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Every Friday I’m going to post a new chapter of my novel, featuring the adventures of Dr Sean Ferguson. I’d be really glad if you read the stuff and let me know what you think.


This first story is as long as a short novel – it’s got 54 chapters (so we’ll be e-talking to each other for a year) and I hope it’ll make you laugh (as well as keep you interested).


Here we go, the story is called….


JUST A LITTLE PRICK WITH A NEEDLE


A NOVEL

BY

DR ROBERT BUCKMAN



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Thursday

      CHAPTER THREE: NO SHILLY-SHALLY SHERLOCK

(SIX YEARS AGO)

The whole problem has to do with the way we doctors are trained.

In medicine, a person’s reputation and career can be made on the basis of a single brilliant diagnosis of a very rare condition that is causing a symptom which is quite common. All of us, from our very first moments in medical school onward, hanker longingly for that moment of brilliant deduction when we prove that, in this particular case, the diagnosis is not the usual and ordinary Condition X but actually a very rare and unexpected form of Condition Y.

It’s rather like the denouement in the final pages of every Sherlock Holmes story. Sherlock always manages to create a chain of inexorable logic, proving at the last moment that “this wasn’t a case of suicide after all, but was actually murder, because only the real killer would have known that the 3.42 train to King’s Cross was running nineteen minutes late that Monday, which gave him just enough time to bludgeon the vicar to death, put the brass candlestick in the victim’s hand and still make it to the railway station in time.”

Well, most doctors, deep inside, want to be like that. We all have a deep desire to reach a brilliant conclusion when the rest of the world (or Scotland Yard if you’re Sherlock Holmes) is baffled.

Let me give you a few examples of the type of Sherlockian brilliance that we physicians all seek.

Here’s one: the fluid that circulates round your brain (the cerebro-spinal fluid or CSF) may, under exceptional circumstances, leak out through your nose and cause a drippy, running sniffle. This very rare condition is called CSF rhinorrhea, and although the patient may seem to be suffering from no more than a common-or-garden runny nose, the rare diagnosis of CSF rhinorrhea can be made by testing the nasal fluid for the presence of protein. That’s because CSF has got a fair amount of protein in it, and ordinary snot hasn’t. So, like many nerdy doctors and wannabe Sherlocks, I’ve had endless samples of routine snot tested for protein and have never – not ever, not once – diagnosed a case of CSF rhinorrhea.

Here’s another one. There’s a very rare cause of kidney failure called angiokeratoma corporis diffusum (known to its friends – of whom it has precisely none – as Fabry disease). This condition also causes a red spotty rash on the skin, sometimes on the buttocks only. So, if you want to be a brilliant medical Sherlock, you carefully examine the buttocks of every patient with kidney troubles, in the hope of one day seeing Fabry’s spotty signature there. I've done that dozens of times and never found a single case.

Also, there’s a really rare cause of the symptom of losing your sense of balance and starting to stagger when you walk, due to problems in the area of the brain called the cerebellum. Very very rarely a type of cerebellar disorder can be caused by a chemical found only in red grapes in Italy. So, only Italian red-grape-treaders ever get this particular occupational hazard. It’s called Machiafarva-Bignami disease. In the hope of making that astonishingly rare diagnosis, I’ve always asked anyone who has difficulty in keeping their balance and walking in a straight line whether they have ever worked as a red-grape-treader in Italy, in the hope that one day a patient would reply ‘funny you should mention that, doc, but yes, that is the job that I did for nigh on twenty years’ and I’d win the gold medal with an open-and-shut case of Machiafarva-Bignami disease. Guess what? It has never happened.

Then, there’s a very rare benign glandular tumour called a phaeochromocytoma – usually referred to by the abbreviation ‘phaeo’ (probably at the suggestion of the Endocrine Tumour Marketing Department).

Anyway this tumour, the phaeo (pronounced faye-oh), can cause the patient to have episodes of high blood pressure, sometimes causing headaches. So if the doctor wants to seem like a real genius, he’ll order a couple of special chemical tests on the urine for any person who has high blood pressure, hoping that, one day, the tests will show that the diagnosis is actually a phaeo. At which the whole world will be stunned by (and deeply envious of) the physician’s utterly Sherlockian brilliance. This would be even more brilliant if the phaeo happens to be located in the wall of the bladder (as happens even more rarely) when it may cause a release of blood-pressure hormones as the bladder contracts down during the act of emptying, thus causing a headache that worsens towards the end of the urination process.

Which is why, when Roger Mulholland came in with a report of high blood pressure and a headache, I did two things. First, I arranged an immediate CT scan of his brain to find out if there had been a small haemorrhage in the brain, either of the type called a sub-arachnoid haemorrhage or possibly a small stroke. That’s the ordinary standard procedure that has to be done anyway in those circumstances. But second, and in true Sherlockian style, I also arranged for a bunch of urine tests to be done, as well as routine blood tests, after the scan, in order to diagnose (brilliantly) a phaeo.

So while Roger was in the imaging department getting his CT scan done, and because there was a temporary lull in the stream of the Walking Wounded, I decided to take a ten-minute coffee break, in order to savour the way I had handled Roger’s case, and to speculate about how good I would look if it turned out that the CT scan was normal and if the tests for a phaeo happened to come back positive.

But what I was REALLY hoping for was a casual meeting in the cafeteria with my boss, the Head of the E.R. Department, Dr Maynard Beadle. I was hoping to bump into him so that I could oh so casually mention the case of Roger Mulholland and show Maynard how brilliant I was. Without really trying to, of course.


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