Thinking

Thinking is a skill.

 

“Think better” in on the Personal-Development node of my Life-Map. I think that I should write about the implications of accepting thinking as a skill at some time; sooner rather than later.

When There Is No Cavalry

When There Is No Cavalry (s+b)

Observation

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?

“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.

Health Insurance

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?

Ambrose Bierce

FUTURE, n.  That period of time in which our affairs prosper, our friends are true and our happiness is assured.

 

Ambrose Bierce

First principles

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.

Disease

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.

Innovation

Greenhalgh Powerpoint Presentation

UK Cancer Statistics

Cancer UK

Out of hours care: BBC

Out of hours care inadequate

A layman's healthcare economics

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.

Liability

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.

Extraordinary

The world is filled with extraordinary people. The top 1% = 66 million people.

Social Contract

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.

 

 

de Bono's six hats

•         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

 

Kindness

 “To give pleasure to a single heart by a single act is better than a thousand heads bowing in prayer.”

 

Gandhi

 

 

Kegan

“… what the eye sees better the heart feels more deeply.”

 

Robert Kegan

Mentoring

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?

 

• Technical and emotional support
• An overview of the nuances within the department
• A sounding board
• Continuity

 

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.

7 Billion

I just realised that we are seven years away from a world population of 7,000,000,000 people.

Ambrose Bierce: Logic

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.

BBC: NHS Errors

C. Difficile

On 4-hour targets

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.

St. Emlyns Virtual Hospital

Here.

Blog posts: A review

Blog posts have been about:

 

• Patients
• Colleagues
• Pathologies
• Processes
• Judgement and Decision Making
• Heuristics
• Learning and Metacognition
• Knowing
• Poetry

 

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.

 

 

Hickam's Dictum

Wikipedia

Patient Expectations

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?

 

AI

How best to use a general AI:

 

• automate the mundane
• answer all questions
• anticipate needs: biopsychosocial
• manage finances
• manage health
• build wisdom
• time dilation
• enhance experience
• prune tasks

 

 

 

Enthesitis

Enthesitis

BMJ Rapid Response: Workforce planning a wicked problem

There seem to be several peculiar assumptions underlying the arguments made:

 

• Workforce planning is a science
• The future will be like the past
• Change is easy
• Equity matters
• Cost is not a consideration
• Consequences can be accurately vectored

 

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]

Context and Parsimony

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.

Competence Is a Habit

Competence Is a Habit

David C. Leach, MD

JAMA. 2002;287:243-244.

 

Booker's Law

An ounce of application is worth a ton of abstraction.

 

Booker's Law

T.H. Huxley

“The great end of life is not knowledge but action.”

T.H. Huxley

Canaries and Zebras

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….

Simon

“How complex or simple a structure is depends critically on the way in which we describe it”

 

Herbert Simon

Emerson

We are always getting ready to live but never living. 

 

Ralph Waldo Emerson

Fromm

Man's main task in life
is to give birth
to himself,
to become what he
potentially is.

ERICH FROMM

 

Type 3 Error?

It is better to solve the right problem the wrong way than to solve the wrong problem the right way.

Richard Hamming

Haiku: Self

The first work of art

is always Self: bridge between

Appetite and ACT.

The neuropsychology of synaesthesia

Here

Medical Supercrunchers

Isabel

DNAR

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.

Via Minerva

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).

Grammar, a weapon against disease

2007 Winner

Avian / Bird Flu H5N1

Study Confirms Limited Human-To-Human Spread of Avian-Flu Virus in Indonesia in 2006

Author : Fred Hutchinson Cancer Research Center

Intelligence

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.

One Skill

If you had to choose one skill to have, what would it be?

 

Me: judging character.

Staff and Associate Specialists Wiki

Created a wiki.

Medical Research

The purpose of medical research is to

 

• find diseases
• find causes
• find treatments
• improve diagnosis
• improve treatments

 

 

The evolving science of translating research evidence into clinical practice

EBM notebook

Ian Scott, FRACP, MHA, MBBS

Trend data

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.

Goethe

“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

 

Studies Report Inducing Out-of-Body Experience

NY Times

ED Efficiency and Effectiveness Mindmap

Here.

Praxis

Praxis

 

Wikipedia

 

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.

Books Read

Connectviabooks

 

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.

Wi-fi

The technicians visited to survey the department for our wi-fi. Optimistically, it should be operational in 2-3 months!

Warfarin superior to aspirin for stroke prevention in AF: BAFTA published

Theheart.org

A Haiku

Say it, say it true.

The bell tolls, tolls, tolls for thee.

Yes. Every heartbeat.

Thriving After Life's Bum Rap

NY Times

A Haiku

Speak simply, clearly.

The bell tolls, tolls, tolls for thee.

Yes. Every heartbeat.

Speaking with patients

Patient satisfaction is entirely irrational and reasonably so: it is subject to a host of cognitive biases. Ultimately, satisfaction depends on whether the patient feels cared for, heard and understood. Patients are in no position to judge the technical or cognitive skills of the doctors who attend them and so they rely on their assessments of their clinicians’ social skills as proxy for everything else. I am reminded of Beckwith’s anecdote in which the lawyer stated that she had never had a client who said that she really, really liked her doctor, but that she felt, absolutely, that she had to sue him.

 

Speaking with patients needs time – time without distraction and time without a pressing deadline. And then there’s the real world. It also needs a history: people are subject to idiosyncratic shames, guilts and other prejudices that lead to omissions, ambiguities, diversions, misrepresentations and lies. No-one is immune: a colleague presented with a history of abdominal pain radiating to his groin when the truth was that he had an acutely painful and swollen testicle. Repeated interaction creates and improves trust which leads to more open and less ambiguous communication.

 

Communication is inherently and usefully ambiguous. In high pressure situations, the usefulness is inversely proportional to the ambiguity. We all need clarity when the stakes are high and ambiguity is most useful (ego-protective)in those circumstances.

 

Speaking with patients also needs simple language because stress slows down processing and big words and long sentences don’t make for easy repetition. Simple language is, unfortunately, very difficult and when I am tired almost entirely beyond me. It needs first that one know what is most important medically and to the patient. These may be two different things entirely. It needs also, an assessment of the patient’s receptiveness and the willingness and ability to recall the information given. To hear, to understand, to remember and to recall are all different things.

 

Information is provided with some end in mind, some action that must be taken or not or some burden that must be accepted. As always, one should begin with the end in mind.

The art of apology

The art of apology: when and how to seek forgiveness. Roberts RG. Fam Pract Manag. July/August 2007;14:44-49.  

LIFE BALANCE ANALYSIS MINDMAP

Generic Life Balance Analysis

Risk Management Mindmap

Risk Management

LAFB Mindmap

LAFB Mindmap

COPD and IV Magnesium

I disagree

 

Today I gave a COPD patient Magnesium sulphate IV. My consultant said, ”There’s no evidence of benefit…. Don’t do it.” I didn’t argue: Mondays are too busy for these kinds of arguments.

 

There is evidence that Magnesium:

 

• acts as a bronchodilator
• that it improves clinical outcomes in severe asthma not responding to inhaled beta-agonists
• is safe (LD50 in rats is 1200mg/kg)

 

We know that the following patients have reduced intracellular magnesium:

 

• those with severe chronic disease
• those who take long-term corticosteroids
• those who take inhaled beta-agonists
• those on diuretics
• those with abnormalities of potassium and/or calcium metabolism
• those with diabetes
• the very elderly
• those on chemotherapy
• those with eating disorders
• those with alcohol dependence disorders
• those with severe COPD

 

We know from the law of diminishing returns that those most severely affected by disease benefit most from its treatment and that harms and benefits have different curves that cross at different points for all patients.

 

We also know that “no evidence of benefit” is not evidence of no benefit. We lack data.

In COPD, we know that combination therapy acts synergistically and that steroids and antibiotics for acute exacerbations improve outcomes (even in patients without evidence of bacterial infection).

 

My patient had severe COPD: she had had multiple admissions this year, had suffered respiratory arrest more than once and was already on maximal therapy before her acute presentation. Did my patient benefit from the IV Magnesium sulphate? Probably. Can I prove it? No, but neither can it be proven that she did not benefit.

Friends?

NY Times

A Blueprint For 'Smart' Health Care

 

Where should people die?

Should people die at home or in hospices or in acute care hospitals? Who should decide? When should the decision be made? What should inform it? And when should it be reviewed?

Discovery

"Discovery consists of seeing what everybody has seen and thinking what nobody has thought."
--Albert Szent-Gyorgyi, 1937 Nobel Laureate in Medicine

 

Ovarian transplant

Woman has successful ovarian transplant from her sister - News-Medical.net

from Google News - Health

 

 

Reflections on retirement

Morale in the NHS

Reflections on retirement

Philip D Welsby

 

 

Do I need to say that I enjoyed this?

Glan Clwyd

Hospital may need rebuilding

Resuscitation

A dead patient arrived late on Saturday and I initiated resuscitation. It was the wrong call.

 

The history: the patient, in her 80s, had been found collapsed. She had been leaning to one side and she had facial asymmetry. She had been collapsed for an indeterminate period of time and it was ten minutes between being found and the paramedic crew arriving on scene.

 

On arrival on scene, the patient’s GCS was 3. She was breathing but stopped soon after and was then ventilated by bag-valve-mask. IV access failed and the patient was transported with bag-valve-mask ventilation. She arrived at the ED 35 minutes after being found. GCS remained 3.

 

Initial examination: apnoea, pupils 5mm bilaterally and unreactive with no brainstem reflexes. Pulse (radial) present, bradycardic, MAP = 54.

 

The patient was dead. Dead people do not have beating hearts. That was my reasoning. However brain dead people do have beating hearts. The probability of CPCR was zero. The incongruity of a beating heart led to a futile attempt at resuscitation that was continued for an additional 15 minutes.

 

The next dead patient who arrives with a beating heart will not have resuscitation attempted. Information that does not make sense cannot be processed under extreme stress. I know that I should disengage, but knowing and remembering under the circumstances are two different things.

Suturing

I did a rotation in plastic surgery as a junior doctor: I wanted to have practice suturing.

 

During my first on-call I spent 6 hours suturing one patient: he had been assaulted with a panga. At the end of that and with more than 12 hours to go to the end of my call I felt that I had had as much practice as I could conceivably want. I still had six months of my rotation to complete.

 

Our commitments are made in ignorance. And hindsight is no good: given the answer all problems look solvable.

 

Last night I sutured a complex facial laceration on an elderly patient – it was slow, difficult suturing and took some time. It reminded me of two things: practice makes perfect (cf. practice makes permanent) and time is the ultimate value (cf. Wal-Mart vs. Google).

 

Spannungsbogen

Where do you draw the line between maturity and pathology?

Brain Scans Reveal Why Meditation Works

Live Science

Dr. Robert Schuller

What would you attempt to do if you knew you could not fail?

    Dr. Robert Schuller

Personal Development

Personal Development

Metacognition

Metacognition

LPFB Mindmap

LPFB mindmap

Personal development goals

• Think better
• Speak better
• Read faster
• Type faster
• Move better
• Imagine!

 

 

 

Life and Death

All stress, including fatigue, narrows one’s focus. A narrow focus means failing to attend to relevant information and weighting some information too heavily. A narrow focus, then, misdirects sometimes disastrously.

 

Reflection improves performance and reflection in action improves it sooner. In clinical care many events are singular so that reflection after action helps only with process rather than specific actions whereas reflection in action helps with what one is dealing with specifically. Highly dynamic, time critical events do not lend themselves to reflection in action particularly because they are stressful. What is needed is the facility to step back in critical moments, to disengage.

 

The patient is dying; disengage. That, friend, is easier said than done.

 

My belief that I have no control over life and death and that death is destined allows me to disengage. I cannot save those who will die: nothing I do will make a difference. My task then is to see that those who survive do so with the best possible outcomes. There is a central inconsistency here, but inconsistency is human. And I have no wish to debate whether death is destined or not. My conviction is pragmatic: I do not decide life and death so I am free to be as heroic as I choose: I have control of the process, not the outcome.

 

How do you deal with stress? How do you free your stuck cognitive gears when life is on the line?

To my networks

What are you particularly good at?

 

What are you becoming particularly good at?

 

What would you want to be particularly good at?

 

 

Social Networks

If memory is part structure, part process and part cue and knowing is largely network both internal and external, how is social-network knowing if it is unmapped and almost all tacit? We don’t know what others know and can never know.

 

Needing to know, we can ask. Broadcast is most efficient, but how responsive are our networks to broadcast requests? Until such time as networks are ubiquitous and intelligent and people are responsive, broadcast will not be workable for important things.

 

ICT literacy is generally, lamentably, poor.