Without a tertiary Emergency Department at the end of quick ambulance ride Rural Procedural General Practice holds lots challenges, some more satisfying than others.
And that is not saying that rural practice is better than urban practice; we both serve our communities well.
Recollections from this week with details muffled to protect the innocent.
A young guy from Canada comes in worried he has caught a STD, as he called it. Should be about time to change STI to something else? Seems whilst backpacking on his way through Asia he had unprotected sex with a fellow backpackers and ever since then he had been worried about the possibility that a little penile irritation was a sinister disease. I know that PCR techniques on urine are considered as good as culture these days, but when I was a lad being threatened with a swab down the urethra was a good incentive to wear a condom.
I’m not sure if country folk are more resilient or its a generational thing? A 70-year old farmer turns up saying he wanted to find out if he had a heart attack….a week ago! Was too busy with the sheep at the time but it did slow him down, his wife’s GTN spray he borrowed without telling her had helped. His ECG showed his diagnosis was probably right and the 15 minute consult blew out as I organised transfer to a friendly cardiologist. He had a CABG later that week – now that will slow him down. The cracked chest will probably hurt more than his heart attack.
Not to be outdone a few patients latter another bloke comes suggesting he had a stroke this morning. Fell over all weak and confused for a while and still a bit unsteady on the legs. He had driven in from his farm. Similar thing happened a few weeks ago but the wife thought is was low sugar. She had given him a jam sandwich which maybe helped a bit. Today he had breakfast, so his sugar couldn’t be too low this time. True enough, Rhomberg was positive, he had left sided weakness. More phone calls, and thankfully for the rest of the afternoon patients, a colleague doing on-call at the local hospital offered to organise the transfer. My patient was a bit cross he couldn’t drive home to drop his dogs off first.
I few year ago I began wondering what people do with sheep that makes them neglect their own health. Since then I have delivered a still born sheep, helped shear (very badly, but did a great job of fixing the cuts, IMO), and discovered that a granny knot in an excised rectum was important in not letting fresh sheep poo mess up a hanging carcass. So that where lamb chops really come from. If I had to look after 1000 of the buggers I’d probably be busy too.
A fellow with a lump in his nose tells me he saw an ENT specialist three years ago and was patiently, very patiently waiting for a city tertiary hospital to tell him when his operation would happen. A quick call discovered that he had been dropped off the list for no good reason and would need a new referral to get back on it. A careful look at he lump revealed it pretty much unchanged from previous descriptions (thankfully not some nasty malignancy) but still in the way and needing removal.
Obstetrics care can be unpredictable. One evening, a young lass presents to the midwife in early labour thinking her waters have broken. The midwife agrees with her and tells me that there may be possibly meconium stained. Up until now everything all had been normal, normal, normal. A CTG showed variable dips, examination showed she was indeed in early labour. Within the next hours or so she fully and pushing, fetal heart beat 60 for far too long, instrumental delivery, neonatal resuscitation, cord pH 6.9, blood glucose 1.5, so IV in, glucose drip and transfer to tertiary hospital in case of seizures. Bed in the wee hours of next morning.
“About this sore on my leg doc it isn’t healing”. Hmm. Pathologist suggested I had biopsied a morphoeic BCC. My reading and chat to a friendly dermatologist suggested Moh’s surgery which meant a trip to town. Second best was a wide 15 mm excision. Patient had to stay to look after sheep (again) so I did the 15 mm excision around a 20 mm lesion and closed the hole some artful cutting and suturing. Fingers crossed and antibiotics to keep poo and sheep bugs at bay. The pathologist suggested I had cut a clear margin which was good. We’ll wait to see how well he heals. Now how about sunscreen and a hat and a closer look at his nose!
And talking about skin cancers. The tragedy of putting a bandaid over a SCC for six months thinking it is a spider bite is all so real as I help a man and his family through the final phases of his palliative journey.
Each week is an interesting week.