The top medical cases of June 2018

This month, some of the most engaging cases shared on Figure 1 weren’t so much about the patients as the healthcare professionals treating them. A medical student discussed his first experience with a terrified child. An emergency physician reconsiders his decision not to order a CT scan. And a UCLA professor of medicine reports that patients of older surgeons have lower first-month mortality rates.

Healthcare professionals around the world use Figure 1 to learn from real medical cases shared by their colleagues. We identified these cases as the month’s most engaging based on:

User Metrics: The number of times they were viewed, discussed, and shared by the more than 2M healthcare professionals on the platform.

Clinical Value: Our medical and community teams assess the quality, complexity, and educational merit of our top cases to highlight the most credible and clinically useful material.

These five cases showcase the depth and breadth of medicine as it was discussed around the world in the month of June.

1.“You never fully comprehend how difficult it can be”

In this case, a medical student treated a child with a large laceration on his forehead. (Note that the patient’s face is obscured to comply with Figure 1’s privacy rules.) The student was admirably open about the disconnect between classroom education and real-world medicine.

“When you are in medical school learning how to suture, practising on banana skins, pigs feet or any kind of fabric, you never fully comprehend how difficult it can be: a 2-year-old who is in extreme pain, scared, screaming, kicking, and a mother who is even more scared than the child,” he said.

Naturally, the discussion included treatments to calm the child.

“A little intranasal Versed can go a long way!,” said one emergency medicine resident. “Indeed,” responded a family medicine physician, “but ketamine also helps reduce psychotrauma by inducing a period of retrograde amnesia.”

One emergency medicine resident recommended a non-pharmacological treatment:

“I always keep some childrens’ films on my mobile phone. Pixar short films are great as they have no real language. I’m always amazed how easily kids get distracted. In my university they even had a study about the use of films during painful or frightening procedures.”

A registered nurse agreed:

“Yep, papoose board, an assistant to firmly but non-threateningly hold the pt’s [patient’s] head, Peppa Pig on a phone, and promises of ice cream after usually do the trick. Have mom sit down to prevent you from having an additional pt from inevitable vaso-vagal.”

2. Why patients of older surgeons fare better

Physicians use Figure 1 to share their research as well as their cases. In this study from The BMJ, Dr. Yusuke Tsugawa (@yusuketsugawa) found that patients operated on by surgeons over the age of 60 had lower mortality rates in the first few weeks after surgery than patients operated on by surgeons under 40. Dr. Tsugawa took questions from the Figure 1 community about his research. Some highlights:

Younger surgeons proceed through surgery like reading a manual for building a model airplane; thinking a desired result is axiomatic. Older surgeons operate like cooking. We understand how decisions made during the procedure and how circumstances that arise can change the outcome and adjust accordingly. It may be elective, but every surgery should be viewed as a trauma case. - Orthopedic Surgeon Well said. However, the existing evidence before our study was published was showing that older surgeons had worse outcomes than younger surgeons. We believe it is because previous studies included elective surgeries and older surgeons were treating sicker patients. Our study focused on emergency surgeries to fix this problem.- @yusuketsugawa You need the young, inexperienced ones to eventually get the old, experienced ones, though. The age doesn’t help, if they haven’t spent their younger years operating on (and killing, apparently) lots of patients. - Family medicine physician That is true. I think what our study suggest is that we need a better system in place for the supervision of the young surgeons to make sure that patients don’t have to experience poorer outcomes only because the operating surgeons were inexperienced. - @yusuketsugawa Thank you for your reply. I’d like to respond. I think a positive way to paraphrase the results of this study in one sentence is: surgeons learn from their mistakes. They get better with age, becáuse of the mistakes they made when they were younger. So increased supervision should, in a way, allow for the younger surgeons to keep making those mistakes. - Family medicine physician

3. “Are these lesions expected?”

This case demonstrated the instant cross-specialty discussion that Figure 1 can inspire. A speech language pathologist shared images of a patient who reported difficulty swallowing.

“Patient with bullous pemphigoid seen for reports of dysphagia and odynophagia. Noted with obvious lesions/discoloration seen here on the soft palate. Patient with absent uvula - no report of uvulectomy. Build up on lingual surface was able to be scraped off. Are these lesions expected for patients with this skin condition?” she asked.

“Bullous pemphigoid can indeed co-exist with mucous membrane pemphigoid. Patient needs to be managed by a clinician familiar with its various manifestations, including ophthalmic and esophageal,” a dentist noted.

“I agree that this is likely to be anti-epiligren cicatricial pemphigoid or typical cicatricial pemphigoid or anti-alpha 4 beta 6 integrin disease. Tetracyclines will probably not work. Some of these diseases are only minimally inflammatory because the autoantibodies cause damage without inflammation, in which case the best treatment is rituximab,” responded a dermatologist.

“Interesting case, never seen #Pemphigoid in the mouth. Thanks for sharing this,” said a licenced practical nurse.

4. An octogenarian saxophonist

While Figure 1 cases often highlight new research, dramatic interventions, and emerging epidemics, there are just as many cases about ordinary ailments — and these are often where the best peer-to-peer learning happens. In this case shared by a family doctor, an elderly woman complained of difficulty playing the saxophone in her seniors’ jazz group. Her issue was evident upon X-ray, and the physician was eager to ensure students had a change to guess the answer before he provided it.

5. To CT or not to CT?

One of Figure 1’s top emergency medicine physicians is @forderit, and amid his regular cases he shared this patient encounter with a difficult question:

An 85 y/o patient tripped over a step and hit her occiput against the wall resulting in a non-depressible scalp laceration which was sutured. She was not anticoagulated, did not lose consciousness, did not vomit, did not develop any neurological deficit, and long story short, did not meet any of the NICE guidelines for CT brain (NICE: UK’s National Institute for Clinical Excellence). She was discharged with safety advice. Ten days later, she presented to the ER complaining of dizziness. She was found to have a subdural hematoma. Despite the best neurosurgical care, she passed away 10 days later. Would you have CT scanned this patient in your institution? Do you think the decision not to scan on first attendance (as per local guidelines) constitutes any degree of negligence?

A cardiologist responded:

“Her age automatically puts her in a different category of care. As we age, our brain shrinks, a fall that does not even result in a blow to the head CAN cause this as the brain will hit the inside of the skull, and vessels will tear. Those vessels become stretched as the brain shrinks, rip easily. She should have been hospitalized for a few days and watched closely, with follow-up CT scans.”

A radiologist agreed:

In our institution, we don’t follow these guidelines. We scan every trauma patient we see, no matter how little and unremarkable the injury as long as there’s reason to believe there was a head trauma, even with a normal GCS and no visible lacerations. We usually catch a lot of intracranial hemorrhages from the most unassuming trauma cases this way.

To which @forderit replied:

I am a big fan of this approach, however it cannot conceivably be implemented in the UK due to their strict adherence to NICE recommendations.