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At the heart of general practice since 1960

A killer instinct

An outstanding entry in Pulse’s 2015 writing competition by Dr Pamela Barcella

It was a Friday afternoon in the cold winter of 2002. I was still relatively new to the job and still quite worried about long afternoons on call.

One of the patients on my list was a young man, in his late twenties, who presented with a problem of sore throat. ‘Great!’, I thought, ‘an easy in and out consultation.’ But I couldn’t have been more wrong.

This was the third consultation the patient had in the week for the same problem. He saw the nurse practitioner first, who prescribed penicillin.

Then he saw a partner of the surgery, who prescribed another course of penicillin but with no help at all.

The patient was complaining of a bad sore throat and even talking was causing pain.

‘I am sure I know what this is,’ I thought (with the classical cocky arrogance of the young GP). ‘I am sure it is quinsy!’.

But, when I looked at the patient’s throat, I couldn’t see anything. Not even a hint of redness or swelling of the throat, let alone a sign of an abscess.

I looked at him in disbelief. What is going on? I thought.

It was then that I noticed the patient seemed to stutter slightly when speaking to me. I have never seen this patient in my life. How do you ask a patient: ‘Excuse me—do you stutter, by any chance?’

But even if reluctantly I did indeed ask him the question and he answered ‘yes’ — but only for one week. He described some difficulty in pronouncing the words of some objects, like glass or cup. All the rest of the history and examination was unremarkable, and his blood pressure, temperature, pulse and neurological examination were spotless.

But I wasn’t happy. I didn’t know what but I knew something was wrong - really wrong.

I picked up the phone (by now running 30 minutes late in my surgery) and spoke with the admitting nurse for acute medicine. She didn’t want to accept the patient – the case was too complex she said. So she put me through the registrar. He didn’t want to accept the patient as he was not acutely unwell. The registrar advised the patient undergo a CT scan as an outpatient, but I wasn’t happy. I had then to call the consultant medic at home –and , believe you me, he wasn’t a happy bunny.

In the end, after a true verbal combat on the phone, he accepted the patient to hospital.

I didn’t hear anything for two months. One day a letter came from our tertiary care hospital. When seen in hospital his head scan showed two large brain abscesses. He had to be airlifted to the nearest neurosurgery centre where he had emergency brain surgery and abscess drainage that night.

Final diagnosis was brain abscesses caused by toxoplasmosis—the patient had worked as a chef in the restaurant of a local hotel.

He had a long stay in ITU and has been left with epilepsy as a result of the abscesses but he is alive and well otherwise.

He came and see me in the surgery six months after. He entered the room, sat down and said:  ‘Doctor, I come here today to say thank you — you saved my life. I owe you my life’.

That day was a good day for me - the best ever. One I will never forget.

Dr Pamela Barcella is a GP in Woodbridge, Suffolk

<<< More from Pulse’s Writing Competition 2015

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Readers' comments (3)

  • Lesson -----All patients should go straight to A&E for all medical issues where most serious conditions including brain abscesses, tumours etc. are picked up.

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  • a lot of things are also missed in A+E Mr private GP perhaps more than in GP land with junior docs.

    very poignant and brought a tear to my eye. Not much thanks in this job. upsetting that the hospital docs tried to refuse admission. I don't think ive ever really been in that position.

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  • lesson -- all patients should go to emergency for emergencies. in this case yes had they known but probably would have been sent home with penicillin anyway if a sore throat was the presentation or more likely told it was a virus with no tonsillitis and presumably the cerebellar signs developed later if the first doctor missed the signs? an unusual presentation that's for sure and not in my differential of sore throat.

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