I thought of this incident recently when I was privy to some doctors complaining about stupid referrals. This was the only one I could think of. In reality it was more a moronic patient than a moronic referral.
As usual it was late at night. The casualty officer said he thought the patient had an enterocutaneous fistula (connection between bowel and skin). I asked why someone with something like that would wait for the middle of the night to turn up in casualties when the condition was almost always chronic. He gave a nervous chuckle and agreed. When I started asking about possible disease processes which could give rise to this condition (which pretty much can’t just happen spontaneously) he had no answers. In his voice I could almost hear him saying:
“Come on. I’m tired. It is a stupid thing to come into casualties for at this hour but here she is. Just come down and see her so it is no longer my problem.” I answered before he was forced to actually say these words.
“Ok, I’m on my way.”
The patient was an old Indian lady fully-clad in her robe-like traditional garb. I asked her what the problem was. She was quite a bit less than forthcoming. I asked her to show me the problem if she couldn’t describe it. She lifted her robe. I was not prepared.
She presented a disfigured torso and abdomen. It seems when she was younger she had been severely burned by hot water. Those areas that had been burned were devoid of fat and had skin attached directly to the underlying muscle. Between being young and the present she had become obese. Actually that is only partly accurate. Only the unburned areas had become obese. She had areas of supreme obesity interspersed by a network of amazingly slim. On one of the fat areas, towards her flank was an opening which was oozing pus. The smell was unearthly. I may have gagged a bit. But something was missing.
“Where is your umbilicus?” I asked. She looked sheepishly away. She was determined to not be forthcoming. A more direct approach might work, I decided. I pointed to the suppurating hole almost on her flank and asked:
“Is this your umbilicus?” She nodded. The burn wounds interspersed with severe obesity had dragged her umbilicus to her flank leaving behind a long oozing tunnel. I was annoyed. She knew what the problem was from the beginning. She also knew that it wasn’t something to come into casualties for in the middle of the night. She had been taking us all for a ride. But what could I do? She was there and I had to do something. Something, I decided, would involve double gloving.
I inserted my finger into the oozing hole. As expected, now that I knew what it was, It tracked towards the midline where the umbilicus had been many years before. At its base I felt a tennis ball sized mass of old debris. This time I did gag. This mass I scooped out bit by bit until the umbilicus was something it hadn’t been for years…clean. Annoyance fell away to disgust. I almost couldn’t speak because of my gag response, but I forced myself.
Fortunately all I really had to say was:
“Have you heard of soap?”
*This blog post was originally published at other things amanzi*