Archive for June, 2010

Ain’t that good news

This week has been a bit of Scott McKnight overload

From preaching in MCC on Sunday to a leaders day (that i somehow got sneaked into) on tuesday and then IBI’s summer institute on Friday and Saturday.

McKnight appeals to me because he talks a lot about the gospel and what we mean when we say that and what the Bible means when it said it. This builds on a major learning point I got from Tom Wright when I read (mainly in Surprised by Hope & Simply Christian) that the gospel was perhaps something more than what I had originally presumed.

McKnght explains that in the last few hundred years that the meaning of the word gospel has shifted somewhat to mean good news about forgiveness of sins (primarily through justification by faith).

This is a shift from an earlier tradition (and McKnight argues – Biblical position) where gospel meant good news that the messiah has come and brought fulfillment to the story of Israel.

The key text he quotes is 1 Cor 15:1-5 which he also argues is the basis for the Apostles/Nicene Creeds.

This gospel includes within it justification by faith but states that GOD is doing more than that.

This was a pretty cool thing to learn at the age of 27. It certainly helped me make a lot more sense of what was happening in the Bible.

Some of this seems to scare people in certain circles – in many ways understandably, it seems a major shift in understanding of a fairly basic aspect of what we do. Just examine your hymns and prayers and you’ll see that they’re full of justification theory as the main (if not sole) point of what GOD is doing.

I don’t think I’m a heretic for my shift in position. Jesus has got bigger not smaller.

I’d love to tell you what the implications for how we evangelise are but we had to skip the last session on Saturday – perhaps Dr Mitchel could fill me in?

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Diagnostic and prognostic utility of troponin estimation in patients presenting with syncope: a prospective cohort study Emerg Med J 2010 27: 272-276

The basic overview for everyone

About 2pm every sunday we have a wee run of ambulances of people who have fainted/passed out/fallen over in church. Religion is bad for you. We can all agree on that.

99% (Warning – made up number alert) of these are what we call syncope, or if we try to be more technical and make it sound like a real disease we say neurcardiogenic syncope of vasovagal. This is largely to make doctors and patients feel better that “I thought it was a faint but I went to the hospital and said it was neurocardiogenic syncope…”

We like to make light of syncope (if you’ll pardon the pun) but in reality it can be tricky. The vast majority of people who fall over, collapse, or have something like a faint then that is exactly what it will be – a faint, a funny turn and of no further consequence. Unfortunately some won’t be. Some will have horrible things happen to them.

As you can imagine most of emergency medicine is like this.

We go to medical school and learn nothing and graduate as doctors and screw up loads and eventually learn something and after a while we get pretty damn good at working out which are just faints and which mean lots of badness.

Some call this clinical gestalt. I figure that this is what we’re paid for.

Most of the time our gestalt is pretty good. Really well people look well, really sick peopl look sick, fire is hot, ice is cold etc…

The inbetweeners where you’re not sure are the tricky ones. Sometimes we use tests to help us. If I suspect you have a broken wrist I can do an x-ray and then I have a useful answer to my question.

Unfortunately when it comes to syncope we have no such tool or test.  Mainly we have gestalt – we talk to them, hear they’re story and we make an educated guess clinical judgement.

Understandably when we make our guess (ahem…) we err on the side of caution, often this means admitting the patient. When it turns out that the patient is fine then you could say that it was a waste of both hospital and patient time.

The more complex critical appraisal bit

this study from Edinburgh is part of yet another “rule” to help us leave our brains at the door work out who is safe in syncope. In particular it wanted to examine the utility of troponins in making a decision on people with syncope.

I like it’s conclusion “estimation of troponin I provides little additional benefit to the presenting ECG in identifying patients with syncope due to AMI” however I’m not so keen on how they got there.

They approached patients who presented with syncope to assess eligibility, a quarter were deemed ineligible (by reasonable standards) and 2 thirds of these got enrolled.

My biggest problem comes here: for a study that wants to assess troponins they only managed to do a trop on half of the patients enrolled. I can’t work out if people got troponins at the physicians discretion (in which case it is a selected group of presumably higher risk syncope patients) or if the troponin was part of the protocol (in which case they did a really bad job of following the protocol).

This kind of invalidates a lot of the conclusions if I’ve read it right. How can you make statements about a general syncope population and troponins when only half of the patients got the test? There may have been reasons why these patients didn’t get the test done which makes them different.

Anyhow.

Of all who had the trop done there were 4 MIs – all of which had ECG changes. Which is reassuring. If they have a normal ECG then you really shouldn’t have to worry about an MI.

They also found that of the 256 analysed patients, 9% had a bad outcome (their definition of this was slightly more dubious)

And as in lots of other studies, lots of the raised troponins were for non-MI reasons. Hopefully by now we’re learning this – don’t automatically think MI when you see a raised troponin.

Given the constant battle that we find in the NHS to get a patient admitted the trop is sometimes a useful stick to beat the admitting team with – which is truly terrible practice I know but sometimes you just have to do what you need to get the patient admitted – despite its lack of utility.

I send the vast majority of my syncope patients home after an ECG and history and examination (you know that thing you do where you touch the patient and use the stethoscope thingy – it’s largely useless but it looks good…) In general when there’s something bad happening it’s fairly obvious from the start.

My problem with decision instruments for things like syncope is that it’s too complex a problem to simplify into 4 clinical variables. For ankles this works, for syncope I’m not sure.

All the first pages

The best bit about getting married – doubling your library

Party Fears Two

I’m getting married June 17th. We have a silly little website here.

We’re trying to do the wedding a little bit differently, partly because we have made a life career out of trying to be a bit different and part because we believe most weddings are a big pile of steaming horseshit. I think I paraphrased Wylie somewhat there…

For someone who enjoys making lists and logistics it has been a wonderful experience – unlike marriage which sounds painful and depressing…

I have 4 different wedding related spreadsheets and lots of little notes and “to-dos”

I have had a lot of fun planning all this. Mainly.

But occasionally you take a deep breath and go “aww crap… we have an awful lot to do…” I think in those moments I am what most people would call “stressed”.

But come June 17th at 4.30 pm I have to become “hands off”

The whole shebang needs to run without me. That will be a blow to my fragile go. My significance and identity in any situation resolves on how useful I can be.

Watch me next time I’m in a situation when something needs done. I’ll probably already be doing it. Whenever I throw a party I’m always the one at the sink doing the dishes.

I am Martha to your Mary. Though I often wonder that if Martha had just been organised or had a dishwater she could have got the dishes done and sat at Jesus’ feet.

Winners never quit

Talking to Transfarmer the other day I mentioned how my sense of achievement and success in life has changed somewhat.

When I was younger and lived in NZ I saw a big part of what I did in life as that doctor type stuff. To work hard at it and do it well. Because a well done thing is worth doing – a general principle I had learnt cleaning corridors in Craigavon Hospital in my student years.

Medicine is that wonderful vocation where they pay you well, respect you and you get to do something where you can easily fool yourself into thinking you’re a good person (by which we mean better than someone else of course).

Which makes it awfully easy to to get muddled in your motives and purpose in life.

I am good at what I do. I think. People tell me I could be better – this usually involves being at the top of the hierarchy in the hospital. I’ve never quite understood why that makes me better. Though as much as I’ve never understood it I’ve always found it very tempting. I’ve realised that most of this is just good old-fashioned pride. This does not mean that career advancement is inherently bad, it is merely a statement about where I think my motives come from.

Transfarmer once told me that my job was to love my patients. I’m pretty sure this isn’t covered in the GMC’s good medical practice. That was fairly insightful to say the least. My basic purpose in life is to love people, so why does wasn’t that extending to the work sphere?

Professionalism is important no doubt but loving people trumps it. We can argue about what that looks like but not about the starting point.

So what does acheivment or success look like today – loving my (almost) wife, loving my family, loving those around me, loving GOD.

[Yes I know this is very Jesus Creed but I am about to hear Scott McKnight speak on 4 different occasions this week…]

As life goes on, more and more this looks like a 3 day employed working week and the rest of the time devoted to the people in my life. I could live with that I think.

New houses

I moved in here two years ago.

It looked like this

Then we lived in it and it looked like this

Then we all moved out again and it looked like this

And all these years I thought I wasn’t a materialist and then I moved back home with wee Liz and filled her garage with all this stuff.

I hate stuff. Let me clarify that – I like stuff that works. I’m more about functionality than aesthetics (I think this sneaks into my view of philosophy and even fashion sense…) in most aspects of life. I like stuff if it does something. A thing unused is a crime.

Unfortunately I have moved into a new house so full of unused stuff that it looks like this

Sigh…

The Beastie Boys

The idea of having a “stag do” was just an excuse. I’ve wanted to get a bunch of folk on coney island for an overnighter for a while. This just seemed like a good opportunity.

Regular readers will realise that I have a little bit of a thing about Coney Island and it seems to be my ambition to get everyone I know out there at some point.

I managed to beg/borrow/steal a total of 7 canoes for the trip. Which is not bad going for an extensive budget of nothing. Canoe people (people who canoe…) seem to be fairly generous folk. I made lots of phone calls looking for canoes and trailers and folk bent over backwards to try and track stuff down for me.

Occasionally that involved me moving the canoes in a less than ideal manner.But with Zoomtard‘s help and a little bit of refinement we managed to get 5 canoes on one car.

So 14 of us made it for the evening and only 4 of them were yellow bellied, scaredy cats, reluctant to paddle and went over in the motor boat with the warden of the island.

The rest of us with our fairly widely ranging levels of experience made it under our own power. Even if some of our senses of direction weren’t quite so wonderful.

There had been a recent hatch of flies from the lough which provided a rather dramatic cloud of “smoke” over the island. They’re the type of flies that can’t bite you, but they’re still blood annoying when they fl;y up your nose. The good thing is that come evening they go up high into the trees and instead make an almighty buzzing noise while you chat.

One tented village later (I assumed dictatorial role and shouted at everybody like a school teacher) we were ready for the BBQ and the banter.

We were joined at a bout 10pm by a group of 50 or so drunken young farmers from Portglenone who had come down on a “booze cruise” on the Maid of Antrim for a trip. They were charmingly pissed and entertaining apart from the one idiot who thought it would be funny to break one of our tents and throw a few sleeping bags in the hedge. Shame we didn’t find that out till after they’d left otherwise we could have thrown him in the lough.

One bottle of Woodford Reserve later it was 4am and starting to rain and time for bed. Good times.

Sleep was more of a formality than an enjoyable experience. So it goes.

Next day was damp and getting damper but we got our tour round the island from Peter and all home safely.

Much appreciated to everyone involved, especially to those who helped with the shifting of the canoes.


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