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Our chosen line of work is pretty unusual. You don't particularly need me to tell you that, but when you reflect at the end of the day on what you've done, or sometimes go over it with non-medical friend, you realise how strange things are. We are allowed to—for the good of our patients—to ask some of the most astonishingly intimate questions within minutes of meeting someone. We're given permission to invade personal space and undertake invasive, painful procedures. And, we form a small fraction of the population who are legally licensed to poison people. That's obviously a fairly dramatic way of putting it, since in common useage, poisoning would ordinarily imply a pretty nasty outcome. But I quite like to remind myself of this as I'm prescribing. I don't quite mutter, on the ward round “Well, shall we see if poisoning the histamine antagonist receptors in the stomach will help, eh?” but I think about it when I write my General Medical Council number next to a prescription.
In a pharmacy update paper (see page 101), Nanna Christiansen writes about excipients—the supposedly inert additions which are added to medicines for a variety of reasons, including colouring and palatability. The particular excipient focused on in this paper is ethanol—and I was astounded by the realisation that while I'm being pompous about my carefully wielded licence to poison, I should have been equally concerned about the dose of ethanol I'm simultaneously delivering. Christiansen quotes a study which estimated that children in an intensive care unit were getting, when corrected to the adult equivalent, an average of 1.4 units of alcohol a week, with one child getting 15.2 units a week. If that's not enough to give you pause for thought—or, more appropriately, a headache—then I don't know what is.
There are some other thought provoking papers in this month's issue. One of them, the paper by Amjad Khan, Lindsay Shaw and Jolanta Bernatoniene (see page 64), includes the line “Eczema herpeticum is a dermatological emergency”. I wondered a lot about the word “emergency” in that sentence, and concluded that my main problem with it is that I'm not very good at diagnosing eczema herpeticum. Or, if I rephrase, it seems that a great many of the children who I see who have been admitted with infected eczema and who have also acquired the label “eczema herpeticum”, but don't come to serious harm. From this I'm forced to conclude that if the original label was correct, then I'd be seeing more morbidity and mortality; the fact that I'm not isn't because I'm so good at treating it but because I'm getting the wrong label.
Sticking with with the herpetic theme, Kirsty Le Doare, Esse Menson and colleagues look at the appalling consequences of herpes encephalitis (see page 58). I have to say that I really like the way they've written this paper; a series of clinically relevant questions—the sorts of questions I find myself asking on the ward round. The particular stand out question for me was: “If herpes encephalitis is unlikely, when is it safe to stop aciclovir?” Hands up if you've never poisoned anyone's kidneys with aciclovir… (there's a paper here too about auditing this sort of thing). While I'm writing about this paper, I'd just like to thank Esse Menson for her hard work helping curate this mini-series on infectious diseases within the Fifteen minute consultations; I've learned loads. The herpes encephalitis paper is this month's editor's choice.
There's too much good stuff to write about in this month's issue, so I think I'd probably best stop and let you start reading and worrying for yourselves. Please keep the feedback coming.