Confessions of a Grumpy Urologist
Bless me, Father Hippocrates, for I have sinned. Again.
It has been one week since my last confession.
I nearly missed something.
Not just missed it, either. I walked right past it, nodded politely, and carried on with my shift like a man who believed the world made sense. By sheer luck, we caught it in the end. Luck, not brilliance. And that distinction matters more than most of us care to admit.
This goes back a few years, to my SHO days. Orthopaedics.
Purgatory, depending on who you ask. Paradise, if you lacked ambition or had already been beaten into submission by the system.
No emergency referrals. No chaotic take. No 3 a.m. existential crises triggered by a lactate of six and a consultant who won’t answer their phone. Complex cases were someone else’s problem. Trauma was mythical.
It was elective. Predictable. Tidy.
Patients slept at night. I wrote papers. Drafted audits. Pretended I was building a future rather than surviving the present.
Then she arrived.
Every system has a patient that doesn’t fit. The loose thread. Pull it, and everything starts to unravel.
She was young. Too young to be in an orthopaedic ward for anything meaningful. Old enough to navigate an iPad without looking at it. Young enough to know who Olivia Rodrigo was, which immediately aged me by about twenty years.
The operation was uneventful. As far as joints go, it was barely an intervention. A procedural shrug.
Week 1
“Hi doc, her heart rate is 118.”
Of course it is. Everyone’s heart rate is 118 at two in the morning.
I went to see her. She looked fine. Too fine, almost.
No obvious bleeding. No fever. No distress. Just… tachycardic.
Fluids and reassurance. The oldest lie we tell ourselves.
Her heart rate settled. I moved on.
Later.
“Hi doc, her respiratory rate is 26.”
Right. Now we’re playing.
I went back. Still looked well. Which is always more unsettling than looking unwell.
You learn early on that appearances lie, but you still want to believe them. It’s easier.
CT pulmonary angiogram. You say it confidently, as if you’re chasing a diagnosis rather than covering yourself.
It was normal. Of course it was.
I gave her morphine. Her breathing slowed. Numbers behaved again.
Post-operative noise.
Background static.
She’ll be fine in the morning.
No more calls that night. I handed over, went home, and slept the sleep of someone who thought they had done a decent job.
Week two.
“Bear!”
I turned. The F1. Bright. Alert. Still hopeful. The system hadn’t got to her yet.
“What’s up?”
“She’s still here.”
That got my attention.
A week. In orthopaedics, a week is a lifetime. Wounds heal. Bones settle. People leave.
“Why?”
“She’s got really bad abdominal pain. CT was normal.”
Of course it was.
Now it was interesting.
There is a moment, when the algorithm fails you, where you are forced into something uncomfortable. Something almost archaic.
Thinking.
So I did what we all claim we do, but rarely do properly.
I took a history.
Not the surgical version. Not the “any pain, any bleeding, bowels opened” script.
A real one.
The kind that takes time. The kind that makes you feel exposed because you realise how much you’ve been skipping.
Orthopaedics hates this part. Not because they’re incapable, but because they’ve evolved past it. They deal in certainty.
Fracture. Fixation. Healing. Discharge.
Their notes read like engineering reports. Clean. Precise. Final.
No ambiguity. No philosophical wandering. Just facts.
I’ve always admired that.
Their understanding of bone is borderline obsessive. Biomechanics, tensile strength, microscopic architecture. If you’ve ever looked at their exams, you’d think they were designing bridges rather than fixing wrists.
And yet, there we were.
A young patient.
Normal scans.
Persistent symptoms.
And a growing sense that something, somewhere, had been quietly unfolding while we all congratulated ourselves on how straightforward everything was.
That’s the problem with simple cases.
They make you careless.
Long history of admissions with abdominal pain. No cause ever found.
Someone had chased endometriosis. Negative.
Every now and then, she’d get these odd episodes of muscle weakness.
Never at a convenient time. Never long enough to catch properly.
Everything else? Normal.
“Well… it’s non-specific.”
“Turf her, Bear. Nice history, but we don’t have the setup for this.”
Liaison said it like a fact. And she wasn’t wrong.
Normal bloods. Normal scans. Nothing you could point at with any confidence.
So we planned discharge.
Week three.
She’s still here.
Every time discharge comes up, she seizes.
Not clean seizures. Not the kind anyone wants to commit to.
Enough to make people uncomfortable. Not enough to make them certain.
We don’t call them pseudoseizures anymore.
So she became “functional.”
She got moved to a bed by the window. More light. Bit of sun.
Then the rash started.
Blistering. Fast. Sunlight hits, skin reacts immediately.
That’s when it stopped feeling vague.
That was the clue. I was too stuck in my functional diagnosis to really pay attention.
Someone was.
Enter the medical student.
He wandered around like a backpacker on a gap year, chatting to patients, smiling and unphased by the abusive relationship the NHS has with its employees. Slightly irritating. Slightly admirable.
He sits with our “functional” patient. Actually talks to her.
“Bear!”
“Yes mate?”
“You didn’t consider porphyria?”
I laughed it off. “Bit rare, isn’t it? And those weren’t exactly convincing seizures.”
He doesn’t bite.
“Fine. But what about the rash?”
“Sunburn.”
“That’s not sunburn. It’s November.”
Fair.
Then he leans in, properly thinking now.
“You starve her for the op. Then she gets symptoms. Could be a trigger.”
Annoyingly… not stupid.
Alright.
Let’s send it
Here’s the problem with porphyria.
The test only really helps if you catch it during an attack.
Which means you need timing. Or luck.
We got lucky.
She develops abdominal pain again. Proper pain this time.
No one’s mentioned porphyria to her. No performance. No suggestion.
Just symptoms.
We grab whatever we can find. Kitchen foil. Urine pot.
Wrap it like we’re hiding contraband and send it off to some lab in London that probably hasn’t changed since the 80s.
Now we wait.
I give fluids. Glucose. Do the right things, without fully believing in them.
And quietly wonder if I’ve just backed the wrong horse based on a medical student I met two weeks ago.
Three days later.
The call comes.
Positive.
He nailed it, the kind of diagnosis that leaves a room full of doctors scratching their heads, and of course he just saw it. No way to text him, no easy “fair play,” so I did the unhinged thing and emailed his university and consultant like that would somehow land. Nothing back, obviously. Funny how easy it is to tell someone they’re wrong, but try giving them credit and the whole world goes quiet. Meanwhile he’s probably already onto the next case, not even knowing he was right.
Sometimes we get a little too comfortable with the easy answer. Slap a “functional” label on it, pat ourselves on the back, move on to the next chart like we’ve solved something. Truth is, behind closed doors, plenty of doctors roll their eyes and call these conditions imaginary. Fiction. Convenient fiction.
But here’s the uncomfortable bit no one likes to say out loud: we don’t actually know. Not why these patients hurt, not why their bodies go off-script, not why nothing seems to fix it. We just know it doesn’t fit neatly into our boxes, and that makes us nervous.
So we reach for the diagnosis that asks the least of us.
And in doing that, we forget the basics. Diagnosis of exclusion. Actually excluding things. Not just the usual suspects, but the weird, messy, inconvenient ones. Porphyria sitting there like an uninvited guest we pretend not to see.
Because God forbid a patient refuses to read the textbook before getting sick.
Maybe the real issue isn’t that these patients are “functional.” Maybe it’s that our tolerance for uncertainty is dysfunctional as hell.