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Wood for the trees!
  1. Colm O'Mahony
  1. Countess of Chester Hospital NHS Trust, Chester CH2 1UL

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    “You want him seen in Casualty, come down and see him yourself. It's wall to wall grannies on trolleys down here. It will be ages before any of us get to see him, so just come on down—it's your patient.” Oh dear! Don't they know I'm allergic to A&E. I never did a proper A&E job, and the place has always filled me with trepidation. Even as a medical registrar or as an SHO in Gynae, I always felt like an unwelcome intruder, conscious only of not knowing where anything was, and fully aware that the staff looked at me with that kind of look reserved for men in a clothes shop when they can't fold the jumpers back the way they were before they took them off the shelves.

    Two hours earlier, Nigel, one of my long term HIV positive patients had phoned through to the clinic to say he felt extremely unwell, with abdominal pains. He had chronic hepatitis B&C, among other difficulties. I, of course, told him to phone his GP and ask for an urgent home visit. I get on well with the local GPs, and like to involve them intimately with the HIV care. Nigel, however, phoned me an hour later, saying he had phoned his GP, but it would be another hour or two before he could be there, and now he felt as if something had snapped inside, and he was even sicker. I told him to hang up, I'd phone an ambulance and get him brought into Casualty.

    Oh for the luxury of a specialist registrar or even an SHO—I'm too old to be subjected to the frantic chaos, panic, and excitement of A&E. Anyway, there he was, in a wheelchair, obviously in severe distress, gasping in the Entinox. Eventually, some granny got displaced on to a proper bed and I had the luxury of the trolley in a cubicle. Nigel's anxious boyfriend accompanied him, calming him as much as possible. I suspected it might be something infective, and the pain seemed mainly in the right upper quadrant, so I was worried about sclerosing or ascending cholangitis. A plain abdominal x ray was normal, so I asked one of the radiologists to come over and ultrasound the liver and gall bladder area, which he duly did. This was disappointingly normal, so I suggested he ultrasound the renal areas. “Try the spleen,” I said in desperation—normal. Bladder—I tentatively inquired, “also normal, and that's enough of that! I'm back over to radiology where I was in the middle of a list anyway—bye!” My patient Nigel was now in obvious distress and sweating profusely. So was I. I had been an hour in that cubicle and was no nearer a diagnosis. There were also irritated mutterings from outside the cubicle about how long was he going to be blocking up A&E.

    The boyfriend, who had been sitting patiently through all this chaos, eventually suggested, “Dr O'Mahony, it couldn't be his appendix could it?” Appendix, appendix—of course! “Tell me about that pain again Nigel. Where did it start?” “Oh, it started there and then moved there.” “Oh, I see, and you've never had your appendix out?” Rigid abdomen, rebound tenderness—“Get the on-call surgical SpR down here fast.”

    The SpR was delightful. Just one or two questions, put her hand on his tummy, and beaming at me said—“Well done, Dr O'Mahony, you are absolutely right, it's acute appendicitis and it might even be perforated.” I glanced pleadingly at the boyfriend, hoping he wouldn't say anything that would disillusion her faith in me.

    I hung round and spoke to the senior surgeon who did the appendicectomy. He did say it had been a few years since he had dealt with a perforated appendix but, in his opinion, the person who should operate on HIV positive patients should be the oldest member of the team!

    As I reflect on my performance that day, I was indeed pathetic. If only he had been seen by his GP, appendicitis would have been instantly diagnosed. Indeed, if only he had been seen by an SHO in Casualty or even a pre-registration house officer, or worse still, even a medical student, appendicitis would have been top of the differential.

    I learnt a lot that day. Superspecialism can be dangerous when it replaces common sense. Patients who are HIV positive should be registered with a GP they know and trust. Indeed, this could be their only protection from the blinkered vision of the specialist.

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