I wished I had all the time in the world to pen my thoughts.
I don’t.
I have a hurdle to jump. An Everest to climb. A Surgical Fellowship Exam to sit. Until then, this blog will be on hold while I pursue the F word. (“FRACS” – Fellow of the Royal Australasian College of Surgeons)
Will miss your company.
Cheers.
29 year old male referred by ED for sore throat and jaw trismus with a provisional diagnosis of quinsy (para-tonsillar abscess). On the phone, ED doc said, he also has a large right sided neck swelling and the tonsils “don’t look too asymmetrical”.
Could this be quinsy? NO!
On review of the patient, he did have trismus and a large right neck swelling. Also, the patient added, “I have always had rotten teeth and I think this is a bad tooth infection”. The patient is right.
On examination: jaw trismus, large right neck swelling involving the jugulodigastric region (anterior triangle, inferior to angle of mandible) and extending over the submandibular region. Swelling feels hot and tense. Patient is drooling, Tongue is elevated (not swollen). Right inferior molars are rotten. Tonsils look normal and symmetrical. More importantly, the floor of his mouth feels swollen, tense and tight.
Diagnosis?
Ludwig’s angina secondary to odontogenic infection. This could become an airway emergency.
Paratonsillar abscess (quinsy) is an abscess formation behind the tonsil in the paratonsillar space (between tonsil and superior constrictors). Key findings: inflamed asymmetrical tonsils, uvula deviated to opposite side, bulging of abscess seen superiorly over upper pole of tonsil and soft palate, jaw trismus. Neck swelling is not likely. Neck lumps due to lymphadenopathy is possible.
Ludwig’s angina is cellulitis in the submandibular space. Think of it as compartment syndrome of the floor of mouth. It is often due to teeth infection. It can rapidly lead to an airway compromise as the tight space result in swelling posteriorly and inferiorly. Key findings: rotten teeth! trismus, tongue elevation (not swelling) due to tense swelling on floor of mouth, deep neck space infection and inflammation.
Imagine intubating a patient with trismus, tongue elevation and tight floor of mouth. Hence not a small number of these patients get emergent awake fibreoptic intubation or tracheostomy (up to 20% according to some reports).
Tips for docs: The patient tells you that he has rotten teeth. Believe him. Examine the floor of mouth and teeth when you think that a patient has any intra-oral infections. The clues are hidden there in the history and examination.
This is it. The last day of this 31 day challenge to better doctoring. If you have traveled with me this far, I sincerely thank you. I hope you have had as much fun as I had in going through these little daily challenges. Let me recall, that these exercises were written just for me, so I can push myself to be a better doctor. Not in terms of knowledge, but as a person, a colleague, a worker, a public servant. I hope you had enjoyed the thoughts behind these challenges as well.
This day is yours. Fill in the blanks. Choose your own little challenge to better doctoring today. You can pick from the last 30 challenges and repeat one of them, or you can come up with a good one on your own. Whatever it is, challenge yourself. Today, you can be a better doctor than yesterday.
Thanks again for traveling with me this far. To my dear friends on Twitter and blogosphere who had conversed with me along the way, a sincere thanks. It is really encouraging to see that there are many people out there wanting to make a difference wherever they are. I salute you for your hard work.
Love,
Otorhinolarydoc
Someone said that the secret to happiness is not in doing what you love, but in loving what you do. As doctors, we are in such privileged positions. We get to practice our art and help others along the way. As medical students, we fell in love with medicine. But as we grew up in medicine, we get lost in the busyness, stresses and demands which are inevitable parts of a career. We get hypnotised by the temptation of money and fame. Along the way, we lost our love of medicine. We lost the reasons why we entered medicine in the first place. We lost the child-like awe and excitement that used to greet our days at the hospitals. We lost the inquisitive curiosity that used to fill our minds. We lost the love of medicine. No wonder many of us become quite sad, grumpy, cynical old doctors.
If there is one challenge in this whole 31 Days to Better Doctoring Challenge that I hope every doctor would do, it would be this: The challenge to love your work. The challenge to fall in love with medicine and surgery all over again. The challenge to infuse more enthusiasm and love into everything we do. The challenge to love what we do. I could almost guarantee that the more you love your work, the happier you would be and the better your work would be.
So today, I challenge you to fall in love all over again with your work.
‘Doctor’ comes from the Latin word ‘docere’, meaning ‘teacher’. ‘Surgery’ comes from the Latin ‘chirurgia’, or Greek ‘kheirourgia’, meaning ‘working with hands’.
I believe as a surgeon I am called to be a teacher who works with my hands.
The primary duty of a doctor/surgeon is to teach. To teach patients how to live better. To teach students the causes and treatments of diseases. To teach nurses how to care for patients. To teach families how to support a patient in need. To teach, teach and teach. You’ve heard it said before, “Give a man a fish, and you’ll feed him for a day. Teach a man to fish, and you’ll feed him for a life time.” And that is true. Caring for one person for a day limits my impact. Teaching how to care for a person will teach the patient, their families, their carers, their nurses, my students, colleagues, and many others the art and science of better living. Teaching is foundational to the legacy of health I will leave with my patients and the doctors after me. Long after I’ve laid down the scalpel, it is my legacy of education that will continue to bear fruits of healthy outcomes. By teaching, I do not mean a transfer of information. No, the photocopier does that. Teaching, to me, is primarily measured by a change of action or behaviour resulting from an educated mind. A life change, like stopping smoking, caring for ear health, vocal hygiene, etc, are the outcomes of my teaching as a doctor. Antibiotics and surgery are just some of my tools. And when I see a non-ENT doctor being good at managing BPPV, otitis externa, chronic rhinosinusitis, salivary stone, etc. then only have I done my duty as an ENT surgeon. Teaching is not focused on the teacher, but the student. Teaching a patient to stop smoking requires a different technique to teaching a medical student the biochemical carcinogenic effects of smoking.
Every moment is a teachable moment. Not a lecture session, but a teachable moment. Be proactive in teaching today. Fulfill your ancient Latin calling as a doctor/teacher.
Throughout my training I’ve found that even the hardest bosses are really softies at heart. Some of the nastiest surgeons I’ve met turn out to be very reasonable and friendly mentors once you get to spend time with them. It’s just that they don’t let too many people come close to them and they demand perfection from everyone working with them. That gives them an air of unapporachability, though they’re really human beings wanting to do their best for their patients. I’ve actually fallen in love with some of these hard to break surgical bosses. In fact whenever I start with a new unit I still make it a point to identify the ‘hardest’ boss in that unit and aim to ‘turn him/her around’. I make it my goal to soften the hardest boss. And surprisingly, it always starts with appreciation. So today, do something to appreciate your bosses. A word, a card, a gift, etc. Surgeons and bosses are people who also need to know that they’re doing well in their work. They too need feedback and appreciation.
Which is harder? Writing down the bad stuff you’ve done, or the good ones? Yesterday you wrote about the things that you could have done to improve your game. The wrongs that could have been made better. Today, write down the events in the past week where you have done well. Think about your interactions with your patients, the procedures you’ve done, the jokes you shared with the nurses, the plans you’ve set for your patients, the drugs you chose, the presentations you’ve made, even the clothes you wore. The ability to fairly assess your performance as a doctor is important. In the current context of cynicism and negativity at workplaces, it is always important to be able to assess your own performance and determine how well you are doing. Celebrate the good you’ve done.
ENT News
