Internal Optimist

Heart block and the breakdown of marriage

Another little hiatus to blogging as I was on holiday! Coming back, I want to share an explanation of the different types of heart block using the breakdown of a marriage as a metaphor. I heard this explanation recently and want to share it with you mainly because I found it funny!

Science stuff - heart block is a problem with the electrical conduction of the heart, which delays (or blocks) the normal signals progression through the heart muscle. Depending on the degree of this blockage you get different appearances on ECG, which are 'graded' into different types of heart block. Simplistically, the greater the level of heart block the more dangerous it is. Heart block is measured by the relation between the 'P' wave of the ECG and the 'QRS' complex of the ECG - see image below

P wave comes before QRS complex as shown here

The metaphor is a marriage and the washing up leading to the breakdown of this marriage.

Normal heart:

A good marriage with a slightly lazy husband. In this he sadly needs to be reminded to do the washing up every day. The P wave shows the wife having to remind him to do the washing up, and the QRS is him doing the washing up. At the early states of marriage he is good and does it every time promptly when asked. See normal ECG below:

Nice short regular spaces between P and QRS. Not much nagging needed!

First degree heart block:

Now comes the start of the marital breakdown. First degree heart block has a regularly prolonged period of time between the P and QRS waves. Here the hubby is getting a bit more lazy - every time he is nagged to do the washing up he delays it before doing it, perhaps leaving it overnight until the morning before doing it. This is due to poor conductivity of the electrical impulse in the heart slowing things down.

Look at those big gaps between the P and QRS. Leaving it to soak all night is not a valid excuse!

Second degree heart block - Mobitz type I (also known as Wenckebach):

As things start getting worse in the marriage the husband now sometimes misses doing the washing up all together! In this situation the ECG shows a prolongation of the interval between the P wave and QRS complex each beat until it gets so long there is no QRS complex following the P wave at all. After this missed beat, the interval becomes short again and the process repeats. This is the husband becoming lazier and lazier, leaving the washing up longer and longer until he just cannot be bothered to do it. This obviously leads to an argument and then he has to buck up and he gets on with doing it properly again, but then becomes lazier and lazier until he misses another washing up. See ECG below

See the interval between P wave and QRS complex getting bigger until the whole QRS is missed, then repeating

Second degree heart block - Mobitz type II:

Here the husband just misses doing the washing up every so often because he is out of the house (with friends, with a mistress, we will never know). Here the interval between P wave and QRS complex is kept the same (perhaps due to guilt) but there is a regularly absent QRS complex. ECG is below

Intermittently the P wave is not followed by a QRS wave as it should be

Third degree heart block (complete heart block):

Here there is no association between the P wave and QRS complex at all - P waves are happening and QRS complexes are happening but they are not linked. The wife has become fed up with the husband and has left him - they are both doing their own washing up independent of one another in different houses.

Here you can see regular QRS but no relation to the P wave - some P waves fall before, after, or on other parts of the ECG.

That's the stages of heart block explained as though through marital breakdown. I thought it was quite funny and helpful to help remembering which is which. I hope you find them helpful too!

[For the rest of the post, and the rest of my blog, with pictures, please go to:Internal Optimist - A Junior Doctor Blog: Heart block and the breakdown of marriage ]
Open the floodgates

I often see a lot of unusual presenting problems on GP, and having watched a couple of those Channel 5 programmes "GPs: Behind Closed Doors" I can certainly say that there doesn't seem to be much exaggeration...

On Friday I had a very strange day. The roof was leaking a strange yellow coloured fluid quite heavily for the morning, and I couldn't be moved to another room as there were no others available. We are part of a multi story complex, so I was worried it might be urine, but I definitely hope it wasn't! It certainly didn't have the smell at least. Either way, trying to explain the hodgepodge of buckets I had created on the floor to try and collect as much of the (large) quantity of water which whooshed down every 5-10 minutes, and all the paper towels I was (unsuccessfully) trying to use to dam the errant fluid from the patient's shoes.

In this ridiculous situation I had to consult all morning until I got to move room (when one came free) in the afternoon. Among the other patients, I had a lady who was convinced that she had high blood pressure because every time she touched something after walking for a while at home she got a shock (feeling all the high pressure coming out of her body). It took all my persuasive powers to convince her that her new carpet (Sherlock Holmes right here!) and the phenomenon of static electricity was to blame. This consult was followed by a lady who was concerned as sometimes she woke up and her arm felt as though it was 'dead' and she was worried it would fall off. She had recently come to the UK from another country, so trying to explain that this was a normal phenomenon was complicated by trying to use a telephone translation service.

I was getting quite frustrated throughout the morning, mostly due to the roof leaking all over me and my patients rather than due to the patients coming in, and my final patient must have sensed this. After talking about their problems they asked me if I had ever considered Islam as a religion as I was a very good listener. I didn't really want to get into a religious discussion and tried to deflect the question, as I wanted to get off to lunch by this point. Stranger still, in the afternoon after dealing with another patient's issues (a ganglion of the wrist) she handed be a leaflet on Christianity and asked me if I had accepted Jesus into my life. Perhaps it was the weather, or the time of year, but you couldn't have written a better script for an absurd day!

[For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: Open the floodgates ]
God's balls

Wow, it has been a long time since I last posted. This job is quite busy, but isn't busy enough to give me an excuse. I suppose I have just been distracted by other things going on in life.

I am on paediatric surgery at the moment, which is a big change to anything I have done before. I was pretty scared when I came into this rotation as I didn't have any paediatric experience previously, and it has taken me a little time to get my head around things. On surgery I am the only F2/SHO and there is usually a registrar and consultant on at the same time. As with most surgical specialities, they spend much of their time in theatre so I am left on the ward trying to work out what to do with my patients. Fortunately at the start of the rotation the general paeds team, who share the paediatric hospital with us, were very helpful. Sadly in the last month or so, due to politics which is well above my paygrade, they have been distancing themselves from my team so I have had to make do much of the time, but fortunately are still around in case one of my patients is genuinely ill. I am getting to spend some time in theatre as well, though, which is quite interesting, but I don't think surgery is the profession for me. The initial cutting is exciting but then all the searching around and stitching up layers is not!

The reason for coming to post today was an absurd situation I found myself in, and I felt I should share it. A 9 year old patient had come in yesterday with an acutely painful testicle. We were worried that this was testicular torsion - a surgical emergency which results from, surprisingly, your testicles getting in a twist. His mother was not keen on him having the surgery and it took about an hour and a half to persuade her that this was necessary. The surgery was performed overnight and found a torted hydatid - a little extra bit on the testicle which is the remains of the female reproductive organs (from when the boy was a foetus). This has no known function and is not important, and doesn't need surgery if it is diagnosed before the operation. The problem is, having a twisted testicle is an emergency and you don't want to faff about trying to work out which one it is with ultrasounds and the like if you are unsure - leaving the testicle twisted for too long will result in it dying permanently. In fact there is a surgical 'saying' - ""Testicular pain - don't engage brain"

The next day, the child was well and happy to go home, but the mum was not happy. I had been left to review this child, as the consultant and registrar had gone to theatre for a different case. The mum was upset that we had operated on the child and found nothing wrong, and upset that we had removed the dead hydatid of Morgagni which had been causing the pain. The reasons for this were that she knew that there was no problem with her child's testicle (hence why she was initially refusing the operation) because she was very religious, and she knew that God wouldn't want to harm her baby; she was upset that we had carried out the operation as she felt that God had been testing her faith and she had failed, showing she didn't trust in him to provide for her; and she was upset that we had removed the dead twisted tissue (why did God put it there if it has no use).

A picture found from the internet of an ultrasound of someone's testicle with the face of the Egyptian god of male virility in it

First, I was glad that the consultant was not around, as I would probably not hear the last of him being compared to God in 'providing' for this woman. I wasn't too sure how to address her concerns though. I tried to explain that bad things did happen to kids (a point helped by being in the middle of a ward full of sick and disabled children); I tried to point out that perhaps the presence of the hospital was a way for God to provide for this woman in her time of need; and tried to convince her that we had no known function for this tissue, and its removal shouldn't affect her son in any way. She was not amused by my attempts at explaining things and kept trying to drag me into a theological argument. All of this was watched by the husband who was clearly on 'my' or the medical establishments side with regards to the need for the operation, but not keen on speaking up. I feel a lot of the passionate arguments the mum was giving were more for his benefit than mine. I am not a religious person by any means and was trying to keep things civil, but it took me an hour and a half to escape.

An hour and a half!

I was called back twice for questions about wound management by the nurses, which just turned out to be more theological arguments over why God wouldn't want to hurt this boy, and how he must have a special plan for the hydatid of Morgagni, if only we would wait and see. I felt that these recalls were likely due to the husband arguing things with the wife, so she would bring me back and argue them with me. Not ideal given we have about 20 other patients in the hospital at the moment to look after. The third time the nurses called me telling me she just had a couple more questions before she left, I asked them to tell her that I would happily come down if she promised not to talk about God anymore, and if she had any more questions of this nature then perhaps she should take them up with the hospital chaplaincy service. Unsurprisingly, she changed her mind and decided that she didn't need to speak to me any more. I will have to go back tomorrow and ask the nurse if they had to call the chaplain as an emergency to explain the reasoning behind an omnipresent, omnipotent, omniscient, benevolent God.

[For the rest of the post, and the rest of my blog, with pictures, please go to: Internal Optimist - A Junior Doctor Blog: God's balls ]
12 days of Christmas in the ED

Working in A&E brings plenty of different experiences, here is a selection of true stories from the 12 days run up to Christmas.

On the first day of Christmas, the ED gave to me: a cockroach infestation in resus bay 3

On the second day of Christmas, the ED gave to me: a patient with a baseball bat to the face, and the chance to assist in a lateral canthotomy

On the third day of Christmas, the ED gave to me, a psychotic gentleman after losing a loved one in hospital , the questionable choice to bring the body to A&E due to a flooded morgue to help the patient come to terms, and the dire mistake and consequences of bringing the wrong body up to the ED.

On the fourth day of Christmas, the ED gave to me, many giggling nurses, several confusing PA calls, my name changed on the computer system to 'Bieber', and in inability to change it back until three

On the fifth day of Christmas, the ED gave to me: A patient who had been hit by a bike, a swollen and painful hand, an X-ray showing a dislocated trapezium bone, a referral to a surgeon who wasn't sure what the trapezium bone was, and the feeling that the MRCS must be pretty crappy.

[For the rest of the post, and the rest of my blog, with pictures, please go to: ]