GO A S Y P

Here's an edited email from another specialty about a patient with an ischial pressure sore. There are no patient or doctor identifiers. The writer of the email had not seen the patient concerned.

Thank you for your email. I have discussed this with the registrar who received a phone call  from a Foundation doctor regarding this patient.

Note the sniffy tone. What was the F1 doctor meant to do? The specialty concerned refuse to carry pagers, and are routinely a hassle to track down. The point of all the specialties being under one roof - which is called 'a hospital' -  is undermined by such difficulties in access.

Advice was given with regards appropriate dressings, ensuring good nutrition (albumin of 21 is not optimised) and appropriate pressure relief with mattress, cushion, turning, etc.

As the ward nurses concerned said to me: "appropriate dressings and nutrition! Brilliant. We'd never thought of that". Furthermore, the patient was verging on being morbidly obese. Malnutrition was not an issue. Isolated albumin results are not the gold standard. This was an obvious 'end of the bed assessment' point.

He also made it clear that we do not routinely operate to close pressure sores, and would certainly not do so in the presence of osteomyelitis.

This was not requested. The specialty concerned are just one part of the appropriate multidisciplinary input the the patient needs (and can reasonably expect). A bedside review would be the obvious first step

I have reviewed the recent MRI scans, which show destruction of the ischial tuberosity and oedema of the surrounding muscles.

'destruction' suggests something dramatic. In reality it was typical superficial osteomyelitis at the base of a sore. The ischium was essentially intact. MRI is very sensitive and needs to be interpreted with care

He should continue with dressings and antibiotics. The pressure sore will never heal unless the osteomyelitis is adequately treated.

The first bit is misleading,  he definitely needs an operation, which is why the second bit is true. Established osteomyelitis is not treated by antibiotics without surgery. If there's pus, let it out (the old ones are the best).

As it turned out, the pressure sore was excised and the osteomyelitis debrided back to healthy bone, there was plenty of soft tissue to allow a tension-free closure, so there were no secondary soft tissue reconstructions needed. This was exactly what could be expected from even a brief visit to see the actual patient. 

Hence the title, GO A S Y P  or 'goasyp' to keep it catchy. Go and see your patient.

This is not picking on any one specialty - we are all capable of making this mistake. I don't, to give a common example, think you can properly assess an acute abdomen without a bedside assessment. In that example and in others more orthopaedic, like possible compartment syndrome, it may easily need several such visits. That's your job.

Once the problem has been referred to you, it becomes to a variable degree your patient. Act accordingly. When was the last time you let Kwikfit sort out your car over the phone?

Being easily available (why do people not want to carry their pagers - mobiles are no substitute?) makes a huge difference and will enhance your reputation.

This is not just  kind and humane - the patient always appreciates a bedside visit - but how the hell can you make a key decision without all the relevant facts? You can't, at least not consistently. Relying on data from your work PC instead is part of what I call Google Medicine (more another time). Anyone can look stuff up. It is not equivalent to taking a history and examining your patient. How could it be?

Not only is this advice good for the patient, it is good for you too. It will protect you when if, one day, there is a clinical mishap because of advice given over the phone or by email, though there had been nothing stopping you from actually doing what every doctor since Hippocrates has been routinely taught.

GO A S Y P !!!

....old school (in every way). Note that the surgeon is at the patient's bedside.