This week, we look at the medical management of aortic dissection. You can also read the almostadoctor article on aortic dissection here.

Dr Dilip Wickremasinghe is an Emergency Department Registrar in Canberra, Australia.

• You can follow him on youtube here.
• See all the previous Brief Reviews here.

The post Brief Reviews – Aortic Dissection appeared first on almostadoctor.

This week, we look at hypertensive emergencies. You can also read the almostadoctor article on hypertensive emergencies here.

Dr Dilip Wickremasinghe is an Emergency Department Registrar in Canberra Australia. You can follow him on youtube here.

The post Brief Reviews – Hypertensive Emergency Part I appeared first on almostadoctor.

If you like what you see, don’t forget to subscribe to Dilip’s channel on YouTube!

We kick off with an unusual presentation of chest pain – Sponataneous Coronary Artery Dissection, or SCAD.

The post Introducing: Brief reviews appeared first on almostadoctor.

Highlight the clues and answers to reveal them!

Clue	Really big clue	Answer
Day 0 – Example
Clue	Really big clue	Answer
You might prescribe this for AF [highlight above to reveal]	River – Ox – A Ban [highlight above to reveal]	Rivaroxaban! [highlight above to reveal]
Day 1 – May 16th
Clue	Really big clue	Answer
Hmm … that looks like tartan	I think that tartan belongs to Symba!	Simvastatin (“Symba’s Tartan”)
Day 2 – May 17th
Clue	Really big clue	Answer
Are those… Tetris socks?	Tetris + cycling	Tetracycline
Day 3 – May 18th
Clue	Really big clue	Answer
Just stay what you see!	Lamb … Otter … ???	Lamotrigine
Day 4 – May 19th
Clue	Really big clue	Answer
Dog … sea …	Cycling!	Doxycycline
Day 5 – May 20th
Clue	Really big clue	Answer
Microphone. On a shoe.	Or, as some might say, a mic on a sole	Miconazole
Day 6 – May 21st
Clue	Really big clue	Answer
A tenner…	… LOL!	Atenolol
Day 7 – May 22nd
Clue	Really big clue	Answer
Its tartan	Its nice tartan	Nystatin
Day 8 – May 23rd
Clue	Really big clue	Answer
Nap …	Rocks…	Naproxen
Day 9 – May 24th
Clue	Really big clue	Answer
Its a Katy Perry Doll	Hello, Perry doll!	Haloperidol
Day 10 – May 25th
Clue	Really big clue	Answer
Is that a bum mark?	…or … an ass print?	Aspirin
Day 11 – May 26th
Clue	Really big clue	Answer
Monty…	Luke…	Monteleukast
Day 12 – May 27th
Clue	Really big clue	Answer
Its a thigh…	With rocks in…	Thyroxine
Day 13 – May 28th
Clue	Really big clue	Answer
Not really liking it…	… one might call this a “faux lick”	Folic Acid
Day 14 – May 29th
Clue	Really big clue	Answer
Lever…	“Dope”…	Levodopa
Day 15 – May 30th
Clue	Really big clue	Answer
Can…	Des…	Candesartan
Day 16 – May 31st
Clue	Really big clue	Answer
Carbs…	Marzipan…	Carbamazepine
Day 17 – June 1st
Clue	Really big clue	Answer
Its Alan!	An Alan-Drone	Allendronate
Day 18 – June 2nd
Clue	Really big clue	Answer
Amy…	No fill line…	Aminophylline
Day 19 – June 3rd
Clue	Really big clue	Answer
Morph	E	Morphine!
Day 20 – June 4th
Clue	Really big clue	Answer
Amy (again)	She’s tripped…	Amitriptyline
Day 21 – June 5th
Clue	Really big clue	Answer
Its a cat…	o’mine	Ketamine

The post Drug Name Meme Pun Lockdown Fun! appeared first on almostadoctor.

He reports that he is not able to sleep due to the pain and has seemingly very limited ROM of his neck from the end of the bed.

He also reports night sweats, and has a very swollen, red left elbow. He tells you that he had a minor puncture wound to the left elbow 8 days ago from a rose thorn in the garden. He says that actually his elbow seems to be improving (“You should have seen it on Saturday!”), and so he hadn’t thought to trouble a doctor about it.

He is otherwise previously well, takes no regular medications, and works as an academic at the local university.

He says that he had vaccinations as a child (in the USA) and he “got a lot of needles” before a trip to India that was “probably more than 10 years ago”, but as far as he can remember he hasn’t had any vaccinations since then.

On examination:

• He is alert and oriented, GCS = 15.
• T = 36.2. HR 68. Sats 97%. BP 128/74.
• He has normal tone, power and reflexes in all 4 limbs. PEARL. No photophobia. Kernig and Brudzinski negative.
• On his left elbow there is what seems to be a large bursitis and cellulitis, but he has full ROM of the elbow and reports it is not painful and only minimally tender.
• There is no tenderness in his neck, and no palpable nodes or other masses.
• His active ROM of the neck is roughly <30 degrees in all directions. Passive ROM is slightly greater. He has good mouth opening but reports that it feels “tight”. He also comments that he has found it more difficult to swallow in the last 3-4 days – for solids only – and that it sometimes takes several attempts before he is able to get the food down.

[After some quick reading on UpToDate I performed]… The “spatula test”

Believed to be the most reliable clinical sign for tetanus (sensitivity 94%, specificity 100%). This ‘test’ involves touching the posterior pharyngeal wall with spatula (tongue depressor):

• Positive = involuntary contraction of the jaw (biting down)
• Negative = gag reflex

In our patient – the spatula test was ….. equivocal! No gag and no biting down on the spatula.

Impression at this point:

• Cellulitis and bursitis of the left elbow
• Neck stiffness and swallowing issues
  • ?Collection / lymphadenopathy in neck secondary to infection at elbow
  • ?Meningitis
  • ?Tetanus

Investigations and initial management

• FBC + CRP
• Tetanus serology (anti-tetanus toxoid)*
• CT neck
• Tetanus toxoid vaccination
• Tetanus Immunoglobulin (prophylactic dose)

I decided that given a suspicion of tetanus, and his unclear immunisation history, that I would give a dose of tetanus Ig in addition to vaccination. The prophylactic dose is 500 units (treatment dose 3000 to 6000 units).

*This is not a very useful test and is not recommended. Will only be positive in about 30% of clinically diagnosed cases. 

The results were as follows:

• Hb – 146
• WCC –  9.2
• Neut – 7.39
• Na – 140
• K – 4.1
• Ur – 6.4
• Cr – 100
• CRP – 70

CT Neck

• “No walled off collection or foreign body identified”

At this point, I felt I had effectively ruled out a lesion within the neck itself, and meningitis seemed unlikely given the presentation. I called the ID consultant on call and referred the patient as a “suspected tetanus”. The ID team came promptly – performed another spatula test – and then admitted the patient with ?Tetanus. He was taken for washout of his elbow under orthopaedics later that afternoon and received IV metronidazole and a cephalosporin.

He had a subsequent MRI brain and neck which were also unremarkable. His symptoms slowly improved and after an otherwise uneventful stay in hospital he was discharged after several days.

A bit about tetanus

Read the full Tetanus article here.

Summary

• Caused by tetanus toxin, produced by clostridium tetani
• 10% of cases are fatal
• The toxin is so potent, that it does not cause an immune reaction, and those whom have had tetanus are not usually immune to future infection
• Most cases are in previously unvaccinated individuals
• Most common in >65 age group
• Most dangerous in neonates

Infection

• Clostridium tetani is found in soil and animal faeces
• Penetrating wounds – i.e. puncture wounds (the above patient’s rose thorn) – are associated with higher risk
• It is often associated with co-infection with another organism – clostridium tetani typically needs dead / necrotic / ischaemic tissue to thrive
• Clostridium tetani bacteraemia and sepsis are rare
• Incubation period can be from 3-28 days – and depends on the site of infection – the toxin travels up to peripheral nerves to the brain – the longer the distance – the longer it takes to reach the brain. Infection sites on the head and neck have short incubation and on the limbs it can be weeks

Mechanism

• Affects motor neurons
• In the brainstem, it irreversibly binds at synapse to prevent release of neurotransmitters – particularly those involved with inhibition
• New synapses form but this process can take up to 8 weeks – as such duration of symptoms is typically 6-8 weeks

Presentation

• Prodrome: fever, malaise, headache
• Trismus
• Neck stiffness
• Dysphagia
• Risus sardonicus (grinding expression of facial muscles)
• Opisthotonus (arching of body with neck hyper-extension)
• Spasms – initially induced by movement/noise but later spontaneous
  • Muscle spasms can be so severe that they cause long bones to fracture
• Autonomic dysfuction (arrhythmias and BP fluctuations)
• Rigid board abdomen

Signs and symptoms can continue to progress for up two weeks after presentation, and can be variable, depending on the amount of toxin that reaches the CNS. Some studies have also suggested that the severity of symptoms is correlated to the previous level of vaccination – those with more up to date vaccination suffer less severe disease.

Symptoms can last for 4-8 weeks.

Death is due to respiratory arrest.

Management

Good quality published evidence for many of these interventions is lacking

• Clean and debride the wound
• Metronidazole (clears the bacteria but has no effect on toxin already produced)
  • If adequate wound debridement has not occurred, re-infection from spores in the wound can occur
  • IV 500mg TDS
  • Often a mixed infection is present – consider empirical antibiotic therapy for cellulitis +/- wound swabs for directed antimicrobial therapy
• Tetanus immunoglobulin IM/IV
  • 3000 – 6000 units recommended
  • This neutralises the unbound toxin, but has no effect on the toxin that has already bound to synapses
• Give a tetanus vaccine – e.g. DTaP
• Diazepam/magnesium- to control muscle spasms
  • High doses – typical doses might include diazepam IV 10-30mg Q1H, maximum daily dose of 500mg
  • Continuous infusion of midazolam may be considered
• In severe cases – neuromuscular blockade and I+V
  • May be required for 6-8 weeks!
  • Nutritional demands are often very high due to prolonged muscle contractions. PEG feeding plus TPN might be required
• Control the autonomic dysfunction
  • Magnesium sulphate, often in combination with beta-blocker (often an IV infusion of labetolol) and morphine have been used

The post Hey – I just met you, and this is crazy, but you’ve got Tetanus, so take this Ig appeared first on almostadoctor.

*COMPETITION HAS ENDED*

Thanks to everyone who entered, this competition has now ended.

Congratulations to the app competition winners: Buhle Mbeje (via twitter) and Nimai Vadgama and April Mckay via Facebook.

I’ll be in touch via messages on Facebook and pm via twitter. For everyone else, sorry you missed out this time, and good luck with your studying.

*COMPETITION HAS ENDED*

Original post below.

– – – – – – – – – – – – – – – – – – – – – – – – – – – – –

1. Like or retweet the competition post
2. Tell us why you use almostadoctor and tag a friend in the comments
3. Like or follow the almostadoctor social media account where you are entering (if you don’t already)

The post Win a free copy of the almostadoctor app! appeared first on almostadoctor.

Ta daa!

As promised –  almostadoctor is now available on android, for phones and tablets.

The app has all of the same features as the iOS version. All the almostadoctor encyclopaedia articles saved to you device – for instant access, even without a connection. There’s no loading times, and no ads. And it keeps all the articles up to date by regularly synchronising with the almostadoctor server. The flashcards are included too, but these will require a live connection to download on demand.

For a full rundown of all the features – head over to the almostadoctor apps page, or to the Google Play Store.

The post almostadoctor now available on android! appeared first on almostadoctor.

An opinion piece by almostadoctor author, GP Registrar and Emergency doctor – Dr Tom Leach. For information about novel coronavirus (COVID-19) see the almostadoctor coronavirus encyclopaedia article.

I am worried

I am worried about coronavirus.

I am not a statistician, or an epidemiologist, nor am I involved in any public health planning or even hospital level planning for dealing with the coronavirus outbreak. I am just a regular front-line doctor, with an interest in the issues surrounding coronavirus. Many of my colleagues in the hospital, some of whom are involved in such planning decisions are having the same thoughts as I am.

We are worried. 

Not clutching-hoards-of-toilet-roll-whilst-wearing-PPE-in-the-street kind of worried. But I’m concerned enough to warn all my patients to be diligent about basic hygiene measures, and if they are elderly or have comorbidites that they should be planning to isolate themselves.

I am also not overly worried about my own health. I am a relatively fit and well 30-something, with no serious health issues. I’m likely to catch it – and possibly early on in the outbreak – just due to the nature of my work. But I suspect I’ll have an illness somewhere between a bad flu and a mild cold – like the vast majority of cases, especially in young adults.

What really worries me is how health services around the world will cope if (more likely – when) the disease becomes widespread. The point is perfectly illustrated by this tweet from Tim Steller:

If you want to understand more about how social distancing can help to slow the spread of an outbreak, take a look at this interactive simulator from The Washington Post. 

Why I am worried

The UK government estimates that the outbreak will infect between 20-80% of the population, and that 50% of cases will occur within a 3-week window, with 95% of cases occurring in a 9-week period.

We also know that typically 80% of cases are mild and can be managed at home, whilst 20% require hospital admission, including about 5% of the total number of cases requiring ICU and ventilation. The typical ventilator requirement for a COVID-19 patient is 2-3 weeks. 

• Some reports from Italy place the ventilator requirement as high as 10% of patients

If it really turns out like that, then the scale on the graph above might look quite conservative. Even looking at the low end of that estimate, that would mean 13 million cases in the UK, with over 2 million hospital admissions and over 500,000 ICU admissions. We just don’t have anything like the capacity required for that numbers of patients. There are about 4,000 ICU beds in England, and about 2,000 in Australia. 

In Italy, already, even though they have “only” about 20,000 confirmed cases, tough decisions have had to made about who is treated, due to some services reaching capacity. Age-restrictions were placed on access to ventilators – to give those with the best chance of survival the best access to treatment. Patients over-65 have been excluded from ICU on the basis of age.

What are we going to do, when the next seriously unwell patient comes along and there is physically not another ventilator to use for them? How about when there are 200 such patients in your emergency department, and no beds to put them in? And another 500 people in the waiting room, who can’t even get into the emergency department. A lot of people are probably going to die, whom might otherwise survive if we had the resources. 

Some governments have suggested novel approaches – like putting 2 patients on a single ventilator, or re-using typically disposable supplies – such as ventilator tubing. 

The numbers

Let’s use a fictional example to look at the numbers. 

Sarshampton is a medium sized city in a Western nation. It has a population of about 300,000. It has two main hospitals, which take about 55,000 admissions each year, and between them, they have 50 ICU beds. 

Normally the hospitals run at about 90% capacity, and in winter, extra wards are opened to cope with winter-pressures. 

Let’s imagine that 30% (the low end of the estimate) of the population are infected with coronavirus over a 9-week period. That’s 100,000 people. 5-10% of these might need ventilation. Let’s be conservative – and say 5,000 patients. Each of them could be in ICU for 2-3 weeks. Let’s be ambitious again, and say that on average this is just 2 weeks, and to make the maths more simple, we’ll stretch out our 9-week outbreak to 10-weeks. 

• 5,000 patients require ventilation for 2 weeks each, over a 10 week period
• An average of 1,000 patients will have clinical need for ventilation at any given time during the outbreak
• Sarshampton has 50 ventilated ICU beds. Remember – about 40-45 of these already have ventilated patients who are sick from other diseases. So, Sarshampton has capacity for about 10 ventilated COVID-19 patients
• This is a scenario at the lower end of the predicted scale of the outbreak
• This is why I am worried

What can be done about it?

The approach taken by most nations is that of social distancing to spread the outbreak over a longer period. 

Going back to our healthcare system capacity graph above (doesn’t that scale look a bit off now?) – the total number of cases would still be the same – in Sarshampton – 5,000 patients requiring ventilation. But let’s imagine we manage to spread it out over say 6 months – 24 weeks. 

This means that ‘only’ about 420 patients would require ventilation at any given time during the course of the outbreak.

What else can we do?

We could close almost all of our operating theatres for all but the most urgent operations. We can then use their ventilators. Maybe that gives us an extra 50 ventilators. Because non-urgent surgery has been cancelled, we might also have fewer ventilated patients in ICU following their surgery. Maybe this gives us an extra 10 ventilators. So, maybe Sarshampton now has capacity to ventilate 70 COVID-patients at any given time

We could try running two patients to every ventilator – I’m not even sure how this would work but it could be possible.

Now we have capacity to ventilate about 140 patients at any given time. Perhaps we can use spare ventilators – Sarshampton has about 10 old ones in a storeroom. Maybe the local ambulance service has some spares too. Maybe we can get another 30 ventilators together. We can ventilate 200 patients at once. Still less than half. And remember – this is if only 30% of the population catch the virus. 

BBC news reports today that UK manufacturers are being urged to switch manufacturing to assist the coronavirus pandemic – including for example by producing more ventilators. The longer we can stretch out the outbreak, the more helpful measures like this will be.

And we need the doctors and nursing staff to care for these ventilated patients. Its a pretty specialist role. And probably >30% of our medical staff in Sarshampton are off work with COVID-19 during the course of the outbreak. 

Now what? This is where we have start rationing. But who decides? And on what criteria?

Conclusion

The peak is coming. It will be somewhere between 20-80% of the population. The longer we manage to spread it out, the more lives will be saved. Business should be urged to assist in fighting the pandemic. Social isolation restrictions are likely to be in place for months – the longer it goes on the better for our health (but the worse for our economy).

It is encouraging  as as an Australian resident to see Australia taking more-drastic social isolation measures than many European countries have done at the same point in the time line. But even these are not likely to be severe enough to slow the spread far enough to prevent health care systems reaching capacity. 

Recommended Coronavirus (COIVD-19) resources

• Worldometer – a great source of statistics. Scary exponentially growing graphs of cases
• Number of coronavirus (COVID-19) cases and risk in the UK – gov.uk
• CDC (USA) – Coronavirus (COVID-19)
• Health.gov.au – Coronavirus resources

The post Should I be worried about Coronavirus? appeared first on almostadoctor.

The app has all of the almostadoctor encyclopaedia articles saved to you device – for instant access, even without a connection. There’s no loading times, and no ads. And it keeps all the articles up to date by regularly synchronising with the almostadoctor server. The flashcards are included too, but these will require a live connection to download on demand.

For a full rundown of all the features – head over to the almostadoctor apps page, or to the app store.

Android users have got their own version of the app with all the same features too!

The post almostadoctor iPhone and iPad apps out now! appeared first on almostadoctor.

Have you ever burped?

My entire life I have never been able to burp. I can count on one hand the number of times that gas has spontaneously escaped upwards from my oesophagus, and all of these times have been whilst I was laughing heartily.

“What do you mean you can’t burp?”, often accompanied by a smirk, or outright laughter when I reveal my secret to others. “Just drink a some coke / lemonade / dandelion and burdock” (my favourite suggestion, followed by a gift of the stuff from a work colleague).

But it never works. It just makes it worse. The more air goes in, the more air gets trapped.

I never thought it was too much of an issue until I started drinking beer in my teenage years. One teenage birthday my friends and I ‘borrowed’ a crate of beer from a friend’s Dad, and along with a delicious cake we camped in the woods. Great times. Except that later into the evening it felt like a giant balloon had been inflated in my oesophagus and it hurt to swallow and eat for days.

The same thing happened every time I drank beer. When I was about 19, I drunkenly discovered that I could stick my fingers down my throat to initiate my gag reflex and “vomit air”. Oh the relief! During a night out this became part of my routine. After about the third beer I would disappear off to the bathroom, and produce noises that once prompted a friend to run to my aid as he thought he had heard “moving furniture dragging along the floor”. I would feel much better, and the nights festivities could continue.

Now, in my more mature years I am effectively a non-drinker, but certain activities and foods will still cause problems. My favourite activity, cycling, is a particular culprit. After riding a bike for a few hours hours, with all the associated heavy breathing, swallowing, and eating and drinking in the saddle, I soon end up with (I imagine) litres of air inside me, incapacitating chest pain, and an abdomen that might pass for at least 6 months gestation.

It all comes out eventually of course. I am a legendary farter.

The Symptoms

Symptoms occur daily. Usually in the morning I feel great – after a long night of flatulence – and my apparent pregnancy resolves every night. But as soon as I eat or drink the problems begin.

Symptoms vary from comical gurgling noises in the neck, through to gastroesophageal reflux, chest and abdominal pain and marked abdominal bloating. Drinking anything carbonated (especially beer) is a decidedly unpleasant experience, and after most meals I feel a sensation of fullness that it seems others do not.

“It’s not a thing”

I first consulted my GP about the problem aged 21. “That’s not a thing I’ve heard of” I was told. I was instead diagnosed with reflux. PPIs made no discernible difference. I had a scope but it was normal. I commented about my inability to burp to the gastroenterologist but it wasn’t a symptom that registered much interest or interpretation.

I pondered if it was all in my head. I gave up drinking, and made several other lifestyle modifications with limited success. Life went on. But I became more and more convinced that my symptoms were really due to trapped air.

I looked through the literature, but all I could find was a single case study from 1987, and certainly no cure.

• This case study provides some useful insight into the possible pathophysiology of the condition. The patient in this study underwent oesophageal manometry, and it was noted there was a seemingly endless cycle of an air bubble being released by the stomach, travelling up the oesophagus, and then reaching the upper oesophageal sphincter (the cricopharyngeal muscle) which – under normal circumstances relaxes under the presence of air in the oesophagus – but which in this condition stays firmly closed. The air bubble would then be pushed back down the oesophagus with normal peristalsis. Upon the air bolus arriving at the stomach, the cycle would repeat.
• As a sufferer I can attest that this is exactly how it feels – like a big bubble of air in constantly moving up and down the oesophagus and trying (but failing) to get out
• Much higher pressures were noted within the cricopharyngeus muscle – confirming its inability to relax under the normal stimulus.
• Patients with R-CPD have also been noted to have a “saggy” or “baggy” dilated oesophagus on scope – presumably due to years of over-distension.

In my mid-twenties I took up cycling, and I started Emergency Medicine training. And this is where it seemed to become more of a problem. Now symptoms were severe every day. Over the course of about 2 years, I lost 10kgs (from an already Marfanoid body habitus) and my BMI was 19. I just didn’t want to eat because the symptoms afterwards were too unpleasant. One day a consultant at work pulled me to one side to check I was OK. I blurted out that I had such incapacitating GI symptoms, presumably exacerbated by my shift and eating patterns, and that reflux treatment had not made any difference. On the spot my colleague referred me to a gastroenterologist.

I had another scope, and oesophageal pH study. And then they referred me to another gastroenterologist. But still nobody had an answer.

In the end, I gave up shift work to be able to better control my diet. It worked – mostly – but the cycling was still a problem. I had to give up career aspirations for Emergency Medicine too but my old hospital were understanding and I continue there as non-trainee working day shifts part time, around my GP training.

Occasionally reports would pop-up in the popular press about others with the condition. Around this time I came across a reddit group – r/NoBurp (tagline “The Struggle is Real”) – and things started to pick up pace. Here there were hundreds, indeed perhaps even thousands of fellow sufferers!

There was certainly a pattern of symptoms, but the disability seemed variable, from minor annoyance to intermittently totally incapacitating.

It seemed it “was a thing” after all. Some of those in the group were seeing an ENT surgeon in the US who was performing Botox procedures to anecdotally good effect. I even called him up and spoke to him and had a quote for the procedure. But I didn’t fancy flying half way around the world for a possibly psychosomatic disorder.

Others in the reddit group, usually through laborious trial and error had managed to “teach” themselves to burp – typically with a routine of neck-strengthening exercises, neck massage, aspiration-inducing swallowing exercises and in several cases physically punching themselves in the neck!

It is a thing

Finally, in early 2019 the ENT surgeon in the US – Dr Robert Bastian – published his paper about the condition and gave it a name – retrograde cricopharyngeal dysfunction or R-CPD for short. Now I felt I had the proof I needed to find a fellow medical professional who also thought “it was a thing”. I called and emailed some local ENT surgeons. Only one provided any useful insight. He hadn’t heard of it and didn’t seem to think it was a proper thing and spent a lot of time talking to me about the treatment of reflux. But, he did know a neurologist 300 miles away who did cricoypharyngeal Botox injections. So off I went to my GP, printed copy of the R-CPD study in hand, and was duly referred to see the neurologist. He agreed that it might be a thing and I might have it, and after some more investigations (including a CT of my chest due to my “Marfanoid body habitus” which led to a fruitless wild goose chase for a dilated aortic root – phew!) he finally went ahead with the Botox.

But he was cautious. It was a low dose – only 10 units (compared to 50 units used in the published study), he used a transcutaneous approach which doesn’t require anaesthetic, but it is also less accurate – and it didn’t work. However (and if you’re still with me at this point, I’ll buy you a celebratory carbonated beverage) during the course of investigations I had been referred to another ENT surgeon, and they really did think it was a thing. They had even discussed R-CPD with colleagues at a conference!

I was booked in for the procedure. It typically requires a general anaesthetic, and despite having administered hundreds of these in my career I was still nervous. But it went ahead without a hitch. The procedure took about 30 minutes. The following morning at about 5am I was loudly awakened and startled by my own burps! Over the next few days huge uncontrollable releases of air came from my oesophagus. Oh the relief! I was a proud member of the burping human race.

But it was still far too early to tell if I was cured – the Botox can wear off after a few months, but it seems that most patients are able to “learn” how to burp and retain the ability indefinitely, even once the Botox is long gone.

Unfortunately for me, it wore off. It worked really well for about a month, with then gradually decreasing effects for the following 6 weeks or so. My final burp was about 10 weeks after my procedure. I felt so good, and was able to eat and drink anything I liked, and cycle to my heart’s content without worrying about chest pain or reflux. I was very keen for a repeat procedure.

So, after a delay due to the coronavirus outbreak, I had a second procedure – 8 months after the first. This time a larger dose of Botox was used. The effects were even more pronounced that the first. I had more control, and I didn’t have to “push” so hard.
Now – 4 months later the Botox has likely worn off, but the effects don’t show any signs of reducing – and I am starting to consider that I might be permanently cured. There is one minor drawback however – my wife for some reason does not seem as thrilled as I am with all this burping!

I now feel it is my duty to spread the word – particularly amongst the medical profession, so that fellow sufferers will no longer have to wait years, or be laughed at, casually dismissed or otherwise demeaned for their symptoms.

Lessons (tl;dr)

I think there are at least three things that can be learnt from this whole experience:

• The inability to burp, seemingly caused by R-CPD is really “a thing”. It can vary from a minor inconvenience to a serious disability, and any patient with symptoms suggestive of the disorder should be referred to a sympathetic ENT surgeon (a list of which is kindly crowd-sourced in the /NoBurp group). I suspect that in a few years this list will have grown exponentially. Although officially described as “rare” or “unknown incidence” – I know of at least 6 others in my social circle, and I suspect it is quite common, although minor for most.
• This condition seems to have been effectively “crowdfunded” by the r/noburp reddit group. Without a powerful patient lobby of thousands of patients sharing their experiences, I doubt any ENT surgeon would have been able to collect enough patients for a study, and it may have remained “undescribed” indefinitely. I wonder how many other undiscovered disorders whose symptoms we label as unimportant or psychosomatic remain to be discovered. I have certainly been made to feel by friends and colleagues alike that it is “all in my head”. What is potentially quite exciting about this disorder is that (total conjecture from me here) I believe it may explain a proportion of cases of IBS
• When doctors hear symptoms that don’t seem to fit, or don’t make sense, it is important for us not to be dismissive

What strikes me when reading others’ experience of r/NoBurp, is how badly the medical profession has been reflected. It is an extremely common experience to be told that it is “not a real thing”, or “it doesn’t exist” or even “it’s probably psychosomatic”.

These kind of attitudes are damaging to the individual doctor-patient relationship, and to the profession as a whole. I appreciate the complexities of teasing out unusual biological symptoms from those of a psychological origin. I deliberately refrain from using the word “real” symptoms, because I believe that psychosomatic symptoms are just as “real” to the patient, they just have a different origin.

I think that most of the time, these responses are meant with the best intentions. A misjudged attempt to reassure that patient. “Don’t worry about this, it can’t be important because I’ve never heard of it [and neither have any of my colleagues].”

But, we must strive to find the path of understanding that leads to validation of the patient’s symptoms and appropriate investigation. It’s true that most of the time that the doctor hasn’t heard of the particular combination of symptoms, it probably “isn’t a real thing”, but that doesn’t mean that it’s not important to the patient or their long-term health. Just having someone say they don’t know what it is, but they will look for something serious and try to find someone who might know what it is, would go a long way to relieving diagnostic anxiety and building rapport.

I have written an almostadoctor encyclopaedia article about R-CPD if you would like to know a bit more about its clinical features, diagnosis and treatment.

My enormous gratitude to Dr Robert Bastian MD for his quite literally pioneering work in this field. I would also like to mention Mr Yakubu Kagama, an ENT surgeon in the UK, who has been mentioned in the popular press and widely on r/noburp as performing the Botox procedure in the UK.

Huge thanks also go to my surgeon in Sydney (Australia) – whose details are available upon request for any patients locally wishing to seek treatment.

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tl;dr – reddit speak for “Too long, Didn’t read” usually interpreted as “Summary”.

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