Archive for December 10th, 2008

London Calling [Part 6]

The course’s highlights today: Liver disease and intensive care stuff, from someone who really lived their liver patients – kind of inspiring but also slightly worrying – that maybe you should get out more. That and a great story about a guy successfully resuscitated after 4 and a half hours CPR and an initial temperature of 9 degrees centigrade. You’re not dead till you’re warm and dead. And then you’re dead and you get cold again… And it seems we under does all our status epilepticus patients – which is why they won’t stop fitting it seems.

I leave, inspired to do a better job than I do – inspired to study more and do better –  and audit anything that’s not tied down to see if we can do it better. Though I know when I go through the doors tomorrow it’ll be back to the conveyor belt of demands and waiting times and decisions and annoyed, angry, frightened patients.

Audit is something I hated for years – something I felt compelled to do my bosses who said that you’ll never get anywhere with your CV till you’ve got a few audits on board. This was perhaps the wrong way to explain it to me. I always say I am the least career minded person I know – if it’s not good old fashioned looking after people then I’m not interested. which is all very noble and all that but mostly bollocks. If I’m honest I’m sure I’m in it for the glory as much as the next person. And so if someone said audit was good for CVs and careers then I wanted no part of it.

Then I read some journals and in particular Atul Gawande, who in his simply articulate manner persuaded me that you cant get any better at what it is that you do unless you count the numbers I now love numbers. This was somewhat of a road to damascus experience for me.

What frustrates me in the current job is simply how bloody difficult it is to count the numbers and what an awkward specialty emergency medicine is for counting the numbers.

For example if you do bypass surgery for people with heart disease you almost invariably treat patients who have the same cause (burgers and ciggies and being from Norn Iron) for their disease and the patients themselves are a fairly homogenous group. You will have a fairly predictable number of these to do each year. The technique for doing them is largely standardized from operative technique to anesthesia to post-operative care to expected complications. Therefore it is relatively easy to measure your outcomes (who died, who lived, who had complications) and see how you’re doing.

In emergency medicine, anything (in terms of pathology) can walk through the door and frequently you have the wrong diagnosis when the patient is either admitted or discharged. The population you deal with is from as young as 2 days (the youngest one who i was involved with who i’d done the baby check on before they’d went home and came back dead within 36 hours – how good did i feel…) to 101 (who was fine and went straight home again). And even if you do know what’s wrong with them, you don’t tend to be involved in their ongoing care and therefore have no idea how they do in the longer run –  that’s a number for someone else to measure.

So you end up trying to find the stuff that is peculiar to us, stuff that belongs to emergency medicine as such. And the list is fairly small though significant. There are certain standards of care that are expected of someone with a certain diagnosis, for example early antibiotics in severe sepsis, nimodipine in sub-arachnoids, time to reperfusion in heart attacks(though that’s more down to the cardiologists these days…).

The problem is simply getting the data. In the twenty-first century we are still using DOS based systems for blood results, patient tracking and printing X-rays on film. We record all our notes on paper. Do you remember paper? And writing things with a pen and all that…? Welcome to early 70s… It seems the health service has the monopoly on dot-matrix printers – pleas just stop making them and we’ll be forced to change…

Without a decent digital record the whole thing is a complete nightmare to measure. How do you archive and database all this paper. How do you retrieve all the data. Well by simple hard work and lifting through reams of paper which is what people did in the old days but it galls me to even think about it.

It is important to note that computer systems and electronic care records and digital radiology are unlikely to save lives but they will keep your doctor sane and I figure that’s always a good thing.

Phew…

I skipped the last lecture, having to sneak out to get the train to Stansted, which seems to take so long that you might be better flying from Bristol instead.

I always used to say that I quite liked London to visit but I could never live there. And I suppose after a few days dandering around and being a bit older and a bit uglier i think i could probably live in London. I used to think it was only famous people and druggies and politicians who lived in London (often combining the two or even all three…) – in fact the only famous person i saw walking around was the chap Lizo who does the entertainment stuff for BBC news. And i suppose that doesn’t really count does it.

It turns out that London is in fact full of normal people, going about normal everyday lives. Just with worse commutes into work and better suits.

I’m not saying I want to live here, just that I’m no longer scared and intimidated by the place. Which has got to be some kind of step forward.

Incidentally – almost finished David Copperfield which I started back before Da died. It’s like all of the old proper books i read, initally a bit bewildering and dull, and nothing seems to happen, then a few folk die, people get older and the book ends. Though by the end you’ve been reading the book so long that you’ve grown rather attached to everyone in it.

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