A 50 year old lady presented to our tertiary hospital with abdominal pain of a non-specific origin. It was decided by the ED consultant to order an abdominal CT scan (otherwise known as a ‘grope-a-gram’). Although there was no obvious pathology detected to explain her symptoms, I was still showed the abdominal slices to look for an interesting finding:
I will post a short precis on this condition (and its classification) in a few hours leaving some for the Twitterverseto have a gander. I wonder how long it takes you to find it, I remember it being well over 30 seconds for me!! ===============================================================
So after my almost minute of searching through the above grey/white/black image for subtle fat stranding, flaps of aortic lining and pancreatic abscess, it hit me. “Oh s**t. The liver isn’t supposed to be on that side.” My heart sank when a medical student came up and said straight away “this CT looks weird” and without missing a beat exclaimed “everything’s on the wrong side.” A few terms of colorectal surgery and general medicine had me looking for minutia. I’d failed to see the forest for the trees, or leaves even! The more thoracic slices were easier to pick:
What we had was a case of situs inversus. This condition can also be known as situs transversus, situs oppositus or situs organsaroundthewrongwayus*. Their internal organs are mirrored across the sagittal plane, or more simply: things usually on the right side of the body (liver, gall bladder, caecum) are found on the left and vice versa.
*Term made up by me, just now.
So what is the first thing you should think of when you see a CT like this? No the answer shouldn’t be situs inversus. Common things happen commonly. Mislabelling or image mirroring of the CT may be to blame. Then if you are confident this is not the case, time to delve into the rarefied air of such genetic abnormalities. Rare, yes. But the classification of position of internal organs is quite simple. It is not clearly essential knowledge, however very good for impressing cerebral physicians…
- Situs solitus (‘normal’) - How most of us and the anatomy text books are put together/drawn
- Situs inversus with dextrocardia (situs inversus totalis) - Most common form of inversus which has a right sided heart, in keeping with the switch
- Situs inversus with levocardia (situs inversus incompletus) - A much more rare form of an already rare condition in which the heart remains on the left (normal) side of the thorax
- Situs ambiguous (heterotaxy syndrome) - Any combination of the above that does not fit a pattern of complete solitus or inversus. Calling it ‘incomplete’ situs inversus probably explains it better, but sounds too much like the latter.
Situs inversus is thought to have a prevalence of 1 in 10,000 people. It is inherited in an autosomal recessive manner and is usally associated with other congenital heart defects (most commonly transposition of great vessels, TGV). Interestingly, although Leonardo Da Vinci was the first to describe dextrocardia, it was Matthew Baillie who described situs inversus and TGV. He was a Scottish physician who in 1793 wrote the best titled text I have come across: The Morbid Anatomy of Some of the Most Important Parts of the Human Body.
Interestingly 25% of patients with situs inversus have an underlying diseased called Primary Cilia Dyskinesia (PCD). Cilia are tasked with placing organs in their appropriate positions during embryogenesis and this is where things can go wrong. If patients have the triad of chronic sinusitis, bronchiectasis and situs inversus, then this is known as Kartaneger syndrome. Perhaps its worth conducting a thorough listen to the chest (or ECG) for those patients with recurrent sinusitis and mucousy coughing?! These conditions pose interesting anomalies, but what are the practical consequences for the patient sitting across from you?
- ECG interpretation: If you attach the leads (correctly!!) and see strange axis deviation, p-waves inversions and a decrease in QRS voltage across to V6, then there may be inversus. To confirm this, swap all of the leads across to the right chest, including limb leads. The lesson though, is always double check lead placement lest you end up diagnosing ‘technical dextrocardia’
Pain/Tenderness: We are taught in surgical training to know that for pain or tenderness in the abdomen, think about the underlying structures to help differentiate causes. Clearly if things are mirrored it will change your thinking. LIF pain could be appendicitis, RIF pain could be sigmoid diverticulitis and LUQ pain could be gall bladder related. Bruising over the right flank might mean you are worried about a splenic rupture.
- Organ transplantation: The vast majority of organ donors will have anatomy orientated in the usual way. However if a patient with situs inversus needs a transplant, problems arise. Not only are arteries and veins in different positions, but the physical shape of the organs will not match up. In fact, an American patient with situs inversus underwent a heart transplant in 2007. The six-hour long operation was likened to solving a “three dimensional Rubix cube” (actually not sure what other dimensions Rubix cubes come in…but here is one solved in 30 seconds)
Thanks for reading and contributing. Clearly this is not a common presentation or finding, but hopefully if you happen across an interesting CT, CXR or ECG, you will have some background knowledge of these rare and fascinating disorders.
“I have an opinion about men who wear bowties. They are mavericks; truly adventurous dressers who live on the sartorial edge. They are nonconformists and often seen as threatening to the establishment. Yes, look out for the man who sports a bowtie – he probably has an attitude.” – Chris Hogan, 2008.
So I’ve been busying myself this year by watching online lectures as part of the Diploma of Child Health. This is run out of the Children’s Hospital at Westmead in the outer suburbs of Sydney. Throughout these lectures, I have noticed many of the doctors sporting natty bow-ties. During my time at Flinders Medical Centre and in GP land, I could probably count the number of docs setting this trend on one hand (free from polydactyly). But it seems every second professor or head of department on these web-based lectures are wearing them! What is going on? I propose this hypothesis: As one delves deeper and deeper into the sub-speciality crevasse, silent pressures force a required dress code. The most obvious and classic of these, the humble bow-tie. The graph below summarises my findings. Unfortunately elbow patches, jumpers tied across chests, pocket protectors, grubby white coats and mad scientist hair variables have not been investigated, but pose areas for future study.
Additionally, my off the cuff choice of neurologists at the pinnacle of this fashion statement seems to be rather accurate. In an article published in 2010, an American medical news outlet outlined neurologists penchant for wearing bow-ties. The American Academy of Neurology’s self-appointed spokesman on neckwear, John C. Kincaid, MD states that “Bowties suggest the wearer is ‘on the precise side,’ which describes many neurologists.” Yes it also describes the majority of people diagnosed with OCD. Perhaps suggesting a slight overlap in populations? The Academy is pretty serious about this caper, so much so that they even have an official bow-tie festooned with miniature neurons. But you are a renegade infectious diseases consultant, you want something slightly more relevant adorning your small piece of tied fabric. Well never fear. This website makes and sells bow-ties featuring microscopic lovelies such as: Anthrax, E.coli, Swine flu and Rhinovirus. Just don’t get any Syphilis on your neck….
But this lighthearted choice of bow-tie material brings us to an important point in medicine. Infection control. Millions of healthcare dollars are spent around the world trying to reduce the number of hospital acquired diseases. Instead of regular neck ties dangling around in purulent exudate or hospital food (equally as nauseating) ready to be transfered to the next vicitim/patient, bow-ties remain high above strangling the neck of the treating physician. Neck ties have been shown to carry nasty bugs such as Staph aureus, Klebseilla and Pseudomonas as shown by a study of New York doctors in 2004. But obviously it depends on the specialty of the wearer, as you wont see much patient/doctor interaction from a radiologist. On a recent Twitter discussion it seems that along with neurologists, gynaecology and urology have higher proportions of bow-tie wearers. Whereas neurologists may be keen to avoid a long tie tickling a patients face during cranial nerve examination (albeit a nice quick way to check CNV sensation), our friends working below the umbilicus may well be avoiding ‘bits’ on their attire. (I chose the word ‘bits’ as the alternatives have been getting too much coverage in the media of recent days and I thought it rude of me to slipper them in.)
I can also see the benefit of bow-ties in paediatric populations as a way of breaking the ice. Whether the use of novelty ties that spin or flash lights would entertain the children as much as the wearer remains to be seen. Another avenue of research that may be followed. Until then, myself like many rural docs are happy with rolled up sleeves and the occasional boardshort/thongs combo. US readers should note the Australian use of the word ‘thong’ unless you have a confession KI Doc?
So it turns out that the SA Country Footy Barometer was indeed correct in predicting the 2012 AFL Premiers, Sydney. Unfortunately, it did not help the SANFL red and white team North Adelaide get to the very end. The Roosters were knocked out in the preliminary final by West Adelaide (like Sydney, also nicknamed ‘the Bloods’). So time will tell whether that part holds true!
But I have realised, as had the Sydney Morning Herald in an article published in early September, that the Swannies success was not only due to the goings on of SA country leagues. In fact my old secondary school Xavier College has provided five of their team this year, above. Those on the list being Matt Spangher, Alex Johnson, Dan Hannebery, Josh Kennedy and of course, Ted Richards. And there is form for this Swans-Xavier link as past captain Andrew Schauble was a past pupil. With Jobe Watson winning the Brownlow medal last week, it will be interesting to see how many other football stars Xavier pumps out in the next few years. (For the record, old Xaverian Gerry Considine, right, only managed 6 games for Wudinna United B-grade in 2012 including one best on, one goal and one dislocated finger. He was perhaps better known for looking a bit like Stevey J)
Like most of Australia (well the intelligent half that follow AFL codes rather than NRL) I’m looking forward to the big game between the Swans and the Hawks this Saturday. At the time of writing, Thursday lunchtime, the Swans were out to $2.90. Pretty good value if you ask me. And I’ve put some money of the bloods to get over the line too.
“Cheer, cheer, the red and the white”
But the clincher for me was not to do with a paucity of Meatloaf entertainment, possible line ups, or the even weather in Melbourne in two days. Its all about colours. Here in country South Australia, more than a handful of the red and white teams in each league have clinched the flag. Here is the list so far (not all of the photos are from 2012):
Elliston – Mid West League
Crystal Brook – Northern Areas League
Tasman – Port Lincoln League
South Augusta – Spencer Gulf League
Two Wells – Adelaide Plains League
Konibba – Far West League
Parndana – KI League
Bordertown – Kowree, Naracoorte & Tatirara League
Will it also mean that North Adelaide are set for a win in the SANFL grand final also?
If SA country footy is the bellweather for the AFL Grand Final, as a Collingwood supporter, Im waiting for Wudinna, Paskeville, Jamestown/Peterborough et al to get up next year. Go the Magpies!! But for this year, it seems the odds are stacked for the red and the white. So do yourself a favour, pop a tenner on the Swans…even just to keep Tim Bastian quiet for a few more days.
Benign – What you be, after you be eight.
Artery – The study of paintings
Bacteria – Back door to cafeteria
Barium – what doctors do when patients die
Cesarean section – a neighborhood in Rome
Cat scan – searching for kitty
Cauterize – made eye contact with her
Colic – a sheep dog
coma- a punctuation mark
D & C – Where Washington is
Dilate – to live long
Enema – Not a friend
Fester – quicker than someone else
Fibula – a small lie
Genital – a non-Jewish person
GI series – world series of military baseball
Hangnail – what you hang your coat on
Impotent – distinguished, well-known
Labor pain – getting hurt at work
medical staff – a doctor’s cane
Morbid – a higher offer
Nitrates – cheaper than day rates
Node – I knew it
Outpatient – a person who has fainted
Pap Smear – A fatherhood test
Pelvis – second cousin to Elvis
Post Operative – a letter carrier
Recovery room – place to do upholstery
Rectum – darn near killed him
Secretion – hiding something
Seizure – a Roman emperor
Tablet – a small table
Terminal Illness – getting sick at the airport
Tumor – one plus one more
Urine – opposite of you’re out
Varicose – nearby / close by
Over the past three days, over 600 people involved in general practice education and training converged on Melbourne for the annual GPET conference. Peppered throughout the gathering were sessions relating to the current and more excitingly, possible future use of social media in the medical field. Some areas that have already started down this track and will in the future include:
- National e-Health Record (PCEHR)
- Registrar and medical student training
- Connection of doctors, nurses and allied health
- Patient education and FAQ videos or sites
- Medical Practice information, booking and contact details
- Videoconferencing between rural patients, GPs and specialists
At the afore mentioned GPET2012 conference, one notable session was run by noted internet savvy practitioner Dr. George Forgan-Smith (The Healthy Bear). He highlighted to the standing room only session the different uses of internet based systems. It was inspiring to hear about the use of exciting and ever-changing web-based tools. For example:
- YouTube: for the production of medical themed videos
- Facebook: for your own advice site and medical practice information
- Yahoo Answers: providing common sense answers to those too scared to ask
- Google: Patients being able to find you and your practice
It was especially heartening to listen to this doctor who has seen lots of misinformation on the internet trying to provide his own considered (and safer) information. As a GP registrar, I am both excited and wary of the prospect of this brave new world. Already after the conference and session run by Dr. Forgan-Smith, I am newly motivated to explore the role of producing amongst others: online teaching videos, patient consent videos and education snippets.
Recently, the national board AHPRA has released a consultation paper to help “to clarify…the expected standards relating to social media use.” Some blogs have already highlighted the lack of clarity offered by this statement. They have punctuated the areas (below) with related examples. I won’t delve into these myself, but please visit Impacted Nurse, Croakey and Phillip Darbyshire as all have summarised this very nicely.
- Professional boundaries
- Professional behaviour
- Confidentiality and privacy
Interestingly, Impacted Nurse has observed that already their social media activity (along with mine and many others!) would already be in breach of the proposed policy. The whole tone of the AHPRA statement is restrictive and casts a dim view of social media in medicine. In fact it highlights a lack of knowledge and experience in the very area that they look to place boundaries around.
But AHPRA is not the first group to try to address professionalism relating to social media. The Royal College of Nurses have already released useful and supportive guidelines. Medical peak representation bodies have also been proactive and drafted guidelines addressing these issues. The AMA DiT, NZMA DiT, NZMSA and AMSA released a joint initiative way back in 2010. They identified that there was the potential for legal and professional risks. As such, many medical defence organisations have drafted and published case studies, guidelines and recommendations for their members. In the age of an increasingly connected society and the further blurring of professional and social boundaries, an increase in medico legal cases with a social media focus is inevitable. Although I agree that there is a need for nationally regulated guidelines or policy regarding online conduct and behaviour, they need to be permissive enough to allow innovation and progress while maintaining professional standards. We must not let a nanny-state approach stifle this form of interaction that has to potential to do so much for a great number of patients in an increasingly fast paced online world.
Given that AHPRA is calling for feedback on the issue of social media in medicine, the lack of Twitter/Facebook*/YouTube presence is notable. Therefore, AHPRA is asking for feedback by regular old email (email@example.com) by COB on 14 September 2012.
*The only AHPRA site to be found on Facebook is “Asociación Hondureña Protectora de los Animales y su Ambiente”
A copy of the letter that I help GPRA co-author as a submission to AHPRA, sent on Friday 14th September 2012:
The story is picked up by Medical Observer on the 17th September 2012:
Response from AHPRA on Wednesday 19th September 2012:
“Thank you for your submission to the preliminary consultation process on the National Boards’ draft Social Media Policy.
Your feedback will be considered by National Boards but as this was a preliminary consultation process, your feedback will not be published.
There will also be a public consultation process in which you are also welcome to participate, and information will be available on the Board’s website about this soon.
Thank you again for your interest in this issue.”