Tourniquet. Cleany wipe. Safety needle. Blood bottles. Cotton wool. Tape. Gloves.

I wander over to the lady lying in the bed at the end of the ward, curled up in the sheets as if hiding from the world. I introduce myself, explain that I need to take some blood, and wash my hands. My fifth set of bloods that morning – the doctor I was shadowing had already thanked me multiple times for helping with the jobs. I was glad I could contribute after so many years of studying and shadowing, and taking blood was something I’d improved at a lot over the last year or so.

“She’s very difficult to bleed – I can help hold her arm if you like, she flinches a lot, ” the student nurse kindly offered. I gratefully accepted and we walked back to the bedside.

I found a vein, easy as anything, and slid the needle in. The lady flinched but the needle stayed true and felt that flicker of joy as the blood slowly wormed its way along the tube to the first blood bottle.

“You’re the first to manage that!” said the nurse, holding firmly onto the patient’s arm.

“Ah…you can’t jinx it!”

In a beautiful twist of defiance the blood screeched to a halt, tantalisingly close to the bottle. I pulled the needle back a little in an attempt to free up the flow but it wasn’t budging. I found my cotton wool and went to slide the needle out so I could try again, at which point the lady flinched, and my right hand swung just close enough to my left to let me feel the electric flick of the needle darting into my wrist, and out again, as if nothing.


That did not just happen.

I looked at my wrist as the ugly pearlescent globe of blood gradually ballooned out of the skin, confirming my mistake. At first I didn’t believe it. I couldn’t have. I’m so careful. I’ve done hundreds of these and never had a problem. Not me. I did all the online modules about safe venepuncture and got full marks. The needles are virtually idiot-proof, I’ve never been even close to sticking myself before.

But this time I did.

A surge of anger broiling with fear burst over me, sweat rolling down my back and my throat welling up. I wanted to scream. I hurriedly tidied up the equipment and left the nurse with the patient while I ran off to the nearest sink. The glove now had a film of blood smeared around its inner layer, as if mocking the futility of my situation.

Encourage the wound to bleed. 

I stood there for what seemed like an hour with my hand under the hot tap, watching the thin trail of blood run off my wrist into the sink. I imagined millions of viruses pouring down the drain, praying that somehow they’d all be flushed out of my system. My mind went blank.


Shit shit shit shit shit.

HIV, Hepatitis B and C, CMV, Epstein Barr… all the possibilities ran through my head. How likely is it that she has HIV? Do I remember seeing it in her notes? How likely is it to have transmitted to? I was wearing gloves, the wound bled straight away – that’s good – shit shit shit.

I’d done everything right. That’s what hurt the most. I’d done nothing wrong, it was just an unfortunate coincidence that she happened to flinch right when my hands were nearest each other. A second later, or earlier, and there would have been no problem. The needle was still in her skin, for christ’s sake, what were the chances!?


I spent the rest of the afternoon in a daze as I plodded off to occupational health to be told just exactly how likely it is that I’ve given myself some nasty virus, before heading back to explain to my seniors. She was what is referred to as a ‘very low risk’ patient, with no history of blood borne viruses. One thing that was reassuring was the way everyone reacted – as if I’d got a parking ticket – it was one of those annoyances that happens more often than it should. There wasn’t the outright panic that I expected for some reason, and most people were even sympathetic! I gradually came round to the idea that I was actually incredibly lucky. I’ve taken blood many times from people with very nasty viruses that would have almost certainly have transmitted had I stuck myself when taking their blood, yet it was this time, on this patient, that it happened. It could have been so much worse. I also got a free Hepatitis B booster that I was overdue for anyway, and the lovely OH nurse demonstrated (on me) how to do it properly, as she took my blood for testing if needed later.

One day, three needles, and I was on the wrong end of all of them.

As I got home I put my bag down and shuffled in to the kitchen in search of food, bewildered and flustered by the day’s events. I promptly stubbed my toe on the fridge door and then burned my thumb on the frying pan.

I sighed.

Let’s try again tomorrow…

Poop demons

Babies scare me, if I’m honest. There’s no way 10 billion neurons could genuinely be that cute and uncoordinated. I feel they’re hiding something. Kinda like how Jar Jar turns out to be a Sith Lord #spoileralert

However despite a wary respect for these tiny poop-demons (herein referred to as PD), as a medical student and doctor, people will shove their PD in front of you and ask whether it’s normal, and you’re expected to say something a little more informed than ‘ew no’.

literally every baby ever

Developmental milestones are something I found really tricky to learn, and so I wanted to devise a way of making the information more memorable. There are a lot of milestones and average ages of accomplishment, as well as ‘limit ages’, at which you’d start to pay attention if the child hasn’t started doing them yet. I reckon it’s not massively useful to learn each in isolation, since in reality you’re going to have to determine whether said PD is performing adequately in all departments. What I figured is most useful is to have a few ‘model babies’ at a few key ages, to keep in mind, and see if the kid in front of you is more or less skilful than the model. The best way to do this is to actually see real babies – I know, terrifying – to use as your comparison points. However if you don’t want to/are too scared/don’t like going outside, then the following descriptions might help anchor them in your mind a little better.

The story of the psychopath poop demons and their quest for world domination

Poop demon #1

PD1 is pretty useless to be honest. At a solid 6 weeks, he hasn’t exactly put much effort into doing much other than eating, pooping and screaming. He can’t do many evil things yet, so he spends his time trying to inconvenience you, and unsettle you with inappropriate eye contact.

  • He holds his head up – important for holding eye contact while pooping – it shows dominance
  • He follows objects visually – so he can continue to maintain this eye contact while you back away in fear
  • He smiles – to demonstrate his enjoyment of this socially awkward interaction

Please see this terrible video to get an idea of what I mean

Poop demon #2

PD2 is considerably more accomplished than baby number 1. At 6 months, he’s had some real experiences in life, and is now able to:

  • Sit upright, although a little slumped over – for vertical pooping
  • Grab things – to begin destroying the things you love
  • Put food in mouth – to fuel the pooping habit
  • Coo and babble – communicating to his overlord in demon-speak

Poop demon #3

PD3 has developed several new skills at the ripe old age of 12 months, including some murderous tendencies. This little horror story is what made her famous:

Baby number 3 unsteadily walks into the room, occasionally using pieces of furniture to keep her balance. In her pincer-like hands she’s gripping her trident, which she’s transferring from hand to hand while laughing like a maniac. She mutters a few words, but these are not the usual ‘mama’ and ‘dada’ that you’re used to hearing, these words sound evil…

She takes a menacing sip from her infamous sippy cup, and waves bye-bye before sending you to your doom.

These 12 month olds are infiltrating our society, ready to pounce. Do not trust them

Poop demon #4

PD4 is now 18 months old. He has grown out of his petty murdering phase and is now intent on world domination. He is massively aided by his ability to walk more steadily, and he has mastered the concept of making seemingly incoherent marks on a piece of paper with a crayon (actually demon writing). He can say a few more of your pitiful human words, and humours you by pointing at his nose when you ask him to, but ever since he gained the ability to feed himself with a spoon his need for power has become worryingly apparent, and he’s begun prepping his teddies for revolution.

Another laughably terrible video

The final Poop demon #5

At 2-3 years of age our PD is on the verge of taking over. However she’s realised she cannot do it alone, so she has begun collaborating with her fellow PDs, taking turns to act out their diabolical plans with dolls and bricks. Now that she can control when she poops during the day, she has much more time in the day for evil-doings, and is able to give commands using a few simple phrases. (usually ‘kneel to your overlord’). She’s been building towers out of six blocks and gleefully watching it crash to the ground.

Here is one of her evil co-conspirators in an elaborate distraction exercise, while she steals cookies from the cupboard:

Remember – they’re not as innocent as they look.

The milestones can be broken down into four main categories:

  1. Gross Motor
  2. Fine motor and Coordination
  3. Language and Verbal
  4. Socialising and Behaviour

Simple enough.

The tricky bit is remembering the average ages at which each bit of the development is achieved:

Gross motor:

  • newborn – limbs flexed, lying supine, with marked head lag on pulling up
  • 6-8 weeks – can lift head to 45 degrees when prone
  • 6-8 months – sits without support (6m rounded back, 8m straight back)
  • 8-9 months – crawling
  • 10 months – cruising around furniture
  • 12 months – walks unsteadily with a broad gait
  • 15 months – walks steadily

Fine motor and coordination:

  • 6 weeks – turns head to follow moving object
  • 4 months – reaches for toys
  • 4-6 months – palmar grasp
  • 7 months – transfers toys from one hand to another
  • 10 months – mature pincer grip
  • 16-18 months – makes marks on paper with pen/crayon
  • 14m – 4 years – Building towers
    • 18 months – 3 blocks
    • 2 years – 6 blocks
    • 2.5 years – 8 blocks/makes a train shape
    • 3 years – copies bridge
    • 4 years – copies stairs
  • 2-5 years – drawing (6m earlier if allowed to copy)
    • 2 years – line
    • 3 years – circle
    • 3.5 years – cross
    • 4 years – square
    • 5 years – triangle

Language and Verbal:

  • newborn – startles to loud noises
  • 3-4 months – coos and laughs
  • 7 months – turns to soft sounds
  • 7-10 months – first words/sounds to indicate parents
  • 12 months – 2-3 words other than mama/dada
  • 18 months – 6-10 words, can demonstrate 2 body parts
  • 20-24 months – simple phrases
  • 2.5-3 years – consistent 3-4 word sentences

Socialising and Behaviour:

  • 6 weeks – smiles responsively
  • 6-8 months – puts food in mouth
  • 10-12 months – waves bye-bye, plays peek-a-boo
  • 12 months – drinks from cup with two hands
  • 18 months – holds spoon and gets food safely to mouth
  • 18-24 months – mimics feeding pets/symbolic play
  • 2 years – dry by day, pulls off some clothing
  • 2.5-3 years – plays with others, takes turns

Then we have the so-called ‘limit ages’, when children should have achieved the given milestone:

Gross motor:

  • Head control – 4 months
  • Sits unsupported – 9 months
  • Stands independently – 12 months
  • Walks independently – 18 months

Fine motor and coordination:

  • Fixes and follows visually – 3 months
  • Reaches for objects – 6 months
  • Transfers – 9 months
  • Pincer grip – 12 months

Language and verbal:

  • Babbles – 7 months
  • Consonants babble – 10 months
  • 6 words with meaning – 18 months
  • Joins words – 2 years
  • 3-word sentences – 2.5 years

Social behaviour:

  • Smiles – 8 weeks
  • Fear of strangers – 10 months
  • Feeds self – 18 months
  • Symbolic play – 2-2.5 years
  • Interactive play – 3-3.5 years

Well done on getting this far, you’ve earned this


Meningitis is a significant medical emergency and it’s important that you can spot it rapidly, as the mortality associated with bacterial meningitis is already 20% in those that receive adequate treatment, so delay is only going to make it worse.

The key signs are widely known:

  • Fever
  • Headache
  • Neck Stiffness
  • Photophobia
  • Altered consciousness
  • Non-blanching purpura

Here I’ll run through the differentials to consider, the likely organisms and first line treatments, as well as what to look for when interpreting a lumbar puncture of a patient with suspected meningitis.

Immediate actions

If a patient comes in with a fever and altered mental status, you should be thinking about bacterial meningitis as your biggest concern. So use the sepsis six

Give three

  • oxygen
  • fluids
  • antibiotics
    • IV ceftriaxone – broad spectrum against gram + and –
    • Ampicillin – Listeria
    • Vancomycin – Cephalosporin-resistant streptococci

Take three

  • blood culture
  • lactate
  • urine output

However your diagnosis is only confirmed after you have received the blood cultures back from the lab, so what should you do in the meantime?

Your differential for altered mental status and fever include:

  • Bacterial meningitis
  • Viral meningitis
  • Viral encephalitis (usually HSV)
  • Toxoplasmosis and cysticercosis (usually in IV drug users and endocarditis)
  • Brain abscess
  • Subarachnoid haemorrhage
  • Ruptured aneurysm 

The things to check first are the things that are going to kill your patient within minutes, before you can get any imaging or lab results back:

  • oxgen
  • ischaemia

So check their sats, give oxygen as part of your sepsis six and order an ECG.

The next thing to worry about is blood glucose – a very common cause of altered mental status, so do a glucose test.

Next, you’re thinking about slightly longer term processes, such as intracranial haemorrhage, that will kill your patient, but you need to confirm before you manage them. So you can send your patient for a head CT, which should show you any evidence of haemorrhage.

If this comes back clean, then your suspicions of meningitis or encephalitis start to rise, so you do a lumbar puncture… but what do the results mean!?

Interpretting CSF results

The principles of CSF interpretation are fairly simple:

  • White Cell Count
    • Usually below 5 and increased in infection
    • More increased in bacterial than in viral infection (>500 suggests bacterial)
  • Cell differential
    • If you have a raised white count, the type can tell you bacterial vs viral
    • Bacterial tends to induce more polymorphonucleocytes
    • Viral will give a massive proliferation of lymphocytes
  • Red blood cells
    • Normally shouldn’t be any, usually some in infection
    • The key here is a huge red cell count in the presence of minimal white cell elevation is strongly suggestive of herpes encephalitis
    • you also want to consider subarachnoid haemorrhage and ruptured aneurysm, however you’d hope these were picked up on the CT
  • Protein
    • Generally elevated in infection
  • Glucose
    • bacteria eat up lots of glucose, so a low CSF glucose suggests bacteria are present
    • Viral infections usually have a normal glucose level
  • Opening pressure
    • Pressure increases in bacterial infection, and is usually normal in viral infection
  • Gram’s stain
    • 80% of the time in bacterial meningitis you will be able to visualise organisms in the CSF
    • Beware the 20%!

Most common causative organisms

Neonates – Group B streptococcus and Neisseria Meningitidis

Children and Adults – Streptococcus pneumoniae, Neisseria meningitidis, Listeria monocytogenes

And finally – prophylaxis

Anyone who comes in with bacterial meningitis could very well have passed it on to those around them. Close contacts should be given adequate prophylaxis in the form of:

  • Rifampicin 600mg (10mg/kg) every 12 hours for 4 doses
  • or
  • Ciprofloxacin 500mg in a single dose (only for adults)

Right iliac fossa mass

What on earth is that lump?

You have a young patient screaming in pain “my appendix!“, but her mother is much more worried that it might be cancer. You ask her why she thinks he has cancer, and she says

  • appendix mass
  • caecal carcinoma

“He’s had diarrhoea that floats!” to which you reply “Sounds more like Crohn’s…”

  • Crohn’s

You’re interrupted by the patient, who is now convinced her ovaries are exploding and her intestine is eating itself.

  • Ovarian mass
  • Intussusception

Do you think it could be her transplant?” asks the mother quietly – this surprises you so you look at the patient’s abdomen for scars, but instead you see a huge pulsating lump that looks like an aneurysm of some sort.

  • Pelvic kidney
  • Common iliac aneurysm

Have you had a fever?”  you ask? You’re thinking it could be an infection, either TB or an abscess.

  • Iliocaecal TB
  • Iliac lymphadenitis
  • Actinomycosis
  • Psoas abscess

The patient shakes her head, you then ask “can you push it back in?

  • Spigelian hernia

Both mother and daughter look at you like you’re an idiot, before daughter wets herself all over the bed. “What’s wrong with my bladder?” Which makes you think of her other bladder.

  • Gall bladder enlargement

The differential diagnosis for a right iliac fossa mass includes the following:

  • Appendix mass
  • Caecal carcinoma
  • Crohn’s disease
  • Ovarian mass
  • Intussusception
  • Pelvic kidney
  • Enlarged gall bladder
  • Iliocaecal TB
  • Iliac lymphadenitis
  • Psoas abscess
  • Retroperitoneal tumour
  • Actinomycosis
  • Common iliac artery aneurysm
  • Spigelian hernia

Clearly the likelihood of each is going to depend on the patient, the history, and the presentation. Caecal carcinoma is much more common in an elderly person than a teenager, while appendicitis is less likely if the patient has already had an appendicectomy…

VTE risk

Venous thromboembolism is a significant cause of potentially avoidable deaths in surgical patients. It’s important to spot who is at greater risk of clot formation long in advance to help prevent this happening.

Mrs Thrombus is an obese 61 year old lady having surgery for her cancer, currently in a bed on ITU.

  • Active cancer/cancer treatment
  • >60 years of age
  • obesity
  • critical care admission

She is wearing a red jumper with the letter C on it, because she is known to have a protein C deficiency thrombophilia, and she’s downing glass after glass of water because she feels terribly thirsty.

  • known thrombophilia
  • dehydration

Mrs Thrombus has in front of her a mountain of pills for her various ailments, including HRT and an oral contraceptive pill as well.

  • significant medical comorbities
  • HRT
  • contraceptive pill

She downs all her pills and gets up to go to the toilet, when you notice her legs are covered in varicose veins. When you ask her about them, she says they are very sore and run in her family.

  • varicose veins with phlebitis
  • family history 


The Story

Here’s a story to help remember the key features of SLE:

Mrs Lupus is an African woman who has felt tired for as long as she can remember. She has also recently noticed a rash across her cheeks. She’s also had some joint pain and has noticed her skin reacts when she is exposed to bright sunlight. She also finds she gets mouth ulcers and her hair has fallen out in some places, leaving patches of baldness that are upsetting her.

  • Ethnicity risk 
  • Female gender risk
  • fatigue
  • malar rash
  • arthritis
  • photosensitivity
  • mouth ulcers
  • alopecia

She’s recently had a nasty bout of glandular fever, which she recons is because of her low white blood cells. It’s also made her feel very low in mood, and she’s had a pounding headache ever since it started.

  • trigger – viral infection
  • lymphopaenia/leucopaenia are early clues to SLE
  • neuropsychiatric manifestations

You ask her about her chest, and whether she has had any difficulty breathing or chest pain, to which she says she feels short of breath and has chest pain a lot of the time, which is made better by sitting forward. She also doesn’t like to go out in the cold, as it makes her fingers go blue

  • Pleurisy
  • Pericarditis
  • Raynaud’s phenomenon

Mrs Lupus is planning to have a baby, but wanted to ask you about the best course of action with regard to her treatment beforehand.

  • Pre-pregnancy counselling is vital to ensure optimal disease control


You decide she most likely has SLE, so what investigations are you going to do?

To diagnose and monitor her condition:

  • Full blood count
    • White cell count
  • Urinalysis
  • Serum Creatinine
  • ANA
  • Anti-extractable nuclear antigen
  • Anti-ribonucleoprotein = mixed connective tissue disease
  • Anti-dsDNA = useful for predicting those at risk of renal disease
  • Complement
    • C3 and C4 fall with disease activity

In women who are planning pregnancy, it is important to check for:

  • anti-Ro
  • anti-La
  • antiphospholipid antibodies


So now you’re pretty convinced Mrs Lupus has Lupus. What are you going to do to help her?

There are a few categories of management that can be employed:

  • Education
  • Pharmacological intervention
  • Risk managment

Education involves ensuring your patient understands their condition and what it entails. Leaflets and websites can help with this too. You should also give lifestyle advice:

  • avoiding sun exposure
  • avoiding infection
  • using appropriate contraception

Pharmacological intervention includes:

  • Corticosteroids
  • Hydroxychloroquine
  • Azathioprine
  • Methotrexate
  • Cyclosporin
  • Leflunomide
  • Cyclophosphamide
    • often given as ‘pulse’ intravenous therapy
      • usually for systemic vasculitis and proliferative glomerulonephritis
  • Mycophenolate mofetil

The basics:

  • autoimmune, multi-system, chronic disease associated with genetic and environmental risk factors
  • more common in women and non-white ethnicities
  • Lupus nephritis occurs in around half of patients
  • patients need to be counselled before pregnancy to optimise control of the disease
  • cardiovascular disease is a growing cause of death

Clinical features:

  • Arthritis
    • non-erosive (Jaccoud’s arthropathy)
    • generalised arthralgia with morning stiffness but no swelling is very common
  • Alopecia
  • Skin rash (discoid)
  • Photosensitivity
  • Malar rash
  • Oral ulcers
  • Fever
  • Neuropsychiatric
  • Renal
  • Cardiac
    • Pericarditis
    • myocarditis
    • endocarditis
    • pericardial tamponade
    • vasculitis
  • Haematological
    • leucopaenia early clue to SLE diagnosis
    • lymphopaenia most common manifestation of SLE other than positive ANA
    • mild neutropaenia relatively common in black people, but <1.5×10(9) is usually pathological
  • Pulmonary/pleural
    • pleurisy
    • lupus pneumonitis
    • pulmonary haemorrhage
    • pulmonary embolism
    • pulmonary hypertension
  • positive ANA (antinuclear antibodies)

Genetic factors:

  • HLA-DR2 and HLA-DR3
  • Complement C1q, C4 and C2
  • FcyRIIA, FcyRIIIA and FcyRIIB
  • CTLA-4 (a negative regulator of T cells)
  • PDCD-1 (CD28 immunoreceptor)
  • Cytokine genes IFN-a and TNF-a

Environmental triggers:

  • Drugs
    • minocycline, procainamide, hydralazine
  • Ultraviolet light
  • Viral infection
    • EBV, CMV, Retroviruses, parvovirus B19
  • Hormones
    • oestrogens
    • prolactin
  • Chemicals and heavy metals
    • silica, mercury
  • Diet
    • L-canavanine in alfalfa (maybe)

Anaemia in Lupus:

  • Normochromic normocytic anaemia of chronic disease
  • Antibody-mediated haemolytic anaemia
  • Iron-deficiency due to diet
  • Iron-deficiency due to blood loss
  • Pernicious anaemia (autoimmune)

(information from ABC of Rheumatology: Adebajo)

Steve can’t have NSAIDs

Steve can’t have NSAIDs. Poor Steve. Steve needs to take something else. Anything but NSAIDS. And here’s why:

Steve has a hurty, and was told to take a painkiller to make his hurty go away.

diagnosis ‘hurty’

Unfortunately for Steve, the painkiller he decided to take was an evil non-steroidal anti-inflammatory drug, which didn’t agree with him.

The NSAID made Steve’s stomach give up all hope and bleed catastrophically, resulting in quite a mess.

It totally ruined the Nativity

All of this blood loss made his kidneys and liver give up hope too, and he watched in vain as they left to search for a sunnier place to live.

This made Steve really angry, and despite his frankly incredible blood loss and dehydration, his blood pressure still managed to go so high that his heart gave up and fell out as well.

At this point, Steve thought an aspirin might help. In fact, it just sparked off his asthma and his lungs fell off too.

Ok this is just stupid now

He then had a banana. Bananas have potassium. Steve also likes bananas.

Yeah, that’ll definitely make up for the lack of vital internal organs

Absolute contraindications to NSAIDS:

  • History of sensitivity to NSAIDS
  • History of GI bleeding or ulceration
  • Severe liver dysfunction
  • Renal impairment
  • Aspirin-induced asthma
  • Uncontrolled hypertension
  • Cardiac failure
  • Dehydration
  • Hypovolaemia
  • Hyperkalaemia