Guest Blog Post by Dr. Hassan Alraee – “My MRCEM OSCE Experience”

This is our second guest blog post from esteemed colleague Dr. Hassan Alraee – Emergency Medicine Registrar (Ireland). I take no credit for the following text.

Dear Colleagues,
I am sharing my MRCEM OSCE experience with you guys as I realized while preparing for the exam there was not much guidance available online. The aim of this post is to familiarize everyone with what the exam entails and a few tips which may be helpful in your preparation for the OSCE.
This may not be a structured or typical guidance post, it may come out as a random collection of thoughts but I will try my best to note down everything that was helpful to me during the preparation for the OSCE.
First of all to be eligible to appear in the exam you need to have passed the FRCEM Primary exam, passing the FRCEM Intermediate SAQ exam is NOT one of the eligibility criteria. However, in my experience passing the FRCEM Intermediate SAQ exam gives you a baseline in theoretical knowledge that is required for the OSCE. So it would be ideal to attempt the exams in the sequence that has been set, i.e. Primary, Intermediate and OSCE.
Before beginning your preparation for the exam have a look at the MRCEM Information Pack available on the RCEM website. A list of study material that may be helpful includes;
1. MCEM Part C: 125 OSCE Stations by Kiran Somani
2. Mastering Emergency Medicine: A Practical Guide by Mathew Hall
3. Bromley Webinars
4. At least 1 (if not more) of the following courses; The London Clinical Course, The Bromley Course or the Manchester Course.
The exam itself feels like a daunting task during the preparation phase as it is completely different to the previous parts and reading books alone is not the best way to get through it. My advice would be to stick to one of the above mentioned books and go through it once. The next step would be to create a practice group which should comprise of at least 3 members. This would mean all 3 of you would be able to rotate through different roles during the practice sessions, i.e. The candidate, The actor and The examiner. In my humble opinion this practice group is the key to being successful in the exam. The final step would be to book one of the above mentioned courses. In order to maximize the courses you need to be fully prepared for the exam by the time you attend the course and treat it as a Mock Examination.
Each of the courses has their own pros and cons but all of them are helpful in preparing you for the OSCE.
Each OSCE comprises of 18 stations, 2 of which are rest stations. The exam does not test your theoretical knowledge to a great extent, the stations in the OSCE are designed to test various skills. Like all OSCE exams there is a fair degree of play acting and exaggeration of your daily practices is required. By this I mean that the examiner will only mark you on the actions you perform during the exam, so make sure you show every step and tick most boxes in the examiner’s checklist.
The basic outline of the stations encountered within the OSCE are;
1) There are 2 to 3 history taking stations, remember to complete the station by giving the patient a management plan based on the history.
2) A Systemic examination station (CVS, Respiratory, Abdominal, Cranial Nerve or Peripheral Vascular examination)
3) A Joint examination station (Hip, Shoulder, Knee, Back, C-spine or a limb examination)
4) A Breaking Bad News scenario
5) There are 2 or 3 teaching stations which may include teaching a procedure or examination to a student or a junior doctor.
6) There is always a Conflict Resolution in the OSCE as well, which may be a missed fracture or pneumothorax or a difficult referral. This station also includes talking to a patient with Alcohol Dependence or Binge Drinking.
7) 2 scenarios within the OSCE are always Resuscitation Scenarios and test your skills in ACLS, APLS or ATLS. These stations seem like they are the most difficult ones while preparing for the exam, but in my opinion you can easily pass these if you make a good approach towards resus stations during your practice sessions. The Key to the resus scenarios is sticking to the ABCDE approach.
8) ENT and Eye station; in the exam they can check your knowledge on these in various ways it can be a simple otoscopic or ophthalmoscopic examination, teaching may be incorporated into it or history taking could be tested but there will always be a station that will involve ENT or Eye.
9) A quick assessment station; this one is a tricky one, it usually has the task of taking a short history, performing a focused examination and formulating a management plan based on your findings and summarizing it to the patient.
10) An Information Providing station; this station usually involves a relative of the patient to whom you have to explain a new diagnosis or management of a medical condition. Juvenile Diabetes Mellitus and Addision’s Disease are 2 examples that I can recall.
11) A Psychiatric Station is always present in the OSCE, you may be asked to performed a Mental state examination on a patient or assess suicide risk, they may add a conflict resolution component to this station as well.

In my opinion if you divide your preparation according to these 11 types of stations you will be able to cover most of the things required to be successful. Some additional topics that are tested in different ways and I haven’t categorized under the stations include; DVT, major incidents, seizures and driving advice. It would be wise to look up the NICE guidelines on these.
I would also suggest that you reach the city where the exam is being held one day earlier and have a look at your examination center that day. Just so you know how long it takes to get there and don’t have the extra stress of finding the center on the morning of the exam. Please spend your last 2 days traveling and relaxing, there is no point in trying to cram in stuff over the last 2-3 days as this is not a theoretical exam where they expect you to know everything.
On the exam day itself it is understandable to be anxious and stressed and believe me the examiners know that the candidates are under pressure and are not there to fail you. You should know that staying cool and calm is the most important feature that will enable you to be successful. It usually takes 1 or 2 stations to get into the groove of the exam as the 1st station comes up it is normal to feel a little nervous or blank out temporarily. Do not act bold and wing it if you are unsure about something, be safe at this stage and say you are unable to recall at this point in time and that you will consult the department policy or your consultant before implementing it.
Do not worry if any of your stations don’t go as well as you expected them to, leave the previous station behind you and move on to the next one. Do not let your performance on the previous station affect your performance on the next one. I know this is easier said than done but it has to be said as it is human nature to dwell on the past. You should also know that there is not a minimum number of stations that need to be passed to pass the exam, that was how it used to be in the past. The marking scheme has changed to a cumulative score now and a different passing mark is set for every OSCE day so even if you fail a station you carry forward marks from it towards your overall score. Therefore it is imperative that you score marks for the basic things on each station. Some of these include greeting the actor, washing hands before and after examination, wearing personal protective equipment (or at least mentioning it to the examiner), being warm and courteous and thanking the actor at the end. These simple things may be the difference between a pass and fail score in your OSCE.
I hope it was helpful for all those that are reading this post, good luck with your exam, with a bit of structure and practice I’m sure you will pass the OSCE.

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.

Anesthetics introduction – teaching day

(very rough edit of the knowledge gained from this teaching day – will edit by tonight.)

Introduction given by first speaker – (I missed out the first 10-15 minutes of it, maybe longer, was searching for parking) Gave a few pearls of wisdom, in particular, the Royal College of Anesthetics e-learning website link

2nd speaker – Difficult Airway
objective is to oxygenate – help with ventilation
can be by mask, tube through nose or through mouth, or through trachea
airway assessment — HISTORY -check for pathology – burns etc, identify previous anaesthetic history, charts etc, visualisation of laryngoscope views – grades
clear is grade 1, partial block is grade 2 (take home message was that 1+2 easier) EXAMINATION – multiple airway assessment tests – none accurate enough – 5 things most important to be done – 1)-how likely to face mask ventilate, tight seal etc, facial trauma, elderly, dentures, sunken face, high BMI, snorers/sleep apnea – /2)-mouth opening – 3 cm magic number, estimation usually, LMA/laryngoscope fit, foreign objects, tumors, masses – 3) – neck movement ‘sniffing morning air position ‘ flex neck, extend head trying to align the axes for optimum visualisation, 4)-malampatti score (4 classes – first gen reassuring. upright,mouth maximum open and tongue protrusion max, visualise tongue, posterior, uvula, tonsillar pillars
DAS difficult intubation guidelines – 4 plans need to be aware of
(5)-cricothyroidotomy explained theoretical but not practically ever used – worth knowing in case ever required – explained cartilages etc and neck surface anatomy – I noticed everyone palpated their neck involuntarily, including me!)
priority is ventilation not intubation – whichever way that may be achieved

3rd speaker – PRE-ASSESSMENT
HISTORY (what surgery, elective/emergency, major/minor, PMH, systemic review, medications, allergies, anticoagulants, any prior problems with anetshetics/personal or familial – any surgery to same site, starvation time, risk of reflux, dentition, how they have been in last few weeks, assessment of fitness (climb upstairs) , less than 4 mins exercise tolerance is not good for anaesthesia/ EXAMINATION (gpe, murmurs, chest, vascular access, airway, the back, high BMI, positioning)/INVESTIGATIONS (confirm, assess or alter risk – depends on patient)/MAKE A PLAN (think about conditions cvs -heart failure,aortic, mitral stenosis, ACS/MI within 3 months; fracture NOF)
Preassessment is your own personal way to do things, no perfect way: “there are many ways to skin a cat” (!!!)
patients risk of undergoing surgery/undergoing anaesthesia (?high risk patient, ?high risk surgery, ? high risk anaesthetic) for each problem identified, has it been optimised as much as possible, or how can the risk be reduced/optimized, and do you need to change your plan.
PLANNING
– pre-operative – optimisation any more investigations, treatments, fluids/inhalers etc, ask for help if needed.
intra-operative – technique, induction, maintenance, wakeup
post op

CONSENTING THE PATIENT – Royal college website (anesthetics rcoa pils) details consent information for any medical condition/procedure
complications – sore throat, dental damage, cuts to lips etc, pain, nausea, anaphylaxis, death, loss of airway, awareness and regional complications – low bp, particularly with obstetrics, itching, urinary retention, headache, failure of procedure, infection, bleeding, nerve damage (1/50000 spinal, 1/13000 epidural)

4th speaker(s) – scenario enacted by actual anaesthetic consultants and fellows from the department – to give an idea about how things go in theaters. walking though an actual scenario – from introduction, consent, explanation of steps to patient, end tidal co2, patient under, putting tube in under vision – grade 1 view – inflating cough, good chest rise – end tidal trace, fix tube. looking at the monitor —–smooth induction

5th speaker – anaesthetic drugs
induction agents – 1)propofol -lipophillic, stings a bit, onset 20-30 seconds, 2-3mg/kg generally 300mg given, bradycardia, propofol infusion syndrome 2)thiopental -4-5mg/kg onset 10-20 seconds, tachycardia
muscle relaxants – neuromuscuar blocking agents – depolarising (suxamethonium, succinylcholine) and non depolarising (atracurium, rocuronium, pancuronium, vecuronium)
inhalation – no2 (not very common), sevoflurane, isoflurane, desflurane
reversal – anticholinesterases (neostigmine usually, sugamamadex – newer drug)
other drugs
MAC – minimum alveolar concentration of anaesthetic agent which is required to prevent movement in 50 percent of patients.

6th speaker – anaesthetic equipment

LMA – must have absent airway reflexes, cuff deflated, muscle relaxant not required – but is not a definite airway (vomit, aspirate)
i-gel – preferable
ETT – SIZE – 8 FOR MEN, 7 FOR WOMEN, AGE/4 +4 PAEDS – definitive airway
uncuffed for smaller children; RAE tube – out of the way of head neck surgeries.
bougies – angle tipped rubber tube, aid intubation
laryngoscopes (under direct visualisation)- mac (size 3 adult, size 4 for large adults), mccoy (lever to lift epiglottis), miller (paeds)
indirect laryngoscopy -in cases where visualisation is not optimum. e.g. airtraq, mcgrath (video laryngoscope)

breathing circuits –
APL VALVE
Bain circuit – most commonly used
BMV – AMBU BAG
WATERS CIRCUIT

Anesthetic machines
PENLON NUFFIELD 200
draeger primus – main anaesthetic machine
explained the charts etc – lots f abbreviations lots of number, lost of values and waveforms and colours – confusing but will become second nature to us! reassuring? not really!

7th speaker – chat with an ODP who tells us about his experience and his duties and what is required of them and of us – they check the instruments, the machines prepare trolleys, the tubes, the drugs etc for each interaction – make sure everything is clean or new or usable, batteries etc, lights of the laryngoscopes etc, and going through the checklist, who’s checklist – (something that he asks the whole room if they know about and they all say yes, but I have never heard of. yikes.) they also offer suggestions, ideas, but the final responsibility of what is happening is the anaesthetists. they won’t draw the medication, they won’t give meds (unless emergency situation) here to help you, work with you and make sure your training opportunities are met and are fulfilling – someone asked what pisses you off – lots of laughter – nervous, me thinks?

8th speaker was just the first speaker again – qualified the previous talk with “know your ODP, they will be your best friend”

BREAK FOR LUNCH (not provided *frown*)

Coming back in from lunch to another scenario that started off as a smooth induction but then went on to become a critical incident (penicillin administered to a patient with no known allergies – while undergoing surgery) – some hilariousness ensued as the “surgeon” put her hands up when the patient became critical and watched as the “anesthetist” dealt with it all, even exclaiming “oh is that what is done?” when the anesthetist administered epinephrine as part of the anaphylaxis treatment. *titters of laughter*

9th speaker – vasopressors/pharmacology
background – vasoconstriction, inotropic effect, sympathomimetic – alpha 1 blood vessels, beta 1 in lungs, beta 2 are in lungs, blood vessels
indications – hypotension due to whatever reason – treat if >30mm hg drop from baseline systolic BP or MAP <60, or any evidence of hypo perfusion/end organ damage – always fluid resuscitate before chronotropy.
most commonly used agents – ephedrine (synthetic sympathomimetic), metaraminol (mainly alpha effect, can be given peripherally, reflex bradycardia) and noradrenaline (usually for very sick patients in profound circulatory failure, both alpha/beta actions, needs to be given via central lines)
others – adrenaline (all adrenergic receptors, asystole, anaphylaxis), dobutamine (beta 1 agonist – cardiac effect, should be given through central line), dopamine (central neurotransmitter)
Points to consider -access : peripheral vs central ? arterial line if needed, boluses, side effects, tachyphylaxis (with long term treatment, receptors become desensitised), arrhythmias

another qualification from speaker 1 who I feel might be the head of the department or atleast leading this day. “These drugs are your best friend!”

10th speaker – one of our peers from an ACCS program currently rotating in aesthetics/itu somewhere : hemodynamic monitoring
NIBP, HR, pulses, mental status, etc do the basics
Invasive – ARTERIAL LINES (continuous BP monitoring, trends etc with drug administration, ABGs, posy-major surgery) commonly put in the radial artery (always do the allens test) discussion of types of art lines followed by a discussion of how to put up and put in an art line (OFF TO PATIENT OPEN TO AIR), complications (air emboli), can stay in for a week; CENTRAL LINES (cvp measurements, medications that can’t be given in peripheral lines), goes in a big vessel, should all be usg guided, patient positioning important, aseptic non touch technique, explanation of the technique (excellent explanation and demonstration, including usg) followed by blood gas, transduction image and a car – also discussed complications, how to measure cvp (normal cvp 0-8) – web links provided – frca
session in the middle about us being able to handle the instruments and ask questions

11th speaker – introduced himself as the last speaker of the day (thankfully!) with 9 slides to his presentation and the first slide was his name and he reported the last slide is thank you and any questions.
analgesia – definition – unpleasant sensation associated with emotional connotation related to tissue damage
types/managements/etc etc This part was particularly vague for me as I was just checking the clock by this time, looking forward to the long drive home.

Sometimes it is the smallest things that make you the saddest

Ever notice how you can go on being an automaton, robotically engaging in work stuff, moving from one patient to the other, each one a statistic on your ever growing list of patients to see or having had seen – no interaction long enough to actually create a connection other than that of patient/doctor and you professionally enter and exit the cubicle and move on to the next job, next patient, or indeed next shift. And yet sometimes it does happen that something hits the mark, and there is a chink in the armour, the professionalism slips (not outwardly, but it surprises you that you feel something other than empathy towards the patient in front of you – you really look at the patient, not as just a patient but an actual human being with feelings, and thoughts start milling around your head – or your heart? – and you think of the patient’s feelings, their desires and weaknesses, the consequences of their actions – and you realise with a jolt that you are not an automaton, that you are, indeed, human.

I am usually a happy presence at work (if I may say so myself) but I was having a particularly ‘smiling-from-ear-to-ear’ day a few days back. A recent couple of professional achievements, along with being well rested from a full night’s sleep meant I was walking around with a bit more bounce in my step. I was working a late shift, but from the broad smile on my face you would have thought I was about to go home on a 2 week holiday! (I was not, but yes, I am a bit weird – I actually have fun at work!) – I was assigned to see paeds patients in ED, all the minors, majors, ENP ones etc – and I was going about my day when the consultant asked me to come out of Paeds for a bit and see the next adult patient, who was already at 3 hours (that much time had elapsed since she had come in to the hospital) – the brief note from triage nurse said that this was a young female between 25-35 years of age, who had come in with a self harm injury or injuries – she was categorised as a ‘yellow’ which meant there was no imminent threat to her life but she did warrant a thorough assessment.

Treatment/management of such cases is usually 2-pronged: one, manage the obvious injury or insult and treat the current presentation, and two (and more importantly) try to deal with and manage the longterm/shortterm psychological aspects of the presentation (not an ED thing but there are certainly specialist who are better equipped to deal with this and who very kindly assess and evaluate patients from that perspective after they have been treated from a physical ailment point of view. So anyway – I went in to see the patient – it had been mentioned in the notes that she was accompanied by her support worker – but the woman who stood up when I announced the name in the waiting area was alone. And she stood up at once and followed me into the cubicle to be assessed, along the way I introduced myself, and thanked her for her patience in waiting. She was extremely polite, and even offered me a smile, but she kept looking anywhere but at me directly. I asked her what had brought her to the ED that evening and she matter of factly stated that she was here because she had self-harmed. Again. She did not seem to be in any sort of pain, so I assumed (wrongly) that she had a superficial sort of wound that wouldn’t really require too much medical attention. I smiled at her and said something along the lines of ‘well, let’s see what we are dealing with here, and I will try to help you any way I can.” She exposed her left arm unto her shoulder, and I took off her temporary dressings from her upper arm (above her elbow) – while I was doing so, I kept making small talk, and registered the many, many scars from previous self harm attempts there before me were 4 very large, very long, and VERY gaping full thickness lacerations to her upper arm. In places where normally the skin/muscle sags a bit, it was really using the lacerated margins to gape quite widely. The patient had something like an hour left before they breached? NO WAY was I going to be able to administer local anaesthetic AND suture all 4 of these wounds in under an hour. Alone.

This patient completely threw me off my game. I have closed wounds in numerous ways, and in all sorts of weird and wonderful places – I have once years ago even raced my mentor consultant orthopaedic surgeon in bilateral knee replacements to see who closed up their respective knee first! – But this time was different. This patient was different. And the reason will become apparent up ahead.

I called my consultant because he may have been under the impression this was a quick ‘tape-wound-shut-refer-to-psych-move-on’ kind of situation – he stepped into the cubicle and hemmed and hawwed. I was silent throughout. This felt like an operating table scenario with a patient’s body cavity open up in front of me – The smell was exactly the same. Flesh. Blood. Sadness.

Right then, the consultant asked me to stitch the wounds up – I gave the wounds a good thorough clean with some saline and the patient did not flinch. She did however, apologise quite sincerely for wasting my time. I will not go into the details of why she thought she needed to do this today – absolutely no judgements to be passed here on that account. But I did assure her she was well within her rights to be there. I said I would go calculate the amount of local anaesthetic require and get it and get it all ready – and her polite demeanor stiffened up. She absolutely refused any local anesthetic. She said, and I quote: ‘ I am not here to waste any of your valuable resources. Please use them for someone who really deserves it – and anyway, I am not in pain and the stitching can’t hurt me more than I have done myself – also (and I was surprised that she knew this) the amount of local anaesthetic required would be a bit too much and wouldn’t be safe for me – and it would wear off by the time it was done being administered!” She was right on all counts – but I requested my consultant to give me an opinion, since she had me absolutely flummoxed. He agreed, no need for the anaesthesia – and that I would achieve better results with a skin stapler rather than suturing the wounds. I had never used skin staplers outside of an OR before, and never on a patient who was conscious and sitting up and talking to me and FEELING THE STAPLES GOING IN! I took a few deep breaths. Got the stuff ready. Took a few more deep breaths. And a few more. And dove in. I put in upwards of 45 or so staples (yes metallic pins sharp enough to stab through the superficial tissues of skin etc and pull them close to optimise wound healing) – did I mention the wounds were exceptionally gaping? Each staple gun comes with 30 or so staples – and I had to use a second one about halfway as well. Wow. My mind was already blown after the first 2-3 staples. But I went on putting more in. I did my best – and to her credit she did not flinch. There was silence. And that smell. And sometimes she would talk to me.

She kept thanking me, and apologising to me, and kept pushing her other hand through her hair as if berating herself mentally. She told me she had a masters degree in something (I forget what – my ears still start ringing everytime I think back to that cubicle) and we chatted about how I wanted to pursue another degree, maybe a masters of some sort and hadn’t quite decided what. She guided me about which staple to remove because it had been bent at an awkward angle due to how gaping the wound was initially, and so when I had ‘scaffolded’ it with staples next to it either side, I removed the offending staple and put another one in. Like I said, she didn’t flinch. At all. She kept that small polite smile in place, was very respectful and I learnt something new about myself that day. That this had gotten to me beyond what I can express here or anywhere. I had seen dead and dying people almost on a daily basis. People in pain, people vomiting with pain, people trying to process bad news or loss or a shock. I have been the villain in so many stories in peoples lives – the bringer or the news that someone they loved had passed away, or what the reports had shown or why we feel that further aggressive measures would be futile – But I had not been affected by those things as much as this calm young woman had affected me. What about her affected me? Nothing about her situation. It was sad, no doubt. But what really affected me was what I realised about myself: I judge people, I am cynical about them, about their diagnoses, about their mental health problems – I never fully appreciated that when someone comes in to hospital following an overdose or some deliberate attempt at self harm, I focus solely on the physical aspect of the case, and let someone else deal with the mental/psychological/psychiatric aspect of it. But this time, I was metaphorically chained to the situation I usually avoid and judge as a spectator – and I could not escape how normal this young woman appeared. She was well read, had a grace and calm in her manner that belied a good upbringing – yet she was obviously in this mental pain and it got so severe sometimes that like this day, the thought of cutting herself and so brutally was her only way to cope with it, and possibly caused her less pain that she was already in. And to be able to get sutures or staples without any anaesthesia on board – how remarkably strong a pain threshold would you have to bear that? Or that you were so used to it that this was all just commonplace occurrence to her. And this wasn’t even the worst part. The worst part was that this was neither the first time, nor (we both knew) the last time that she went down this route. I could help her physically, suture/staple everything – but did I actually do anything at all to really, truly help her?

So like I said – we are usually automatons, going about our daily drudgery – and then one day a patient really opens our eyes and makes us sit back – and question …absolutely everything we know and believe in and understand. Or don’t understand.

(Edit: The rest of the shift went by in a blur or a haze, I don’t know if it was all too fast or all too slow for me. I am I think back to my usual self now – albeit with one difference. I am maybe not so quick to judge – and maybe not so quick to dismiss mental anguish based upon my perception of the physical consequences of that mental anguish. I admit to not knowing enough – and hope I can change my practise in a way makes all of this worthwhile.)

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!