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.

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’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.]

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

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.

[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.

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.

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…

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.

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.