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GPs buried under trusts' workload dump

After 35 years in medicine, I’m having an endarkenment

Copperfield 

30349 1 copperfield 280x131uo 1500x1000px

30349 1 copperfield 280x131uo 1500x1000px

I don’t know what the opposite of an epiphany is, but I think I’ve just had one. And all it took was a hernia.

I’d seen the patient a month before with a few weeks’ history of mild, left-sided abdominal ache, worse with movement but becoming more constant. No other symptoms, though he felt the area was swollen at times and so reckoned he had a hernia.

But I couldn’t demonstrate any swelling and he was pointing to his left iliac fossa, miles away from inguinal or umbilical hernia territory. So I told him it was muscular and arranged a therapeutic ultrasound only because of the look of utter disbelief on his face.

Which is exactly the expression I have now. Because I’m looking at the ultrasound report and it states, ‘Left-sided spigelian hernia, high risk of strangulation. Suggest referral.’

What? A what?? A left-sided high risk what??? A quick bit of Googling later and I discover that, yes, a spigelian hernia is a Thing - a Thing my patient actually gave a classic history of, in fact, and a Thing, yes, with a high risk of strangulation.

But I have never even heard of a spigelian hernia. How can this be? How did I miss that lecture/chapter/article? Why has everyone been keeping this secret from me? What have I been missing, literally? The only consolation is the absence of any note of a recent A&E attendance, plus the fact that he does appear to be in the waiting room now, rather than in ITU.

This does nothing to ease my endarkenment. Let’s face it, after 35 years in medicine, I reckoned that I knew, or at least had heard of, everything. It turns out I don’t and I haven’t. This freaks me out to the extent that I know I’m suddenly going to be diagnosing a lot of possible spigelian hernias, even in patients who come in with a sore throat. Also there’s the uncomfortable implication that I’m going to have to start listening to what patients are telling me, and I’m not sure I can change the habits of a professional lifetime.

I sigh, deflated. Poised to call him in, I quickly read the scan report again. Because there’s more. Something about an ‘abdominal aortic aneurysm’. Now, what the hell’s that when it’s at home?

Dr Tony Copperfield is a GP in Essex. Read more of Copperfield’s blogs at http://www.pulsetoday.co.uk/views/copperfield or follow him on Twitter @doccopperfield

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Readers' comments (12)

  • Cobblers

    To paraphrase Einstein “As our circle of knowledge expands, so does the circumference of ignorance surrounding it.”

    Or perhaps Donald Rumsfeld " The more we know we know, the more we know we don't know".

    Without going into unknown unknowns :-)

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  • An obuturator hernia is another good one.
    When patients had non-discript pain I used to refer them to exclude it.
    A lot harder now with the ease of getting of MRIs.

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  • Just found a sister Mary Joseph nodule, holy crap

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  • Scary? How about this. Many years ago, single handed I did minor surgery at the end of surgery. I'd seen a lady with an 'obvious' lipoma and agreed to excise it for her. However when she arrived it seemed bigger than I had remembered and after some humming and haring I decided to refer - UNHAPPY patient! - The surgeons saw her agreed with my diagnosis and arranged day case surgery - you guessed it - spigalean hernia - I had actually seen and heard about these in medical school! Glad it wasn't me cutting through a loop of bowel!

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  • there was famous surgeon who admitted having a Spigelian Hernia as a spotter case in the FRCS exams; every candidate bar one, who said it was a lipoma, got the right diagnosis...until the surgeon operated a week later...and found a lipoma...

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  • I remember learning about them for an exam, and the next week suggesting it as a differential for some abdo pain on a ward round. The consultant laughed and said "no one gets those"...

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  • I remember my surgical reg taking a patient to theatre one night having diagnosed this, only to find a hydronephrosis at the laparotomy....

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  • I have seen one in 45 years

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  • Don't worry Copperfield. Its reckoned that you start as a GP with 90% clinical knowledge and 10% bedside manner. After 35 years drop that clinical base to say 30% and the other 70% is bedside charm which is what patients love and I am sure you have it in bucket loads despite your heroic attempts to prove the opposite!

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  • I certainly remember being taught about it in my London med school circa 1981.
    Uncommon but to be considered in differential diagnosis.

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