Emergency Departments do not exist to serve primary care needs, social care needs and/or long-term care needs. In practice, they serve all three these functions.
Today I was asked about New Year Resolutions: I said that I had given up on them in favour of new week reviews. Everyday is difficult enough if one has to focus on good habits, balance and small wins.
I have alluded to my life map before: it is a move towards “one bin, one queue” living. It is one response to TIABIM (Taking Into Account and Bearing In Mind) given our current cognitive deficits and it makes New Year Resolutions obsolete because one is always pruning.
I have said that I added “Build Wisdom” with subnodes for knowledge and judgement. Knowledge is overrated and liable to expiry so we need just-in-time knowledge rather than a whole corpus of uncertain utility, but this is a problem that time will solve. Judgement is a bigger problem and I do not know how to design a process that improves it.
Any suggestions?
In all the discussions of H5N1 I have not seen any mention of the probability of bird to wild non-human primate cross infection. Discussions about avian in vivo mutations that would allow easy human-to-human spread seem to me to restrict unnaturally the virus’ path to dominance.
We believe that HIV is descended from SIV. Co-infection with H5N1 and SIV is likely to occur before any human flu pandemic and genetic exchange between the two is likely to be disastrous for humanity in terms of both the HIV and the flu pandemics. Such a scenario predicts recurrent, not singular, flu pandemics with repeated high mortality.
For the powers that be: a flu pandemic is closer than anticipated and will likely be worse and recurring.
Newton’s first law is the law of inertia; extended in a simple fashion it is the law of the status quo. Newton’s law of universal gravitation is fundamentally also Coulomb’s law of electrostatic attraction, which is not to say that the macro and the micro necessarily behave in the same way, but rather to remind that different scales and spheres may share fundamental properties that are unnamed and unrecognised.
That is perhaps a clear manifesto of a lumper.
Problems may be peculiar to their contexts but the experiment seeks to generalise, to abstract rather than make concrete. If the specific can educate to the abstract then that generalisation can be more widely applied specifically: algebra is genie to arithmetic. I am being clumsy and inarticulate. It takes genius to be simple, clear and I am tired and frustrated.
Simple problems allow for simple solutions. Even complex problems allow for simple solutions: the Gordian knot was cut.
I do not know if my problem is simple or complex; it’s boundaries, it’s density or it’s field. Step one: define the problem. Some problems defy definition. Where disagreement exists and one cannot simply agree to disagree because action is binary and mutually exclusive how does one proceed without insanity?
If you could only communicate by blinking a letter and word chart would be very useful. This is a proposed simple chart based on letter and word frequencies in English.
Blink for Row – Column – Letter/Word
eta dlc pbv
oin umw kjx
shr fgy qz
The of and to that
· Resting pulse and blood pressure
· Exercise induced pulse and blood pressure variability
· BMI
· Fasting blood sugar
· Health literacy
“You ask hard questions.”
“No I don’t. I ask easy factual questions: you know the answer or you don’t; no thinking involved.”
Facts are easy; deductions are harder and inductions are hardest. I would so appreciate it if people were taught to think much earlier in life deliberately rather than by some undisclosed process of osmosis.
Developing expertise is said to take about ten thousand hours: at 4 hours per day, 5 days per week, 45 weeks per year that is about 11 years. It cannot be hurried or circumvented.
The medical students and doctors who come through the department cannot be much better than they are because they have not had enough time to be better. They cannot be expected to learn A&E medicine in their short stints. They can learn an approach, a perspective, and a process and they can calibrate their knowing and their not-knowing.
In conducting research we need to begin with what is known, then what needs to be known and finally what can be known. We need too to allocate resources to answering the questions that would provide the greatest gains.
The larger proportion of clinical research is without clinical utility and the clinically useful tends to be actuarially so rather than allowing clinicians to answer specific questions related to specific patients at the bedside. The few nuggets to be found lie in a morass of the unintelligible and the useless.
There is very little evidence for anything and a great deal of research simply ends with a defined need for a well designed blinded randomised control trial. We do not have the resources for well designed blinded randomised control trials; we need to find some other way to answer the questions that need answering.
The police brought a young man who had self-harmed and threatened suicide to the ED for assessment and treatment late at night. They had tasered and handcuffed him in order to do so. He had cut himself 21 times, none of them serious and the worst of them the instant he was shocked because “he lost control”. Only two lacerations were sutured. And he had never cut himself before.
He had acted impulsively after breaking up with his girlfriend of 6 months.
He was an angry young man professing depression with an energy and animation uncharacteristic of depression. He had also cooled down and although still upset about the break-up had decided to speak to his girlfriend rather than kill himself or otherwise harm himself. My assessment, credible as he was, was that he was not at immediate or high risk of self harm and that he could be assessed by a member of the mental health team in the morning (normal business hours).
The offsite supervising officer in charge was not happy with my assessment and instructed her officers to arrest my patient and take him to a psychiatrist to assess him which would involve taking him to the psychiatric hospital where they would be directed to return him to the ED where a psychiatric SHO would come to assess him. It seemed to make no difference to her that a second assessment several hours later would be by a junior doctor with considerably less experience of self harm and dangerousness.
Assessments of dangerousness are probabilistic, difficult, inexact and often no better than chance. The variables that contribute are numerous and unstable and like predicting the weather become meaningless beyond the immediate future. Some things make prediction easier: a history of violence; acute psychosis; drugs and alcohol; and severe antisocial personality disorders.
Most cases like this one do not have obvious predictors and so the assessment is made on the basis of the lack of predictors, the patient’s stated intent, observed impulsivity and self-regulation, level of emotional arousal and my own improvised provocations over a relatively long period of time: hours rather than minutes. Prolonged exposure to many dangerous people over many years also helps build a tacit model of the dangerous.
The role of the doctor is four–fold:
The nature of medicine is changing much faster than the practice of medicine: we are human and as such the older we get, the less flexible, the less malleable. The role of the doctor cannot be tied up in specifics because life is complex, uncertain and – at the individual level – entirely probabilistic.
After-action reflection means learning something everyday, but not all learning is noteworthy on short timescales. Perspective is important and time offers better perspectives.
Looking back at my day I find my emotionality an issue: part of that is fatigue and part is the nature of the work and part is that all those who interact with us do so with imperfect and incomplete information. Life is complex.
Many profound truths sound asinine stated baldly: they are too obvious. They get their meaning, their depth and breadth from the hearer’s interpretation: the mouths of babes yield only the words of babes; no more. Meaning is tenuous and personal.
And generosity is always welcome; as is compassion.
What if life could be understood forwards? What if you could see the shape of your life now, well before its end?
I walked this path and left a legacy….
Sculptors often say that they do no more than liberate the sculpture rather than create. Can a life be sculpted in the same way? The means can be varied infinitely towards the same end.
What tools, whose hands and how long?
My question, essentially, is how early in life can you know or discover your purpose? If you know that your life’s work cannot begin until you know what it is, how can you go about discovering it sooner?
A doctor remarked that had she known that a patient was a consultant she would have spoken differently: he had broken his femur and she would have said that he had a femoral fracture and needed some pain killers and an x-ray. She didn’t say what she said instead or would say and found my request for clarification “annoying”.
If I broke my hip, I would have no feelings about the use of the word “hip” instead of “neck of femur”. I would not consider the word itself condescending. I do not believe myself atypical in this.
“The meaning of the message is the response you get.” Even a professor of orthopaedics would not take exception to “hip”, he would simply ask to see the x-rays: a picture is worth a thousand words.
Simple, clear, unambiguous language is not exceptionable. If your language can be understood by a six year old, it can unexceptionably be understood by an adult. Being simple, clear and direct is no mean feat.
I am to do a case presentation in two weeks. In choosing my case I was reminded of another patient – somewhat like my sentinel case because the entire time I was assessing the patient I am going to present, I was thinking about the other patient.
My sentinel was a middle aged woman who did not know why she had been brought to the hospital. She had no complaints and her examination was unremarkable except that she was disengaged and avolitional. She was not psychotic or depressed and this affect was entirely new.
She recovered whilst in the ED before her admission to the medical ward and we spoke again before her admission. She said to me that she knew earlier that something was wrong, but that she could not be bothered. I would tell you my diagnosis, but that would be a spoiler for my next presentation and it is not my diagnosis that is the point of this post; rather that medicine is an education in observation.
There is an old joke in medicine about the student who failed an OSCE for a simple lack: he did not ask the patient his name. The patient had no somatic complaints and his physical examination revealed nothing abnormal. The student’s diagnosis was “Normal” and the patient’s actual diagnosis was “Psychosis”: he believed himself to be Napoleon.
An acute observation can tell by a woman’s walk whether she is ovulating or menstruating; by a child’s resting expression how well he slept the night before; and by an old man’s signature how good a day he is having. We are all unconscious broadcasters of our fundamental states.
“What are you? A house office, SHO or what?” I find the question intensely irritating; rather than apropos the questioner finds it fundamental. I understand that experience is relevant to evaluations, but I do not see it equally relevant to observations.
I can see that this will be a problem in 5-10 years time with registrars and new consultants who see a job title as proxy for knowledge, experience and effectiveness. And I do not have a solution other than to become a consultant myself or learn a deeper patience. Given that NHS powers recognise that job titles cost more without truly being proxies as above, they are hoping to give people cheaper job titles and still benefit from their expertise, so becoming a consultant might be a little more difficult going forward.
I am not too keen either on the training rigmarole.
Rand observed that patience is not a virtue; it is a necessity. I agree.
The world will be a very different place in 10 years time, but medicine will still be more art than science and people will be as human as ever.
In populations where people self-select for cover for health insurance and it is not mandatory no degree of insurance is affordable for anyone: those who are healthy and who would subsidise those who are not would tend to leave, raising the risk profile and costs leading to a new marginal group who would leave. Until the worst risk members would be clustered and they would not be able to afford the premiums as a class. In populations where people have mandatory health cover and where risk / morbidity is normally distributed, 2/3 would be much better off than without such mandatory cover and 1/6 would be very badly off with such mandatory cover. The remaining 1/6 could live with it, if unhappily. However, risk / morbidity is not normally distributed, nor is it binary. Those with the worst risks are least able and least inclined to deal with them.
This means that mandatory health insurance is unfair to those who take care of themselves - however large a minority they are. How responsible people are depends also on their level of development. (This is also why HIV prevention efforts are doomed to fail: those most at risk, <25, are not able to adopt the behaviours necessary to make a difference. And preventing MTCT simply delays infection by a median of 15 years – not accounting for child rape.)
So, insurance that is not mandatory and non-profit has to discriminate against a large proportion of any population. It also has to rely on imperfect information, non-rational choices, and high transaction costs.
What do you insure against? Why?
FUTURE, n. That period of time in which our affairs prosper, our friends are true and our happiness is assured.
Ambrose Bierce
As an intern I thought that ill patients took precedence over everything: meetings, eating, sleep… because what could be more important? I mean ill patients, not dying patients. Most patients in hospital don’t die and those who do are usually not unexpected or avoidable deaths. Some may argue this as a self-esteem issue, but I think it was no more than a wrong-priority issue.
As a first year SHO I learnt that my learning took precedence and I wasn’t entirely comfortable with that. I understood that doing the wrong things was worse than not doing anything, but not-doing just did not feel right.
Now I know and understand that Hazards-Hello-Help is the right and necessary order, but I don’t always remember or apply it: and my failure is not machismo.
I know that balance is important and that First Principles are FIRST: first things first: only a fool insists on tying his shoelaces in a fiercely burning building. Having said that, stress narrows our cognitive focus acutely so that we cannot remember things we know very well.
This post is because of the reason I left work late this morning, at 0h35, and walked home in the rain. It was quite pretty.
My intention to post frequently has come up against the unwilled and unpredictable vagary of illness.
Disease is aptly named: dis-ease = the absence of ease; misery. A hiatus; meanness; prayer; mercy – a little free association.
Several times, at night, I actually considered going to A&E – my A&E – for…. I didn’t go: I don’t relish being prodded and stabbed and fussed over.
This was going to be a long, rambling post, but I find that I must stop now.
What is the ideal median age for a country with a population greater than 10 million? What is the ideal demographic profile, long-term? What is the optimal healthcare expenditure as a percentage of GDP?
My personal shortcut for a human development index (HDI) is a combination of median age and Gini co-efficient: a high median age and low Gini equals a high HDI; a low median age and low Gini is not likely to obtain anywhere in the world and most countries with a low HDI have high Ginis with variable median ages, however larger populations tend to have lower median ages because of high fertility, high maternal and infant mortality and low life expectancy.
The ideal demographic profile does not exist – it is too complex, depending on the size of the population, extant infrastructure, literacy levels, life expectancy, savings levels….
The optimal healthcare expenditure too is complex and depends on gains to be made by spending on infrastructure, education, public health and security. Most non-healthcare expenditures tend to have higher health related benefits than direct healthcare expenditures. In all cases, I would expect the optimum healthcare expenditure to be less than education related expenditures.
Many people present to the ED because of minor injuries that happened in a public place: someone slipped on a banana peel on the sidewalk in front of the bank. If you saw it happen, you’d have a hard time not laughing and yet the first responder, usually someone within the bank, is unwilling to accept the responsibility for saying that things are probably okay.
They may say just that and suffix “but it’s probably better to go to A&E just to be sure”. And people acquiesce as if autonomy and interoception are like unicorns – one is not allowed to act according to one’s own common sense and one cannot know intrinsically that something is wrong within one’s body.
These people are correctly triaged as priority 4 and usually end up waiting an hour or two to be seen to be told what they already knew: no harm has been done. They usually apologise right off for wasting time. I used to demur, now I say nothing: they are right. Unnecessary presentations introduce friction.
The world is becoming less personal at the same time that it is shrinking faster. My solution to this problem is authentic living: to act in good faith, honestly; to say what you mean and mean what you say with due regard for the feelings that may be evoked; and to be willing to be wrong.
About some – few – things we cannot afford to be wrong, but the world is increasingly becoming a place where no-one is willing to be wrong: a bland and constricted living.
I see patients. Patients come to be seen.
I see patients to deal with their perceived problems. I often ask patients, “What would you like me to do for you?” and many times they answer, “I don’t know.” Sometimes, I deal with problems that patients do not perceive, that I believe have to be dealt with. In those latter circumstances patients can usually be persuaded to let me solve the problem I see.
I am not invested in a course of action or an outcome. I am invested in the process. So, I don’t have intrapsychic difficulty with patients who won’t let me solve a problem they haven’t presented with (incidental problems).
I have a problem-solving orientation. It is perhaps a default male position: we expect to fix things. It is nevertheless a reasonable ED orientation: we find and fix problems. And that is the reason that patients present to us, but not all problems can be defined nor can all defined problems be fixed.
That adults present with problems they should know cannot be defined or fixed is something that puzzles me no end. Do they present in the hope that their assessment is wrong or do they present…?
Adults do have a highly developed sense of the impossible. They do not seem to have an equally developed sense of the possible. I am not being facetious: the one does not imply the other.
When terminal patients present because they fear dying they violate fundamentally our social contract. It is reasonable and human and expected that one fear one’s death. It is a rape to expect a stranger with an impotent fiduciary responsibility to deal with that fear. As clinicians we remain humans in our interactions with those humans who present to us as patients: our humanity leaves us open to emotional contagion. And I find such emotional contagion more tiring, more draining, than extreme physical labour.
• White hat (Blank sheet): Information & reports, facts and figures (objective)
• Red hat (Fire): Intuition, opinion & emotion, feelings (subjective)
• Yellow hat (Sun): Praise, positive aspects, why it will work (objective)
• Black hat (Judge's robe): Criticism, judgment, negative aspects, modus tollens (objective)
• Green hat (Plant): Alternatives, new approaches & 'everything goes', idea generation & provocations (speculative/creative)
• Blue hat (Sky): "Big Picture," "Conductor hat," "Meta hat," "thinking about thinking", overall process (overview)
De Bono Hats - Wikipedia, the free encyclopedia
“To give pleasure to a single heart by a single act is better than a thousand heads bowing in prayer.”
Gandhi
Our department pairs one middle grade and one consultant as mentors to two junior doctors. We have been doing this for at least 2 years now. It is an entirely unstructured process and unmonitored.
I have no idea what purpose it serves or was intended to serve. Nor do I know how the pairings are decided. I do not even know what mentees think of it. All of which means that it is not important.
It is important to me.
However, like all relationships, nothing exists without both parties being engaged. Mentees do not seem to recognise a need for mentors: the relationship is foisted with no apparent utility.
I have several times found myself more engaged with junior doctors not assigned to me because they chose to relate.
What advantages are to be expected from being mentored?
That relationships are sustained by reciprocity seems clear and undeniable to me and yet my experience has been that most people are not aware of this.
I just realised that we are seven years away from a world population of 7,000,000,000 people.
LOGIC, n. The art of thinking and reasoning in strict accordance with the limitations and incapacities of the human misunderstanding. The basic of logic is the syllogism, consisting of a major and a minor premise and a conclusion -- thus:
_Major Premise_: Sixty men can do a piece of work sixty times as quickly as one man.
_Minor Premise_: One man can dig a posthole in sixty seconds;
therefore --
_Conclusion_: Sixty men can dig a posthole in one second.
This may be called the syllogism arithmetical, in which, by combining logic and mathematics, we obtain a double certainty and are twice blessed.
4-Hour targets are valuable and useful: they provide information on capacity and workload. They do not determine or indicate the quality of care, nor do they determine or indicate clinical outcomes.
4-Hour targets are of no use on a day-to-day basis. They help plan future investments in staff numbers and training and in facilities and support processes. Clinicians do not have control over process times and for clinicians to act to effect mandated targets skews and compromises clinical care. To see a non-urgent case at 3 hours in preference to an urgent case at 35 minutes in order to meet a 4-hour target is nothing less than obtuse.
4-Hour targets represent a management metric, not a clinical one.
Blog posts have been about:
I think that I have been groping towards the most recent addition to my Life-Map: BUILD WISDOM.
Wisdom is about seeking the right and doing right --- naturally, consistently and completely.
Patients always arrive with expectations: mostly tacit and nebulous.
Sometimes they arrive with chronic problems that their GPs have been unable to diagnose or successfully treat with the expectation that the ED doctor seeing them for the first and only time under significant time pressure in a busy and very noisy environment will be able diagnose and cure the problem.
Who said that patients should be reasonable?
Sometimes they arrive expecting an x-ray or CT scan convinced that this investigation will somehow, magically, cure the disease or injury. And sometimes it does seem to: those who could not walk are x-rayed and miraculously walk immediately after. Faith does not work as often.
Sometimes patients arrive with bags packed with the expectation that they will be admitted because they feel unwell or they fear they may become unwell or they are depressed or the rest of the family is off on holiday or….
Who said that patients should be reasonable?
How best to use a general AI:
There seem to be several peculiar assumptions underlying the arguments made:
People make decisions that serve their own perceived interests; governments do the same.
Should UK graduates be preferred? Yes, that is fair. Should foreign graduates be locked out? No, but the rules should be stated clearly and commitments already made should be honoured.
[BMJ]
My ignorance is monumental and my proportion of know:All_Knowledge continues to shrink. Until such time as consilience is a reality and subliminal learning is confirmed and routine I have no hope of the trend reversing. I can confine myself to a shrinking domain but doing so is intrinsically unsatisfying and reduces me to technician rather than professional.
I work in emergency medicine and most of what I see is not emergent. The context, however, teaches parsimony and requires an action orientation. Usually, those who are unwell need admission under the care of some other speciality. It is my sad and often frustrating experience that those working in the receiving specialities have no appreciation of context: of the administrative, cognitive and emotional milieu of an emergency department. I suspect that I am perceived as stupid rather than ignorant with some regularity (von Schiller notwithstanding).
I console myself: “When I was 20 I was amazed and disappointed by how ignorant my father was. At 25 I was astonished at how much he had learned in a mere 5 years.”
This little rant – if such – was occasioned by the almost obligatory quiz I enter daily with my referrals. More information is not necessarily better: I’d refer them to Gigerenzer, but I suspect they do not have the time.
Common things occur commonly, but as a group uncommon things are also frequent. Exactly how frequent they are we do not know. We do know that our estimates are biased under-estimates. Similarly, randomised control trials are not as unbiased as we would hope….
“How complex or simple a structure is depends critically on the way in which we describe it”
Herbert Simon
Man's main task in life
is to give birth
to himself,
to become what he
potentially is.
ERICH FROMM
It is better to solve the right problem the wrong way than to solve the wrong problem the right way.
Richard Hamming
I had an 83 year old female who presented with a large, rapidly progressive, intracerebral and intraventricular bleed. She was on warfarin and presented an hour after a sudden collapse already persistently comatose. The extent of the bleed made it inoperable.
In situations where an attempt at resuscitation would be futile we decide and document that when cardiac or respiratory arrest occurs, it won’t be treated. Such decisions preserve resources, emotions and patients’ dignity. Making such decisions can be extremely difficult especially considering that family and caregiver sentiments are not medico-legally relevant. We like to get agreement from those close to the dying patient but initiating or terminating treatment is not a democratic process. Wide agreement helps share the emotional burden.
DNAR orders are, however, not binary: there are many interventions between doing nothing and providing pressor support with IPPV. Bodies need fluids, electrolytes, calories, vitamins, trace elements, oxygen and movement. They also need to get rid of wastes. Medication related side effects and adverse reactions need to be managed and disease complications need to be anticipated and prevented or mitigated.
The medical registrar to whom I referred agreed that death was imminent and inevitable; he nevertheless prescribed vitamin k as anti-coumadin. I asked why and he said that she may have been continuing to bleed and that the treatment would stop the bleeding. He felt morally or ethically obliged to close the gate after the horse had bolted. If the treatment would make any difference, it would serve only to delay death; it would not reverse the coma, relieve pain or in any other way make dying easier.
I pointed out that not giving vitamin k could – not definitely would – hasten death and that it was an acceptable omission similar in essence to treating cancer pain with high dose opiates that ultimately hastened death. In both cases, death was not an aim, but the end of an inevitable process. He remained unconvinced.
As humans we are inconsistent. For the most part it does not matter. In matters such as these, I believe it does.
NHS Direct, the UK's 24 hour healthcare telephone service, has reported a big rise in the number of callers reporting mosquito bites over the past three months. Since the country has not enjoyed much hot weather recently, the mosquito explosion is more likely to be caused by warm and humid conditions, as well as the lakes of standing water left by severe rainstorms. Calls in August about bites are 28% up on the same time last year (www.nhsdirect.nhs.uk).
What is the marginal utility of intelligence? At what point does increasing intelligence provide decreasing returns? I refer to a composite of g, processing speed, size of working memory and pattern recognition applied to a domain that is not in itself limiting.
The purpose of medical research is to
People differ; this is a truism. However, they still fall into distinguishable statistical classes. This allows for population level interventions like vaccination and water fluoridation and for double-blind randomised control trials.
The objective measurements that we make as clinicians – point measurements – are generally not useful unless they are obviously deranged / abnormal. Generally, we are interested in trend data: is this normal for the patient? Is it correcting or worsening? How fast is it changing? Is the trend reversible? What is the cause?
The highest priority is always the preservation of brain function. Heart, lungs and kidneys follow.
I look forward to the introduction of real-time sensors with some way to capture and analyse the data stream: emergencies should be fewer and more easily managed.
“The unreasonable thing about otherwise reasonable people is that they don’t know how to sort out what someone is saying when he’s not really put it as precisely as he should have done.”
Goethe
Maxims and Reflections
There is some reason for these links: tomorrow will be different. How does that matter if today is very different from yesterday and you didn’t notice? It is a truism that change is constant and that most progress is emergent without being accidental. We need to make distinctions – more acutely – and with an action focus.
Having created a bookshelf on Facebook I don’t expect to be updating the list on Connectviabooks. I am certainly in favour of OpenID if it means all services can be aggregated.
The technicians visited to survey the department for our wi-fi. Optimistically, it should be operational in 2-3 months!
