Cautionary Tales - Dr Liz Marles

RACGP vice-president Dr Liz Marles explains why the cases that are likely to steal a GP’s sleep can be a sign something may be seriously wrong.

AFTER taking a break from work to have a baby, I returned to complete my first GP registrar term in a busy city Aboriginal Medical Service.

It was a drop-in clinic and at times could be quite chaotic, often with patients attending in family groups.

As a registrar, I was quite daunted, as patients would come with a huge variety of problems, and it was often hard to know where to start.

Nurses and health workers helped keep things moving, and the GPs were usually working flat out.

It was on one of these busy afternoons that nine-year-old June came in with her mother.

Her mum was concerned that she had been hot and her ear had been very painful and was now discharging pus.

June was uncooperative and complained of pain as I examined her ear.

Despite dry mopping, I was unable to visualise the drum as the discharge continued to accumulate.

Following our relatively standard protocol at the time, I prescribed oral antibiotics and Ciproxin ear drops and arranged an ENT consult for three days’ time, making sure I had booked transport for them.

That night I found myself worrying about June. She had been sicker and in more pain than most children with a ruptured drum, and I really wanted to know she was responding to treatment.

As a part-time registrar, I was not due in again until the next week, so I phoned the medical service the next day to see if they could collect June and bring her in for review with a doctor.

When I rang back at the end of the day to check this had happened, the nurse told me the family had sent the driver away as June seemed a bit better.

Feeling somewhat relieved I put June out of my mind and went back to looking after my own children.

The next Monday I opened up June’s file to see whether she had attended her ENT appointment.

I read the notes and to my horror found she had been admitted with suspected mastoiditis. 

I rang the ENT registrar who had seen her, who told me June had a mastoid abscess, and hearing my distress reassured me that my initial management was reasonable and that it may have developed in the intervening period.

I couldn’t help thinking about whether I had done the right thing and wondering why the family had sent the driver away.

I discussed her case with my supervisor, who recognised the family immediately.

Apparently June was one of eight children whose father had been admitted to hospital with an AMI a few weeks ago, but left against medical advice the next day and died.

As well as caring for the eight children on her own, June’s mother was suffering from depression.

June received excellent treatment and recovered, but left a lasting impression on me.

Lessons learned? 

I now have a test that I run past myself – if this is a situation where I will go home and lose sleep and worry then better to err on the side of caution and admit the patient.

Secondly, I now always try to find out my patient’s social circumstances, which can be just as important as their physical presentation in determining a diagnosis and management plan.

As well as talking to the patients, talking to other members of the practice who may know the family can save lots of time and provide great clarity.