Urgent referral to ED

It is definitely true to say that GPs undergo several stages in their development. Those in their first 10 years of life tend not to be attached to any specific practice and are focused on developing their own careers and experience. In the second decade of GP life, many are attached to the practice, usually as a principal partner, and the focus shifts onto the business and they start to become more willing to teach, and often have pet interests but some become jaded by clinical practice due to their experience. The next decade refers to pre-retirement where older GPs reignite the spark of clinical work and become very keen on teaching and continual education of their successors. 

Today, I would have to say that I nearly experienced the attitudes of all these stereotypes at the medical clinic. To begin with, I began the morning co-consulting with a young-middle age GP, career and business focused. A very efficient executor of clinical decisions. Well-respected by his patients, but also tongue-in-cheek humour. I spent from 9-12 working under him, booked in to see 3 patients. Of whom only 2 showed up. Both who came for reviews and checked out normal. What a waste of time I thought. I spent the long intermissions between patients reading case studies and learning that way. Whilst the patients were here, I practiced on them as if clinical skills mannequins on the various aspects of physical examination. Yet, despite their obliging nature, all they wanted was a pat on the back plus/minus a script.

The afternoon, however, proved more interesting as I caught the attention of a pre-retirement GP examining a patient for ?fb in eye in the slit lamp examination room. Curious, due to my interests in eyes, I poked my nose in. Found out who I was dealing with, and was invited to perform the SLE. Recommended Fluorescin to exclude penetrating injuries - and discussed future actions. What a marked contrast! We ended up bringing him into the treatment room everting his eyelid and looked for grit together with dorky jewellery magnifying specs. Being the duty doctor, he later asked me to see his next patient. 

Happy to do so, after such a boring clinical day. Little did I suspect that I would have to be dealing with an acutely unwell gentlemen requiring hospital attendance. As I saw him walk in holding his belly, a prominent hernia protruding from his shirt, and in tears from the pain, I felt a sense of unease in the atmosphere. I quickly took a simple AMPLE history (NKA; Novomix, crestor, amoxil, Candersartan, Effexor; Diabetes on insulin, phx of rectal cancer, CKD; last ate in the 2/24 ago, last opened bowels in the AM, 3/7 h/o worsening abdo pain with assoc n/v today), performed a brief abdominal exam which revealed signs of peritonitis - guarding, percussion tenderness, distended abdomen. Good to note that no rebound tenderness was detected and his herniae was reducible. There were also previous midline laparotomy scar noted from previous bowel surgery - which surprisingly were not mentioned in his notes. I did all this without my stethoscope or any equipment, as this was fortuitous and unplanned!! 

I was thinking about bowel obstruction -with his history of hernia and surgery being the major culprits. I dashed quickly to tell the GP that he needed to be reviewed in hospital for AXR and NGT insertion with IV access. I told the patient straight away, despite him requesting some water. On the way back, I declined him any water thinking that if it is surgical that it would be better to be NBM. The GP came to confirm my assessment and we made the necessary paperwork for emergency hospital review with ?admission. The adrenaline pumping through me at the time, thinking that this could have been life-threatening if my skill wasn't good enough to exclude strangulated herniae and possibly ischaemic bowel. The GP was more calm and took control of the phone call to ED, while I nervously huddled over and typed the referral letter and faxed it off. What a great learning experience I thought to be shoved into the deep end of private practice. To make the call to send someone to hospital. This was what it was this IMMERSe program was all about.

After doing the necessary paperwork, I followed this patient to the emergency department at the local hospital. When I arrived, the attending was already assessing him. I managed to squeeze a brief handover after this, despite her already knowing the story. Clarified the actions of blood tests: fbe, uec, lft, crp, amylase/lipase, coags, trops; and axr - erect/supine + cxr. Whilst the nurse cannulated and collected bloods. 

Whilst waiting for these results, there was an interesting fall in the bed opposite which I decided to check out. 

This gentleman had sustained some lacerations to his right brow and cheek which required sutures. Seeing a tired intern on the case, I decided to help out. After putting in two sutures with an arched back at 45 degrees. Both of us learnt the invaluable lesson of adjusting the bed to an appropriate height before establishing a sterile field. Relieving each other from the struggles of awkward positioning, together we put in 6 stitches into the brow. However, in the meantime, I did miss the NGT insertion on the previous patient with the distended belly. XR later revealed multiple dilated loops of small bowel and multiple fluid levels. Diagnosis success - confirmed SBO. Winning. What an awesome day!!!