Respiratory Tract Infection

SPEAKER_02 0:12

Hello and welcome to the Home of Medicine Podcast, a podcast in association with the Royal College of Physicians, Edinburgh. I'm Amy Burbridge and I'm joined as ever by Ben Lovell.

SPEAKER_00 0:24

Nice to see you again, Amy. How are you?

SPEAKER_02 0:27

I'm good, thank you. I've got a a good case for you today, one that I struggled with and still am to a certain extent. So I really would like your input. So this was this year, it was a 68-year-old man who I saw in MDU, the Medical Decisions Unit, for a post-tate ward round. He'd been admitted overnight through the emergency department. And he'd been seen in ED and diagnosed with a respiratory tract infection that had been diagnosed on point of care ultrasound, which you know I mention and I'm a big fan of. So when I picked up the notes, well, I didn't pick them up anymore because it's all on computer, although metaphorically I picked them up and read them. Um I saw that they'd been seen very clear history, very good examination documented, very clear investigations, management plan was beautifully documented. And I thought this isn't going to take too long. You know, this is a quite a simple case of a lower spiritual tract infection, has been picked up on uh focused um long ultrasound. Um, so whip round. I mean, me doing anything quick is unusual within the workspace of ward rounds, although I do do lots of other things quickly, just maybe not ward rounds. Um, so I went to see him and he was in bed, and his wife was sitting next to him. And we just had a chat, and I said, and this is my first mistake. Oh, so you've got a chest infection, I said to him. Oh, I didn't realise I got a chest infection. And his wife said, I don't have any chest symptoms. Where did you get that diagnosis from? And I was like, Oh, okay. Mistake number one. Any thoughts on that?

SPEAKER_00 2:22

I thought you were gonna say, This is where I made my first mistake. Hello, you must be uh the wife. Yeah, no, I'm his daughter.

SPEAKER_02 2:29

Yeah, I've done, yeah.

SPEAKER_00 2:31

Um, never never never guess who uh family members are.

SPEAKER_02 2:34

Never, never, never.

SPEAKER_00 2:36

Um, I don't think you've committed a big crime. Okay. Uh uh, we've talked a lot about like how we approach post-tate ward rounds and second of use and things like that. And I've always been a fan of opening up with, so I understand you're here today because of XYZ. Um, rather than saying, hello, I'm the consultant. Tell me why you're here today. I don't like that for a couple of reasons. Number one, it it's slow. I find that efficient use of my time and sort of with them, what's the point of the resident Dr. Clarking if I'm going to do it all again after them? And second of all, I don't think it fills patients with confidence if they're now on their third or maybe fourth healthcare professional who's come to them and said, So why are you here today? Patients get irritated, patients get a bit nervous saying, Why is no one talking to each other in this gaff? Um, why has he not read the notes? I even though it's done with good intentions, you know what you want to keep an open mind and we want to make sure we get the right information. I find that when you just it's open with us, so what's brought you in today? Once you know you're doing the post-take round, patients get can either get a bit shirty or get a bit nervous and being like, but I've I've done this before. Or it's so boring, they start changing things in their store because mix it up a bit. They're so sick of saying the same thing, or they've been thinking about it and they've got a few things to add, or they want to retract a previous thing. Anyway, so I always I do that. I I would I say to patients, hello, I'm I'm Ben Love, I'm the consultant. I'm so sorry you've had to come into hospital with what what looks like a nasty chest infection. How are you feeling? And I don't mind that because it gives them the opportunity to say, as your patient did, whoa, yeah, that's not right. And then I'll go, Oh, oh, I'm so sorry. So tell me on your own end, and then I'll ask. But um otherwise, I don't mind opening with that because as long as I'm letting them correct me if it's wrong.

SPEAKER_02 4:22

And it's really interesting because I'm the complete opposite, as we've established quite a lot of times on this podcast, is that for me to say that was very unusual, and I normally go in and say, So then tell me why you've come to hospital, and I'll go back to the beginning.

SPEAKER_01 4:35

Yeah, yeah, yeah.

SPEAKER_02 4:36

Much to the annoyance of you and probably the patients. But that's just, and maybe I've got to that point because I've done this. You've come in with a chest infection a few times, and they've got no, I haven't. And I'm like, oh no, now I sound really silly. So I think it depends what feels right and authentic for you. And I don't think there's a right and a wrong way.

SPEAKER_01 4:55

Exactly.

SPEAKER_02 4:55

And I think it's what's right for you, and ultimately, we've figured out on this podcast, we always get to the same endpoint.

SPEAKER_01 5:02

That's true.

SPEAKER_02 5:03

It's just how we get there is slightly different, but there is no right or wrong way. There's a right way for me, and there's a right way for you. Um, and I think that's something to tell all our medical students and doctors in training is you will be told probably this is the way you have to take a history. And there are certain questions that must be asked, past medical history, allergies. But the way that you phrase them sometimes and the way that you introduce yourself is actually what feels right and authentic to you and what upholds your values. Would you agree with that?

SPEAKER_00 5:35

Absolutely. There are many, many paths to the top of the mountain, but they all go in the same place eventually. Exactly. I think it it's more of a postgraduate education focus for me because for medical students, it's a bit like learning a driving test. You have to learn this way. Then when you've got the hang of it, then you can start doing things that work better for you. But we've got to get you to a single recognized point. But I love teaching postgrad doctors because it's about differentiation and saying, now let's work out your way. Because you're going to be a consultant one day and you're going to have your way of doing it that's going to work for you. Exactly. What your way is. I'm really interested to find out.

SPEAKER_02 6:11

Your style, your way. Absolutely. Yeah. Okay. So um I, as I I guess did what you, Norm, would do and say, okay, so um, I apologize for that. Let's go back to the beginning. Because obviously I've gone in with a with um a bias, had framed it already. And I let's go back to the beginning. So he said he was a little bit confused. Um, he knew where he was, but sort of didn't know where he was. Do you know what I mean? And was able to answer questions properly. But his wife would chip in and say, No, that's not quite right, is it? Um, so there's a little bit of confusion there. So he said he had some leg pain, some right leg pain and redness. Very different. And I was like, okay, he said, I've been falling quite a lot recently at home. And his wife said, Yeah, he has been confused and he's been complaining of pain in his right leg. No documentation of the leg examination um I could find um in the notes. So I carried on asking more questions. He said he'd been feeling unwell and feverish for a few days. He's not normally confused, but had noticed that he couldn't quite grasp Eve's words or was having fluctuating levels of just not feeling quite there and quite with it. And he'd been falling a lot around the house. And he said that the reason he'd been falling is because of the pain in his right leg. Now he doesn't remember injuring it. He hadn't been on any travel recently, he hadn't been on any long coach journeys or flights or anything like that. So the initial presentation and the diagnosis given to me was low respiratory tract infection. But actually, when I took a history, he said, Oh, it's leg pain, falls, and confusion.

SPEAKER_00 7:54

Were you uh at this review, were you with the doctor who made that initial chest infection diagnosis?

SPEAKER_02 8:01

No, but what was fascinating is he reached out to me um a little bit later and said, Um, my gut instinct is uh something was off.

SPEAKER_00 8:11

It's funny because we all I remember from when I was in training, patients do sometimes change their stories. Yeah, quite between your assessment and the consultant assessment, and then they come up with an absolutely different story for the consultant, and you're feeling a bit desperate because you do want to interject and say, you want to say, hang on a minute, hang on a minute, hang on a minute. This is nothing like what you told me a few hours ago. Can I just make sure that my my boss is aware that I'm not an idiot? And I and I'm this is the different information. And I know it can be quite awkward for them, and I'm I'm aware that happens. Uh so I just wondered if they if they were there getting a bit hot under the collar and a bit panicky that the story was coming out.

SPEAKER_02 8:48

So that was on a night shift, but um they had they did reach out to me and wanted to chat about it and debrief about it, um, which I thought was excellent. Um, so I took a further history, past medical history, um, ischemic heart disease, you know, all the expected things, hypertension, atrial fibrillation, a bit of cardiac failure, a bit of diverticular disease, a bit of osteoarthritis, hypercholesterolemia. He'd been anemic in the past, but that and now resolved, and also some um CKD as well.

SPEAKER_00 9:25

All right, so I guess we have to go back to basics now.

SPEAKER_01 9:27

Yeah.

SPEAKER_00 9:27

Yeah, you you've come in. Let's go over why you come in. Great that the wife is there.

SPEAKER_01 9:32

Really helpful.

SPEAKER_00 9:34

If someone is confused, they won't give you, you know, all the data that we're looking for. And it's very often that you're talking to the patient, for example, in this scenario and saying, So, so are you confused? No, I'm not confused. And I was like, what's going on? And you can see out the corner of your eye, the wife is standing there shaking her head, going, no, no, no, no, no. And you have to say, I'm just gonna double check this with your with your wife now. What what's your view? Do you find them confused compared to usual? So it's useful to get a second pair of eyes on the situation. Um, confused for a few days. Tell me more, sir. Has this happened before? What's going on?

SPEAKER_02 10:07

No, it's never happened before. This is the first time this has happened.

SPEAKER_00 10:11

What do you think's caused it?

SPEAKER_02 10:13

I don't know. I don't remember banging my leg, just don't feel right.

SPEAKER_00 10:18

And your leg hurts.

SPEAKER_02 10:19

Which leg? My right leg. It's really painful.

SPEAKER_00 10:22

And is it for just a few days as well? The same time have you been getting a bit muddled?

SPEAKER_02 10:27

Yeah, yeah. A few days. A few days of right leg pain.

SPEAKER_00 10:30

The whole leg?

SPEAKER_02 10:32

No, just the bottom of my leg.

SPEAKER_00 10:33

Maybe just below the knee? Below the knee. Well, I'm definitely gonna have a look at that leg in a minute. But let me ask you a few more questions first. We've got into role-playing mode here.

SPEAKER_02 10:41

I know, so that was very, very slick.

SPEAKER_00 10:44

Yeah. I don't know why that's happened. And you've been falling over it. You don't normally fall, do you?

SPEAKER_02 10:49

No, but I think the pain in my right leg has been making me fall, and I just feel a little bit weak.

SPEAKER_00 10:56

Do you think maybe the leg is so painful? Sometimes you put your weight on it and it just goes out from underneath you, and that's why you fall.

SPEAKER_02 11:03

I think it is the pain. Yeah. Right.

SPEAKER_00 11:04

The pain's quite bad. Understood, understood. And does the leg look different to you? Is it swollen and red?

SPEAKER_02 11:09

Yeah, it's very red and swollen.

SPEAKER_00 11:10

Right, definitely gonna have a look at that in a bit. And when you've been falling over, have you hurt yourself?

SPEAKER_02 11:16

No. No.

SPEAKER_00 11:19

It says here that you've got something called atrial fibrillation. And maybe you take blood thinners? Can't remember. Okay, I'll have a look at your medication list. That's important because if you take medication to thin your blood and you bumped your head, you might need to do a quick scan of your head to make sure there's no injury or bleeding in there. But I'll I'll come back to that. All right then. And I've got past medical history. And do I have a drug history available?

SPEAKER_02 11:43

Yeah, absolutely. So the patient was on a doac.

SPEAKER_00 11:47

Which one?

SPEAKER_02 11:48

Rivoroxaban.

SPEAKER_00 11:49

Lucky Doke. Yeah.

SPEAKER_02 11:51

Aspin.

SPEAKER_00 11:52

Yeah. Oh, aspin and a doac. Okay, yeah, I guess. I yeah, fair enough. Yeah.

SPEAKER_02 11:56

Yeah. A torbostatic?

SPEAKER_00 11:58

Yeah.

SPEAKER_02 11:58

Bruzamide?

SPEAKER_00 11:59

Oh, how much?

SPEAKER_02 12:01

80 milligrams, BD.

SPEAKER_00 12:03

Okay, decent dose, yeah.

SPEAKER_02 12:04

Didroxin, one two five micrograms.

SPEAKER_00 12:07

One two five, yeah.

SPEAKER_02 12:08

Bazopralov, five milligrams once a day.

SPEAKER_00 12:11

Five, yeah.

SPEAKER_02 12:13

That was it.

SPEAKER_00 12:14

Okay, and no allergies, I hope.

SPEAKER_02 12:16

No allergies, no.

SPEAKER_00 12:17

Right. And who's at home? Is it the two of them?

SPEAKER_02 12:20

Yeah.

SPEAKER_00 12:22

Walk before this all happened the last few days. Were you fit and well manned?

SPEAKER_02 12:26

So yeah, I stopped working in early 60s. Um, I used to work at the supermarket. Um, and in my last few years, I was working on the trolleys and I used to collect the trolley, so I was very on your feet all day? All the time.

unknown 12:40

Yeah.

SPEAKER_00 12:41

And what about these days? On your feet a lot?

SPEAKER_02 12:43

Yeah, quite. I mean, I get I get limited by my breathing.

SPEAKER_00 12:50

Do you walk around on your own and your own steam or do you use walk-in sticks or a fan?

SPEAKER_02 12:54

Um always by myself. I don't need any walk-in sticks.

SPEAKER_00 12:57

Great. And you get out the house every day. Brilliant.

SPEAKER_02 13:01

I love pottering in the garden.

SPEAKER_00 13:03

Oh, you got a garden, lovely. Okay, independently mobile. Um, do you smoke?

SPEAKER_02 13:09

No, never.

SPEAKER_00 13:10

And do you drink much alcohol?

SPEAKER_02 13:13

A bit of whiskey in the evenings.

SPEAKER_00 13:15

How much are we talking?

SPEAKER_02 13:18

Um every night I'll have a tot of whiskey with a bit of water.

SPEAKER_00 13:22

A tot's right, a tot. A tot's alright, I suppose. Like your wick, maybe. Yeah.

SPEAKER_02 13:28

My grandma always used to say, Do you want a tot? What is a have you heard that before? A tot's.

SPEAKER_00 13:32

Yeah, it's like it's like a glug. It's like a what is it? It's like a little bit.

SPEAKER_02 13:37

A tot of whiskey, yeah.

SPEAKER_00 13:39

Right. Yeah. Okay. Um, you just mentioned your breathing. Is that something that bothers you on a day-to-day basis?

SPEAKER_02 13:49

If I'm trying to do activity that's more than walking, yes.

SPEAKER_00 13:54

I notice you're taking this fruismide, this water tablet. You get to get the fluid off your chest, I suppose. And are you someone who wakes up in the night gasping for breath?

SPEAKER_02 14:06

Yeah.

SPEAKER_00 14:06

Could you seat flat on your bed at home or do you have lots of pillows popping you up?

SPEAKER_02 14:10

Three pillows. What happens if you lie flat? I don't. I get indigestion.

SPEAKER_00 14:14

Oh, okay. But you don't you don't you don't lose your, it's not your breathing that stops you lying flat.

SPEAKER_02 14:18

No, no. I mean, I do I do snore.

SPEAKER_00 14:22

That's all right. No crime against that. Good. I need to have a look at this leg of yours, if that's okay. So let's lift up the covers and what do I see?

SPEAKER_02 14:30

Okay, so um on examination, so the patient is um in bed, lying flat. When you lift up the covers, you notice that the right leg is red and inflamed, and you can see a clear demarcation where the redness stops, and it's just underneath the patella.

SPEAKER_00 14:51

Okay. Looks cellulytic possibly. Yeah. Yeah. And is it swollen as well? And um, is the knee joint all right? The knee's fine. Yeah, it's not joint, he can but lets me bend it back and forth.

SPEAKER_02 15:04

Absolutely. So that's one of the things I always think about is is this septic joint? Um, yeah, the knee had full range of movement, there was no swelling in the knee. And I also love to look at people's toes. I think it's said a huge amount about people's toes and having a look in between the toes. Is there any tineopedis um that could have contributed to the cellulitis? But no, there wasn't.

SPEAKER_00 15:25

And I've got a feeling that fungal foot infections are one of the commonest causes of cellulitis because it causes the entry point for the bacteria. So we should always be looking for fungal foot.

SPEAKER_02 15:35

Always, always looking between people's toes for athlete foot.

SPEAKER_00 15:39

If you're bunging someone on some flu clock, you might want to give them some topical uh antifibal as well, some cochimazole or something like that. Absolutely irrelevant. All right then. A swollen leg, I mean, sometimes you do get a DVT as well as cellulitis because the inflammation of the infection causes disturbance of flow, which is one of Virkoff's triads for developing a clot, but he's on a doax. That would be really unusual for develops a DVT as well. So that's going to go down the list a little bit. So at the moment, I'm thinking cellulitis.

SPEAKER_02 16:05

Other leg looks all right, absolutely fine, no problem at all.

SPEAKER_00 16:09

And let's examine him all over.

SPEAKER_02 16:11

Okay, so temperature 37.9.

SPEAKER_00 16:14

Okay, february.

SPEAKER_02 16:16

Blood pressure 170 over 92.

SPEAKER_00 16:20

Bit high.

SPEAKER_02 16:21

Respirate 14. Pulse 96 AF, irregular.

SPEAKER_00 16:28

Yeah. And I mean, he won't mount a tachycardia if he was septic because we won't let him do that because he poured loads of bisoprolol into the room. Exactly.

SPEAKER_02 16:35

And he's on quite a good dose of bisoprolol, actually. He's on five milligrams and age 125.

SPEAKER_00 16:40

Yeah.

SPEAKER_02 16:41

Yeah.

SPEAKER_00 16:42

All right then. Um, have I got everything I want? D-da-do-do-do. Blood sugar.

SPEAKER_02 16:46

Blood sugar is 7.4.

SPEAKER_00 16:49

I always put that under vital signs for some reason.

SPEAKER_02 16:51

And that's a good way to remember it, isn't it? Sometimes it can get forgotten.

SPEAKER_00 16:54

Now, what about um the usual examination? So chest and cardiovascular exam?

SPEAKER_02 16:59

Chest is clear. So remember, he came in with a low respiratory tract infection. So chest was completely clear.

SPEAKER_01 17:05

How funny.

SPEAKER_02 17:06

Abdomen was soft and non-tender, heart sounds were normal, apart from the irregular um rhythm. I didn't hear a gallop rhythm or a third heart sound and S3. Um, when I looked at the legs of Woody Comments said that the right leg was swollen. The calves on both sides were soft and non-tender, so it wasn't necessarily looked like a DVT.

SPEAKER_00 17:26

And the JVP wasn't waggling his earlobes.

SPEAKER_02 17:29

Nope.

SPEAKER_00 17:30

So clinically euvemic. So his heart failure is well managed with the diuretic treatment that he's on at the moment. So that's good to know. Just what I'm thinking, how they got to chest infection. I wonder if they put together the fever and the difficulty breathing, um, added two and two together to get five. You just I just wonder where it came from.

SPEAKER_02 17:48

He looked well, this man. You know, and he I mean, although his wife is saying was confused, he looked well.

unknown 17:53

Okay.

SPEAKER_02 17:53

You know, we were sitting in the bed and he was it was really funny actually. We had a bit of a laugh and yeah. Looked well.

SPEAKER_00 18:00

Uh any interesting blood results for me, please?

SPEAKER_02 18:04

White cell count, 14.

SPEAKER_00 18:06

Yeah.

SPEAKER_02 18:07

Neutrophil count, 12.

SPEAKER_00 18:09

Yeah.

SPEAKER_02 18:10

CRP, 242.

SPEAKER_00 18:13

Decent.

SPEAKER_02 18:14

Mm-hmm.

SPEAKER_00 18:15

Any interesting usernease or all that were normal range?

SPEAKER_02 18:18

So creatine, he does have CKD, so his creature creatinine was 142 as well.

SPEAKER_00 18:24

Is that his baseline? Creatine.

SPEAKER_02 18:26

His baseline, yeah, absolutely.

SPEAKER_00 18:27

That's fine with me.

SPEAKER_02 18:28

Yeah, yeah. Sodium and potassium were normal. Liver function, normal, iron clotting was slightly elevated, uh, PT slightly problem, just as you would normally expect with a doac, but nothing hugely out of the ordinary.

SPEAKER_00 18:41

Just as a sidebar, talking about CKD. Again, I remember that um a very nice older consultant when I was a more junior doctor, I was an SHO, and he would never accept um a diagnosis of CKD in the past moment of history. If you'd say, Oh, and the patient also has a diagnosis of CKD. They go, Oh no, they don't, my assignment. No, they don't. That's not the full diagnosis. CKD, secondary to what? You have to say C and I'm assuming for this chap it's secondary to hypertension, hypertension and diabetes being the main two causes. Um, but you just reminded me. It's funny how you remember these little things that people say to you when you're in training, and then you sort of keep them on your own, adopt them as your own practice, don't you? So um, but he's he's not got an AKI. All right, and and you know, this this confusion thing is anything I haven't quite squared away. Quick meeting mental examination, he did AMTS rather, he knows where he is.

SPEAKER_02 19:34

I didn't do an official one, to be honest, but when I saw him, he wasn't confused at all towards it. It was at you when he was he was a little bit he knew where he was, and he knew, you know, I always ask people what date it is, but he was able to have a conversation, was a I guess just not quite right, but I wouldn't necessarily say that was confusion as such.

SPEAKER_00 19:56

I would then turn to the wife and I'd you know, I asked the patient's permission, right? I'd I'm just gonna quickly chat to the wife here just to see if she's got anything that she's worried about, and I'd say to her, just did you find him his normal self now? Is the usual question I asked.

SPEAKER_02 20:10

That's a good question. Yeah.

SPEAKER_00 20:13

Was this all a mild infective delirium in a 68-year-old man with skin infection? What's her point of view on that?

SPEAKER_02 20:22

So she said he wasn't his normal self.

SPEAKER_00 20:24

Oh, right. Well, what was what was wrong? What's the issue of it?

SPEAKER_02 20:27

So it was he just wasn't as quick as normal. Was taking difficulty word finding and struggling to. He's very eloquent normally, likes to read, do lots of things, but just wasn't his normal self. So she couldn't really put it into words, just wasn't right.

SPEAKER_00 20:44

There's something's off. My heart sinks a little bit in these situations. So no, I'm gonna have to do a neuro exam.

SPEAKER_02 20:51

My favorite.

SPEAKER_00 20:52

But you've gotta, you've gotta do it.

SPEAKER_02 20:54

What I've just found on my desk. Why?

SPEAKER_00 20:56

Attendant hammer in your own home. I agree with what men, get a line.

SPEAKER_02 21:00

I don't know. I don't know why I've got that there.

SPEAKER_00 21:02

Just as I said, neuro exam. But I we have to check. Isn't it is is it word finding difficulty? Has he got a mild expressive dysphasia because he's had a ugh? Um, I mean, he shouldn't have a stroke, an embolic stroke if he's doaced for his AF, unless doses, but we've got to at least try. So is there any neuro exam available?

SPEAKER_02 21:22

Any I didn't, I didn't do one.

SPEAKER_00 21:24

Okay.

SPEAKER_02 21:24

I'm sorry. And I should have done, but I didn't.

SPEAKER_00 21:27

Yeah. I I I I always do a neuro exam. I'm not saying it's the world's best neuro exam, but if someone says someone's confused, particularly if they say, Oh, he's struggling to find his words, I still need to make sure this is part of sort of global cognitive slowing, any kind of encephalopathic process or or delirium, or or had they knocked off a very focal part of their neurological system, such as broker's area or something. Um, all right then. So we have a man, I think I've got a good good enough reason here to call this cellulitis.

SPEAKER_02 21:57

Okay, yeah, and that's exactly what I did.

SPEAKER_00 22:00

Like it, smells like it. Um it's got the CRP and everything. I would start this gentleman on fluproxacillin.

SPEAKER_01 22:06

Yeah.

SPEAKER_00 22:08

Um, and then home versus admission. I suppose there's good good groundings for ambulating this man, i.e., giving a shot of um antibiotics and then using our outpatient cellulitis pathway by STEC to give daily reviews and antibiotics. But there's a bit of a pause here, which is the wife is concerned about something right. And I think overall, this might be someone who I'd start on flu clocks and maybe would come back and review um after half a day. Absolutely. Is it the morning? I'm seeing the patient.

SPEAKER_02 22:42

It was the morning, yeah. Yeah, yeah. First patient I saw actually that day. Yeah.

SPEAKER_00 22:45

I would say, look, you've got a skin infection, maybe a super fungal infection, I'm not sure. But um, I'm gonna give you some strong antibiotics. Let's see how you let's draw a little line around this infection here. Yeah. And I or the resident doctor who's working with me today is gonna come back and see you maybe 12 hours from now. And fingers crossed, if you're feeling better, we'll get you in your own bed tonight and we'll be giving you antibiotics at home. Um, but if things are still not quite right at our next review, you might be looking at a nice hospital just till we get this infection sorted out. But that would probably be my approach.

SPEAKER_02 23:17

Yeah, and and again, we come we always come at things very differently, Ben, but we always end up with the same. That's exactly what I did. And I um I did actually say, because something didn't fit right and the wife was worried, I said, I'm gonna admit you for 24 hours. I'm I'm gonna go to Ivy Flu Cluxicillin, one gram, QDS, and I'll pop back later. And when I've seen patients in the morning, um, even if I don't actually physically see them in the afternoon, I'll always do a walk by um and check their bloods, just make sure they're okay. And anyway, if anybody's got any concerns, eye on them in the end of the bed. Yeah, and sometimes I will go in and say, How are you feeling? What we've done, is anything better any worse? I think that's really important. Certainly for for me as well. That's how I feel like I learn, you know, have I made the right decision in the morning? So that is exactly what I did and thought nothing more of it, and I continued to see the rest of my patients. However, in the afternoon, I was still doing the ward round because, as you know, my ward rounds are incredibly long and it deteriorated quite significantly, actually. And um, another doctor had been asked to see him because I was somewhere else seeing different patients and was very in charge of what was happening with the situation. Um, I sort of poked my head round, had a chat to the wife, um, said, Is everything okay? She said, Yeah. And I was like, fine. Walked away. About an hour later, I noticed that the doctors were still with him. They'd done a blood gas and they said he's very unwell. He's on the end of life pathway. I was like, What?

SPEAKER_01 24:52

Oh my goodness.

SPEAKER_02 24:52

What? What? Like, is this the right patient? Have I have I missed something? Um, and he'd been seen, um, he deteriorated rapidly. Um, they thought it was um uh huge acute pulmonary edema, um, maybe from the fluid that he'd been given or the antibiotics, the amount of flu that is in the antibiotics, but it deteriorated. And I was like, oh gosh, you know, this is this is not what I expected. And I was quite shocked, but at that point I had so many other patients that I was looking after. Somebody else was now managing that, that I thought, I actually don't need to get involved. Now, again, I don't know whether that was right or wrong. Um, and I sort of left it. And the next thing I remember was the next morning I came back into work and the night registrar came up to me and said, Amy, can have a chat about the patient. And I knew which patient she talked about. So, what happened?

SPEAKER_00 26:00

I'm very shocked.

SPEAKER_02 26:01

I mean, yeah.

SPEAKER_00 26:02

How much fluid did he get?

SPEAKER_02 26:03

I mean, with well, it wasn't a huge amount.

SPEAKER_00 26:06

Do we know his ejection fraction or or anything? Uh any previous echoes, no, we don't know.

SPEAKER_02 26:11

Um sorry, I didn't have those that the details.

SPEAKER_00 26:14

Maybe you don't, but uh it's I mean, unless he's got an ejection fraction of like 10%, then you you should be able to give ietrogenic pulmonary edema from a litre of fluid in the context of of infection. So, and this is the kind of stuff that does make your blood run absolutely because the first thing you think is, what did I do wrong?

SPEAKER_02 26:33

Exactly.

SPEAKER_00 26:33

What have I done to that man? This is my fault until proven otherwise. Yeah, quite um I felt sick, yeah. Yeah, you know, like that is listening to it because I can imagine myself in that you feel like that lurching sensation.

SPEAKER_02 26:47

It's a lurching sensation, and it feels like the ground has opened up beneath you, and you're you know, like that you go on a roller coaster, and it's like the I can't. It's so I felt like that, and um she was brilliant. The registrar was when we sat down, and she said, Um, she'd been asked to review him overnight because of a low GCS um and severe lactic acidosis. And when she saw him, she said, I I don't really think that end of life was was appropriate, actually. And I I truly believe that we could try and do something for this man to figure out exactly what was going on with him. And because it didn't seem right. She'd read my notes in the morning, cellulitis. A few hours later, end of life, and then a few hours later, decreased DC. She was like, something, it didn't fit. The puzzle didn't fit. It wasn't logical.

SPEAKER_00 27:39

I'm worried now. I'll put I'm so empathic, I've put myself in your place. So I feel like I've seen the patient. Yeah. I've missed something, and I'm worried that I've missed a um a subdural hemorrhage in someone who's anticoagulated and has been falling over at home. Uh-huh.

SPEAKER_02 27:51

Yeah, good point.

SPEAKER_00 27:52

And I should have scanned his head. That's my that's my initial reaction. Wrong or rightly.

SPEAKER_02 27:58

At this time, I'm gonna tell you that he was in ITU.

SPEAKER_00 28:01

Okay.

SPEAKER_02 28:02

So he ITU took him overnight.

SPEAKER_00 28:05

Yeah.

SPEAKER_02 28:06

And the doctor started from the beginning again. So because she went to see him in the evening and went this makes no sense, she went back to the beginning. And I think that is what we need to do in medicine when something doesn't make sense, when the story doesn't fit, is to go back to the beginning and start with that history and go back to basics. Take the history, examine the patient. And she got the diagnosis by looking at his leg.

SPEAKER_00 28:39

It wasn't neckfash, was it?

SPEAKER_02 28:41

It was neckfash.

SPEAKER_00 28:44

Normally neck fashion, you see it because they scream when you touch them in. It's excruciatingly painful. Um the rash is very violent, and they're very, very ill.

SPEAKER_02 28:55

So I luckily I'd taken photographs of his leg and uploaded them onto our system on the day. So she'd looked at the photographs I'd taken in the morning and looked at his leg and was like, oh my, the difference. And she noted severe erythema, hemorrhagic bully, yeah, incredibly tender, very, very unwell, very, very hypotensive urine output was in its boots.

SPEAKER_00 29:24

This is all new, then. All new. All new. And just to be clear, because we're using um uh a nickname, which about necrotizing fasciitis, just in case people uh aren't familiar with fascia.

SPEAKER_02 29:36

Yeah. Astonishing. And and he went to theatre and had depriment overnight by the plastic surgery team.

SPEAKER_00 29:42

Did he lose his leg?

SPEAKER_02 29:43

He didn't lose his leg. Um, he went to ITU and remained very unwell and had further depriment, um, and sadly, sadly passed away within 48 hours.

SPEAKER_00 29:59

So I think there's gonna be a lot of people listening who are you know at the beginning of the medical career who are going to be filled with absolute terror and dread at this story, thinking it how do how do consultants reach this?

SPEAKER_01 30:13

I know.

SPEAKER_00 30:14

I think it'd be interesting just for you to talk about how you have processed and this.

SPEAKER_02 30:20

And um have I processed it then? I'm not sure. Um no, I have. I have.

SPEAKER_00 30:24

How how you how uh this is part of our role. This is we're we're the risk holders for patients. Um, how have you made sense with this in retrospect?

SPEAKER_02 30:37

So for the first week, I didn't. I completely and utterly beat myself up. How could I be such a crap doctor? How am I so rubbish? How have I missed this? Um, you know, and it's you go through a process, I think, of first processes, and I was so angry at myself. Anger, and I was really disappointed in myself. Um, I felt like I'd let myself down, I'd let the patient down, I'd let his family down. And it was, I I spoke to lots of people about what was going on.

SPEAKER_00 31:10

And you know, is that part of your process? It is you get a second, third, fourth, fifth opinion. You get it.

SPEAKER_02 31:15

Oh, many opinions.

SPEAKER_00 31:16

Yeah.

SPEAKER_02 31:16

And and do you know what? That's not probably the right thing to do. And I think I want to get an opinion until I like the opinion that I get.

SPEAKER_01 31:22

Yeah.

SPEAKER_02 31:22

Which is it's again not necessarily right or wrong, but so I I sought lots of opinions. Um, and then the rational side of me sat down, which was actually the doctor who'd saw him overnight and said, Okay, so let's have a look at this. These were the images in the morning when you saw him. That's cellulitis, that is not necrotizing fasciitis. Yeah, the images that we've reviewed 10 hours later, that is necrotizing fasciitis. You didn't see him in between. I don't know what happened in the daytime in the middle when I wasn't involved in the care, but I should have been involved. Should I have been involved? Should I have gone? I saw the patient this morning. That patient belongs to me, I'm gonna take ownership. And I didn't, and again, was that because of we are under so much pressure sometimes that a lot of it is my oh I'm pressure to see everybody that I didn't I couldn't even compute seeing the patient again. I I don't know. I've done a lot of reading, I've done a lot of learning, I've reflected a lot on it. I I wouldn't have diagnosed neck fascia necrotise and fasciitis on him in the morning because he had no signs or symptoms. And the necrotides and fasciitis diagnosis came nearly 12 hours after I'd saw him, which is what necrotizing fasciitis is very rapidly developing. So could I have done anything different in the morning? Oh, probably not in hindsight.

SPEAKER_00 32:54

No, and I think that's very clear to me. There was nothing in that initial review you did which suggested this man was going to get neck fash and have to go to IT for deprivement and organ support and then eventually pass away. Uh, you know, without without being able to tell the future, it just wasn't there. The signs were not there at all.

SPEAKER_02 33:11

The signs weren't there.

SPEAKER_00 33:13

Yeah.

SPEAKER_02 33:13

And I think that's what we do have to remember as well in medicine is things change.

SPEAKER_01 33:18

Yeah.

SPEAKER_02 33:19

And just because a patient comes in with shortness of breath, for example, that patient may have a different presented complaint three hours later, six hours later, nine hours later. People change. Stories evolve. Sometimes we get frustrated when somebody might come up to us and say, Oh, you know, Joe Bloggs has got, is now saying he's got chest pain in a lot. Well, he can't have chest pain because he came in with a bad leg. Of course he can have chest pain. People change. And I think that also showed me how how unwell people can become within minutes. People can become very unwell very, very quickly.

SPEAKER_00 33:59

Imagine if you'd sent him home.

SPEAKER_02 34:01

Oh I d uh yeah.

SPEAKER_00 34:03

Seriously, it's something to do with the fact that you decided to keep him in for observation.

SPEAKER_01 34:08

Yeah.

SPEAKER_00 34:08

Based on gut, gestalt, you whatever you want to call it, um, something telling you that things weren't quite right. And this, you know, this was not just um a cellulytic uh leg. Um there were some other not red flags, maybe faintly pink flags that meant they let's just keep an eye on things. And he was in a safe space and people did so. And as soon as it was noticed that something had altered, people leapt into action and and go for the thing they could. And this of the mortality rate for necrotizing fasciated is unfortunately desperately desperately high.

SPEAKER_02 34:44

And in as a I've been a doctor for 21 years, that sounds absurd. 21 years. Me too. Yay! I have only seen necrotize and fasciitis once before. So a lot of uh illness scripts that we develop in our brain, which we go to like a dictionary of diagnosis in our head. I don't really have a illness script for necrotizing fasciitis because I haven't necessarily seen it.

SPEAKER_01 35:16

Yeah.

SPEAKER_02 35:17

Um, but I've got one now. And every time I see a red leg, I'll be like, is this neckfash?

SPEAKER_01 35:23

Yeah.

SPEAKER_02 35:23

Could it become neck fash? You know, what are the risk factors? Um, and I think that's really important there. And I think it also highlights seeing patients is the best way to learn medicine.

SPEAKER_00 35:38

Oh, no argument from if you've got to build your library, and there's only the one way of doing it, and that's to see patient after patient. We have to build our library. Patient after patient. But you know, I'm not to say there's nothing that can't be learned in the classroom or in a PowerPoint lecture. No. Have you? Then you know, that's great.

SPEAKER_02 35:53

But or on a podcast.

SPEAKER_00 35:55

Hey, yeah. But um, but yes, you there's nothing that can replace just see and and and you know, even not excited patients, you know. Sorry, patients, you're all exciting, and we love you. I meant not exciting presentations, but what might say, oh, this is a bond or stuff, but you have to see the bond or stuff. You just see the stuff that isn't very glamorous, you have to see all the folds, you have to see all the UTIs, so you know which one is a bit weird.

SPEAKER_02 36:21

And I've yeah, and it's when you see a patient, you remember the smell, you remember the bed they were in, remember what they look like, what often sometimes what they're wearing. And it's so, yes, you can learn something in a book, but that doesn't truly activate all your senses. And we learn through senses, we learn through see, touch, smell, sound, and we can only do that when we actually see a patient. Yeah, so difficult case.

SPEAKER_00 36:57

It's a difficult case, and I think when you're working through cases like these, you have to sit with it for a while. You can't tell like I want this sorted out in my brain by close a clay today, so I can park this and move on. You have to just doesn't work. This is gonna sit there for a while, and your subconscious is gonna chip away at it a little bit when you're doing other things like doing the washing up or you know, brushing your teeth or something, even when you're not actively thinking about it, you you will be unconsciously processing, processing, processing. One of my teachers called it composting. You get these things and you're turning it slowly into mulch, into compost, and you have to wait for it to compost down, and a lot of that happens below the surface of your consciousness. Oh, absolutely, and then eventually it will be turned it will be composted down, and then things will grow out of it, and you will start to um develop shoots of of new new understanding information. But but that is a time-laden process, and you can't you can facilitate it by doing by by many different ways, and the way that you did it is the way that I do it, which is I need to talk about this, and I need other people to tell me honestly what they think about this. Um, other people don't find that helpful, they need to do it in the inside their own head first of all, and then and then maybe be vocal with it. But I'm like you, um, I need to get 19 opinions now. Yeah, like exactly exactly what I did. Does that deviate from consensus or or not? And that actually helps me understand. And I think uh if people ask me, Ben, what would you have done in a case like this? I I do try to take that seriously and take time to give them a reasonable answer and not just brush off and say, Oh, no, no, no, I'm sure you're fine. You're fine, you did nothing wrong.

SPEAKER_02 38:35

Yeah, exactly.

SPEAKER_00 38:35

It doesn't help to say close my eyes and say, Okay, let me put myself in your shoes, like we've just done today with this this episode, and try and give them a really, really good answer and take my time and think about it and say, honestly, I think I would have done that as well. Or the only thing I might have done differently is I might have done this, but I don't think it would have changed the eventual outcome. But I try and be honest because I think that's more useful.

SPEAKER_02 38:56

Yeah. And I think, you know, I also want people to take away from this that I still think about a medical error I made 10 years ago. Um, so it's not, you know, if you're still thinking about something that you did three, four years ago or even longer than that, that's okay. That doesn't mean that that's a bad thing. It just means that your brain is processing things at different speeds and at different ways and different times. And um these things, every patient, every patient interaction I have is a story for me to remember and it helps me get better and improve.

SPEAKER_00 39:33

That's a nice way of looking at it.

SPEAKER_02 39:37

Thank you so much, Ben. Just to say that those of you who are listening to the podcast, um the cases are based on real cases, but you know, we do change details and quite a few things. So it is grounded in fact, but obviously patient confidentiality is paramount to us. So we do change things. I hope that you listening enjoyed that. I hope that you got something out of it, got some key learning points, uh, prompted some reflection. Please, please, please rate, review, and subscribe and share. Our podcast we're doing really well. We want to do better, we want more people to listen to the podcast and you know, and hear us talk and think about our clinical reasoning. Huge thank you to you, Ben.

SPEAKER_00 40:22

Thank you to you as well.

SPEAKER_02 40:23

Thanks for listening. Bye.