in were equally stumped. The last registrar advised after seeing the patient himself to send him home, and to recall to the consultant review clinic the next day, as he felt this was not vascular in origin. I did as I was advised. Documented everything and sent the patient home. Patient was also happy with this plan. Was still laughing as he left, thinking he was some sort of medical marvel (he was!) who had confused all the doctors (he had!)

I still wasn’t happy, as even though we had done all we could, I had been no closer to finding out the how or the why or even the what behind the patient’s bizarre presentation. I then went to the consultant when they came on shift a while later. She did sort of freak out that i wanted to seek advice about a patient AFTER I had sent them home. I told her that I had sought the advice of whoever was available to me at the time, but since that still left quite a few unanswered questions (what why how) I wanted to know what she would have done in my place, or atleast what she would have advised me had I had the opportunity of asking her at the time.

Now thinking about it, and having discussed with the ED consultant, I have a better plan of action: I should have discussed it with vascular surgery, and sought their opinion. I also probably should have considered investigating for a cervical rib, something she strongly suggested.

A cervical rib is an extra first rib, that can potentially cause pressure on blood vessels or nerves as they arise in the arm and may cause symptoms distally down the arm. This case doesn’t really suggest that sort of presentation, but still it would be worthwhile to do it for completeness.
An assessment or opinion from vascular surgery would have been optimum. I did end up speaking to vascular surgery after the patient left, to ask them for further advice. They advised that since they hadn’t seen the patient, they would have recommended ruling out a cervical rib (surprise!), and giving a stat dose of enoxaparin, and sending him home on apixaban, and recalling him in for a vascular surgery review within a week. I discussed this plan with my consultant who for the first time during this whole debacle, agreed with me that anticoagulation in this particular case was not indicated.

In my defence, I thought at the time I was doing the right thing, I was confused as to how to proceed further and so sought senior help from the sources available to me; it was more than one source!

I now know that I had the option of asking for specialist advice as well, which even if I disagreed with their plan would have guided me a bit further and made me more confident in that I had utilised all the resources available to me in order to optimally manage what turned out to be a very confusing patient.

The patient turned up the next day, and the consultant reviewing him went through my notes, but could not understand why I had been so concerned as to call him back for a review. As the patient’s symptoms had somehow magically vanished over the course of 24 hours, all that was left was a slight discoloration – no swelling, no movement problems and definitely no numbness or congestion or schema. Hallelujah!

If anyone has any bright ideas about how they would have managed this case, please let me know in the comments section. I really should start taking pictures of these bizarre presentations, and uploading them here, as for some reason, they do magically disappear and all that is left is my description of it! Anyways, do let me know about your thoughts.

Pearls of Wisdom – what I have learnt, the hard way

  • NEVER request a chest x-ray JUST to rule out rib fractures. It won’t change your management, unless the patient is short of breath or there are concerns for a pneumothorax, then request a chest x-ray to rule out PNEUMOTHORAX – but I repeat, NEVER for a rib fracture. If you put those words in the request form, that may well be the one (and only) time a radiologist will leave their dark dungeons and come out into the light, TO HUNT YOU DOWN AND KILL YOU.
  • ALWAYS have a chaperone present, or atleast offer the patient one, in cases of intimate examinations (PR, breast, pelvic and/or genitalia). Document – name of chaperone, or when the patient declines having a chaperone present, make sure to state that in the notes clearly. A chaperone is for your protection, and not for the patient’s only.
  • NEVER request x-rays for (suspected) broken toes. If it looks and sounds and feels like it is fractured, it probably is.  Before you x-ray it (which you should never do!) you will neighbour strap the affected toe to the next toe, sort of to act as a splint and reduce the pain. THAT is the management for a fractured toe. If you request an x-ray (once again, something you should never do!) you will find that it is indeed fractured, and then proceed to tell the patient that yes, it is indeed fractured but I have already buddy-taped (another name for neighbour strapping) your toe and the x-ray doesn’t really change my management. I will now run away because the radiologist is probably going to kill me now.
  • Always reduce an ankle fracture BEFORE x-raying. If it’s clinically requiring it, you won’t change the management by wasting time with x-rays; you don’t want the patient to lose their blood supply or stretch out their nerve to point of no return while they’re waiting in the x-ray department, do you?
  • NEVER discharge someone from the department on behalf of someone who has given advice over the telephone. They need to physically see the patient and make a judgement. You can ask for advice, but active management issues, and discharge from hospital on someone’s advice, doesn’t stick in a court of law. If they didn’t come down and document they saw the patient and THEN recommended this and that, then IT DID NOT HAPPEN. They will backtrack faster that a patient on furosemide will need a wee. Well, probably faster than that!
  • ANYONE presenting with abdominal pain, or loin pain, or back pain, above the age of 40-45, PLEASE CONSIDER AAA. It is never a good idea to miss anything, but it is a scary-ass thing to miss a AAA when you have been sitting on it for 3 hours.
  • LISTEN to your gut feeling.
  • Ask for advice BEFORE sending the patient home. No shame in asking for an opinion or running it by someone more experienced. But no forgiving the thing you missed that your ego didn’t allow you to question or ask someone for advice.
  • ALWAYS x-ray pelvis in elderly patients presenting with a fall, I have seen patients walking in to the department with a slight limp, found to have impacted femoral neck fractures. Specially patients with dementia or learning difficulties or any sort of cognitive impairment.
  • Be that extra bit more thorough in patient with cognitive impairment of any sort, delirium etc, they are the ones with hidden signs/symptoms that they sometimes can not express in usual ways of communication. Not every patient who is in pain will tell you (or will be able to tell you) that they are in pain. They may be agitated, or fidgety, or moaning, or distressed, or literally crying out every 2 seconds “Help me!” yet when you ask them what they require help with, they wouldn’t be able to tell you. Pay extra heed to them and be very, VERY vary of what you may miss in these cases.
  • Whenever doing bloods/putting a cannula in, always make sure you have a trolley near by or at least a comfortable chair in a private cubicle – patients have a tendency to faint/go vasovagal on you at the touch of the needle, you don’t want them to be flailing around while you have a cannula/needle in them.

    ———————————————————
    WATCH THIS SPACE FOR FURTHER LOVELY NUGGETS OF INFORMATION THAT I HAVE GLEANED IN THE PAST. AND I HAVE LEARNT THE HARD WAY. DO NOT MAKE THE SAME MISTAKES I DID.

Advice that I wish I had when applying or even thinking about applying for EM training

Pre-alert! Boring post with an avalanche of information up ahead, kindly move on if not interested in EM as a future.

I was not always interested in EM. No, unsurprisingly, I used to be interested in surgery. I completed my medical school education in Pakistan, and actually did an elective placement in surgery at a Harvard hospital. WHILE in medical school. It doesn’t get any more committed than that.
Fast forward a few (read quite a few years!) and I found emergency medicine (or it found me, but that’s a story for another blog post – can’t put ALL my ideas in the same post now, can I? otherwise I am not going to have too much of a blog, right?). I did 3-4 years of emergency medicine as a non-training doctor back home in Pakistan, passed my PLAB exams which gave me a license to practise in the UK, and moved here to really try and get into a training post. I got into a non-training trust grade post as an ED SHO, and I have to admit, (credit where credit is due) my experiences in both the department of ED back home in Pakistan, and here where I started and got my bearings in this ED world, have quite a significant part to play in finally landing me this current training post I am in.

My advice to my peers and readers of this blog who are considering or might consider a future in EM to be their thing, is going to be severely bullet-pointed, for emphasis:

Start early. Prepare yourself. Arm yourself with as much information as possible about the program or specialty, about its general requirement and then its finer more intricate details. Look at the RCEM website, speak to college tutors and colleagues who are within the department, glean from them information about the various different pathways available, and what you need to do to get started, and also, of the many pathways available which one is best suited for your unique experiences and skill set.

– Pick a pathway that meets your requirements (or vice versa, you meeting its requirements, it’s all one happy marriage!) and set to work fulfilling the criteria for application. Now there are usually two sets of criteria for application to these posts: the mandatory, or absolutely necessary requirements, where if you apply with even one criteria missing from this list your application will go directly into a large waste bin the size of Suffolk that has accumulated many a CV since the olden days; and the lesser known and hence considered less important (but can be the difference between being offered an interview and going into the reject pile) preferable criteria, which aren’t mandatory, but if you have one or more of these, your application becomes a lot more likely to be considered over someone who say, has all the mandatory requirements but none of the additional preferred ones. Most important question? Where do you get this information. Ask around, read a blog (!) or google search ‘Person specifications for application to EM training‘ followed by the year when you will be applying, as they tweak the requirements every year. Look at the criteria now, and make a list of the things you have, and a list of things you still need to work on.

– Then decide on a timeline: is it achievable by application deadline this year? Ask yourself, is it really worth applying this time round with minimal criteria? Or can you look a bit better (atleast on paper!) next year and have a better chance? At any rate, if you have all of the mandatory criteria, it can not hurt to apply. If nothing else comes of it, then you can atleast consider it a learning experience, filling out the application and making yourself aware of the timescale and what needs to be done etc.

– Get a few things out of the way, as soon as possible. Get a National Insurance number, make sure you have at least 1 major course out of the way, ALS always helps, wherever you are applying, even if it is a non training course and I mean, come on, it should technically make you feel good about yourself and give you the confidence to handle a critical emergency, should it suddenly arise while you are let’s say standing in line at the Costa in the hospital and the woman in front of you collapses. Yes, ALS is definitely a plus to have on board, but do consider doing at least one other course – ATLS or APLS, or even the European versions of them – depending on availability, and your calendar of events for the rest of the year, your study leave and your budget. Never underestimate budget restrictions and always have that in the back of your mind. You can’t book an exam or a course or…do anything essentially if you can’t afford it. Also, make sure you are a member of medicolegal indemnity/insurance organisations like MDS or MDU.

Look at exam dates, if there is an exam requirement, make sure the exam requirement is met, atleast you should make an effort towards it (an honest effort, not just applying for an exam just so you can let someone know that yes I will be appearing for this exam, but I intend to party my free time away!) Factor in exam prep and study leave for an exam and travel and stay expenses if the exam is out of city, which it usually is. Also factor this in with your plans to participate in a course like ALS, ATLS etc, so that these don’t clash.

– Looking at the list of person specifications, you will notice that every requirement has an indication of when it is infact required by. So it will say, for example, that A is required by the time of application, and B is required by the time of interview, and C is required before the start of the program. So you can factor those elements in, and change the timeline of your requirements as needed.

Audit. Audit. Audit. Re-audit. It is so important, not just as a requirement for your application, but also for your GMC appraisal etc, and for your own growth as a physician, to participate in some form of quality improvement projects, from a minor audit to actual active research, anything that may serve to improve patient care from any aspect in the future. The topic of the audit can be relevant to your specialty, or a general one, or just any specialty actually, but what people tend to ignore is the fact that an audit is not just a tick-off-from-a-checklist-and-forget-about-it-now-that-I-am-done thing, but you should create a timeline where you spread the findings from your audit like the joy it will bring (it will not) to everyone concerned, for example your department staff, and let them know how to improve things. Keep reiterating the how-to-improve-things and keep reminding them till you achieve a little things-have-improved situation. THEN YOU RE-AUDIT THE WHOLE THING AGAIN, after a certain time period to allow for improvement, see if there is any improvement. You could re-audit it again, and again. Interviewers and the people considering your application want to see commitment to a goal, and what better way to show commitment than to keep trying to address an issue that you think is a problem and can be improved. Speak to your supervisor or any consultants, they will be glad to receive some help in some ongoing audit or you could give an idea for an audit of your own.

Get started on an e-portfolio, and started getting any and all competencies signed off as early as possible. What you do matters, and make every bit count. If you have intubated 500 patients, but can not provide any documentary proof of it, then you will be second to the person who can show signed competences of having done even 25 intubations. MAKE EVERYTHING COUNT. Read more about this here.

While this is in no way an exhaustive list – it is still a work in progress and I have still got so much to learn – but I do feel that this list forms the basis for entering into any training post, not just emergency medicine. You could embellish your CV in any way to make it better suited to a certain specialty – but these particular little things form the crux of any training application.
In the end, I would like to add a forgotten little adage: “Anything worth doing, is worth doing right.”
So make sure you do it right. Good luck!”

 

(WATCH THIS SPACE FOR MORE POINTERS, I WILL COME BACK AND EDIT THIS AND ADD SOME MORE THINGS.  THIS IS AS MUCH AS I COULD TYPE FOR NOW, DADDY DUTY CALLS. MY SON IS TRYING TO TYPE onNTHELaptopsh and canhtwriteakh anyFURTHer862mx..

An interesting case – if I had just connected the dots

Always probe more. And I mean it in the inquisitive, analytical way (but I appreciate the way your mind works! *wink wink* *nudge nudge*) Never take anything for granted, and if you feel your gut telling you something, it might be a good idea to listen to it.

Case in point: I was on a clerking shift a few months back during my Acute Medicine rotation. My next patient was a 37 year old female, who had presented to ED with a headache of 2 days duration, and ED had referred her to medicine for admission because of her very significant past medical history. 1 month ago she had suffered a stroke, an ischemic infarct. Yes, I found that very hard to believe as well so I looked through her hospital records and sure enough she had had an infarct in one of the areas of her brain, leaving her with significant left sided weakness, a weakness that had since then improved quite a bit, but she still required a cane to walk, otherwise she was fully independent. She also was on a significant amount of pain medications due to degenerative disc disease , and she had long-standing sciatica. She also had a long-standing skin condition, that I was unable to ascertain, and she did not know the name of. She had recently had that biopsied and was still awaiting the results of that biopsy.

Her admission today was indicated because her previous stroke had begun with a nasty headache in a similar location. It began 2 days back, and even though she noticed no new neurological symptoms, she sought help from her doctors, who referred her to ED, who referred her to us. Something did not set quite right with me and I probed further, asking about any early pregnancy losses etc (yes, I did think about the antiphospholipid syndrome, it was on my differential list for a young patient with thromboembolic phenomenon like a stroke, and I was looking for other clues to reach a conclusion). She told me she had 1 daughter, 5 years old, and that the daughter was a twin, and her sibling had passed away during or just after delivery. And here I must admit I stopped the probing nature of my questions, and did not ask about any further pregnancy losses, I just assumed since she told me about the loss of a child, she would have mentioned any other such incidents. I advised some pain killers and a CT scan, baseline set of investigations.

Enter my consultant, who was coming in to do the post-take ward round. I briefly told him the summary of the case. The first question he asked was, any previous early pregnancy losses. I said no. He went in to her, asked her the same question directly. To which she nodded her head and informed us that she had had 2 miscarriages early trimester, and that her maternal uncle and aunt both had DVT/PE and maternal grandfather had passed away after a massive stroke at age 47. On examining the patient, the consultant noticed the rash, commented on it as being very likely the livedo reticularis that is seen in cases of antipospholipid syndrome, and turned around and gave me a look which clearly meant to say ‘We will investigate further, but I have no doubt that this is antiphospholipid syndrome.’

We called in haematology, and rheumatology, who agreed with us. We sent off a panel of studies including anticardiolipin antibodies and lupus anticoagulant. And started the standard treatment for it.

I almost missed this case because I did not probe further, when I knew I was on the right track. Granted, I did not know about the rash being classical for it, but I was still headed in the right direction, till I backtracked because I took information for granted.

Hello world!

Greetings! New blogger in da house, what?!

Three days. That’s when I had this sudden bright idea (read ‘overheard my wife and sister-in-law talking about the benefits of blogging’) of starting my very own blog. I do, after all, have some interesting stories to tell.

I am a doctor by profession, and my chosen poison or…errr…specialty is emergency medicine. Yes, all the stories you have heard are true. We not only deal with the mundane cardiac events and road traffic accidents and strokes, but we also deal with the very interesting (and not so mundane!) foreign bodies in weird places that you ‘accidentally fell on to while climbing a ladder in the middle of the night naked and that’s how it ended up in my bum’. Very classy, and we totally fall for it. Not.

I also have an almost-2 year old, and the combination of sleepless nights due to daddy duty, and that of my lesser evil but equally exhausting shift work that I do, leads to quite a collection of interesting … incidents, shall we say? Some of them I would not breathe a word to anyone, and others, well let’s face it, they do make for great dinner party conversation.

So here I am, sharing my wisdom (or lack thereof). These are my stories, memories, anecdotes, reflections and thoughts – the inner rantings of a 30-something budding (balding?) doctor, trying to be an emergency physician, while also trying to dad.