Low tech Wednesday

Low tech Wednesday

Today hanging my washing out I discovered my treasured Drug Dose had been left in a pocket! left out in the sun it is drying out. All it needs is an ironing and it should be back in use.

Try doing that with your high tech ipod app!!

The art of delivery – hyperstimulation

Recently, I helped care for a young woman whose patience has finally been strained by her pregnancy. She had endured the previous 39 weeks pretty well I thought but with three nights of sleep deprivation because of irregular contraction she asked for an induction. I do wonder how well young Mums will cope with a new baby when they ask for an induction in this not uncommon situations. I put out of my mind the nearly 12 years of my own sleep deprivation due to on-call and then toddlers and thought through what I could offer her.

I know that the NICE Guidelines suggest that spontaneous labour is more likely after sweeping the membranes.

My own experience suggests the outcome can be better judged on a toss of a coin. More sophisticated studies have suggested better odd in favour of membrane sweeping. Cochrane suggests the NNT is about eight, that is if you can find eight women to put up with the discomfit.

I know a variety of other methods proposed.

  • I had seen one poor young woman disabled with terrible diarrhoea deliver a flat baby because she thought a bottle of castor oil would do the trick.
  • I usually use a list of corrugated roads, long walks, hot curries, hot sex, raspberry leaf tea. Which I guess reflects where I have worked after leaving the comfort of teaching hospital obstetrics. Some suggestions go down better than others.
  • Some midwives adds nipple stimulation to the list, but my opinion is the babe’s going to traumatise the nipples enough in the first few days so I suggest keeping that in reserve.

With consent, I examined my patient and gave her a bishop score of 5 then performed a stretch and sweep. There was an expected grimace. But according to Cochrane I had done my bit to reduces the chance of my patient still being pregnant at 42 weeks by 0.53.

Two days later and still incubating and with little restful sleeping, my patient asked whether she could really have an induction? So we discussed a plan and settled on dinoprostone gel then an amiotomy if favourable the next morning.

I explained that an induction with prostaglandin was safe and unlikely to increase the risk of a caesarean section beyond what she would face should she go into labour on her own.

In my experience, if a course of prostaglandins failed then we could try again after a good night’s sleep with the same or a mechanical method or decide on a caesarean. I have never used the mechanical alternatives a Foleys or Cook catheter as a form of induction.

That night her bishop score was now five (her cervix being a little easier to find), she had been having only irregular contractions; had the strip and stretch has done anything? We proceeded with our planned dinoprostone gel and amniotomy in next morning.

Within 30 minutes of inserting dinoprostone gel, she had started to be more uncomfortable with contractions. And then she has a contraction that continued beyond a minute. She looked more uncomfortable and worried. “Is this what labour is going to be”, she asked? She was still on the cardiotocograph. I watched the tocograph line continue its plateau, expecting any minute it would begin to return to normal. At two minutes the tocograph had no intention of returning to baseline and the uterus was still contracting. The fetal heart rate was still fine at that stage. Best find something to settle this contraction down. Instinctively, I thought lets get the gel out. So armed with speculum, saline and gauze swabs. But this made little difference. I have since been told the prostglandin is absorbed quite quickly and I had wasted my time.

We turned her onto her left side and started oxygen. As the midwife went for the IV trolley, I grabbed a bottle of Nitrolingual. Two sprays under the tongue didn’t seem to make any difference. The contraction distracted her even from the GTN headache I explained she may get. The patient now had a startled kangaroo look in her eye

I asked the midwife to get some salbutamol ready, it is fiddly to prepare. 0.25ml of 5mg/5ml solution in a 1ml syringe, dilute to 10ml with normal saline in a 10ml syringe then give a 50mcg bolus (2ml) IV.

As I gained IV access, pregnant women always seem easy to cannulate, I heard the baby’s heart rate drop below 100. By the time the first dose of salbutamol went in the heart rate was 80. I waited a minute then gave another. With my hand on her belly I’m sure the uterus felt less tense; the tocograph agreed and started to return to baseline. The baby’s heart rate picked up, and quickly rose to 180. There seemed enough variability, however.

Things seemed to quite stable now the contraction had settled. I had salbutamol at hand. Mum looked more settled, her heart rate was normal. The CTG revealed were no further decelerations, although I was looking at a persisting reflex tachycardia likely due to the anoxia caused by the contraction or the salbutamol. It was time to phone a friend. The on-call tertiary hospital consultant was helpful. She reinforced what I had done with the exception of the vaginal washout was fine. She recommended waiting an hour and if the CTG became more normal then to attempt the amniotomy. If not, then a Cesarean was indicated.

Over the next hour the CTG settled to normality and I did the amniotomy. The fluid was clear.

My patient finally went onto have a normal healthy little girl. Although, it was by Cesarean section after slow progress beyond 6cm and further decelerations with an epidural in place. Baby was delivered deflexed OP, cried at delivery with cord pH 7.21. She is thriving and Mum is managing very well.

The tertiary hospital consultant also suggested that Cervidil was probably more useful than the gel since the Cervidil could be removed in hyperstimulation. I had heard about the prostaglandin on a string when I did my DRANZCOG training, but the hospital did not adopt it because of the cost compared to the gel. This has been my first experience with this side effect of gel after being involved in about 500 inductions over the last 8 years. Was this enough reason to change my practice? Should I give up on dinoprostone gel even though I have never had a problem before? Or should I seek comfort that if similar happened the Cervidil string will allow easy removal? Or should I fiddle with pushing a Foleys or Cooks catheter into a cervix?


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Where’s the White Coat?

“Hmmmm  160/90” I muse with my best concerned look

“Oh my blood pressure is always up when I see a doctor – it’s white coat blood pressure” Accompanied by a dismissive hand flap.

“Okay, now here’s your sick certificate….that was three days last week?”

Hold on there !!

There is something wrong with this scenario.

Sure if I had a 12 patient an hour habit that would be an easy level B.

White coat blood pressure!

I haven’t worn a white coat since my days as a pharmacy student and after a busy day compounding that surely wasn’t white. If I recall the white coat went into a vat of purple dye just prior to graduation but that is another story.

Today, I read a paper by O’Callaghan in the AFP (Aust Fam Phys 2013; 42 (6) 376-9) which suggests that this patient runs a 40% chance of developing hypertension over the next 10 years even if his diagnosis is correct.  The next step would a suggestion that ambulatory blood pressure monitoring may prove him absolute correct – lets give it a go.

And so a new conversation trail begins…….

If you want to know how the story ends have a look at this Heart Foundation link.

Waiting is a pain

In this week’s Medicare Locals Newsletter was a brief note about referrals to the Royal Adelaide Hospital Pain unit.

Referrals now have to be made on their proforma which I can appreciate would ensure that all the required information has been submitted.  But I think I can write a better letter freehand. The space left to write some information is exceedingly small.

What really surprised me were the stated waiting times. Well it didn’t come as a real surprise, but it was illuminating to see the triage system documented

Category 1 – Wait time 1-2 days.

  • Refractory cancer pain

Category 2 – Wait time 6 -8 weeks.

  • Early neuropathic pain or complex regional pain syndrome (CRPS) < 3 months since onset.
  • Patients in whom an interventional procedure may be indicated
  • Children whose pain interferes with school attendance
  • Pain interfering with sleep or self-care

Category 3 – Wait time 3- 4 months

  • Pain < 1 year not responding to GP management; frequent pain exacerbations occasioning Emergency Dept. presentations 
  • or hospital admissions, neuropathic pain, persistent pain following trauma or surgery, pain associated with marked physical 
  • interference or emotional distress, children and elderly

Category 4 –Wait time 12 – 24 months

  • Pain > 1 year not responding to GP management, diagnostic advice, medication optimization, psychological distress, 
  • physical interference. These patients will undergo Multidisciplinary assessment.

Okay now for some personal observations on the waiting time.

Category 1

If I had refractory cancer pain then please, please just start the morphine and midazolam infusion and crank it up until I am not in pain anymore.

Thankyou and good night…..

Category 2

I think if I had a child who was in so much pain that they couldn’t attend school then a TWO month wait is TWO months TOO long.

I recently helped two patients with a Complex Regional Pain Syndrome. I have to admit this is not a pain I have a lot of experience with. For those who need a refresher, a summary from a Lancet paper (The Lancet Neurology, Volume 10, Issue 7, Pages 637-648) describes what may happen

  • Typically, patients with CRPS present after minor or moderate tissue injury (eg, a wrist fracture). In the acute phase, the injured limb is usually extremely painful, red, warm (although sometimes it quickly becomes cold) and swollen. Other features, which are also confined to the injured limb but not confined to the distribution of a specific nerve or nerve root, include allodynia (whereby usually non-painful stimuli evoke pain) and hyperalgesia (whereby painful stimuli evoke more intense pain than usual), changes in sweating, changes in hair and nail growth, and muscle weakness. In particular, mechanical and thermal hyperalgesia are frequently present in CRPS.
  • Pain persists beyond the normal time expected for tissue healing.

Uptodate (which I find is very useful for many things) suggests

  • “A multidisciplinary approach is suggested in a guideline for management of CRPS developed by a consensus of experts. Clinical experience suggests that treatment is more effective when begun in stage 1, as soon as the diagnosis is established and before radiographic changes appear. However, it is uncertain whether immediate referral to a specialist in pain management results in superior outcomes compared with referral to physical or occupational therapy for protective and assisted mobilization of the affected limb within pain limits, supplemented by conservative pharmacologic interventions, to be followed by referral to an expert in pain management if the patient does not improve. On the other hand, early referral to an intervention pain specialist for appropriate nerve block can reduce pain and can enable CRPS patients to tolerate aggressive physical therapy.”
Complex regional pain syndrome

Complex regional pain syndrome

As a remote GP without immediate access to pain specialists, occupational therapists, psychiatry and physiotherapy this makes optimal management of a patient with suspected CRPS difficult. Waiting up to 8 weeks to get someone seen at a referral centre for a condition where early recognition and management prevents maladaptive changes, makes it even more difficult for my patient.

Prevention of complex regional pain syndrome would be better. There is evidence that early mobilisation and vitamin C (500mg/daily) may be useful particular for distal wrist fractures ( Zollinger etal  J Bone Joint Surg Am. 2007;89:1424-1431) and possibly after foot and ankle surgery (Bessea et al, Foot and Ankle Surgery 15 (2009) 179–182).

Maybe the expression should be an “orange a day keeps the doctor at away”!

Category 3

Even if I get admitted to hospital and become a category three patient I will have to wait up to 4 months to be seen! Do I wait in hospital, the car park or go home?

Category 4

Finally, for those poor sods in category four who are still in pain after a year of the best a GP can throw at them, well they get the rawest deal – they have to wait up to 2 years to be seen!  Maybe it should be be “Category forgotten“.  Surely they should be seen before those who have pain less than 12 months? And what if I am waiting as a category three less than 12 months and then become a category four because my pain has gone on for more than 12 months now. Do I go to the back of the queue?

Seems to me as a country GP that some health dollars need to be used to reduce this waiting list. I wonder whether the number of people with chronic pain waiting to see a pain specialist is on public record or would that be too embarrassing for the SA Health Minister ?

Is it this as bad in other jurisdictions????

Thoughts on The Impossible

The Impossible is a movie I watched last night.

The movie is based on the plight of a Spain family caught up in the 2004 Boxing Day tsunami as it tore through Khao Lak in Thaland.

The Spanish directer, Juan Antonio Bayona, used English actors instead of Spanish presumably to appeal to a wider audience. Naomi Watts did a better job than Ewen McGregor in being convincing, but the young boys playing their children shone brighter.

The makeup artists must also get recognition for the work they did in making it truly appear as though the actors had been plunged into a spin cycle of a garbage littered tidal wave.  They would make any EMST moulage look scary.

The movie coped a bit of misplaced, IMO, criticism about portraying western tourists in an Asian disaster.

The movie brought back thoughts of the small part I played as an intern in helping the victim of the 2002 Sari Club bombings in Bali at Royal Darwin Hospital. It was a lot more controlled and organised than the medical response  portrayed in The Impossible. We didn’t have to deal with shell shocked walking wounded but more importantly  the body bags, shattered infrastructure and anxious family and friends.  Our casualties were mostly evacuated in an orderly manner apart from those early walking wounded who managed to get flights out of Bali in the immediate aftermath of the bombings. I maintain a sense of pride in seeing everyone from consultant to cleaners put in a magnificent effort to deal with the demands placed on the hospital.

bali2       bali3

In 2004 my wife and I visited Sri Lanka.  I had heard it was a very pretty country, a little like India but more compact and indeed it proved to be. It was few years after the tsunami and some part of the countryside affected had yet to be cleaned up and recover. Images that stayed in my mind were the dotting of coastal cemeteries, the wrecked train carriages outside Galle, the signs that suggested you could run to higher ground in the event of another tsunami, fallen tree trunks rotting in coastal hinterland and the massive number of brand new boats laying unused on the beaches.


The other memory of Sri Lanka was seeing how well the local hospital at Polonnaruwa dealt with mass casualties from a bus bombing whilst we were there. After many years of civil war the medical system unfortunately had become used to dealing with 100 or so injured at a time. Top and tail two to a bed!

My final thought thought would be how well could my local hospital on KI deal with a mass casualty event. Probably not a tsunami, nor a bombing but what if there was an explosion at the local petrol station, a ferry sank, a bus ran off the road or a passenger plane crashed on landing? How quickly would the local resources be swamped. After dealing with six people injured in a rollover one night last year, I think that it wouldn’t take too long before our small ED would be overwhelmed.  I’m sure that the small of doctors and nurses would manage well up to a point. I think that the local islanders would be quick to offer assistance. And thankfully we are but a short flight from a major capital city.

In the meantime, I hope I only get to experience it vicariously through the likes of Naomi and Ewen.