“Nothing Propinks Like Propinquity”

Mr McEnroe, immortalised by a remark accusing a tennis umpire of levity (chalk, after all, flew up), has received some stick for feeling bad for Emma Raducanu, who had to retire from her fourth round match at Wimbledon, with apparent breathing difficulties.  Well, in the days before the conciliation and arbitration of Hawk-Eye, McEnroe probably got most of his line calls right.  He knows a lot about tennis, and no doubt he knows a lot about what is going on in a tennis player’s mind.  But in any case, he’s not a doctor, so he can hardly be held to account for expressing a lay albeit quasi-medical opinion.  He might as easily have expressed sympathy for somebody having an asthma attack as a panic attack.  It is McEnroe’s critics, rather than the man himself, who seem to assume that hyperventilation, rather than bronchoconstriction, betrays a lack of moral fibre.    

But it just shows you; spot diagnosis, even from a ring side seat, is fraught with hazard.  Doctors have got into terrible trouble for making remote spot diagnoses.  They have phoned the police, convinced that the child they saw on telly must have suffered a “non-accidental injury”.  Type 2 Salter-Harris fracture of the distal radius, officer.  Battered child.  Can’t be anything else.  Pathognomonic.  The police, blinded by science, make the arrest.  But it is the doctor who ends up in court. 

“Pathognomonic” is one of these fancy pieces of medical terminology cobbled together from a dead language, in this case, ancient Greek pathognomonikos (from patho(s), condition, affection, + gnomon, gen. gnomonos discerner, indicator, from (gi)gno(skein) to recognise, perceive), thus, specific and characteristic of a particular disease or condition.  If you elicit the clinical sign, the diagnosis is secure.  Full stop.

Personally, I don’t believe in “pathognomonic”.  Life is never that cut and dried. 

Of all clinical presentations, dyspnoea (there we go again: Latin dyspnoea, from Greek dyspnoia – shortness of breath, laboured or difficult breathing) is perhaps the most hazardous, because a misdiagnosis can have dire, even tragic consequences.  Dyspnoea is a symptom rather than a sign.  It is the patient’s subjective sensation of breathlessness.  The clinical signs associated with it might be a rapid rate of breathing, or short, ineffectual respirations from a baseline of hyperinflation, or evidence of hypoxia – the patient is not transferring oxygen from lungs to blood, and turns blue. 

On the other hand, the patient’s dyspnoea might be “functional”.  It has no underlying pathological cause.  The patient is “just hyperventilating”.  Get them to breathe into a brown paper bag.

Next to making remote diagnoses on the television, deployment of the brown paper bag (why does it have to be brown?) is an even more hazardous undertaking.  Before you make a spot diagnosis of anxiety, better exclude life-threatening pathologies.  After all, people experiencing an asthma attack tend to be pretty anxious.  I remember seeing a 12 year old girl in the emergency department who was “just hyperventilating”.  Her irate mother told her to pull herself together.  Then she told me to tell her daughter to pull herself together.  When she realised that I was taking her daughter seriously, she made up her mind to leave the emergency department and take her daughter home.  I had to think of something creative, and quickly.  I negotiated to carry out a single blood test.  I measured the girl’s arterial blood gases.  It turned out she had DKA (diabetic ketoacidosis).  First time presentation.  For the benefit of any docs – bicarbonate of 3, pH of 6.85.  She was desperately trying to blow off carbon dioxide in an effort to make her milieu intérieur less acidic.  She wouldn’t have survived the night.  A little intravenous fluid (well, quite a lot of intravenous fluid) and a little insulin, and she was fine. 

Of course it can work the other way.  One night the ambulance paramedics radioed ahead that they were bringing in a young lady with severe asthma.  A resus team was assembled and as the young lady was wheeled, gasping, into Resus, the team pounced with oxygen, nebulisers, iv drips and steroids.  I happened to be in the room at the time, and I said to the team leader, “She doesn’t have asthma.”  And indeed as it turned out, she was “just hyperventilating”.  So you can’t win.  Moral of the tale: it doesn’t matter how dire your emergency appears to be, there is always time to pause, and take one long, comprehensive look.  The so-called “endofthebedogram”.

The team leader said to me, “How did you know?”  I said, “I don’t know.  But I’ve spent the last decade in this room treating people with asthma.”  It made me reflect.  What are we doctors doing when we say we have “a gut instinct” about something?  I came to the conclusion we are actually practising triage.  We look at the patient and we say, “Airway… breathing… circulation… neurological disability… exposure and environment…” over and over again.  It’s the long, comprehensive look.

On rereading the above, it sounds to me to be nauseatingly self-serving, and I certainly don’t mean it to be.  I always thought of myself as an average doc, a plodder, who tried to make up for a modest endowment of skill by sheer hard work, close attention to detail, and conscientiousness.  But the episode of the hyperventilating girl who did not have asthma was important to me, because it brought home to me the enormous diagnostic power in acute medicine, of sheer experience.

Mr Hancock, before he retired hurt as Health Secretary, wanted all the GPs to do all their work online, like John McEnroe diagnosing Emma Raducanu from the commentary box.  Perhaps if I had seen my two patients on Zoom I’d have given the first a brown paper bag and the second a ton of oxygen, salbutamol and hydrocortisone.   But why would you want to distance yourself from your patient?  As Ian Fleming once remarked, Nothing propinks like propinquity.  But let’s see now whether Mr Javid is minded to follow in Mr Hancock’s footsteps.             

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