A well respected man

First patient

Recently retired professional, ended her career on a high point. Happily married. Granchild recently born. Phones an ambulance with palpitations. Arrives in ED. I pick up the chart look at the normal ECG, have a quick chat with the med student about what to look for and thankfully leave the student outside the cubicle.

After a fairly standard “you have benign sounding palpitations” type of chat I ask is there anything else worrying her. Queue floods of tears and confession of 2 years of alcohol abuse and loss of position and importance since retirement. Frustration with life and continual guilt and negative thinking fueling the cycle.

She had palpitations because she had alcohol withdrawl from recently stopping her bottle and a half of wine a day habit.

I say nice things, point out the positve aspects of her life and and family and her willingness and motivation to change and as I leave I have the impression that – yes, probably I have probably played a key and significant role in changing this woman’s life.

Second patient

Woman, early forties [incidentally both these patients are women, not because they're all weak and useless but because they have the balls (sorry) to actually deal and talk about the issuesin their lives. If they were men they'd just drink more and beat the wife...] is brought to ED following what sounds very clearly and obviously a fainting episode while attending an out-patient appointment.

Tells me she has been under a lot of stress lately. [Again, incidentally, if you go and ask all the patients in our waiting room, all of them will tell you they're been under a lot of stress lately -  therefore stress causes all illness right?...] I ask why.

Queue floods of tears regarding pressure of caring for ageing mother, guilt over not being able to live with and care for mother, constant worry and anxiety over her health coupled with poor sleep and poor diet – both leading to further anxiety.

I tell her my story of responsibility (to a minor degree) for my own mother and my mother’s story of responsibility for caring for her elderly mother and how yes this is very difficult. Again I stress the importance of positive features and motivation to think better about things and change.

As she leaves the cubicle she shakes my hand and thanks me with a knowing “you’ve changed my life” look.

—

These are probably the two most useful and effective interventions I have made in the past two months. Well OK so I’ve seen a few sickies too, but even then the majority of who I see and treat will either die (if they’re that sick) or will get better anyhow and who knows if what I did actually helped.

With these two patients I’m pretty sure I made an impact.

When I came out from both these patients I was in many ways disappointed by my realisation of this.

To stress it again – I most enjoy (and think I am actually most talented) at resuscitating really, really sick people. I think I’m quite good at it. Never mind the fact that I’m not sure it makes that much of a difference. If you’re that sick that you need my skills then there’s a fair chance you’re stuffed anyhow.

I see making sick people better as my key role. Yet here I am changing lives by being a decent human being.

So perhaps I should explain how I changed their lives.

1) Very simply – I was a decent human being. I listened, I encouraged, I dispelled myths and pointed to encouraging signs. I empathised.

I learnt none of this in medical school. Well they tried to teach me this in medical school I just don’t think they did it very well. If I am a decent human being to my patients then it is not because of anything I learnt in medical school. I learned more at my parents knee and and my friends love.

2) And this is the clincher. It was because the person who was a decent human being to them was a doctor that made all the difference.

We have a mythical (and I think misplaced and usually undeserved) respect and understanding of virtually any possible problem. If an engineer and a doctor are faced with a problem regarding astrophysics or the economy then I imagine people would side with the doctor’s opinion. Not because they know but because they must be really smart – cause they’re a doctor. Because remember you don’t have to be smart to be an engineer.

It is slowly diminishing but the respect that is given to the medical profession is colossal. What we say goes.

What I say to the family of the dead motorcyclist is indelibly printed on their minds for the rest of their lives. People don’t remember what the nurse says who stays with the family after I leave. The sound byte that’s passed around about uncle billy’s health will be always be what the doctor says.

So there you go – I change lives by being a decent human being but it only works cause of the scrubs and the stethoscope.

Like eating glass

I love my day off. In fact as I now work 4 days a week I have 3 days off a week. But I usually get one sneaky one to myself. When normal grown ups are earning a living and being responsible members of society.

My tendency of late has been baking. Call it a late twenties crisis.

I tried my first slightly misshapen potato bread today.

I made more my new favourite – the brownies

And my repeating frustration (like doing a poached egg) is my plain white bread. It just doesn’t seem to rise quite the way I’d like it to. This photo makes it look more risen than it is.

For tomorrow night I have a duck and some lamb on offer if you’re interested. If it’s defrosted that is.

On a non-food related note I also managed to make my computer into a flag waving nationalist

I was thinking I could clean up for Christmas

I’m being drawn (kicking and screaming of course) towards this cult church in Maynooth. It may have something to do with Transfarmer but it’s mainly for tax avoidance.

Anyhow. Was there on Sunday and heard all about the advent conspiracy.

Now this really floats my boat. Imagine a theological reason to be a tight arse scrooge. You can tell I liked it.

Christmas is well known for becoming a holiday like Valentine’s day – invented by greeting card companies. Yes of course good and wonderful things are done – people get together and have a bit of a piss up and a party. My problem does not lie there, it lies with the rampant materialism.

The advent conspiracy does not say – cancel Christmas – indeed it says the opposite – come and celebrate.

Just imagine hijacking Christmas back off the greeting card companies.

[Now of course the global (though mainly western benefiting of course) economy would suffer in that no one would be buying all the stuff they don't need but hey that's kind of the plan...]

Just imagine providing clean water to the planet for 2% of an American Christmas.

[PS I have a vague plan in my head for a sister site called the matrimony conspiracy.]

Life in technicolour

Regarding his main character:

…I had given him a life not worth living, but i had also given him an iron will to live. This was a common combination on planet earth

Kurt Vonnegut

Breakfast of champions

Don’t worry about a thing

I got this through the post this morning:

A flyer on screening for cardiovascular disease, where you can turn up and have scans done for “peace of mind” and all that bollocks.

I’ve no idea where they got my name from or why they think a 28 year old is at significant risk of stroke (must be all that cocaine use…)

It got me in a bit of a rage. These things do.

They use unproven, emotional driven language to make money out of people’s anxiety. Surely the fact that they “can see inside your arteries” impresses you?

Yes it is true that being over 55 increases you risk of stroke – as does obesity, smoking and lack of exercise. But wait they’re all entirely modifiable risk factors, something you don’t have to pay 140 pound for the privilege of.

My favourite bit of that photo is the fact that i don’t have to remove my clothes. Phew…

These tests are not accurate. Let me emphasise that. All tests have limitations. Some more significant than others. Lots of these tests find false positives. In other words they tell you have the disease when you don’t. When you screen a population with no symptoms (which is what screening does) then by nature you screen a population with a very low prevalence of the disease you are looking for. If you screen the whole population for pneumonia with a chest x-ray only a very small number will have the disease. If you only take a chest x-ray on people with symptoms of pneumonia then you will pick up far more.

When you screen asymptomatic patients then often the number of false positives outweighs the people actually found to have disease.

Which is why screening in the NHS is so controversial.

Some are now well-established – like breast screening for ladies of a certain age and cervical cancer screening for presumed sexually active women (incidentally they presume everyone is sexually active and therefore screen all women over 18, they just don’t phrase it that way).

Screening for prostate cancer has been less successful – all the men complained that just because they don’t have cervices and boobs that they shouldn’t be left out…

The problem with the PSA test for prostate cancer is that it leads to far too many false positives – it leads people to have prostate biopsies that confirm either no cancer or such low-grade cancer that it’s not actually going to be significant (ie you often die with prostate cancer, not because of prostate cancer).

Ask all the people who get false positive PSA tests if it gave them peace of mind.

Tests are not benign things – one trial (and i can’t find the damn reference) looked at the use of x-rays to assess low back pain. People were randomised (ie both groups were the same) to receive either x-ray or nothing. Those who received the x-ray had worse symptoms at 6 weeks. And of course the x-ray revealed nothing useful to help them. Simply by doing the x-ray these patients were worse.

That is a plain old fib. Most tests are only worth ordering if you have symptoms but there are other tests that are often ordered in populations at risk – for example the screening programmes already mentioned or simple blood pressure measurement.

The goal to identify patients with significant disease before a problem occurs is very noble (even though their real goal is of course to make money) but unfortunately not possible with what they offer. Every now and again a patient or two will benefit – but over all people will not benefit and some even come to harm.

This one was my favourite – it’s not entirely clear if the Will had carotid dopplers done or not but at least they’re happy together…

And just to finish: Read this if you’re interested and see what you think about peace of mind for the people found to have aneurysms in their brain.

Vernooij, M.W., et al, N Engl J Med 357(18):1821, November 1, 2007

BACKGROUND: Increasing use of MRI of the brain in clinical practice may be associated with increased detection of incidental cerebral findings of uncertain clinical significance.

METHODS: This Dutch study reports on incidental findings on high-resolution noncontrast- enhanced MRI studies of the brain performed in 2000 asymptomatic subjects aged 45-97 (mean, 63.3 years) (52.4% female) participating in a population-based cohort study.

RESULTS: Incidental findings were common, and most often included asymptomatic cerebral infarcts (7.2%), aneurysms (1.8%), and benign primary tumors (1.6%). The most urgent finding was a large chronic but asymptomatic subdural hematoma in a patient with a history of minor head trauma one month prior to participation. A possibly malignant primary tumor was identified in one subject and cerebral metastases in another. Of the 35 aneurysms, 33 were located in the anterior circulation and 32 were smaller than 7mm in diameter (believed to have a low likelihood of rupture). Operative intervention was considered to be indicated in two patients (the patient with the subdural hematoma and a patient with a 12mm aneurysm). Increasing age was associated with an increasing incidence of asymptomatic cerebral infarcts and meningiomas, and a greater median volume of white matter lesions, but not an increasing prevalence of cerebral aneurysms.

Don’t make me laugh

[Yes this is another medical related blog but you'll all love it. All 3 of you]

This one’s for all the people I amuse at dinner parties (like I go to dinner parties… really I mean just dinner) with rude x-rays.

This one is written by a guy I pulled a shoulder with once

Hat-tip to Vinny for the website.

Put the book back on the shelf

I read a lot of books. At least I try to read a lot of books. I like the pretentiousness mainly. Sometimes I even like the books.

I read War and Peace – it took me 4 months and I didn’t enjoy it and I’m not entirely sure what happened, apart from a lot of stuff about Russian farming.

I read Crime & Punishment – it rocked.

When I start these things I tend to finish the. A bit like Magnus Magnusson on Mastermind.

I tried Kirkegaard’s Fear and Trembling on the basis of the cover line

if there were no eternal consciousness in a man, if at the bottom of everything there were only a wild ferment, a power that twisting in dark passions produced everything great or inconsequential, if an unfathomable, insatiable, emptiness lay hid beneath everything, what would life be but despair.

I get that. I gave up two thirds of the way through the book. I’m sure he said great things. They were just over my head.

How you can mend a broken heart

Roughly 4 years ago I started to blog (on a different site) and this was one of my very first.

long time no blog people, my apologies. Busy with lots of different  stuff. I was on a course with work last week. Interesting experience.  You get thrown in a room together with all these random punters who  become your “group”, we were group E, we rocked. It was a life  support course so it was lots of role playing and pretending that the  dummy in front of you is having a heart attack, and then shouting  CLEAR and shocking them with the defibrillator thingy. But it’s not  hard not to get into it, and all of a sudden the whole group is  pretending to treat this plastic dummy and saying calming reassuring  things to it.

You also get all that wonderful small talk, trying to engage in  conversation with this random punter. “so.. where do you work then?”  My job becomes that much of my identity that i find it hard to engage  in conversation with people on any other level. I always had this bit of a thing against small talk and superficiality. How we have a  complete inability to say what we actually mean and instead stick to Coronation St and the footy, nice safe topics.

So by the end of our two day course, we’d bonded to a certain extent,  we knew each others jobs well and a brief insight into our  personalities. And i suppose they knew i was a decent enough guy,  that i was involved in “church stuff”. But none of them came in  contact with the JESUS of the gospels. I made sure he was hidden deep  under layers of banal superficiality.

By the way the dummy had an extended period in ICU but recovered to  walk out of hospital and to full recovery only to be killed testing  air bags 2 months later.

After 4 years of resuscitating actual people I’m not sure I’ve learnt that much more about. We do it infrequently and it is almost universally a failure. If you’re sick enough to need CPR then you’re almost definitely stuffed. Except if you’re a newborn baby when a vigorous towelling and a bit of a squeeze on the chest seem to do wonders.

So 4 years on I’m back on an APLS (Advanced Paediatric Life Support) course (apparently someone started a mock course called Advanced Faecal Life Support – in honour of Mr Hankey the Christmas Poo) in Newry.

And I realise that I kind of know all this stuff already. Shouting at a manequin and pretending to intubate dummies is not so realistic once you’re actually done the real thing. Alas it’s a little piece of paper I’m meant to have so I can’t moan too much.

This type of thing breeds arrogance in me – “won’t you all just shut up with your nonsense protocols and realise that I am the king of all things…” Something like that.

Started at 8am and finished at 7pm. And it’s meant to be a wee dossy day away from actual work…

Guilty cubicles

I’ve recently cut down to working 4 days a week. I found out i’d been working 8 hours of voluntary over time a week since i started the job. I get paid for it. I just don’t want to do it. So I don’t.

Anyhow. Best decision I made – days off in the middle of the week are immense.

I think i’ve realised how stressed i get in work. I used to think that i never got stressed in work – i presumed stress meant that you made lots of mistakes and cried all the time and hated the job. Which is not what I mean.

What I mean is the continual frustration I find with the busyness of the place, with the compromises in care that I make because of the pressures of time and work load. And most obviously (to me at least) is how grumpy I get with the staff.

Ask me to do too many things at once and I start to get a bit short and snappy with people.  With people I love about things that are important. That can’t be a good thing.

As odd as this sounds – i find myself most relaxed and on form when it comes to the sickies – the people needing resuscitation and emergency treatment (alas making up probably less than 10% of my work). It’s the list of comparatively well chest pains and tummy pains and kiddies with temperatures demanding attention that stress me.

Having a day off a week helps me with that. I sleep better. It is in many ways an acknowledgement of weakness – that I do not cope as well with the job as perhaps i once did. Doctors are a fairly high-performing bunch of people -  it seems to attract that type, and perhaps emergency medicine as much as any. I still love the job as much as ever – i just find it harder.

The other thing I’ve come to understand is why I lie awake thinking about the patients I send home, or the patients who I’m not so clear about what’s going on with.

I’ve heard it called anticipatory guilt by the wonderful Jerry Hoffman on EMA.

He’s one of the anti-test brigade. The idea that we order far too many unneccessary and stupid tests on people who don’t need them. Which gives the impression to the patient of being a thorough and wonderful doctor when actually you’re just a bad doctor making up for bad judgement by ordering too many tests. I’m with him on that.

As an example:

A pulmonary embolism (PE) is a clot in the lung and a potentially fatal diagnosis that thankfully we can treat quite successfully once we know it’s there.

Most of the time people with PE look pretty sick and have quite significant symptoms and signs.

A small proportion will look very well and are easily missed.

We define them into low, medium and high risk groups depending on what else is wrong with them (ie having cancer or just giving birth makes you much higher at risk for PE).

When this risk idea was initially thought up about 10% of the low risk patients who we suspected had PE turned out (after tests) to have PE. Today less than 1% of who we call low risk and who we investigate turn out to have PE. We investigate a far greater number of these patients than we used to.

The implication is that we’re investigating a far greater number of people with no real success. We are also testing far too many. A 1% miss rate is considered acceptable for most conditions -  for example we miss about 2% of heart attacks and that number has remained constant over 30 years despite the huge amount of extra testing we do and the huge increase in spending.

What the numbers about PE suggest is that people who are low-risk are effectively no-risk patients these days.

So why do we keep testing them?

Is it a fear that the well looking patient with a mild cough and a bit of pain in the right side of the chest will come back dead?

Yes and no.

Yes that there’s a fear that the patient will come back dead but no because it’s not really the patient you’re worried about. It’s yourself.

We anticipate the guilt we’ll feel if we miss the diagnosis and it’s that that makes us order the unnecessary test.

The guilt will have some relation to the poor dead person’s family but most of it (and for this i can only speak personally) the guilt is how i will feel for professionally missing something important. For the feeling i have when I know that my peers know that i missed the diagnosis.

This is where the rational reasoning of what we know to be scientifically true meets the emotional fear of personal responsibility. The burden of decisions making (which is effectively what i get paid for, even though i’m not sure i’ve had that much training in it) is what we carry – and it seems all the numbers and science in the world won’t change that.

Crosstown Traffic

Coming back from Maynooth yesterday took a good 2 and 3 quarter hours instead of the usual hour and 3 quarters. Largely due to the huge number of Irish travelling north to take advantage of the public holiday in the south and the favourable euro to pound rate.

Coming into newry was backlogged a good few miles with people queued patiently in both lanes. Till some chancers who obviously felt their need to have fire works and wide screen TVs bought by lunch time led them to drive down the hard shoulder and try and squeeze in further up the queue.  These weren’t men driving their wives to hospital in early labour. They were almost without exception two parent families with 2.4 kids in the back and their SUVs or people carriers.

You could sense the rage rising in the morally self-righteous waiting patiently in the queue.

Until that is, a couple of articulated lorries decided to block the hard shoulder by driving the mysterious middle lane with their trailers half in the hard shoulder.

Justice was done. You could see drivers giving the lorries a satisfied look of approval at their policing of the situation.

Losing my religion

Two things:

First – just finished Malachi O”Doherty’s Empty Pulpits – a look at the decline of traditional religion in Ireland. Largely from a Catholic point of view, looking at the huge change in Catholic Ireland’s relationship with it’s mother church.

There are indeed many empty pulpits, there aren’t that many seminarians coming through St Patrick’s Maynooth as Zoomtard will tell you. As an aside – I used to play in a football league in Queen’s as a student (one of the many ways to avoid actually studying) and we had a good relationship with the Catholic chaplaincy’s team to whom we would sing “you’ve only got one priest” to the tune of “there’s only one (insert famous footballer’s name here).”

He rightly points many of the deficiencies in the church and our relationship to it – both in the past glory days and in the present times. Worth reading – if not necessarily always agreeing with. I understand Catholicism poorly so it was good for me.

Second -  just watched William Crawley’s Losing our religion on the iPlayer – charting both his own and Northern Ireland’s changing/declining relationship with religion. (Though you must forgive his James Bond pose on the front page of the iPlayer link)

I remember William from a few church events I played music at where he always played the role of the devil’s advocate and the provoker of deep thoughts and questions about so many basic aspects of faith. I must say I always really appreciated it as a chruch kid who took a while to own his faith.

He now describes himself more as a questioner and on a journey than a believer and has no affiliation with the institutional church. This is no doubt a growing segment in the country but the intellectualism that goes with it will not seem relevant to the majority of Northern Irish punters. Belief in God is still very popular (whether or not that’s a good or a bad thing depends on how you look at it) – though the definition of God is far less precise and people’s engagement with the traditions of religion have declined.

And while critical of our religious institutions (and there is no shortage of that these days – most often with good reason) he remains positive about the idea of faith – and even some of it’s more modern representations.

Northern Ireland’s relationship with religion is no doubt changing. I hope mainly for the better. We have not always been honest with our faith – too many of us choosing nominalism over engagement with a life-changing faith and tradition. Us Protestants have too often busied ourselves with defining what we are not (ie not Catholic), our belief as much a statement of identity as of faith.

Northern Ireland needs the church – in the Holy Catholic Church sense of the term. Though perhaps the decline of its institutions is no bad thing. The decline of the institutions unwilling to take ownership of former and current sin; unwilling to be redeemed and transformed as they would call their members to be -  for these institutions to be left behind is surely no bad thing.

Faith and Christianity will likely be here for the duration. If we lose out on religion as depicted in this book and this documentary then perhaps that is no bad thing.

Worst at the best of times

Most of you who know me will know that today is a year down the line from Da dying. Odd how these arbitrary dates and timings acquire some kind of significance. They do. Whether I want them to or not. You see them coming over the horizon, like a great big box waiting to be ticked.

I was on call overnight and slept poorly and just as I did get over I got rang by work anyhow. Leaves me an excuse for being tetchy and grumpy.

Me and Simy had both booked the day off and we took wee Liz to Castlewellan for the day. With ever present puppy of course. No trip these days is complete without the pup.

We have too many good memories (yes I know that’s a stupid thing, it’s like saying you’ve too much money – oh I’m so sorry for you, it must be so hard…) everywhere you go you remember how happy you were. Not always in a bad way but still it seems tough some how. I suppose you need to be a certain kind of person to get annoyed by happy memories.

Castlewellan is like that. Me and Simy would both (well really just Simy, but if he went I’d keep him company) gladly go back to the late eighties and cycle down from the caravan to feed the ducks in the lake at Castlewellan. We both do the pleasant nostalgia thing.

We did the boundary walk. two and a half hours and saw two people. Great stuff. Found our view point looking over Newcastle and Donard and cracked open a tin of Magners and toasted Ronaldo from plastic cups. Good moment. Good as such a thing can be anyhow.

When we got home Simy produced a DVD from his wedding of Dad’s wedding speech at Simy’s wedding that none of us had seen before.

Weird watching it and have the memories come back.

Number 1 – growing the hair has been such a good move for both me and Simon. I know we may look like prats these days but seriously you should have seen us with the shaved heads.

Number 2 – Dad makes a bloody good speech. Managing foul humour, insults, grace and emotion all in one move. Special kind of gift.

To Ron.

To protect the family name

The college of emergency medicine is a young college. The Royal College of Physicians has been about for donkeys. Most people are members of royal colleges or something or other.

We’re not very royal. We have royal patron but apparently that’s different. Emergency Medicine is still a baby speciality – most people still know the place as Casualty (before my time) or A&E (which I still call it) instead of its preferred title of the Emergency Department.

As such I think everyone still has a bit of a chip on their shoulders. Trying to bustle for significance amongst the big boys.

We now have a logo, Which is kind of disturbing when you look at it close but i suppose it fits.

They were also touting for a tag line – Craigavon Hospital used to have one – caring through commitment. Though I don’t even know what our hospitals preferred name is any more. Maybe caring through incompetence would be better.

Anyhow, not wanting to disappoint there were some rather humerous responses to the appeal for a tag line. These were published in this month’s EMJ.

[incidentally the EMJ has the annoying habit of publishing case reports the week after i see a really interesting case of that just published - ruined my bilateral ICA dissection, posterior SC joint dislocation and my luxation erecta (not what you think). I wanted to try and publish a vertical patellar dislocation but I didn't have my camera. Such a wasted opportunity...]

Find a sample of the best below

Emergency Medicine…
- it does what it says on the tin
- EM sports, it’s in the game…
- We’re not casualty
- We don’t care first
- The thick bit of the thin red line
- Seeing your referrals cause you’re “too busy”
- We did it when they were dying…
- Dare to care in our lair of despair
- Practical solutions to ridiculous problems

And my favourite two
Emergency Medicine…
- Too clever for orthopaedics, too stupid for anaesthetics
- The sickest looked after by the thickest

I probably would have added
Emergency medicine – go get bent and come back when you’re too sick to

A reasonable mistake

All who drink of this remedy recover in a short time, except those whom it does not help, who all die. Therefore it is obvious that it fails only in incurable cases

Galen 2nd Century

Money for nothing

I am deeply in love with the NHS. Our relationship has been rocky and we have had our fights and spats over 4 hour targets and spending cuts. But at heart we were made for each other.

Even if the relationship did only have its beginnings as a way to have a healthier population to send into battle following the disasters of the Boer war.

But in principle it is brilliant. Universal (though i’m not sure it applies to aliens from other parts of the universe – see District 9 for an example) health care free at the point of delivery.

Health care made simply extraordinary leaps in outcomes (in terms of lives saved, and saved well) from the 1930’s to the 1970s (see the wonderful Rise and fall of modern medicine for examples) but to be honest we’ve gone into somewhat of a decline in the past 30 or 40 years.

Now if you watch TV or what you read in the papers then you wouldn’t think that – what with all the sexy new drugs and fancy scanners then surely we’re moving forward. But in reality we’re not. If you take away all the fancy diagnostic technology that gives us all the pretty pictures of the tumour that’s gonna kill you (that we still can’t fix) – take that away and we may as well be living in the time of MASH.

[There are of course exceptions but the overall trend has been poor since we largely cured childhood leukaemia and figured out smoking caused cancer]

In contrast our spending on health care has rocketed. Though our outcomes are perhaps not much better.

Even the NHS (as much as I moan) has seen huge increases in its budget. My concern is where has all the money gone to…

Across the pond they have one fifth of the population with no health care insurance.

This is different from saying they have no access to health care – hospitals are obliged to provide care to patients who present to their Emergency Department (ED). This leads to

a) lots of sore throats and sore toes turning up at EDs

b) patients with serious illnesses only presenting to hospital when they’re really sick and have had symptoms for months.

This is hardly ideal.

Since the Obama health care debate got started I’ve been tremendously interested in the nonsense that it being talked about it and particular about the current state of their system.

It has made me realise how good a job we often do with health care in this country. Given the limited resources that we have (and they will always be limited in any country) we manage to do a better job than the mighty US health system. Just because you can get your coronary angiogram the next day instead of 4 weeks later does not make your health any better. All you get is choice, not better health – presumably why Americans like it so much, given the obsession with choice, individualism and self-determination.

I now subscribe to the institution that is EMA (Emergency Medical Abstracts) or the Rick and Jerry show -  a monthly two and a bit hour podcast where these two guys go through 40 studies on a wide variety of topics. And in general they tear them to shreds, picking apart errors and methods and conflicts of interest in a way that would warm the cockles of Ben Goldacre’s heart.

They are both of the opinion that the US needs universal health care. Part of the reason they believe this (i think) is because they are emergency physicians -  they are the only sector of the US health care “market” that provides free health care at the point of delivery. There are large powerful sections of the medical community in the US who have a vested interest in the status quo. The cardiologists want to provide your angio for you the next day, whether or not best practice and evidence says you need it or not.

There are too many specialists with too many procedures in the US. You want a camera up your arse to investigate your vague bowel symptoms? Sure thing.

Emergency Physicians have no vested interest in this. We don’t have our own specialist procedure that makes us unique – we are the last of the hospital generalists.

And so when these guys speak I listen to them. Rick Bukata has a series of essays on this that i’ve just been reading and they make me want to jump and shout “preach it brother”. But I’m Irish and white and couldn’t pull it off too well.

I’ll make a few brief summary points.

What he describes as the 5 myths of the US health care system:

MYTH 1: THE US HEALTHCARE SYSTEM IS THE BEST IN THE WORLD

- It isn’t. It may be for a small minority, but certainly not in general.
- in 2000 WHO ranked the US health system as 32nd in infant survival, 24th for life expectancy and 54th for fairness (whatever that is…)
- in 2007 they paid 16.2% of their GDP on healthcare for this illustrious position
Some of the others for comparison

[Money per person spent on health care]
Australia = $2,960
Austria = $3,462
Belgium = $3,326
Canada = $3,505
Denmark = $3,643
Finland = $2,546
Germany = $3,247
Iceland = $3,285
Ireland = $2,945
Italy = $2,520
Japan = $2,529
Luxembourg = $4,223
Netherlands = $3,391
Norway = $4,233
Sweden = $3,075
Switzerland = $4,311
United Kingdom = $2,560 (data from 2004)
United States = $6,567

- So they pay more than twice as much as us for their health care yet their outcomes are no better, and probably worse.

MYTH 2: THE UNINSURED HAVE EQUAL ACCESS TO MEDICAL CARE THROUGH THE EMERGENCY DEPARTMENTS

- chronic conditions are not dealt with well in the ED. Ask me – i haven’t a notion of the best way to treat chronic high blood pressure. (I also don’t care so don’t ask)
- he quotes a study that after adjusting for age, smoking, gender, education-  lack of insurance itself lead to a 25% increase in mortality independent of income level

MYTH 3: A FREE MARKET IS THE BEST WAY TO GET THE HIGHEST QUALITY HEALTH INSURANCE FOR THE LOWEST COST

- this one makes some degree of sense but doesn’t work out in practice. When you need your gall bladder out you don’t shop around, you just go to the nearest surgeon and your insurance company picks up the bill.
- the consumer cannot influence price and quality
- for example Medicare (the government funded insurance scheme for over 65s) uses 3% of costs for admin while admin for private insurance companies was 16%

MYTH 4: WE JUST CANNOT AFFORD TO COVER EVERYONE

- every other industrialised nation manages to do so (and for a lot cheaper)
- there is huge scope to reduce costs

• train more generalists (no one wants to do primary care cause there’s not as much money in it)

• decrease unnecessary procedures – eg US does three times as many angioplastys as Canada with no improvement in life expectancy
• decrease the ludicrous charges (one example of an ibuprofen pill costing $25 and an injection, not even the drug just the process of an injection costing $300)

- estimates of providing cover vary from $65 – $130 billion a year but note that half of this is already spent on the care provided to the uninsured that turn up at the ED

MYTH 5: PHYSICIANS ARE LARGELY VICTIMS IN THE CURRENT SYSTEM

- this is my favourite, it destroys the notion of the caring, decent doctor – when in fact we haven’t even got our own house in order. Perhaps… who would dare say it… that we have vested interests in making lots of money…
- doctors are the major determinants of health care costs – we order all the tests, we call the patient back for clinic visits. This is fine when it’s needed but the huge variation in physician behaviour leads us to think that perhaps some of the tests and drugs and admissions aren’t necessary
- incidentally if you read the studies and know your medicine then it turns out that that’s right – we order far too many tests or the wrong tests and use the wrong treatments
- my own personal favourite was a study that looked at how test ordering dramatically reduced at a hospital when it’s computerised test ordering system introduced the price of each test beside the tick box. I’d be interested to see how that would impact practice in the UK where we just order tests often without thinking cause neither us nor the patient will be billed for it.

Gilead

I started reading this on zoomtard’s (with all the Karl Barth I can see why he liked it. Really you should keep the Zoommatics thing going. Otherwise I’ll have to read Barth myself and that’s just not on)  and Transfarmer’s recommendation.

[That in itself is worth discussion - very few things in my life I have discovered on my own. Simy introduced me to almost every cool thing I ever got involved in, Da introduced me to sarcasm and writing (and so much more), Liz to Anne of green Gables... Not so much Liz. (You introduced me to much more than that I just thought I'd take the piss while I could.)

I listen to Pedro the lion because someone I knew listened to it, Skeeno introduces me virtually all my new music, Spuddy pulls his weight in that department too, Phil has bought me more books than hot dinners. I know these people because of people.

I enjoy what I enjoy not because I discovered it in a vacuum but because other people did before me. These things I enjoy have had quite remarkable influences on my life (fight club changed my life I tell you) and I let them because these other people introduced them to me.

Books are dangerous things. You open a book or listen to a song and a few years later you're not the same.

I'll stop there.]

Back to Gilead. A letter (a really long book length letter) written by an elderly dying preacher to his still young son. So that the son will know the father as he gets older.

It is nearly a year since Dad died. And this is what I think about. Gilead. The thoughts of a dying man. And I miss him.

To quote:

There have been so many fine days this summer that I’ve begun to hear talk of a drought. Whatever is coming I’d be sorry to miss it…

Dad died with a coming financial crisis that at least gave him an ironic laugh. Before swine flu, before Obama, before Spotify, before Transfarmer, before sitting here in a pub in Ballyconnell with me wishing i could give him a ring and laugh about it all.

Worth an extra non-dad related quote

He could knock me down the stairs and I’d have worked out the theology for forgiving him before  I reached the bottom. But if he harmed you in the slightest way, I’m afraid theology would fail me.

Canal song – Part 3

We ended up in an Italian restaurant last night. It’s weird how many small Irish villages have really cracker restaurants sometimes. Well fed and waiting impatiently for 10 pm when we felt it would be respectable to go to bed.

Slept till 9am.

Apparently it was breezy overnight. One of the metal gates on the back of the pub had blown off. Or rather the wall had blown off and taken the gate with it.

We had to endure another gruelling carry of the loaded Kayaks down to the river. couldn’t be more than 100 yards but was pulling the arms out of us by the end of it. We are such light weights.

Back in the water for 10.30 am and on our way. The rain joined us. Most upsetting.

By Lunch (which was a cup of coffee on one of the IWAI marinas) the sun came out and made it a very pleasant afternoon.

While it’s wonderful having the facilities in place, it is a bit of a spoiler on the view to have all the marker posts throughout the waterways just to stop some idiot piling a cruiser into a sand bar.

It was here that the going got a bit tougher. Up until this point we had been blessed by having the wind mainly behind us and whatever flow was in the canal was in out favour. At the point we turned into the river Erne and had to go both against the flow and against the wind. Not nearly so pleasant.

We did find this very pleasant old cottage facing onto the river.

Finished in Belturbet about 3.30 pm. Tired and a bit hungry. Good trip.

Canal song – Part 2

Sleeping in tents is something that seemed like a good idea at the time you thought of it. But in general by the time you get round to it you wish you were in your own bed.

Sleeping in a tent on a small uninhabited island in the middle of a Cavan lake seemed like a great idea till it started raining quite so heavily.

Against my usual better judgement (and the 6 quid per mb charge) I used the phone to check the weather. It gave vague promises of a bright spell from 9-10am and then rain till some time in early November. I waited till one of us could wait no longer to get up and pee (it was Phil) then crawled from my sleeping bag to greet the dampness.

Saving grace is the fact that we only planned to spend one night camping. As a general rule only ever spend one night camping. Unless the weather is guaranteed. And in Ireland it’s never guaranteed.

I had such great plans for a lovely cooked breakfast that came to a squelching halt with the rain. The only aim was to get packed up and in the canoes as quick as possible.

Unfortunately with the rain the wind had picked up significantly so our first paddle of the day was a slightly breezy run across the main channel of the lake to get to a bit of shelter on the otherwise.

We did get lost.  Or should I just say that I got us lost.  All these lakes look the same to me really. How should I know. It was only briefly lost. And pleasantly so.

Once you’re in the kayak with the spray deck on and the kag and a hat you’re pretty cosy. Rain becomes something of an irrelevance.

The wind however is a different story. Trying to cross a lake with the wind even a few degrees off your direction leads to a constant battle to keep the canoe going in a straight line.  Couple that with the waves cast up by the wind and it actually becomes really quite hard work.

It never really brightened up all day but I must say it was almost nicer because of it. All my memories of Fermanagh have grey skies in them and it seems only fitting that Cavan should be the same.

A grand total of 3 and a half hours after starting out we arrived at Ballyconnell, (hardly very long paddling is it? I realise that, if you wanted a blog on endurance kayaking then you came to the wrong place) promptly missed the best stopping point and had to struggle back upstream against the wind to make it to the marina.

So two men walk into a bar in ballyconnell dressed in shorts, sandals and life jackets and ask for a room for two. No wonder we got funny looks.

We also had to carry two canoes down the main street (it’s not very main) to get them to the pub we’re staying in. Pretty sure that’s not something that happens every day.

The shower you have after a couple of days living in your own filth is always the best one. The shoulders are begonnign to feel the strain now a bit. Most pleasant surprise is that a pint of guiness here is only 3.20 euro. Pleasantly surprised compared to the 4.50 euro in Dublin. Maybe I should move here.

Canal song – Part 1

[Before I even start, my dearly beloved Canon IXUS died, the lens won't come out. 5 years isn't bad for all the water, sand and dirt it had thrown at it. So all the pictures are from the iPhone and of dubious quality]

So it begins again. Off on another trip. Off on another paddle in the Ireland rarely seen. Kind of like lesser spotted ulster except without Joe Mahon.

This trip started as me and wee Phil wondering what to do with a week’s holiday at then end of September with him just back from 2 months saving lives (and maybe even the world) in Africa.

The original plan was to canoe from Lough Erne in Fermanagh all the way to Limerick. This was perhaps slightly ambitious.

It then became a 5 or 6 day trip to Athlone and then 4 days to Carrick on Shannon and now it’s 3 days from Ballinamore to Belturbet. Good call I say.

Took us about two hours from portadown to find Ballinamore. Down roads I’ve never driven before. Always a good experience.

Just as we’d organised supplies and got a bite of lunch the rain came on. Typical.

Though the silly misly type of Irish rain that makes you nervous that it might start pissing down any minute.

The shannon-erne waterway has a remarkable history. Originally planned to revolutionise industrial transport in the 19th century. In it’s 10 operating years it carried 8 barges. Not exactl profitable for having dug a 60km canal though the west of Ireland.

It’s introduction came just as the railways exploded onto to the scene. Hardly a fair fight. It took us just over 30 minutes to drive from the beginning to the end of our route that we planned 3 days for.

It got reopened for the tourists – mainly Germans (it seems) in rented cruisers in 1994 and seems to be popular enough to still be running.
The locks are automatic controlled by little pass cards and control panels. All very exciting. But we realised after the first one that it’s probably easier just to carry the canoes round them.

I thought I’d go gentle on phil to start with and we only had 6 mile or so for the first day, especially as we only started at 3 pm.

Tonight we’re camping on church island. A tiny place a few hundred yards across in the middle of Lough Garadice (never entirely clear if the Lough is meant to come before or after it’s name). There’s an old (proper old) broken down church and that’s it.

Lit the BBQ, drank some coffee and set the camp. Wonderful really. Just needs to be a bit wamer and it’s perfect. There’s a marina a few hundred yards across the lough and earlier a band was playing 80s rock classics at a quite phenomenal volume. The wind carried it well.

Read a good third of Gilead in one night by the light of the gas lantern and pondered how different a life we lead compared to a hundrd or so years ago. And indeed how different a life we lead compared to the majority of the planet.

22.45: Curled up in the sleeping bags hoping sleep comes easy and the zombies don’t rise from the graves of the abandoned church and gouge out our eyes while we sleeep. Not sure that’s gonna help me sleep thinking like that.

Incidentally – finally got the new David bazan album. About flipping time.

Saturday morning (who’s gonna play with me?)

It’s been a while since we’ve attempted the Upper Bann. There was the incident. It kind of put us off.

But our canoe evangelism has paid off and we’ve managed to get Leggy and Dave round to buying their own canoes.

So at 8.30 on a misty september morning we’re sitting in Leggys’s house watching him take the wrapping off his paddle. I love amateurs.

Leggy has the enviable pleasure of having a house that backs onto the river. I get very jealous.

Had the best of times paddling through the mist. Felt like somewhere nice and foreign. I.E. not Portadown.

There were no major incidents. Apart from the odd part being too shallow. Which is a bit embarrassing if you’re into canoeing – that your major trauma involved being in a river so shallow you could walk across it.

Made it to Portadown just as the sun was breaking through the mist.