Archive for October 31st, 2006

The serum rhubarb

Medicine is not an exact science. People see TV and read stuff in books and think that all the science is directly applicable to these darn nuisances of sick people.

For example.

People widely believe oxygen is good for you. And, yes it is vital to human existence. At very high doses it is kind of (!) poisonous. (One of the other ICU docs is a Scottish guy, excellent doc, very funny stories. He describes oxygen as a toxic substance found only on planet earth without which its victims would not have to endure 70 years of pain, toil, misery and suffering. There’ll probably be a lot of his stories in here).

People think exercise is good for you. And again yes it has its upsides so to speak. But it gives young athletes massive hearts that stop mid-exercise and it gives you arthritis and puts you at risk of nasty accidents where you might end up in hospital and then the world of medicine will get at you and then you’re really stuffed.

Medicine is not an exact science. It’s not even technology and design or woodwork (except orthopaedics I suppose). It’s more like a jazz lesson. Improvisation. Make it up as you go.

Every statement has a qualification behind it. I can say, yes, this patient’s blood pressure is good. But just cause his heart can generate a pressure does not mean it can get the blood to move round the body. Every good number is dependant on another number being good.

Blood tests are another thing. People think we take blood and send it to the lab where a Quincy like gentleman sticks it in a fancy machine and it tells us what’s wrong with the patient. Alas no. We have to tell the machine what to look for first and it can tell us if it’s there are not. The list of things to tell the machine to look for is staggeringly long (even longer than the 39000 words I’ve written since starting writing a blog 13 months ago).

The basic principle of a hospital admission is this. You get admitted because of certain symptoms, for example, shortness of breath, (SOB as we call it in the trade). You’ll get a chest x-ray done. Which will usually not tell us the cause. If there’s something wrong with it you’ll simply get a fancier chest x-ray done. You’ll get some basic blood tests done – we check how much blood you have and if your kidneys and liver works ok. Usually they don’t tell us what’s wrong either. So we do more tests, and take more blood and do more scans.

The natural history of such an admission will be a) we continue to test you till we kill you or, b) you get better of your own accord and leave before we can kill you by investigation. Or much more rarely c) we find out what’s wrong with you.

Sensible docs know when to take an educated guess what’s wrong with you, and get you out of here before we do damage. Lots of these doctors have been sued for occasionally getting it wrong. There’s not many of them left now.

If you get admitted to hospital then that’s generally a bad start. If you get admitted to ICU then you’re generally in trouble big style. If you get admitted to ICU then you’ve missed the boat with b) and so you’ve only a) and c) left and the chances of c) are increasingly less likely.

By this stage you’re either unconscious or we’ve made you unconscious and put lots of tubes in funny places. So now we can’t ask you what’s wrong with you. And it’s amazing how elementary that is.

So we tell the machine to test for lots of things, to test for the serum (blood) level of this and that. And then there’s the code phrase – check the serum rhubarb. And no, ingestion of large quantities of rhubarb has not got you to this position (generally at 30 degrees head up tilt, with a tube in your throat and one between your legs and a few others for good measure). This is code for “we haven’t a notion what’s wrong with you but we’re gonna keep trying for c) and hope we don’t get a)…”

This isn’t what we tell the relatives cause that’s just not PC and I doubt they’d believe us any way. So we just tell them what they want to hear anyhow and what they’ll remember whether or not we tell it to them.

That’s when I use my term “medicine is not an exact science“. I find it works well. My Scottish mate has trumped me with his own personal favourite that he can rubber stamp and apply to all such discussions with relatives – “it’s complex, multi-factorial and it varies from patient to patient.” The usefulness of such a phrase cannot be overemphasised.
He says he once knew a doc whose favourite line in situations where he wasn’t winning was to say “we have to be aggressively conservative in what we do”. Which is non-sensical rubbish but he was a surgeon, so that explains a thing or two.



October 2006
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