Bones, stones, groans and psychic moans

Since my secondary school days, at the beginning of each day, I will decide if a day is going to be a good or a bad day. If it is going to be a good day, I'll be as productive as possible and make risky decisions. If it is going to be a bad day, I will keep my head down and let the day would pass uneventfully. I decided that last Wedsnesday was a bad day on the morning ward round. I knew the theory of the hernia orifices inside out. But when the consultant asked me explain and draw it on a piece of paper, I confused myself (between the mid-point of the inguinal canal and the midinguinal point) and consequently made a fool of myself in front of the entire surgical team. All day everyone from house officer to registrar was teasing me by saying 'so have you learn the hernia orifices?'

Just when I thought of leaving the unit, this lady comes along for me to clerk in. She presented with a week of lethargy, general malaise, constipation and left sided abdominal pain, and the GP sent her in because he was worried of her very high (>100) WCC. On examination, I found a mass on the left abdomen and in the rectum. As well as the physical signs, I thought she was withdrawn with a general apathy and was slow to answer questions. I thought something was really wrong, along the line of haemotology or GI malignancy. The registrar reviewed her and agreed with my findings. He told everyone that he was impressed that I managed to pick up the signs as they are quite subtle. To add to the excitement, the lab later on phoned urgently to inform us that this lady's calcium was 3.9 (sky high!). This is a medical emergency that surgeons are not used to dealing with, so they double checked using the internet. We then realised that this lady has essentially presented with symptoms and signs of hypercalcaemia, well, not really bones and stones but certainly groans and psychic moans! How exciting! Never thought a line like this in the bible of medicine (Oxford Handbook of Clinical Medicine) actually occurs in real life!

Since I am discussing this, I'd also like to talk about the nurses. Some junior doctors recently told me that nurses are stupid. And I thought what a very rude thing to say, not least because most of them are much more experienced than us when we just qualify. Now I can kind of understand what they mean. When this lady come in with a WCC of >100, the nurse wrote in her admission notes ?sigmoid abscess (I don't know on what basis because there wasn't a GP letter, maybe based on her left abdo pain and high WCC?). She said to me that she is septic and we need to get her onto the septic care bundle (a set of tick box protocol for patients with suspected sepsis). That was even before I had a chance to assess this lady. She shoved that form to me and asked me to take blood for lactate and blood culture as dictated by the form. After seeing the lady, I looked at the obs and the blood result, and along with the clinical picture, I thought sepsis was unlikely. When I expressed my opinion to the nurse, she patronizingly said 'It doesn't matter love, I've checked with the registrar'. Well, she's conveniently not informed the registrar that the lady is apyrexial and was haemodynamically stable with no sign of sepsis whatsoever and her main worrying symptom was the general malaise. I was bullied by this nurse into sticking multiple needles into this poor lady to fulfill these septic bundle tickboxes. When I then went on to present the case to the registrar, and he agreed that this lady was not septic and doesn't need to go down the sepsis bundle route. I wish I could smirk at this nurse and said 'I told you so' to her. Nurses doing the doctor's job is currently a big debate among the medical and nursing community. I personally think doctoring (ie decisions on diagnosis and management) is best left to doctors for many reasons, one being diagnosis and treatment is not as easy as ticking boxes.


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