With friends like these…

I went cross country skiing with Jo Kippax t’other day for some light relief from the ongoing drudgery of Fellowship study. The following photos shed a little light on how much fun we had. Or at least how much fun Jo had at my expense. I sent him the heel blister photo with a tongue-in-cheek “exam” question – “Describe and Interpret.” I append his answer below the pictures!

“This is a low quality digital photograph of the posterior aspect of the left heel. The most striking abnormality is a small approximately 2cm by 2cm region of superficial partial thickness desquamation with a surrounding region of non-viable [non-viable? – I’ll show you, smart-arse] epithelium to a distance of 1-2cm. This lesion is macerated with a region of relative pallor suggesting recent removal of an inappropriately moist dressing such as Duoderm [tsk tsk! – the use of proprietary names is to be discouraged Dr Kippax]. The unaffected skin surfaces shown appear soft and uncallused with ample adipose tissue, suggesting a sedentary lifestyle. Also evident are flat arches, varicose vessels [all this from a man famed in high altitude mountaineering circles for having UGLY FEET!] and a cheap towel in the background with a snoopy pattern [incorrect – they are in fact a fine pair of flannel pyjamas] suggesting a lower sociology-economic [SIC] patient group. The overall scale of the body part shown when compared to snoopy’s nose at lower left and taking into account distance from the imaging device would suggest a larger than average build [bigger ‘n you anyway, lad!]. This minor lesion most likely represents the effects of skin abrasion from Ill [SIC] fitting footwear in a moist environment. This scenario is often seen in the context of deliberate self harm whereby external social stresses are manifested in susceptible individuals by repetitive and damaging activities. Alternatively, a similar injury pattern may be seen in the context of institutionalised activity such as army recruits who feel compelled to complete a physical activity but lack the moral fortitude to speak up and thus affect the progression of injury by altering the pace of activity [probably because these programs are designed to weed out those with moral fortitude and instead select those whose thought processes go like this: “do what I am told…must be tough…must shoot people…who cares if it’s wrong, my country needs me”]. I would expect this injury to heal rapidly with conservative management but given the above factors would be mindful of the potential for healing to be complicated by abnormal illness behavior and possible malingering or secondary gain. Given the last point mentioned in the first paragraph regards build, the otherwise appropriate management suggestion of suggesting the patient might “harden the f**k up” (regional vernacular) may well be inadvisable” [it may well be, Jo, it may well be – when my heel heals, I will kick your ass!]

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About dreapadoir

Emergency Physician, author of http://underneathEM.com Emergency Medicine blog, photographer at http://www.dreapadoir.com
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