Chapter 6: See a doctor, support a lawyer

Long ago, during my term as a surgical registrar I was asked to see a rather rugged 65-year-old farmer with chronic intermittent abdominal pain. The problem was puzzling the RMO especially as the patient had ‘the thick file’ syndrome. He was a rather likeable phlegmatic man who seemed to have a genuine problem and was embarrassed by his occasional visits to various doctors and the emergency department. He described the pain which was located centrally as colicky, mild to moderate and dull. It was associated with mild abdominal distension, nausea (no vomiting) and constipation with hard pellet like stools. Diagnoses that had been suggested were irritable bowel syndrome and/or abdominal adhesions. He said that the painful attacks which simply felt like ‘a kick in the guts’ would dissipate as quickly as they came. He had a history of a cholecystectomy 21 years previously.

On abdominal examination he had mild central tenderness with rebound tenderness, minor swelling and the suggestion of a firm mass. We did not have sophisticated imaging such as ultrasound available 43 years ago, so the obvious investigation was a plain X-ray (previous barium enemas had been reported as normal). The X-ray indicated the presence of an abnormal shadow suggestive of a foreign body. This made sense so we organised a laparotomy and not surprisingly found the corrugated drain tubing left accidentally following the cholecystectomy. The thought of litigation did not cross his mind such was the prevailing attitude at the time and the particular nature of the relieved person.

The mother of Greg N, aged 15, rang to say that he was complaining of severe suprapubic pain following its sudden onset. After an hour the pain was also in his right groin and he had vomited three times. I instructed her to bring Greg to the office, adding that acute appendicitis or a strangulated hernia should be excluded. On examination the right testicle was tender, red and swollen. Its elevation increased the pain. I rang the nearest surgeon and asked him to attend to this torsion of the testis, adding that its onset would be three hours by the time he saw the patient. He readily agreed.

DIAGNOSIS AND OUTCOME

The surgeon rang me some seven hours later saying that he had to perform orchidectomy because the testicle was infarcted. I was not surprised but was very disappointed at his error of judgment.

Julie V, aged 6, was enjoying her summer vacation at a seaside resort when she developed severe central abdominal pain and vomiting.

The following sad story is presented in chronological sequence.

Day 1: Sudden onset of central to lower abdominal pain and vomiting. Patient looked pale.

Day 2: Abdominal pain and vomiting persisted; difficulty in walking, febrile. Patient appeared very sick and pale. The doctor made a home visit, took her temperature and palpated her abdomen. ‘It could be appendicitis but it’s probably gastroenteritis. I’ll prescribe antibiotics and she should settle.’

Day 3 am: Abdominal pain now very severe; vomiting and fever worse. Diarrhoea developed and Julie was too sick to get up. The doctor explained over the phone, ‘The diarrhoea is due to the antibiotics. I’ll prescribe an antidiarrhoea mixture’.

Day 3 pm: Mother phoned the doctor to say how concerned she was because Julie was getting worse by the hour. She asked whether Julie should be taken to hospital. ‘It’s not necessary. They’d only do what you’re already doing at home.’

Day 4 (Saturday) am: Patient worse: very pale; diarrhoea now almost continuous. Mother visited doctor’s surgery and was told, ‘These gastro things can go on for a few days’.

Day 4 pm: Parents took Julie to a base hospital about 30 km away. The casualty doctor diagnosed acute appendicitis and peritonitis. At surgery a perforated gangrenous appendix was removed and a pelvic abscess drained.

Day 10: Julie was discharged home, very lethargic and weak with residual abdominal pain.

Day 12: Julie developed abdominal pain, fever, nausea and diarrhoea. I was called to see her for the first time. Examination revealed a tender abdomen and a tender boggy mass was palpable per rectum. A diagnosis of pelvic abscess was made and the patient was hospitalised under the care of her surgeon.

Days 13–18: Pain, fever, nausea and diarrhoea persisted. Conservative treatment was given but the patient grew weak and wasted.

Day 19: Spontaneous discharge of pus per rectum relieved her symptoms over the next two days.

Days 22–41: Julie went home and gradually improved, despite intermittent bouts of colicky abdominal pain.

Days 42–151: Julie was very healthy and normal, free of abdominal pain.

Day 152 (Sunday): Julie had a sudden bout of agonising abdominal pain followed by vomiting. As I was unavailable at the time, the locum service was contacted. A young locum appeared at the door of the house and was told the history, with the suggestion that this new development could be related to the previous illness. ‘Do you want me to stay or go?’ he asked. He stayed and examined Julie’s ears and throat; palpated her abdomen; and asked her to walk, hop on one leg and then jump. (She failed the latter tests.) He then announced confidently, ‘There’s absolutely nothing wrong—she’s possibly coming down with a gastro thing. That will be $90.00’. All in 3 minutes!

Day 153: The patient remained in bed, sleeping almost constantly and moaning occasionally with pain. She had no bowel movement. Her temperature started to rise in the evening and she grew pale.

Day 154: She developed very severe pain and had a possible haematemesis at 1 am. She was visited by her regular doctor and admitted to hospital at once. After several hours of resuscitation in intensive care, being treated with intravenous fluids and antibiotics, she was taken to theatre for a laparotomy. A loop of small bowel, obstructed by adhesions, was found to be gangrenous and perforated leading to blood-stained faecal peritonitis. The section of bowel was removed, an end-to-end anastomosis performed, and the abdominal cavity carefully cleansed with cephazolin solution.

Days 155–180: Julie had a long convalescence in hospital with treatment for a subphrenic and a pelvic abscess.

For the next 12 years, Julie continued to have problems after further surgery for adhesions and intra-abdominal abscesses. Medical litigation was instituted and a settlement was eventually reached. Now, as an adult her main problem is sub-fertility.

CASE 1

Danny, aged 8, presented with three days of pain in his foot causing a limp. His mother said he was complaining of the pain when he was preparing for school, which he dislikes, especially on athletics days. She thought that this was the reason for his complaint and ignored it initially. Danny insisted that the pain came on suddenly when he was running around the house. On examination there was no swelling but deep tenderness over the middle of the sole of the foot adjacent to the base of the second metatarsal.

An X-ray revealed a snapped-off needle embedded in Danny’s foot (Figure 6.2). Danny proudly displayed the piece of metal removed from a bloodless foot under general anaesthesia, while his poor mother, upset at her misjudgment, required soothing empathy from a parent of five children.

CASE 2

Angela, a 66-year-old Italian lady, presented with a four-day history of a very painful knee. It was red and tender over the prepatella bursa, causing her so much discomfort that her relatives brought her in a wheelchair. I referred her immediately to an orthopaedic surgeon in the adjoining medical centre. He contacted me with the news that she had prepatella bursitis due to bacterial infection; he had prescribed flucloxacillin and sent her home. Two days later she presented to Alan, one of my colleagues, claiming that the problem was worse.

An X-ray of the knee revealed a broken needle in the soft tissues over the knee. Red faces all around, but Alan sported a grin like a Cheshire cat for a long time. Angela, incidentally, was an avid seamstress. She gave us no history of a sharp pain while kneeling on the floor.

CASE 3

Ron, aged 48, was a farmer who loved tinkering in his large workshop. One day while oxywelding, gunpowder exploded causing burns to exposed parts of his body, especially to his face. His appearance was quite dramatic but the burns settled and eventually healed nicely. I initially checked his eyes, which he claimed were uncomfortable, and found a considerable amount of grit, charcoal and inflammation. After I removed the debris, he said that the eyes felt better but that the right eye was sore and slightly blurred. I reassured him that it was the effects of the burns. However, when this persisted, I asked for an ophthalmologist’s opinion. The eye was X-rayed and an intraocular metallic foreign body was found.

CASE 4

Bruce, aged 21, a prisoner on parole, presented one evening with lacerations to the wrist caused by a jagged bottle used in a fight at a hotel. I explored and cleaned the wounds, which seemed generally clean, and sutured them. On review for suture removal, he complained that the main wound was very sore but I reassured him and explained that it was a deep wound. Some weeks later the medical officer attached to the prison rang me to say that he had removed a 1–2 cm fragment of glass from the wound, after identifying it on X-ray when the patient complained of persistent pain. He added that the patient was not impressed. I still feel uneasy!

Thomas H, a 54-year-old warehouse manager in good general health, presented with an eight-week history of low-back pain without sciatica.

He described the pain as a deep ache that is present day and night and getting worse. It was aggravated by activity including walking and jogging, and the only relief was provided by analgesics taken orally. He observed that he had become progressively lethargic over the past few months and had lost about 2 kg. He admitted to the presence of a smoker’s cough caused by smoking ‘20 cigarettes daily since he was a lad’ but denied chest pain, dyspnoea, wheezing or a productive cough.

Examination revealed a large, apparently fit man with the main abnormality being tenderness to digital palpation over the spinous process of L4. He had painful limitation of flexion, extension and lateral flexion (bilaterally) of his lumbar spine. There was a flattened lumbar lordosis, but the neurological examination of his lower limbs was normal. Examination of his chest, abdomen and rectum were normal.

DIAGNOSIS

X-rays of his chest and lumbosacral spine were taken. The chest X-ray was reported as normal and his lumbosacral spinal X-ray report read:

When Thomas rang the clinic to discuss the results of the investigations he was informed that the X-rays were normal and that there was nothing to worry about. However, his back continued to ache and so he decided to consult a non-medical health professional who, after seeing his X-rays, rang our clinic to advise that the patient had a destructive lesion in the body of L4.

The X-rays were reviewed by the radiologist who then reported:

A carcinoma of the lung is the most likely primary that could cause this metastatic lesion. Other primaries could arise from the kidney, adrenal, thyroid and melanoma. The prostate causes osteosclerotic mestatases to the spine.

A follow-up X-ray of the lung revealed a 2 cm mass in the right middle lobe. At fibre-optic bronchoscopy there was an erythematous cobblestone mucosal lesion in the right middle lobe bronchus. Brushing, washings and biopsies were taken but the results were inconclusive. However, the carcinoma eventually became obvious with time.

The patient, a young woman, presented with the simple problem of wax in her right ear. It seemed a simple procedure but it suddenly went wrong. A highly unlikely malfunction with the standard syringe led to the violent projection of the syringe nozzle into the patient’s auditory canal.

The threads at the base of the brass syringe were fine and worn presumably from previous assembly on the wrong threads. Combined with a less than smooth-flowing plunger, the sudden detachment resulted in the forward projection of the nozzle into the canal despite the use of a steadying extended small finger for stabilisation.

The patient was acutely distressed by the injury but once composed allowed inspection. There appeared to be a laceration of the canal with an intact drum.

On review the next day, however, the patient complained of deafness in the ear since the injury, a complaint that persisted despite further tentative enquiry at 70 decibels.

I feared my initial assessment may have been wishful thinking. Fortunately, however, an ENT opinion revealed a canal injury with an intact drum and the patient’s hearing returned after clearing of the canal.

The use of a rounded nozzle may have prevented the gouging injury but at the expense of the nozzle sliding onwards and damaging the drum.

CASE 1

A 42-year-old patient of mine presented to the accident and emergency department of a base hospital with lacerations to the first and second toes of his right foot, sustained from a rotary motor mower while he was mowing the long grass in his mother’s backyard. The wounds were debrided, sutured and dressed. He was given an injection of tetanus toxoid and oral tetracyclines.

Four days later he presented to me complaining of severe pain in his foot. The wounds were inflamed and swollen. I took an X-ray, which revealed fractures of three phalanges of these toes and foreign bodies in the wound. He was taken to theatre where, under general anaesthetic, the wound was reopened, and dirt and small stones removed. The wound was left open for some days before eventual closure. Penicillin was the antibiotic of choice.

OUTCOME

The wound appeared to heal nicely but the patient presented later with suppuration and pain. X-rays confirmed osteomyelitis in the proximal phalanx of his great toe.

CASE 2

Mark T, a 23-year-old council gardener, presented with a painful swollen right thigh following an injury 11 days beforehand. While using a rotary motor mower, he was struck sharply on the inner mid-thigh by an object considered to be a stone. The pain was intense and weight bearing on that leg was impossible. He visited a nearby medical centre and he was advised to apply ice packs, and then rest and elevate the leg. The pain became worse and he attended again but was given ultrasound therapy and crutches.

When I eventually saw him, he was in severe pain from a swollen red right thigh in which a 5 mm long wound was noted. An X-ray revealed a piece of wire within the thigh with extensive gas formation, confirming the presence of a foreign body with gas gangrene (Figure 6.7). He was sent immediately to a specialist unit for extensive surgery; he was fortunate to survive as he developed shock and required several days in intensive care.

After a man whom I suspected was an IV drug user left my office, I noticed a used needle and syringe on his seat. Intending to use this as evidence of his IV drug use (which he denied), I decided to keep the needle and syringe.

I left it in an adjacent room. To my horror a small child came into my office, climbed up and pricked himself with the needle.

I had to explain to his mother that the needle was from a suspected IV drug user and that the child needed to have blood tests to determine if he had contracted an infectious disease such as hepatitis B, hepatitis C and HIV. The outcome was satisfactory but it was very distressing to all concerned.