Learning...

It has been more than a year since I reviewed the BTS guidelines on management of primary spontaneous pneumothoraces, which I have reviewed again tonight and which had not changed in the interim, so I felt somewhat "rebuked" when I recently aspirated a moderate sized pneumothorax in a patient with COPD and a pleural effusion.

The medical registrar was quite emphatic that that was not the right management. It was.

The matter is noteworthy for two reasons: the first is that I have been trying to review my management of uncommon and rare conditions at the point of care, synchronously, regardless of my confidence in my knowledge or skill simply as good habit; and the second is that personal confidence is only tenuously linked to being right.

I am not confrontational and verbal aggression is only rarely provocative. I am biased by my history to consider only confinement and physical aggression as aggression, so the opinions of colleagues rarely impose. I am free.

I felt vulnerable and I am not sure why.

Haiku

running rat in maze
trackless mapless lost lonesome
is man is woman

Haiku

sculpting snow dragons
fire breathers formed in ice
... diastolic hearts...

Hope

Can hope be a positive act instead of an expectation?

Meaning

I am reminded of Kegan: to consider the level at which we make meaning.

Evolution

I had wanted to post regularly, both as a discipline and to improve my skills writing and in some sense writing for the sake of writing would have fulfilled both aims, but I have also wanted my writing to be evolutionary.

Popularity and volume have not been relevant metrics; growth has been.

I had invited a group of colleagues to write guest posts as an opportunity for them and as a source for additional material for myself. It has obviously not happened.

I have been in some peri-transition state for a variety of reasons and I expect that the boundaries will only be marked in hindsight. I do not know what outcomes to expect.

I am past my youth. That is no easy thing to accept.

Time, Ends

Time is the only effective cost. If doing must be directed to desired ends, time is best used determining ends rather than doing. That sounds stupid. I believe it is not. What are your thoughts?

Career Development?

A subconsultant grade

Authors: Laurence Wood

ED ATTENDANCES BY AGE

EMERGENCY DEPARTMENT ATTENDANCES BY AGE: A WELSH EXPERIENCE

E. Hassen, R. Bhalla

There is a dearth of epidemiological research into paediatric attendances at Emergency Departments in the UK. Most Emergency Medicine research in the UK has looked at types of injuries although several have looked at all types of ED attendance. Only one study has looked at the epidemiology of ED attendances specifically. This latter study found that most attendances were due to injuries and that these varied by age and location and that the variations were not stable across sites. More information is needed from more sites for longer periods through the country in addition to the sentinel sites monitored by the DTI given the contingent and complex causes of ED attendances.

The lack of research in Emergency Medicine is due to the fact that this is a new speciality, that Emergency Medicine lacks political capital, that no dedicated funding exists for Emergency Medicine research, that no dedicated organisation is responsible for Emergency Medicine research, that Emergency Medicine practitioners have an action focus rather than a research focus and that Emergency Departments are under-resourced for service provision without the ability to do research. The Joint Statement on Children’s Attendances at Accident & Emergency Departments was published in 1999 with its most important references from 1985. The Care Group Workforce Team Recommendations 2003 Report did not deal with Emergency Medicine. The most recent numbers published for NHS Direct referrals to Emergency Departments were for 1999-2000, the first year that NHS Direct was operating.

Emergency Medicine is still an orphan speciality and needs research that proves the growing workload and the effectiveness (clinical, social and financial) of Emergency Departments. Towards that end we contribute this study.

This study looks at all types of ED attendance at one hospital to report on the use of the Emergency Department by children to see how these vary by age, sex and season.

DATA AND METHODS

Our hospital is a district general hospital in Wales serving a population of 250,000.

The Emergency Departments is fully computerised and records information on every attendance made. Data on all new ED attendances by children aged under 16 years of age were available for the period 1 January 2005 to 31 December 2005 (12,443 records).

RESULTS

In 2005 ED attendances peaked at age 2 and then decreased to a minimum at age 8 before rising again. For all attendances the peak was reached in week 28, which was also the week in which paediatric attendances peaked; however, as a proportion paediatric attendances peaked in week 27. For all ages males presented more frequently than females with the smallest difference at age 2 and the largest difference at age 12.

Figure 1 shows all ED attendances for the year for each week with trough at week 8 and peak at week 28.

Figure 2 shows all paediatric ED attendances for the year for each week with trough at week 7 and peak at week 28.

Figure 3 shows all paediatric ED attendances for the year for each age cohort.

Figure 4 shows all paediatric ED attendances for the year for each age cohort by sex as a percentage.

DISCUSSION

This study has looked exclusively at the numbers of children presenting to the ED. It has not looked at the presenting complaints, discharge diagnoses, discharge outcomes, process times and treatments initiated in the ED. These are all important and have all been reported by several investigators to the disadvantage of simple epidemiological information. Investigators have been interested in the effects of social class, ethnicity, learning disability, physical disability, injury types, injury sites, chronic medical conditions and acute medical conditions on attendance at Emergency Departments. Given that there will be more than 25 million ED attendances this year in the UK we know very little about how they will be distributed and how the distribution is changing over time.

Chronic medical conditions are uncommon in children including learning disabilities and physical disabilities and it is not these specifically that lead to ED attendances and yet it is the effects of these on ED attendances that have engaged the attentions of researchers. The factors responsible for ED attendances are many and varied and complex and not knowable. The recent Institute of Medicine Report on the future of Emergency Medical Services states explicitly that indicators should be developed and that these should include structure and process measures and that these should evolve towards outcome measures. To focus on outcome measures first is to put the cart before the horse considering that we do not have structure and process measures.

We have an advantage compared to the fragmented health services sector in America: most accidents and emergencies in the UK are dealt with by the NHS in the Accident & Emergency Department. Centralised data collection, analysis and dissemination are possible. We hope it happens; soon.

Gapcast

Human Development Trends

Arthur Schopenhauer

All truth passes through three stages.
First, it is ridiculed.
Second, it is violently opposed.
Third, it is accepted as being self-evident.

Arthur Schopenhauer (1788–1860)

All movement is information

All movement is information. In falls and road traffic accidents that is obvious because injuries tend to be musculoskeletal. It is less obvious in respiratory tract infections, heart failure and abdominal pain. Obvious or not, the information remains germane.

It is not possible to state explicitly the differences in the movements of patients with renal colic or cystitis or appendicitis, but the gestalt is distinguishable. A great deal of medicine is observation.

I often ask patients to move and those accompanying – friends, relatives and carers – frequently attempt to assist and I must ask that they do not. Always, I have to explain that I need to see them move themselves unless I wish to be misconstrued as callous. Sometimes, I expect, I am still so construed....

The drooping lid of myasthenia, the tremor of hypoglycaemia, the swallow-cough of stroke, the hunching of kidney stones and the pursing of emphysema all constitute relevant information.

Watch, observe and diagnose.

Wisdom

Wisdom leads to wiser choices in wicked domains. A choice is wiser if the benefits are greater for more people, but such a utilitarian argument is intrinsically oxymoronic. Wisdom is necessarily humane.

The uber-rational is not wise. There is a component to wisdom beyond defined scales of costs and benefits. The humane subsumes compassion and empathy.

To be wise, one must be engaged, caring, accepting and generous. This implies that wisdom is an orientation more than a skill in the same way that trust is an orientation. This means that building wisdom is entirely different to and separate from thinking better.

To be wise then, one must orientate differently.

The principles of medical ethics seem wise: to avoid harm, to act for the good and to respect the choices of those who consult us without neglecting the rights of the wider society.

These principles seem wise because they contextualise all our interactions in place, time and community seeking a balance. It is a dynamic balance that needs to be actively maintained.

Wisdom then must include an acceptance that understanding is developmental, that we were lesser and will be greater yet if we can be more inclusive whilst making finer distinctions.

Better thinking and widom are different: as you sow, so shall you reap....

Dell Technical Support

For all its recent investments in customer support I would still give Dell a score of 1/10.

Towards an ideal medical record

A medical record should be problem based and action oriented. I do not consider this a controversial statement.
Actions should be contextual and stakeholder associated and prioritised. It is natural that some desired actions will be mutually exclusive and that many actions will be variably desired.

This all sounds very obtuse. Carers, patients, healthcare providers, families and friends and society may all want mutually exclusive things. Autonomy is most important, but is not absolute.

Problems should be listed by the biopsychosocial frame and should be sorted by time and resolution as acute or chronic or recurrent, open or resolved, assigned or not, actionable or not and prioritised.

Holistic care requires a document that is complete and comprehensive and current to support it. An interactive document would be ideal.

Opacity, stupidity and ignorance

I try not to be opaque in communications that matter: the principles of good communication are clarity, consistency and redundancy and I do keep those in mind when dealing with complex or involved or important subjects. Simplicity can be very challenging.

I find it difficult, nevertheless, to educate. People don't come to me in search of an education and so sometimes I find that our aims are not aligned and I cannot simply walk away. I have to educate and I go unheard or misunderstood. It is frustrating.

If an attempted solution fails one should try something else.

I suspect that I am often perceived as stupid and that disappoints because stupidity is irremediable. I think that a lack of aggression is misconstrued as a lack of conviction, but force of personality is not preferable to valid argument; neither is seniority or position (ipse dixit and ad hominem).

I am inconsolably ignorant. I am less ignorant than most, but I know that the difference between 10^(-19) and 10^(-20) though an order of magnitude is not significant. Even two orders of magnitude would make no difference. The saving grace of ignorance is that it is remediable and it is a natural and pandemic state that is without shame. I can learn.

I write because my measure of ignorance is almost universal and because I am tired. I am tired of many things and I am just tired. I think that patients should take some responsibility for their own ignorance and that colleagues should look and see that they live in glass houses....

All my best wishes for the new year!

Goethe

Knowing is not enough; we must apply.
Willing is not enough; we must do.
Johann Wolfgang von Goethe 

Architecting capability

In order to mine experience one must map experience, that is, one must describe or define a topology so that the experience in its entirety is meaningful. We cannot learn from the chaotic. Making meaning out of chaos is in itself an act of learning, but it is necessarily a prerequisite to further, deeper learning.

Learning itself is instrumental: we learn to effect; we learn to solve problems or to extend solutions. Learning without application is indeed wasted labour.

Consistency over time

In all things consistency is triumphant: investing, learning, rearing, relationships. The problem we have is that we are not designed biologically for persistent action over long periods of time. The long term is counterintuitive.

We can make sense of causes and effects that are not widely separated in time. It is progressively more difficult to separate cause and effect with increasing spans of time between them.

Age is an important factor in the ability to consider the long term.

Research

If you can walk up the side of a three-storey building wearing only calfskin gloves and socks before the age of 20 you will live at least until age 150. A great deal of research makes analogous claims: alleviating the poverty of orphaned African girls will improve their health and longevity.

 

Much research seems entirely divorced from the realities of life: life is complex, fuzzy, stochastic and the problems we have to solve are wicked. There are many silver bullets; there just don’t seem to be any vampires; or more simply: there are many hammers and most things are not nails.

 

“Limitations of this study…. The results of this study cannot be generalised….”

 

We generate googols of information that is unrelated to action. We need to learn some discrimination before we expend our resources.

Compassion fatigue

Everything is personal; and however statistically common a diagnosis may be the personal trumps everything else. We are also comparators and all comparisons are with our own recent experiences: my broken finger has greater immediacy and relevance than another’s broken hip the latter’s seriousness notwithstanding.

 

We are human. We are all human together.

 

That I see broken arms and broken hands and broken legs frequently makes them routine. I care and still my caring lacks some element I lost more than a decade ago worn away by routine. I could not do my work well if cared like my novice self. And I do not want to care like my novice self: disease and distress are emotionally and cognitively burdensome.

 

I laugh. I laugh because laughter is healthy; and because it is unusual and because it is sometimes incongruous. I laugh because laughter is contagious; sometimes. And sometimes, laughter is prognostic.

 

I hope the holidays were good; I hope today is better and tomorrow better still.

HAPPY NEW YEAR!

TO 2008!