one gives up the previous form of his existence
Archive for July, 2010
in the call of Jesus one is met by the fulfilled promise of god as valid for him or her. In and with the command of Jesus, solid ground is placed under their feet when they are on the point of falling into the abyss. What the command requires if them is simply, but comprehensively, that in practice as well as in theory they should regard it as able to bear him, and stand on it, and no longer leave it.
This guy put me onto Vonnegut just after he dies. Vonnegut that is not Jason. I am eternally grateful for that.
The guy who made this give me this book:
So I figured I’d give you a bunch of quotes to chew over:
On Karl Marx
When Marx wrote those words we hadn’t even freed our slaves yet. Who do you imagine was more pleasing in the eyes of God back then, Karl Marx, or the USA?
On career choice
if you really want to hurt your parents and you haven’t the nerve to be gay, the least you can do is go into the arts
On taking Pall Mall to court
i have never chain-smoked anything but unfiltered Pall-malls (since I was 12) and for many years they have promised to kill me. But I am now 82, thanks a lot you dirty rats. The last thing I ever wanted was to be alive when the three most powerful people on the planet would be named Bush, Dick and Colon. [Vonnegut died from a head injury in the end]
On marriage and community
when a couple has an argument nowadays, they may think it’s about money or power or sex or how to raise the kids or whatever. But what they’re really saying to each other, though without realising it is this: “you are not enough people!”
On Jesus
how do humanists feel about jesus? I say of jesus, as all humanists do, “if what he said is good, and so much of it is absolutely beautiful, what does it matter if he was God or not?”
But if Christ hadn’t delivered the sermon on the mount with its message of mercy and pity, I wouldn’t want to be a human being.
Most of the time I think we have more in common with the humanists than almost anyone else but the sermon on the mount falls flat for me without the divinity.
Anyhow, read more Vonnegut, it’ll do you good.
We got married.
It was kind of fun.
Most of you were there. Thanks for coming, we appreciate it.
Once me and Simy had got the bouncy castle sorted I finally had to let go of the reigns and let the party run itself. We’d spent so long organising the damn thing that it was hard to let go of being in control. I have issues with control I think.
But you ask people to do stuff for you and you give them their job and you let them run with it. And they nailed it. Absolutely nailed it. Everyone.
One would think I should have been nervous about getting married. But not a bit of it. I was more worried as to whether it would piss down and we’d arranged for 300 people to stand in a tend in a car park in the rain. I would have felt bad if that had happened.
As for getting married I was cool with that. It seemed like a great idea. And I still think it is so why would I worry? I trusted Wylie would turn up and she did.
I still get all teary thinking about the speeches. I missed my Da. I still do. I always will. I suppose that’s how it works.
Here’s to the Nylies. (Copyright Deb Byrne, all rights reserved)
There may be other things to do in the outer hebrides on honeymoon but between world cup matches I did manage to get through a few books:
– The Idiot – Dostoyevsky – I like Dostoyevsky, I really do but I find all the Russian patronymics a litte bit bewildering to follow. Myshkin is a pretty cool character though, especially in the context of his peers
– Philapelphia here I come – Brian Friel – when I read screenplays I can’t help but picture myself watching a performance somewhere
– The Reason for God – Tim Keller – written with enough sense to realise that reason will only get us so far
– The Four Loves – CS Lewis – so good we got Zoomtard to read it at our wedding. Well a little bit of it anyhow.
– Gilead – Marilynne Robinson – I don’t think I got all the beauty and depths of theology the first time I read this. I read it too quick. This is a book to be savoured. Preferrably with a setting sun and a single malt
– Life Together – Dietrich Bonhoeffer – I think I’ve quoted enough from this for now…
The house is coming along just nicely thanks. If GOD’s purpose in creating is to bring order out of chaos then I have been humanity at it’s very best.
These two helpful chaps helped clear the garden a bit back before the wedding
And they turned the garden from this:
Into something more resembling this:
And now it’s time for me and Transfarmer to turn it into something more resembling this:
One of the remaining tasks has been to tackle the workshop (the nice wee blue stone building) and clear out even more of the endless trash that appears to have been deposited there.
This morning it looked like this:
But then the intrepid explorer was sent in with wellies.
Then it looked like this
And then we made some shelves and now it looks like this
One feels very satisfied with this kind of work.
This is more of a plug so that you lovely people will come visit me and wylie in out mansion.
We’ll make you green curry and brownies and feed you with good coffee and have you beaten at scrabble by Martha. It’s great.
Wee phil (Phildemort/Milhaus/Philly-O-Fish) was the first person to make it down and stay in our B&B. This seems only fair seeing as he and the office did some of the work on the house.
We took a day (well more of an afternoon) out in Dublin today and made an appearance at the Chester Beatty Library. Wylie threatened to take me here on our second date and I was like “no way i’m not going on a date with a hot chick to a library” so we went to see the Bodies exhibition instead.
It’s free. I like free stuff like this, I need a good list of free things to do in Dublin if someone wants to make me one.
The current big exhibit is about the imperial Mughal albums which you all know lots about. Think Taj Mahal time.
I liked a few of the paintings:
(first ones a bit subtle)
And this one (with the translation underneath)
This is what they’re perhaps most famous for:
Though I have a copy of the whole book sitting on a shelf upstairs so I don’t know what they’re bragging about…
It is first of all, the freedom of the other person that is a burden to the Christian. The other’s freedom collides with his own autonomy, yet he must recognise it. He could get rid of this burden by refusing the other person his freedom, by constraining him and thus doing violence to his personality, by stamping his own image upon him.But if he let’s God create his image in him, he by this token gives him his freedom and himself bears the burden of this freedom of another creature of God. The freedom of the other person includes all that we mean by a person’s nature, indiviuality and endowment. It also includes his weaknesses and oddities which are such a trial to our patience, everything that produces frictions, conflicts and collisions among us. To bear the burden of the other person means involvement with the created reality of the other, to accept and affirm it, and, in bearing with it, to break through to the point where we take joy in it.
Dietrich Bonhoeffer – Life Together
I live here now. Which I’m still getting used to. I sit here right now, typing this as I consider that I now live here. I find it odd. Nice odd, but still odd. I keep thinking I’ll have to drive back up the M1 soon.
I start a new job here on Sept 1st but have the privileged position of being a kept man as Transfarmer goes out to work everyday.
So far (in the one week we’ve been home) I’ve spent most of the time cleaning and painting and unpacking. That in itself is a fun and satisfying thing to do.
I have also come up with a list of daily or weekly tasks to do (I’m all about lists). Highlights include:
– Praying with “the wife” each morning
– one blog post a day (tick…)
– exercise occasionally (not s sure about that one)
– try out one new recipe a week
– one dinner a week with friends/family
– at least 60 mins of learning anatomy a day
And so after a whole 30 minutes of reading Gray’s I decided to write instead.
I started at the very start of the book. Which may have been a bad idea. I have forgotten all about basic cell structure. Largely because it’s irrelevant to my everyday practice, but it does fall into the category of “things that someone who teaches anatomy should know”.
So I’m getting reacquainted with desmosomes and the golgi apparatus.
And 30 minutes in I’m overwhelmed by the whole fascinating concept of who we are.
A cell “communicates” with another cell by producing a signalling molecule that another cell “senses” with a specific receptor molecule and something in the other cell changes as a result. This happens often enough and someone paints the Mona Lisa.
This highlights two things
1) how hopeless and inadeaquate language is at expressing such things – in many ways a cell cannot “sense” so much as its own existence in the very way that we cannot hope to sense our own existence without these cells. Cells no more know what it means to “communicate” than the pen on my desk yet without such cells we have no notion what communication is.
2) the inability of scientific reductionism to explain the Mona Lisa. The example of cell signalling above will perhaps explain how I bend an elbow but the painting of the Mona Lisa, or any cultural/creative work is a whole different kettle of fish.
And anyhow why would you keep fish in a kettle?
Telephone and rubber band – further tips…
Published July 12, 2010 apple , technology Leave a CommentFollowing on from this in the BMJ
People like me are crippling the NHS, sucking money from it like leech. Honestly.
I have abandoned my secure pension and holiday priviledges and study leave to become a mercenary.
For those who don’t know what a locum doctor is, it’s kind of similar to a substitute teacher.
Someone on the regular staff is sick or on a course or not present for any number of reasons so we need someone to cover.
Sometimes this gap in the staffing can be filled by other people in the department. frequently the gap is left unfilled and everyone just has to work harder. (or simply the patients wait longer, it’s not like people were sitting twiddling their fingers…)
If the hole in staffing is big enough then we try to get a locum doctor in.
Lots of different types of doctors make up locums.
1) people already in the same department who are looking some overtime – these folk are probably the best to get as they know how the department runs inside out and they have a certain loyalty or commitment to the job already so they often really make the effort
2) people from different specialties/departments who want to keep their experience broad and earn a bit of extra cash – this can range from GPs wanting a bit of hospital experience to guys who are now into specialty training but who did a bit of emergency medicine at some point and are able to work at a lower level in emergency medicine
3) people on time out in a research or academic job who are looking to keep up their skills and supplement their income – these guys tend to be enthusiastic and motivated (motivated enough to do research for a bit!) – this is the category I currently fall into. I’m also working in my old ED (emergency department) so i feel extra wonderful…
4) locum agency staff – often we know very little about who these guys are. Often the locum agencies don’t know. This can range from highly qualified and motivated individuals to guys who have a medical qualification form somewhere but have never managed to obtain an NHS job. Language skills are highly variable and knowledge of both how the NHS works and how the department works is sometimes sorely lacking.
[GP locums and consultant and long-term locums are a slightly different kettle of fish, I mainly refer to middle-grade and junior-grade doctors]
We are also using an ever increasing number of locum doctors. There are lots of reasons for that. I agree part of the blame falls at the feet of EWTD and MMC but there are simply greater demands and expectations on the services we provide. The change in the visa rules leading to a greater restriction in how non-EU doctors work in the UK has also left us short staffed (roughly half of doctors in the UK trained overseas).
The EU regulations that allow free movement and recognition of medical registration means that regulation of EU doctors is to a certain degree out of the hands of the GMC. The best example being this doctor who has been struck off the UK medical registrar but is allowed to freely practice in Germany.
In our department there are two big gaps in staffing. The looming (come change-over in August) gap is that of juniors. No one, it seems, wants to do emergency medicine in Northern Ireland. The training jobs were massively undersubscribed leading the NI deanery to take a trip to India on a recruitment drive.
The junior staff see a large number of our 78000 patients. Will be interesting to see how many juniors we get.
The other main staffing issue is the middle-grade rota. This consists of people who are further on in their training (registrars) but not yet consultants and staff grade doctors (or speciality doctors as we’re called these days). Staff grades are doctors with experience in their specialty, able to work without supervision but haven’t (for any number of reasons) done consultant training.
I’m pretty convinced that middle-grades in our department see the majority of patients (though I’d love solid numbers to back that up). The business of seeing the patients and getting the waiting room emptied and supervising the juniors largely falls to us. Naturally I think we’re the most important part of the department…
[NB the consultants are hardly ornaments in the department but a lot of their day to day job isn’t seeing patient after patient, nor do i think it should be]
We have funding for 8 middle-grade doctors. We had 5 up until I quit in June and now they have 4. To my knowledge the gap is being made up by locums (a group that I now form a part of!).
If we had a fully and consistently staffed rota I think the place would run pretty well but the problem is we can’t fill the posts. No one wants to do non-training middle-grade jobs. Quite frankly it’s too much work for not enough reward (either career or financial) for most people. ED jobs are really tough. Without doubt the toughest of all the jobs I’ve ever worked.
So we will become increasingly dependent on locums and will pay these staff often up to 4 times what the permanent staff are getting. Despite the fact that some of the locums we are paying for this are of dubious value for money to say the least.
I will get (in my opinion) extremely well paid for the few locum shifts I do this summer, in a place I love to work in. But the more the NHS employs locums like me the less likely it will be able to afford the contented and permanent staff it needs.
I’m sure the patient’s consent was obtained for this video…
[Via LITFL]
Effect of delayed lumbar puncture on the diagnosis of acute bacterial meningitis in adults EMJ 2010:27:433-438
Published July 10, 2010 critical appraisal , medicine Leave a CommentThe basic overview for everyone
Meningitis is a bad thing. The bacterial one at least. Around the world it kills kiddies in droves. It’s a big deal. Thanks to vaccines and antibiotics it is not so much of a big deal (as in common) where I live. When it happens it’s a terrifying disease it just doesn’t happen that often. Even more so since the pneumococcal vaccine.
The classic (headache, photophobia, neck stiffness) presentation is no longer considered classic because we see it so rarely that we now only see the really hard cases – the kid with the fever and a sore throat who’s dead by morning. In the third world you’ll see the classic presentation all the time.
The test we do to make the diagnosis is the lumbar puncture – the one they do on House in every episode. And as tests go it’s not bad.
Very rarely, and mainly more than 40 years ago, you would put the needle in to take some fluid and the patients brain would squeeze out of his skull from the pressure change. This is as one would imagine a bad thing.
We are all terrified of this happening to us when we do the test (like most things in medicine we are more scared of doing harm than we are keen to do the right thing) so we often get a scan of the patients brain first to see if there’s anything obvious like blood or an abscess in there that might make the patients brain squirt out.
Rarely does this scan do anything other than make us feel better. It is rarely helpful.
As a result we delay doing the useful test so we can do a less useful one.
Most of the time these days we have enough common sense to start treating the patient before we do any tests. Treating bacterial meningitis quickly is one of the few diseases where treating it early makes a genuine difference.
Now I think these guys conclusions are mainly right but I’m not sure the study they’ve published gives them much evidence to say it.
The more complex critical appraisal bit
They tried to look at people who had meningitis and see how long they waited for a lumbar puncture and why they waited and what impact this had on how they did. But there are lots of problems.
– it’s a chart review – they looked at notes and decided what was wrong with the patient from there. Which can be useful but often you can read the chart whichever way you wish to prove your point. What do you do with missing data? What if someone made a decision on data that wasn’t written down? If you don’t tell how you decided what the chart said then everything that follows is dubious
– the patients they choose to look at are those pulled by discharge coding – so you only get in the study if someone thought you had meningitis and wrote it down. This misses those who had meningitis but no one made the diagnosis and thought they had something else. The famous paper on how to do a chart review is here.
– they excluded people who didn’t get a lumbar puncture – this was 10% of their patients. This is a big problem as there was probably a reason why they didn’t get an LP and so you can’t make statements about all meningitis patients, only the ones who got an LP. Though one would question the validity of a disgnosis of meningitis that doesn’t involve an LP.
– they questioned and reviewed the diagnosis of meningitis – they may well be right that some of the people who got coded as meningitis weren’t meningitis but you can’t do this with a chart review with their methods
– the gold standard seemed to be the British Infection Society guidelines – as with most guidelines these are often evidence light (there’s usually not much evidence in existence). I am aware of no evidence that shows that following the guidelines saves lives even though I agree with the guidelines in most respects.
– they do statistical analysis on symptoms of small numbers of patients from a chart review – this bit is completely pointless – when I think someone has meningitis my aim isn’t to ensure whether I’ve written down whether they vomited before coming in, I ask, but that doesn’t mean I write it down so you can’t find it out retrospectively.
– they try to make firm statements about whether or not a patient should have had a CT based on what was written on the chart when in reality there are lots of reasons, many logistical, why this happens or not.
– they note that none of the patients (they selectively chose) had LP prior to antibiotics even though “antibiotics are immediately started after the LP is performed, or sooner if there is a delay of more than 30 mins”. This is kind of weird as the reason they didn’t get the antibiotics before LP may have been that the docs thought there may have been a >30 min delay (for whatever reason) in which case they were following guidelines.
We do lots of needless CT scans – the most useful point I found was that of the 62 patients (two thirds of all) who got scanned none had anything to worry about on CT.
I agree with these guys that we miss valuable information by sending people for silly scans that take too long to move the patients for and get a report and make a decision(not the scan itself which is seconds). I agree that the 4 hour target has caused problems here [though in recent news we appear to be scrapping it]. I agree that we’re all too scared to do the right thing. Unfortunately this isn’t great proof of that.
What determines our brotherhood is what the man is by reason of Christ. Our community with one another consists solely of what Christ has done in both of us
Following on from Zoomtard’s post on the new iPhone I figured I’d share some tips on how to survive a move from Northern Ireland to The Republic.
iPhone 4 has nothing on this.
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