JuniorDr Blog

 

                                                                                                                                              

WTF!%^???!!! When you hear a kid blurting out these words or far more obscene and inapproriate remarks at you chances are A) the kid’s obnoxious by nature B) he’s possessed by the devil C) he’s suffering from Tourette’s Syndrome.

 If it’s A, go and hunt down his parents. They ought to teach their kids some manners. If B, hire an exorcist. C is when we, doctors, come in, as Tourette’s syndrome is an inherited neurological disorder with common onset in childhood, characterized by multiple facial and body tics. It is often associated with exclamation of obscene words and taboo remarks. Multiple behavioral and developmental problems like Obsessive Compulsive Disease and Attention Deficit Disorder are also co-occurring features of the syndrome. 

 It can be a chronic condition to last a lifetime but most patients experience the worst symptoms in their early teens. Improvements are noted during late teens and adulthood. As if random curses are not enough, the patient may be grimacing, squinting, hopping, twisting or punching himself in the face. Be careful not to get him excited by offering yourself as a sparring partner, for tics are worse with excitement and better during calm periods.

 The exact etiology is still unknown but is deemed to be as complex as the manifestations. No definitive diagnostic tool is available either. It’s a diagnosis of exclusions. Don’t hastily dismiss a nagging wife spurting out vulgar words or a pole dancer twisting herself as a Tourette case. Diagnosis is made after verifying that the patient has had both motor and vocal tics for at least one year.

 Unfortunately, there is no single medication that can completely eliminate symptoms. Since most individuals improve in their late teens or adulthood, some may no longer need medications for tic suppression. Neuroleptics are the most consistently useful medications for tic suppression. However, side effects can get in the way. These can be lessened by initiating treatment slowly and reducing the dose when side effects occur. Treatments aimed at the associated neurobehavioral disorders and psychotherapy are likewise employed in the management of TS cases.

 Although tic symptoms decrease with age, it is possible for neurobehavioral disorders such as depression, panic attacks, mood swings, and antisocial behaviors to persist and cause impairment in adult life. Constant support from family and peers are necessary. Relatively, without the involuntary movements and verbal attacks, these should prove to be convenient enough.

 http://www.ninds.nih.gov/disorders/tourette/detail_tourette.htm

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I'm in clinic when I get a bleep from a number I don't recognise.  After finishing with a patient I call it. It's the office of the chief executive. He wants to see me as soon as possible. I excuse myself for a while and make my way over.

I've never spoken to him before but he's looking rather glum for a plump guy in a pin-stripe suit. Dr Johnson has informed him that he is reporting me to the General Medical Council for professional miscounduct. Specifically, for lying about his approval for the transfer out of CCU. I am completely stunned and have no idea what to say.

I forget about clinic and try and find him. He's in the private sector doing angios all day. I try his mobile and leave a rather brief yet to the point message. I probably shouldn't have commented on the size of his manhood. 

I leave early after clearing out my desk. On the way out I stop and call to find out how my man is doing. The balloon pump has worked and they're moving him out of their ICU.

I leave the building. I don't know if I'll be back.

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The proverbial ‘stuff' has hit the fan. Johnson (my boss) calls me into his office before our rounds. He is absolutely livid that I went behind his back to transfer my man out. He starts ranting about professional obligations and the chain of command. I call him a wanker under my breath (not for the first time) but he doesn't hear. We part on icy terms.

I spend the rest of the morning on the ward round being ignored. Our SHO is still on nights so the poor house officer is getting the brunt of Johnson's rage. He's not happy with a single thing and starts going off on multiple tangents. I take her down for a coffee afterwards but she is still visibly upset. Despite a latte and two chocolate muffins she tells me that she wants to swap firms. It's only been two weeks since she started.

The afternoon passes by slowly as I try to tie up any loose ends before I leave tomorrow. I go home early. There are several messages on my answerphone but I ignore them. I go to sleep early.

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My last general medicine on call for the next two years! I accept the list of patients waiting to be seen with excessive enthusiasm and actually frighten the poor gastro reg on nights. The morning passes slowly but things start to speed up in the afternoon. We get a sick patient with cardiogenic shock after a large anterioir MI. I thrombolyse him and get him a bed on CCU. His pressure starts to drop so we put in a central line and start some dobutamine. Things slowly start to slip downhill after this.

 

As his pressures drop I realise the only thing to do is insert an aortic balloon pump. We can't do this here and it requires consultant approval. I speak to the on call consultant who's a care of the elderly physician-very nice but not much help. He suggests I speak to my boss. That's when I run into real trouble.

 

My boss has obviously been having a bad day and is even more obstructive than normal. He listens to my story and then turns the request down. He doesn't ‘meet criteria based on his pre-morbid state.' I argue that diet controlled diabetes is hardly ‘morbid' but he disagrees. I sulk back to CCU where my man is really starting to go downhill quickly. I start some noradrenaline and then decide to ignore my boss and transfer him anyway. I lie to the accepting consultant when he asks me if I've got approval from my boss.

 

I get home late and open a new bottle of merlot. These things seem to be finishing rather quickly.

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My morning is filled with meetings. To start with there's the regional angiogram meet where cardiologists from district generals present their cases for consideration on cd-roms. They line up expectantly at the back of the room with discs in hand as we go through them one by one. The consultant chairing it this morning is a bit of an idiot and he spends most of the time sneering at his colleagues from other hospitals. The cases are met with grunts of disapproval and comments like ‘do you really think we need to see angios like this?' and ‘he hasn't got a cat's hope in hell of getting a stent from me.' He reluctantly agrees to look into a few.

 

I spend the rest of the morning in management meetings which stretch on into the afternoon. One main problem is that the rest of the registrars have become militant after finding out that we've probably been banded incorrectly. The back pay they owe us will run to over a hundred thousand and the trust is already complaining about laying off staffing order to meet targets.

 

I'm not particularly bothered but the extra cash would come in handy. The management are currently trying to pay us off by offering a sweetener of two grand each but no one is biting. We agree to push them for the full amount. I actually feel a little sorry for them.

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