Further Confessions of a GP

Funny X-ray

It was another chaotic morning in A&E and my first patient was being wheeled into the department on a specially reinforced trolley. Like other 999 services, our local paramedics had invested in some reinforced equipment in order to cater for the ever-increasing size and weight of the local population. The woman being wheeled in was huge, and we needed to transfer her from the special strong-and-wide trolley to a strong-and-wide hospital bed.

The paramedics told me that the woman had collapsed at home, and by the exhausted looks on their faces I could imagine it had been quite an effort to get her up off the floor. How they managed it I don’t know, but they certainly deserved the cup of tea that was waiting for them in the staff room. There wasn’t much more the paramedic crew could tell me about their patient, so I tried to ask her a few questions. Unfortunately she was confused and drowsy and only mumbled a few nonsensical remarks, so I soon gave up.

There are numerous reasons why a patient might be admitted confused and if there is no background history to help point us in the right direction, the obvious next step is to examine the patient. Sometimes examination findings alone can give us all the clues we need, but when a patient is as large as the lady in front of me was, most of the clues potentially gained from the physical examination are hidden under layers of fat. I tried to listen to her lungs, but as I endeavoured to find somewhere on her back to lay my stethoscope, I was met with so many rolls of fat that it was tricky to find a flat surface on which to place it. I tried in vain to listen to lung sounds, but the lungs were separated from my stethoscope by so many inches of fatty tissue that the sound couldn’t be transmitted and I heard nothing. Examining the abdomen was no easier. As I pressed my hand on to her tummy, I knew that there was no way that I would be able to glean any useful information about the organs buried deep below. I could just about feel a pulse in her wrist and so I knew she had a heartbeat but unfortunately, again, I couldn’t hear it. The ECG machine, blood pressure monitor and oxygen probe were struggling as much as I was, and after 10 minutes I realised that I was absolutely none the wiser as to why this lady was unwell.

Thank goodness for the humble chest X-ray. X-rays show the air in the lungs as black and the bones as white. Fat, even a thick layer of it, can be seen through if the clever radiographer cranks up the exposure of the film. I was depending on the chest X-ray to show me a reasonable picture of her lungs to help work out what might be going on. The portable chest X-ray was done and the picture soon showed up on the computer monitor. To my relief, the image was reasonably clear and I could see the white fuzzing of infection in the lower part of her right lung that was probably causing her problems. Oddly though, the infection wasn’t the only thing that I could see. There was some sort of electrical device implanted on the left side of her chest wall. I was used to seeing pacemakers on a chest X-ray film. These are implanted under the skin on the chest; the wires from them travel to the heart and give off electrical pulses to help prevent it beating too slowly. This didn’t look like a pacemaker though, because I couldn’t see any wires travelling from the machine to the heart.

I called over one of the other doctors to have a look and soon there was a small collection of us crowding round the monitor trying to work out what the device was. I thought it might be an implantable defibrillator but one of the other doctors pointed out that these have visible wires too. The cardiology registrar, who was also staring in confusion, had heard about a wireless pacemaker being developed in America and wondered if this was a version. As the number of doctors surrounding the monitor grew, the debate on the identity of the mystery device intensified. During a rare moment of quiet, a voice from the back of the crowd piped up, ‘It looks like a Nokia 1101.’

Everyone turned round to look at the baby-faced medical student at the back.

‘Nokia don’t make pacemakers,’ the cardiologist snapped impatiently before returning to his debate with the emergency medicine consultant.

‘No, the Nokia 1101 is a mobile phone. I used to have one and it looks identical.’

There was a moment of silence before the cardiologist continued to shout down the student for even considering that a mobile phone could be implanted inside her chest. I went back to see the patient. With a bit of help from one of the nurses I leaned her forward and pulled apart a large roll of fat on the left side of her back. I pushed my hand in and felt what I was searching for. The Nokia 1101 needed a bit of a tug, but it soon came free and I returned to the collection of doctors around the monitor to show them my catch. The medical student quite rightly enjoyed his moment of triumph while the cardiologist left quietly, shoulders slumped.