October 7 is an important date for anyone interested in fishing and particularly why lady fishers are so prodigiously successful when it comes to casting a line!

I always raise a glass on this date, and particularly this year, as it was 100 years since a wonderful lady, Miss Ballantine, became the most successful fisher of all time by catching a 64lb salmon from the mighty Tay in Scotland. Think about this, the fish was half her own weight!

This is a fishing story like no other. First, a little about Georgina. She was 33-years-old at the time, had worked as a nurse on the battlefields in France during the 1914 to 1918 Great War and had been decorated with the Red Cross for her services.

She regularly fished with her father James, who was a ghillie looking after the fishing on the Glendelvine beat of the mighty River Tay. This would have been marvellous therapy and a perfect antidote to the horrors she had experienced as a nurse in France.

Saturday, October 7 was a beautiful Autumn day, perfect for fishing and, as luck would have it, the owner of the fishing, Sir Alexander Lyle, was indisposed, leaving Georgina and her father to have the day to themselves…and what a day it turned out to be – positively life changing for Georgina!

The morning went well with Georgina catching three salmon weighing 17lbs, 21lbs and 25lbs. The Tay is 60 yards wide and her father would skilfully row his boat across the river searching out known salmon resting spots or lies, with two rods, one with an artificial fly and the other with a type of spinner called a dace behind the boat; this method is known as harling.

Lunch was taken and they were back on the river afterwards. The weather was still quiet and balmy.

At 6.15pm, the spinner was taken! The shock nearly pulled the rod from Miss G’s hands but somehow she kept control. Her father kept the boat steady, got the other fly rod in and cleared the boat ready for action. 

The unseen monster led them back and forth across the river in 50 yard dashes. The line caught round a rock early on in the fight, disaster, but no, miraculously her father managed to manoeuvre the boat to free it, otherwise the fish would have been lost. The line was free and there was still a chance she would land it.

It was now pitch black and the fish towed them down the river opposite the cottage where they lived. Mum appeared, a lantern in hand, wondering what was going on. They shouted to her that they would be late for supper! Tally Ho!

Not once did the fish show himself,  just  the great silent weight and the line slicing through the black water.

There was the challenge of being towed past the Caputh Bridge and avoiding disaster and after two hours of extreme tension and good team work Miss G was ready to drop from exhaustion.

Could she get the fish close to the boat so her father could hook it with the gaff? This was a challenge only she could answer.

The fish was tired, swimming in short bursts, the line vertical and the fish some five feet down. Now the really skillful action is taken by her father who leaves the oars, knowing there are five knots in the silk line between Miss G and the leviathan below, and uses his gaff hook to run down the line and counts off the knots by telepathic touch and great skill. Number five knot is reached, the fish just inches now below, the gaff is pushed gently forward, turned, and with a great sweep of his strong hands, his daughter’s catch is brought to the surface and hauled into the boat. The fish carried on leaping in the boat and “father thought it was going to jump back into the river and threw himself on top of it” Miss G later said, “my arm felt paralysed and I was so utterly exhausted I could have lain down beside the fish and slept”.

The fish was weighed and witnessed by 16 people that night.

After a celebratory dram or two, she retired, but Georgina woke several times clinging to the brass railing of her bedstead, as she had clung to the rod for those two hours the previous afternoon. Her arms remained swollen for two weeks! 

When she awoke the next morning she was famous, and still is. The newspapers throughout Britain on the Sunday carried the story of her great achievement and every detail of the fish: Weight 64lb, length 54 inches and girth 28.5 inches.    

The male Sottish chauvinists could hardly believe a young 33-year-old slip of a woman could land such a fish. One fisherman said, as he looked at the fish on display “A woman? Nae woman ever took a fish like that oot of the water, mon, I would need a horse and a block and tackle, tae take a fish like that oot.” Georgina heard these comments and had a quiet chuckle to herself.  They would have to get used to it, as women do seem to always get the biggest salmon!

The fish was gifted to the Royal infirmary Hospital in Perth by Sir Alexander and casts were made to immortalise the fish that is still the biggest ever caught in Britain.

Georgina never married but loved to go from her cottage down to the river and relive that fateful afternoon, even when illness confined her to a wheelchair in later life. She would ask to be taken down to the spot where her Mum waved the lantern at the quickly disappearing boat all those years before. She lived on to the ripe old age of 81 years and passed on in 1970. 

I wish I had met her. Saying fishing is a hobby is like saying brain surgery is a job!   

I am going to cover injuries to the legs in this issue. These provide much of the work for the Minor Injury Units in Bantry and Cork. Just as the role of Emergency Units has changed from dealing with ‘emergencies’ to plugging gaps in the health service, as the only true 24/7 service, so the work of our Minor Injury Units sometimes has nothing to do with a minor injury! We all try to care and point the patient on the right path to get help.

I will give you some examples: When I worked at Bantry as a Minor Injury Doctor, I saw patients with broken necks and hips and so on. They were seen, stabilised, and transferred safely but by no means were the injuries minor!

That is the nature of the job, the HSE set up strict criteria of who we should see and who is inappropriate but a patient in trouble sees hospital and goes! We always try our best.

So back to your leg injury. The mechanism of injury is so important. This will determine the forces involved and the chance of serious injury. Height of fall, speed of collision, soft bones, on blood thinners and so on. So too is the age of the patient. Young children and toddlers are particularly difficult to assess and often need senior review in the major Eds, not the minor injury units.

The minor injuries units have different opening and closing times, which can vary, as well as the minimum age, so do check first.

So, you have twisted your ankle – what determines the need for an X-ray? If you can walk on it that is ok. Pain on pressing the bone at the side of the ankle, the fibula, particularly the rear of that bone signals an X-ray is needed and ditto for pain over on the side of the foot where the ankle ligament, when torn, can damage the long bone going to the little toe. 

Pain over the inner aspect of the ankle and inability to take weight on it is more serious, as this is the deltoid ligament and very important for ankle stability. If this is damaged, it can be associated with damage to the fibula bone at the side of the knee, and this will need an X-ray. 

If you are unsure, a good plan would be to elevate the ankle, and apply a cold compress to reduce the swelling. Don’t overdo the cold though.

If you are a sporty type and in training, it is a good idea to see a physio who may even advise a cast and crutches.

On the subject of sport, pain over the ball of the foot in long distance runners is often due to a stress fracture, which does not show up on X-ray initially and can take six weeks before training can resume. Pain over the front of the shin in runners is due to ‘Shin Splints’, as the muscles expand and stretch the tight skin of the shin.

Pain in the heel is common. If you fall off a high wall and land heavily, it is a serious problem, as the heel bone can break and not only need an x ray but a CT to confirm. It is often associated with injuries, due to a shock wave causing hip and spine fractures, and needs expert attention in CUH.

Pain in the toes is common after somebody in stiletto heels stamps on you and just needs rest and painkillers!

High speed twisting injuries to the foot – as in car crashes and falling off a horse with the foot trapped in the stirrup – is serious and needs an X-ray to make sure the bones of the forefoot are not dislocated. Once again mechanism is so important.

Pain in the heel without a fall or injury is often due to inflammation in the soft tissues, is difficult to treat and again, no X-ray is needed. We sometimes consider a steroid injection, weight loss and rest! This is called plantar fasciitis. It rarely needs surgery.  

Moving to the knee, this is another area that keeps us busy. The knee is the largest joint in the body. Unlike the hip, which is a stable ball and socket job, the knee is a hinge joint, needing strong crossover ligaments, the cruciates; and ligaments either side called the collateral ligaments, which are often damaged in sport. It is not a good design.

So you twist your knee on the football field. Can you walk a few steps? Good, no need for panic. If you cannot walk and the knee swells immediately, this means there is potentially serious damage. You will have heard of the notorious ACL injury and torn cartilages. These can cause immediate swelling causing bleeding into the joint, which is not so good. You will need an X-ray; a doctor will test the joint looking for excessive movement or glide due to loss of ligamentous stability.

I usually drain the joint under local, which helps relieve the pain and confirms blood in the joint. We then arrange a visit to orthopaedics to consider treatment options. The knee will need to be rested and crutches with a support brace given.

If the knee swells a day after injury, this is common, as the joint repairs itself; it will need review but not necessarily an X-ray.

Pain and creaking in the knee is common as we get older and is due to wear and tear; it does not usually need a X-ray or MRI unless all simple measures have been tried and you are heading for a knee replacement.

Cuts and scrapes to the leg are common. The skin over the shin is very fragile; stitches make things worse. If a flap of skin is raised and bleeding briskly if the leg is raised above the heart and pressure applied, it will stop. The skin can be put back in place and kept in place with steristrips. Your GP/South Doc and Nurse will be the people to see. Occasionally a varicose vein can bleed and again don’t panic – get the leg up and put pressure over the area. Running around in a panic, as I have seen, can cause bleeding to get a lot worse.

I have covered much of the workload of Minor Injury Units here. I think they have been a great success and I hope my quick review of leg injuries helps you to decide whether to go or not. You can always ring first for advice – it is a great service. Waiting times are short and things much more relaxed than in the major ED units.  Bantry Hospital 027 50133.

Next month, I will cover wrist, elbow and shoulder injuries. Till then take care and enjoy the summer.   

I’m going to chat about the dreaded blood clots in the legs, the deep vein thrombosis and its even more dreaded sequel the blood clot on the lung, the pulmonary embolus.

Calf pain is a common problem. How do we decide if it is a blood clot or just a muscular strain.         First, a bit of anatomy. Blood returning from the legs has to beat gravity. The muscles in the calf, the gastrocnemius and soleus, have the ability when they contract to pump the free-flowing blood back up to the heart against gravity. Together they are called the peripheral heart. Valves in the deep veins stop the blood back-flowing and this usually works well.

I have mentioned the deep veins, which you do not see, but if the valves in them start to fail, as they do as we get older or go through pregnancies, the pressure from the deep system now transfers and dilates the superficial veins in the legs, which become prominent as varicose veins. Most of the time these present merely as a cosmetic problem but sometimes contribute to aching legs and ulcers on the lower leg around the ankle, as the tissue becomes less well drained and poorly oxygenated, which all equates to poor healing.

Blood leaks out around the ankle is an irritant and causes itchy, dark blue patches as varicose eczema. If you are in the supermarket and someone drives their trolley into your lower leg, where you have varicose eczema, the skin breaks then an ulcer forms and it can take months to get better. Be careful!

By the way the big superficial vein in your leg is the saphenous vein, running from the inside of your ankle to your groin, where it joins the deep system as the femoral vein. The clever heart surgeons harvest this vein and use it to bypass narrowed arteries in the heart as a Coronary Artery Bypass Graft, CABG. Very handy! We also sometimes use this vein to give fluids in children when the veins in the arm are inaccessible, as it can be located above the ankle with a simple operation.

During Covid we became aware that this infection causes blood to clot more easily and I have seen hundreds of patients concerned about blood clots in their legs or chest.

So how do we determine if the pain in your calf or your swollen ankle is serious? It can be difficult. First, we look at risks. You may know that long haul flights in rare circumstances can cause blood clots but there are many others. Are you on the pill? Have you or a family member who had a clot?Have you active cancer? Have you been laid up in bed for a few days for example? The doc then examines your leg looking for deep pain in the calf, unilateral swelling, a significant measured difference in the girth of the calf, a warmer leg and a leg with dilated veins. A score is given, the so-called Wells score; if you score high, off you go to hospital.

Why the panic? Well, with a clot in the deep muscle of the calf, rather like a log falling into a river, if this is pumped upstream, next stop where the river narrows is the lung and that can be fatal. It blocks the circulation to a lung or even both lungs as an embolus, and blood now cannot take up oxygen from the lungs! A cardiac arrest can occur, as the heart pumps against an immovable blockage at its most dramatic and serious presentation. If the blockage is less complete and the clot smaller, moving to a smaller vessel in the lung before it jams, it can cause a pain on breathing in deeply, that is a pleuritic pain, shortness of breath and coughing up blood.

So, you arrive in hospital, we will repeat the examination and, if pretty sure there is a clot, an ultrasound is done. If we are not quite so sure, then a special blood test is done. This is called a D dimer test: It measures if there is a blood clot anywhere in the circulation. The level increases with age, so we build in a correction factor and, if still raised again, an ultrasound is done.

A blood clot in the calf is not a major problem but if it starts to move up the leg towards the groin then it certainly is. The log is moving on. We call this clot propagation. An ultrasound determines whether the deep veins in your groin compress. It takes minutes, is performed by an expert sonographer and if the vessels compress, as pressure is put on the probe, then all is good. If they do not, you have a blood clot, which can be visualised within the vein sometimes. Even if the ultrasound is negative and the suspicion high, the test can be repeated a few days later.

So why is it that if you have pain in the calf, the calf itself is not examined with ultrasound? Good question! The vessels in the calf are small and many and a complete examination of every one of them could take hours; and bear in mind the clot only becomes a big problem when it extends or propagates above the knee.

Blood clot mimics are many: A torn muscle, a cyst behind the knee (a Bakers Cyst) simple cramp, fluid retention to name but a few. These can often be teased out with a careful history and examination.

If a blood clot is found and there is a powerful reason for having one, say a recent operation and immobility, we call that a provoked clot and blood thinners are prescribed for three months. If there is no reason for a clot forming then blood thinners may be needed for much longer. This is where the blood specialists come in. They look for reasons for unprovoked clots and investigate for inherited or acquired clotting disorders and there are many. They will then make recommendations on the duration of treatment.

I have mentioned ultrasound. We are taught basic ultrasound techniques in the Emergency Department, we are not experts and rely on specialists to confirm or refute our ‘have a go’ findings, it is so important that no chances are taken. I feel a huge level of frustration that I have left it so late in my own career to learn ultrasound.

I confidently predict however that in the future every GP and hospital doctor will learn to use ultrasound. The stethoscope after all has been around with little modification for over 200 years! It was invented by a French doctor, Dr. Rene Laenec, as previously doctors pushed their ears against a patient’s chest to hear what was going on. You can imagine some difficulties and potential embarrassment with the odd mademoiselle! 

Next month I will look at other common problems. I enjoyed working in Bantry Minor Injury Clinic for many years and will cover common minor injuries next month in my ramblings. 

Over the last two months, I have talked about heart problems and some exciting advances in treatment.

This month I wanted to look at health generally, as I reckon over the last two Covid years, we have been neglecting ourselves. Doctors particularly are remiss in this respect.

How about a check-up? I am booked in myself. My car has been better looked after than my body of late!

So, what can the doctor offer to assess health? There seems to be a full understanding of cholesterol levels and patients often brag about how low it is, while puffing on 20 Major a day and doing no exercise at all. You get my point; health and longevity is complex and there is little place for medical dogma.

However, we will do our best to keep you well. So, prepare yourself for a virtual health check. I will concentrate on the ‘well man’ check, Here we go… 

“Good morning, long time no see! Any worries or symptoms? Right let us weigh you first, oh dear work to be done here. Can I check your blood pressure? Fine, sit down, relax and yes, that seems ok. Now stand up and I will recheck it. Good. Now I need to check your chest, heart and lungs. Great, deep breaths fine.

Just climb up on the couch, I want to examine your tummy. Appendix scar? Ok, liver, kidneys and spleen seem ok. Fine. Do you mind just giving me a urine test, I want a more detailed assessment of your kidneys, I will be looking for sugar and protein to check for diabetes and kidney problems.

While you are doing that, I am going to write some blood forms and then take some samples.

 Fine, your urine test is normal no sugar or protein. 

Now I will draw some blood, just roll your sleeve up. Yes, I will check your cholesterol but also an awful lot more! The bloods will be analysed for diabetes, liver and kidney function. Your blood salts will be checked, and a CRP, which reflects general health and hidden serious disease as well. We will look at your iron and vitamin levels and your blood count to exclude anaemia and an infection through your white cell level. Yes, it is thorough, this is only once a year!

As you have piled the weight on, I am checking your thyroid function and your prostate activity, as you are ‘middle-aged’. If the prostate level is high, I will repeat it, and check the size of your prostate by means of a back passage exam. Don’t look so worried!”

Now, as you smoke, I am going to book you in for an abdominal ultra sound with my partner to make sure your main blood vessel in your tummy is not enlarged. He also has a look at your liver, gall bladder, kidneys and spleen to make sure all is well. 

 How does that all sound? Here is some advice about diet and smoking cessation and I will see you is a week.

If your wife or partner is interested in a check-up she might prefer to see my female partner or practice nurse.

  Great, then we will see you both in a week or so.”

  Now to misquote Dr Adam Kay, that did not hurt a bit! 

I don’t tend to get a lot of feedback from my articles so I can only hope that readers enjoy them and learn from my experience and particular ‘take’ on GP and Emergency Medicine. It is also a real privilege to be in the company of some really excellent contributors to this monthly publication.

Treatment of heart failure is important: There are some drug classes with funny names but I think it is important to understand how they work and how they come to the market. There have been some amazing advances. 

I recently attended an online conference beamed in from Edinburgh, so this month I am looking at the earlier diagnosis of heart failure (Dropsy) the symptoms, and the advances in treatment that are really making a difference and saving lives. 

Also, I love the word serendipity, which means the chance discovery of something that is beneficial!

So many times in Medicine, somebody discovers a new treatment purely by chance with great benefits – penicillin, water tablets and Viagra to name but a few.

So, what has all this got to do with your heart?

Heart failure is the situation when the heart is not pumping enough blood around the body: It is common as we get older and often poorly recognised particularly in ED when the symptoms are missed in up to 50 per cent of presentations, as patients come along with coughs, Covid and shortness of breath from other suspected causes. It is so important not to miss the early symptoms.

What are the symptoms? Well, I have talked about heart attacks; heart failure is usually less dramatic but again, time is of the essence, as early treatment is hugely beneficial. Increasing shortness of breath over a few weeks, ankle swelling, waking up at night short of breath and inability to sleep flat are the big clues. The lungs are becoming water logged. You may need water tablets (diuretics) urgently.

You visit your doctor who looks for these red flag symptoms, examines you, and looks for ankle swelling, the veins in your neck, blood pressure, pulse, heart murmurs and oxygen levels. This is done in minutes. An ECG will be done; if this is normal it is most helpful in excluding heart failure. If the ECG is abnormal, an X-ray of your chest is needed, looking for an enlarged heart under strain and congested lungs.

Bloods tests will be done looking for heart damage (a Troponin Level), kidney problems and anaemia. A water tablet, a diuretic-like furosemide, will need to be started. In an ideal world an Echo of your heart would be done to absolutely confirm the diagnosis to accurately measure the hearts performance.

If symptoms are improving your doctor will add in a beta blocker like bisoprolol and an ACE inhibitor like enalapril or ARB like candesartan to maintain the improvement. Low doses at first and building up gradually with monitoring of blood tests. The Beta blocker stops the heart beating too fast and the ACE inhibitors and ARBs relax the blood vessels lowering the blood pressure and easing the work of the heart.

You might also be put on a drug called eplerenone, which stops the body absorbing too much salt, which complements the above trio. Too much salt is bad. 

If symptoms are not improving, patients are often referred to ED in the hospital and we then speak to our cardiology friends for advice. They have some exciting new treatments up their sleeves.

Back to serendipity. Diabetic specialists, purely by chance discovered that diabetics who have too much sugar circulating in their bloodstream, when put on a class of drugs that drive sugar out through the kidneys, had much lower rates of heart trouble than others who were not. These are the glucose transporter drugs.

We do not know why this is the case…but lo and behold they are now being used to treat heart failure without diabetes very successfully. Even starting them early on with the water tablets, they are that good. This is great news of course.

Another drug now established in treating heart failure is Entresto, a tablet that is a combination  of two different classes of heart failure drugs, which is now well-established in treating more resistant heart failure. This treatment arose from researchers trying different combinations and looking at the benefits over many years monitoring their patients. A little bit of chance and a lot of science again. 

So to recap, watch out for those red flag symptoms. Treatment? We get rid of the excess water first with a diuretic, all going well, then we start a beta blocker and an ACE inhibitor or ARB. If that is not doing the job, try the newer miracle drugs, the glucose transporters and Entresto.

You have to admit…all good news.

For those of you who are following my journey through the human body, the things that can go wrong and what to do about them, this month is all about bowel awareness. Or more accurately, the gastro-intestinal tract.

First, a quick whistle-stop journey of the food you put in your mouth and chew. The bolus (food that has been chewed and mixed in the mouth with saliva) is swallowed and a wave of muscular activity takes it to the stomach down the oesophagus in seconds where acid mixes with the food, enzymes start to break the food down, and it is squirted into the small bowel over several hours. 

The first part of the small bowel, the duodenum, is joined by the tube from the liver, gallbladder, and pancreas, which sends green bile, pancreatic juices and more enzymes to complete digestion. The food is broken down completely and all the good stuff is absorbed in the rest of the small bowel.

On your right side, right down where the small bowel joins the large bowel, there is a valve right next to the appendix, which allows the liquid residue to pass into the large bowel where water is absorbed and the semi-solid waste, the faeces, is passed out through your rectum and anus. 

So, what can go wrong in adult life? Which are the serious symptoms to act on quickly?

From the top down: Swallowing difficulty – so called dysphagia needs to be checked. There are lots of causes but a blockage amenable to treatment is the number one to exclude. For some reason oesophageal cancer has become much more common and we need to be vigilant.  

As we enter the stomach, indigestion that is not settling on tablets or associated with weight loss and anaemia particularly in middle age or older, needs an endoscopy. This is a simple test that takes about five minutes and can be done while you are awake or sedated.

Still in the stomach and duodenum, vomiting black stuff like coffee grounds is s sign of a bleeding ulcer and, if associated with passing dark black motions rectally, is an absolute emergency. The two commonest causes for vomiting blood or coffee grounds are bleeding ulcers and varicose veins in the lower oesophagus (varices), usually associated with the demon drink, and liver disease, in the form of cirrhosis. The clever stomach specialists through their endoscopes can inject bleeding ulcers with adrenaline, and put clips on bigger ulcers. The varices in the oesophagus can have elastic bands put on them or be injected. The varices are really serious, as they represent very advanced liver problems, particularly as often the patient continues to drink alcohol.  

Enter the rest of the small bowel. Here we have Inflammatory bowel disease and Coeliac disease. Both can start with diarrhoea, abdominal pain, weight loss and anaemia. Coeliac disease runs in families, is common in Ireland, can cause problems at any age, and is easily diagnosed with a blood test and maybe a small bowel biopsy. You probably already know that it is caused by a sensitivity to gluten, which makes food nice to chew and palatable; and this has to be excluded from the diet forever. 

To go on a gluten-free diet on a whim or because it is trendy has no scientific basis at all. 

Crohn’s disease is a condition where one’s immunity attacks the bowel, usually the small bowel, but it can affect the whole length. Sometimes it mimics appendicitis, sometimes it causes bleeding and obstruction. Again it is diagnosed with blood tests, endoscopy and looking at a stool specimen to look for inflammatory markers called calprotectins. Interestingly, it is strongly associated with smoking.

Enter the large bowel. You all know about appendicitis and how this can be a difficult one to diagnose. Pain starting around the belly button moving down to the right lower abdomen associated with tenderness, temperature, and going right off your grub, is a classic presentation. A blood count looking for a high white cell count and evidence of inflammation, a C reactive protein level (CRP),  again is classic, but so many patients I see have not read the text books and it can be a tricky diagnosis particularly in the young and elderly!

In the large bowel, we still have inflammatory bowel disease; Crohns is there and its cousin Ulcerative Colitis which, as its name implies, cause ulcers in the large bowel, bleeding and pain. This is more common in non-smokers! 

Most of us also end up with small pouches on the large bowel called diverticulae, which can be painful (diverticulosis) and like the appendix can get blocked, infected and form an abscess. So-called diverticulitis.

I suppose the big one not to miss is bowel cancer. Clues? A family history of bowel polyps and its sequel, cancer, needs to be screened for by means of regular colon examination. A change in bowel habit, having mucus and blood in the motions needs to be looked into. Bowel cancer starts off as a small strawberry like polyp, which if left for several years, can develop into a life-threatening cancer, so snipping off a polyp that is causing early symptoms saves your life or saves you from a major operation later. So keep an eye on your motions!

The HSE operates a screening test for early bowel cancer. It is a great idea and so simple to do, but many don’t get involved out of embarrassment or simply because they just can’t be bothered.

I see many elderly patients in hospital with diarrhoea. This tips the frail patient who is coping at home into a non-coping situation. The first thing we do is look at the patient’s tablets. They are usually on far too many! The patient has mild blood pressure so a tablet is given that causes ankle swelling; a water tablet is then prescribed, which leads to incontinence, so a bladder tablet is given. A urinary tract infection is diagnosed. A urinary tract infection is actually quite rare in the elderly. An antibiotic is prescribed, which then causes diarrhoea. Hello ambulance…

The patient ends up in the Emergency Department with me. This is called the prescribing cascade and such an easy trap to fall into particularly when several specialists are involved. It is called polypharmacy and a careful review of all medicines by your doctor, particularly in the frail and elderly is so important. We sometimes have to decide what is really important to treat and weigh up the balancing act of risk versus benefit, which is not easy with the newer high-tech medicines.

I know I have not covered Irritable Bowel Syndrome (IBS), which can mimic serious disease and when all is said and done can really only be diagnosed when the big stuff has been excluded. A  history, blood and faecal test usually gets the diagnosis. Treatment here can be difficult however, as it is poorly understood.

So that completes the journey through your bowels…I hope I have signposted some important conditions and the symptoms to act on.    

I believe this pandemic will end and life will go on. I don’t wish to trivialise this pandemic or any other global catastrophe but it is a fact that good things can come out of the most appalling situations.

Starting with Covid: Initial predictions were that it would take years for a vaccine to be developed and tested. We had absolutely zero weapons against it and people died in their thousands. Low and behold before 2020 was out, a vaccine was on the horizon. This broke all previous production records and it really works, keeping so many alive and safe. Thank you to Dr Jenner and his cow pox research.

A full understanding and extension of vaccine technology is leading to vaccine development to treat malaria and even cancer. We all know a lot more about immunity. There are lots of unanswered questions however here as well. Why are our children spared the worst effects of Covid? We know that babies don’t have fully developed immunity in their first year of life but they seem protected as well, and that, thank God, has to be good news.

Look at the 1919 ‘Spanish flu’ that picked out young people, 20 million of them in fact, some just leaving the trenches in France as tough as old boots, catching the virus on the way home, and dying en route. Even that devastating disease came to an end and why did it? There was no living with the Spanish flu then. It just disappeared. Apologies to the Spanish of course…we were not so politically correct in 1919!

We have just invested massively in new drugs, which interrupt the passage of the Covid virus through our bodies. These work, and will be another weapon to combat the disease. These drugs are a direct result of the work done on the HIV virus and its journey through our cells. 

Do you remember when we were all going to die from AIDS in the 80s, and now, a patient who contacts HIV and is treated, will probably live longer than an age-matched person without HIV! Amazing!

I could go on. Look at WW2 – nothing moves technology on like a national emergency. Rocket technology was developed and once again led to the Americans landing a man on the moon a few years later, which again was amazing. Let us also face the fact that a technology race between the super powers became a surrogate activity to replace a nuclear war. You get my point.

We all appreciate nature a lot more. We have more time to exercise and enjoy our lovely country. My happiest moment last year was seeing my two children complete the Clonakilty marathon in appalling conditions a lot faster than I ever did. What a great day!

How many new babies have been born as a result of lockdown activity?

Have you noticed how cosmopolitan Ireland is becoming? I work with doctors from all corners of the world, who keep the service going and love being here. It is so interesting talking about life in other countries and the huge sacrifices they have made to get here.

Asylum seekers risk all to reach the Utopia that is the UK and Ireland.

So let us appreciate what we have. Are we all getting a little spoilt and needy? Few of us locals want to do the menial jobs. Foreign nationals keep our factories, hospitals and service industries going. That is good news to some extent but sad that we have lost the run of ourselves looking for more and more by doing less and less.

You will never win the lottery, and if you did, it would ruin your life, guaranteed.

There is an optimal combined income for a married couple well south of 80k; too little is not good and nor is too much. 

There was a daffodil grower in Ireland who was featured on the radio. He put a huge advertising board next to his fields on a main road asking for people to apply to pick his daffs. This was during a time of high unemployment. Not one local Irish person applied and he was offering accommodation and a half decent salary. His daffodil pickers have come from Romania every year since then and do a great job.

The happiest staff in the hospital where I work are the porters. We share the same changing rooms and have great craic every morning and throughout the day. The highly paid managers not so!

They used to say that the happiest person in the hospital, when there were gardens nearby, was the gardener.

A short stint picking daffs might do us all the world of good!

So let’s keep our chins up, appreciate what we have, and try and make this a good year to remember. There is a grand stretch to the day!  

Next month, I’ll continue my series on symptoms started in December.

Over the next few months, I hope to cover those common symptoms, which we all know can mean something serious is going on and which, if missed, could represent a catastrophe.

This month the topic is chest pain.

You are just finishing your Christmas dinner and start to experience chest pain. You ring South Doc and the nurse recommends a visit to A&E by ambulance as this could be serious.

You and the nurse are worried about a heart attack.

This scenario represents 10 per cent of A&E workload and in 90 per cent of cases, after a short stay in hospital, you may be discharged. No system is infallible and there is a small failure rate in existing systems in missing a major cardiac event (MACE). In most studies, this equals about one per cent.

So, what is the system? Doctors use scoring systems to improve accuracy of diagnosis and the best ones are the simplest. They are easily accessed electronically and really do help to improve diagnostic accuracy, not only with chest pain, but also sore throats in children or the chance of having a blood clot in your leg or on the lung; then there is the FEVER PAIN score, THE WELLS SCORE, the ALVARADO score for appendicitis, the Blatchford Score for bleeding from the stomach and so on. It might be interesting to have a look at some of them online.

Back to the Christmas dinner. You have arrived in hospital or are speaking to your GP. The hospital doctor will use the HEART score. Now that is an easy one and very accurate. I will explain: 

H  stands for history. This is the information you give the doctors and is where intuition comes in. A really concerning story get the maximum two points and a lesser concerning story gets zero or one point.

E stands for ECG: No changes, zero points, and more concerning, one or two points.

A  stands for age: Over 65, two points; age 45 to 65, one point and, less than 45, zero.

R stands for risk factors: Things like smoking, high blood pressure, previous heart trouble. Three or more of these and you get two points. Less than three, two points. None, zero points 

T stands for a troponin test. Troponin is a chemical released by damaged heart muscle after a heart attack. A high level gets two points and a normal or slightly elevated level equals zero or one point. The level starts to rise three to four hours after a cardiac event and, the higher the rise, the greater the muscle damage.

For those of you of a mathematical bent, you will have worked out that the maximum number of points is 10, which means you will be seeing the cardiology team very soon!

Scores of four and higher again will be taken seriously and more tests ordered. Scores lower than four and you are safe to go home.

These scores are all well and good but your GP has other tricks up his or her sleeve, which I believe are even more accurate, and woe betide a hospital specialist who ignores GP intuition!

When GPs have gotten to know and examined and talked to thousands of patients, sixth sense becomes very honed. You might not have seen your GP for years and only consult when absolutely necessary. Your GP fixes you with a very careful scrutinising look that takes in so much. Your colour, presence of sweating, your breathing, level of pain and so on. If ‘he does not like the look of you’, after only seconds, a decision is made on what to do next. A full examination and ECG may be superfluous.

This is the Art of Medicine and, with GPs and hospital staff working together and communicating well, most chest pain is managed extremely well. Science and research combining well with good traditional GP skills and intuition.

Enjoy your Christmas dinner, go easy on the plum pudding, and Merry Christmas!

When studying for their examinations and role-playing the ‘difficult referral’, if A&E doctors respond in kind to what boils down to completely unreasonable behaviour by a specialist, they fail the exam! We have thick skins and are slow to anger….we have to be that way.

The specialists like a nice clear-cut diagnosis – an appendix that they can chop out or a case of pneumonia that antibiotics will cure. It would be great if life were so simple; it is not!

A term that has been accepted into the lexicon of doctors in the care of the elderly is ‘frailty’. This is a diagnosis that recognises the complexity of presentations and home circumstances in the elderly and opens the door to careful assessment and admission if necessary. It also recognises that minor non specific complaints (NSCs) like a fall, a temperature or weakness, if not taken seriously, can lead to disaster. 

This appreciation of frailty has led to changes in A&E triage, whereby the elderly are initially seen by a highly experienced nurse and prioritised according to their intuition and clinical parameters like blood pressure, pulse, temperature, breathing rate, oxygen level and blood sugar.

We have scoring systems to assess frailty; the higher the score, the greater prioritisation, and later the Comprehensive Geriatric Assessment CGA is performed usually by a nurse linked to the geriatric teams.

A useful tool in assessing whether an elderly relative needs assessment is the ‘Five Ms’:

MIND – is the patient more confused or delirious and off their normal baseline?

MOBILITY – is the patient having falls and why? A useful test is to time how long it takes them to stand and walk a short distance. The so-called get-up-and-go test is easily performed and monitored and not rocket science!

MEDICATION – is the patient over-medicated? Could we make life simpler by limiting the number of tablets being taken. I try to stop unnecessary treatment or drugs of dubious benefit. The chance of drug interactions when taking more than four different tablets is huge and, is often a reason for admission in the elderly, as they cannot metabolise these drugs with poor kidney and liver function. Multiple illnesses imply the use of many drugs (polypharmacy) and this needs very careful medical management.

MULTICOMPLEXITY – we all have different priorities and these should be taken into consideration with shared decision-making in a holistic approach. These priorities should be listed and agreed

MATTERS – all this leads to a treatment plan with goals clearly defined.

We have guidelines in A&E around allowing a relative to stay with the elderly to comfort and orientate them. We talk slowly and clearly. We preserve dignity and make sure the patient has their glasses, hearing and walking aids.

So, as we are all getting older and living longer, it is at last reassuring to know that the care our elderly has become much more structured with terms like ‘social admission’ and ‘inability to cope’ (Acopia) in the past. The complexities of caring for our elderly are at last being appreciated by all. Patients don’t always slot into one neat diagnostic box.

We try and get a quick accurate discharge letter out to GP teams and safety net with early review, home visits and even transitional care in the unit, as exists in Clonakilty.

Once again, I emphasise, if coming to hospital, do try and get a letter from your GP and do bring your tablets.

 For any of you who like to read about life in A&E, I recommend a book by my old boss Dr Chris Luke: ‘A Life in Trauma – Memoirs of an Emergency Physician’ details his 35 years in Emergency Medicine in Australia, Liverpool and Cork. He now owes me pint!

I was surprised to hear that we now do not recommend sterilising babies bottles. The hours of fun I had with boiling water and being ever so clean with our second baby: All a waste of time and just goes to show how advice changes.

Another interesting spin off of our current Covid-19 precautions is the potential to test the Hygiene Hypothesis.

Allergies have become a lot more common over recent years and cause great concern. The hypothesis says that keeping ourselves too clean does not test our immunity, which when redundant, turns bandit and attacks ourselves.

Children growing up on farms and those from bigger families seem to have fewer allergies; examples being, eczema, asthma, hay fever and drug and food allergies. 

We now have had a whole eighteen months of scrupulous attention to hygiene issues and one might expect the ‘knock-on’ effect to be even more allergies if the hygiene hypothesis is correct. This research is going on and no conclusions have been reached but I will keep you posted.

I ran this hypothesis by a Consultant Haematologist friend of mine. There are some interesting hygiene issues in his field. Childhood leukaemia is more common in affluent families. Does this have something to do with an over-sterile germ-free home? Possibly. Children who attend a nursery from a young age are also less likely to develop leukaemia. A child with no siblings is another risk factor for leukaemia.

If we look at the animal kingdom, domesticated cats are much more likely to get leukaemia than the feral moggies.

So once again, giving our immunity something to do, within limitations, has massive implications!

This is all very interesting and confusing I know. Once again it is all about taking the middle road and using common sense.

Let’s look at antibiotics. It drives me mad when a patient says they are allergic to most antibiotics but cannot remember which ones or who diagnosed their allergy. No bracelet worn either! This is a huge problem if you have sepsis and the antibiotic has to be given more or less immediately to save your life. Penicillin derivatives are still widely used and life saving in sepsis. 

I met a patient recently who said he was allergic to every local anaesthetic, which is amazingly rare, and a huge problem if it was just his personal hunch without any real proof, particularly as he had a wound needing to be sutured. 

We know how to treat allergic reactions. The serious one is anaphylaxis, when the throat closes, the tongue swells, a rash appears and circulation collapses. It is truly life-threatening. You’ll have read about the nut allergy – when someone with that allergy unknowingly ingests a nut product and dies. It usually hits the headlines.

I can honestly say that in my long career in A&E and as a GP, I have only seen true anaphylaxis once or twice. I see patients every day who have ‘allergies’.

On the subject of antibiotics there is a general reluctance to give antibiotics for colds and flu. In our bowel we have two kg of good bacteria. The microbiota. This adds up to ten thousand billion bacteria and we know very little about them. They work with our immunity to keep us well. Bump them all off with powerful antibiotics and big trouble can ensue. It may take months for normal service to resume. Rather like spraying your garden with non-selective weed killer and wondering why your roses have died!

How can you help your immunity over the coming winter months? A good mixed diet, plenty of sleep and exercise and avoiding toxins like alcohol and smoking. Stress is hugely damaging to our immunity and being aware of your stressors and dealing with them is important. I like a good walk, a day fishing, looking forward to new challenges and being proud of what I have done, and accepting I am not perfect by any means.  

The hygiene hypothesis makes medicine very interesting and we are learning all the while. Take home message? Life is all about balance, not too much or too little. If you have an allergy talk to your GP about it. For a serious one get an EpiPen and learn how to use it. For tricky cases there is an excellent allergy clinic at CUH to investigate and confirm the more serious reactions.

It goes without saying that I believe firmly in vaccination. Touch wood, it has kept me safe during some tricky times in A&E. 

I respect that people may decline vaccination but I had a patient of 78 who had significant health issues and refused not only the Covid vaccination but would not even let us do a Covid swab test! This was tantamount to refusing medical treatment and it presented us with a huge dilemma, which took hours to resolve and put staff and other patients at risk. Bizarre! 

It might come as a surprise to readers that doctors are legally obliged to keep up their knowledge and skills every year by spending many hours in training outside of work. The Irish Medical Committee carefully polices this education and woe betide the doctor who falls short with his monitored training!

I recently attended a really good meeting over five hours at UCC, at which we were updated on issues around managing children in A&E over the coming months. It also provided the opportunity to meet the experts and old friends from CUH and MUH. It is important for A&E doctors to know what to do when treating bronchiolitis as winter approaches, as well as resuscitation, burns, foreign body inhalation, Covid infections and non-accidental injury. We dread these emergencies, as they are so emotional and trying. In training, we acted these situations out with mannequins to be prepared for the winter.

What was news to me is that CUH now has an expert lady, whose name is Rachel, dealing solely with play! She is highly qualified and is now a vital part of the team in A&E to make our children’s visit less scary. I am sure all the doctors learned a lot from her. I learned there is more to distraction than playing a cartoon on your mobile! Offering lots of toys is better. It’s also a good idea to introduce the child to a teddy who will go on the same journey with him or her and have the same tests. The teddy is for keeps as well!

We learnt that we should talk on the same level as the child and not direct all communication through mum and dad. We should not give orders like “keep still while I stick this needle in your arm”, but instead, in a calmly modulated voice say “it is really important to keep still, as this might hurt a bit” Children appreciate honesty and are usually very smart, picking up very quickly on non verbal cues.

A patient’s dad came up with the brilliant idea of mocking up a ‘mini’ MRI machine complete with sound effects, which could give the child an impression of what was likely to happen when going in the real MRI. Brilliant, as we probably all find MRIs claustrophobic and incredibly noisy.

As a parent yourself, you may have your own suggestions, tips and observations, so please let us hear them! 

Can we all learn from Rachel? Yes indeed – by preparing our children for what is likely to happen at the doctors or in the hospital. Explaining why a test has to be done to make you better. Explaining about blood tests and needles and how we can make this a painless experience with creams applied on the arm beforehand. Let us make it all a bit of fun and bravery awards work as well.

Our A&E Departments usually, and rightly so, prioritise the care of children in child-friendly areas, but if it all does become a bit scary and the doctor is a bit rushed, there is always Rachel on hand to help, educate and console.

It might come as a big surprise that men also can undergo what has been referred to as a ‘male menopause,’ which is correctly termed Andropause – androgens being a name for hormones producing general virility. It is also known as Late Onset Hypogonadism (LOH).

As with the menopause, it is an area where confusion reigns and few opt for treatment.

How do we differentiate between normal male ageing and slowing down from a testosterone deficiency state? It is not easy!

The symptoms that might highlight a problem are legion, and include physical ones like loss of body hair, low energy, loss of height, increased sweating and shortness of breath. Others involve memory and mood changes coupled with a loss of concentration, hot flushes, changes in dress sense, and slower driving! The sexual symptoms include reduced libido and erectile dysfunction, which unsurprisingly are well known.

So, you have some of these symptoms, just take testosterone and all will be well! No, hang on a minute – the deficiency has to be confirmed by a blood test. An early morning fasting testosterone level is needed with a Sex Hormone Binding Globulin (SHBG) to determine a true testosterone deficiency state. That is how much free testosterone you have circulating and doing its energising functions.

You will have spotted that some of the symptoms of Andropause are vague, just like the menopause; and other conditions masquerading as the Andropause, like depression, thyroid disorders, and anaemia and so on, all have to be considered. A good GP will be well aware of the steps to take to establish an accurate diagnosis. Indeed, middle age and older is definitely a good time to review your general health and get advice on aging well and retirement issues.

Should a true testosterone deficiency be diagnosed, contraindications to replacement have to be excluded as well, like prostate trouble, hypertension and heart failure.

Once treatment is considered, a discussion with your GP is needed to decide on a short trial of treatment and, if this helps, to look at long-term replacement. Thus, treatment is tailored to your response and preferences as to whether you want to take a tablet, a gel, or a patch applied to your abdomen, an injection every two weeks, or an implant that works for three months or so. 

Monitoring of treatment needs a regular blood pressure measurement, and yearly blood tests for prostate trouble, liver and anaemia tests. Most men would be advised to have these checks done regularly anyway, as I have suggested. 

Too much testosterone can cause problems that are well known, like aggression, sexual hyperactivity, male pattern hair loss and skin darkening. So, it is important to get the right balance. Treatment is very much centred on the patient’s response and expectations.

I have not tried to encourage a sudden rush of men to their doctors for a magic rejuvenation treatment at all, but clearly some men are suffering in silence and there is a route, and tests to be done, which can help enormously in restoring vigour in hormone-depleted men.  

As a population, us men are not good at attending doctors unless really pushed – it is not perceived as a manly activity for a hunter-gatherer!

The paradox of course is that in medical terms men are the weaker sex; we don’t live as long as our partners for multiple reasons, which is probably a cunning ploy by Mother Nature, as left to our own devices without a partner to look after us, we don’t do at all well!

So, real intelligent manly activity involves appreciating weakness and accepting medical help and advice. Good luck.