The Needs Of The Few vs The Cost To The Many

One of the problems with trying to adopt an evidence based approach, to anything, but in particular, to medical testing and treatment, is that population studies do not tell individual stories.

The problem with using individual stories is that the plural of anecdote is not data, and association does not prove causation.

However....

A young middle-aged woman with chest pains present to the ED. They had woken her from sleep, but been transient, and she had gone back to sleep. In the morning she had something of a dull ache behind her breastbone, and felt a little short of breath. Simple remedies had not helped. Her pain had settled at time of exam, and she examined normally. An ECG was normal.

Past history, family history, all negative.

How to proceed?

She was admitted for observation and serial cardiac enzymes. Should she have had something else? A CT scan? CT coronary angiography? CT triple testing, looking at aortic root, pulmonary vessels and coronaries?

While waiting the result of her serial enzymes, she collapsed on the way to the toilet. Immediately after the collapse, she was alert, if slightly clammy, and her pain had returned. ECG now showed some T wave inversion, laterally, in keeping with an ischaemic picture.

Before she could be further assessed, her pain became excruciating, and she developed marked cyanosis, centrally. ECG continued to show ischaemic changes, but had not changed from the immediate post-collapse trace.

Within about 15 minutes, she became profoundly bradycardic, and then arrested. Prolonged resuscitation was, ultimately, unsuccessful.

I don't know what the PM showed.

PE?
Dissection?

If she had been investigated more invasively, might the outcome have been different? Maybe... maybe not. But most folks who present as she did, DON'T keel over. So if we scan everyone, won't most of them just have a normal scan, and increased radiation load?

So not scanning makes sense for the population in general... just not for her, I guess.

Sudden And Unexpected.

It's amazing how much better I feel having finished my exams. Conscious of the stress as I was, I'm still surprised to see how much better I feel, with them over. Of course, now I have to wait 3 weeks before learning of my fate,and possibly starting all over again.

Ah, well...

LBF has had to endure more than her fair share of deprivation, and I hope that now, we can spend more time making mischief. Although, of course, my rota may well continue to get in the way. She has been somewhat under the weather of late, but, having undergone emergent needling treatment, and something to do with balls in ears, is feeling more like her old self. Which, in case there was doubt, is witty and funny. (Almost always)

Anyway; the ED is often witness to the unexpected; as it should be, really. Almost by definition, emergencies ARE unexpected. Of courser, that's not always what brings folks to the ED, but there you go...

A young woman spent her evening getting drunk; I'm assuming that's what she did. To be fair, she might have been up to almost anything, but at the end of the day she was virtually insensible. An all too common problem reared its head - she ran out of, or could not find any, money. Her taxi driver called the Police, and they tried to intervene with her family, but they were unwelcoming. How many times must the have heard this call before? For they would not answer the call. Why?

We'll never know.

The Police had subsequently arranged for her to stop overnight in an Hostel, but by the time she reached it, she had grown cold and still. I suspect she choked on her own vomit, en route, but again, we'll never know.

Almost an hour of aggressive resuscitation did nothing to improve her countenance, nor restore her cardiac output.

To see the death of the young is always sad, and to see one that could so easily have been avoided, more so.

Maybe it's true, we pays our money, and we takes our choices, and the Devil take the hindmost.

Supergroup - Guitars

Currently, mulling over Hendrix, Clapton, Mick Taylor and Chuck Berry...

I think there are simply too many legendary guitar players out there.

Mick Taylor on show from about 2:50

Supergroup - Vocalist.

Exams all finished. Now just3 weeks of anxious waiting.

As for my supergroup, I think I want Freddie Mercury, and Janis Joplin. And maybe Elvis. Can't quite decide...

Then again, what about Tom Jones....

Night Shifts, Hard Work and Sickness

Another set of nights, another Doc off sick.

Trying to compare 'now' with 'then' is often fruitless... memory is, by its very nature, unreliable; we both forget things, and remember things falsely. Rose tinted spectacles.

That having said... I'm sure short notice sickness is more prevalent now than it was when I was younger. And I definitely wouldn't have remembered it wrong.

Maybe it's just me. When I was on the house, being off sick meant someone else having to cover your work, or, perhaps more to the point, you having to cover someone else's work when they were off sick. So, in general, we weren't enormously sympathetic to anything we perceived as someone pulling a sickie. There was a culture of 'working through it'. Is it a good thing that's gone?

I'm sure it is. No-one should have to feel obliged to come to work if they feel a bit peaky.

But I can't help but feel we've washed a little bit of the work ethic away, too. I should point out that I'm slightly biased, having had only one sick day, in eleven years.

Anyway, I have yet to work a set of nights with the allocated number of docs.

That's fine. I'll work a bit harder. I'm used to it. But maybe, just maybe the constant stress is what's causing this increase in sickies. Maybe.

What frustrates me the most about working short handed is that management always act surprised, and then lose the plot at about 2 a.m when our breach targets start to drift...

The latest, slightly sinister, attempt to combat this, was foisted on us from on high. Once a patient has breached (waited for more than 4 hours in the dept), perhaps we could see our way to ignoring them, in favour of those who haven't yet breached.

Let me make that clear; people in the ED get seen in order of clinical priority, and thereafter, time. But once you have waited 4 hours, the department is not penalised further until you wait 12 hours... So management appear to have decided that once you have waited 4 hours, you should be being punished by being made to wait another 4 hours so that we can meet our targets.

I'll let you think about that

Ultimate Supergroup..?

Clearly, as exam stress builds, my mind should turn to all things medical...

So, naturally, I have instead been contemplating who I'd like to see appear in a one off 'supergroup'. The supergroup seems to me to have been a short lived trend of the 70s. I imagine there were good resons for this, but still...

Expect uninteresting musing on who I'd choose to follow.

The Black Dog

Apologies for the silence; exams pending have had me all distracted. Game on tomorrow, and I'm decompensating a little bit. I'm sure my ability to deal wit this shit gets less with every passing year.

Anyway, I'm not sleeping, and generally of low mood, and this reflects in my work, which, I guess makes me a bad professional.

We'll see, I guess.

The patient so keen to declare her love for bum sex survived her 4 metre fall, and seems none the worse for her frontal contusions.

Must stop now before I become bogged doen with navel-gazing; the Black Dog looms large on my horizon.

More later; I'm on nights this weekend, which will surely be a fertile hunting ground.