...& so easily are clay feet revealed....

#haiku open on eight sides / no mind in exhalation / violence as repose

#haiku open on eight sides / no mind in exhalation / repose as violence

#haiku Soft hair against my / cheek; scents of joy remembered: / conflate past-future...

#haiku After chrysalis - / samadhi, love, satori / -Lepidoptera

...& my soul exhaled....

one grain

Do you curate

#haiku Purring sigh so deep/ everything slick molten bright/ juddering climax

In search of dopamine and oxytocin

"Communication isn't as simple as saying what you mean."

Favourite word: tinyurl.com/b3pmxf

I collect books to read and probably read 1:9

Machines take consistency to absurd lengths

Working on autobiographical memory

Searching for the story after the fairy tale ending

Great loves are not made of fire and ice

tinyurl.com/avdjel

It's lack of reflection that leads people to believe in hard/clear/determined margins. Edges tend to be fuzzy however sharp they feel - sense and perception are 2 very different things...

Science verifies or falsifies hypotheses but how do scientists generate hypotheses? Clinical medical diagnostics is essentially hypotheses generation and yet when I ask doctors how they arrive at diagnoses they very often tell me that they take a history or examine the patient. The truth is that histories and examinations do not generate diagnoses....

Valentine's Haiku 2

For Valentine's Day:

Loving: fierce hugs, kisses,

Little nips - Passion.

Valentine's Haiku

For Valentine's Day:

Loving: long hugs, soft kisses

Sweet smiles - Tenderness

HAPPY VALENTINES!

Anti-emetics

A little note on Cyclizine and Metoclopramide

It is surprising and sometimes annoying when people state categorically and definitively that cyclizine and metoclopramide antagonise each other. Cyclizine acts centrally on H1, M1, M2 and M3 receptors and Metoclopramide acts both centrally and peripherally on D2 and M1 receptors. Theoretically, there may be competitive inhibition of the one or other at M1 receptors without clinical effect.

These antiemetics do not "block each other" or "cancel each other out".

Act in haste repent at leisure - Why is the repenting always so EXPENSIVE!

protein... fibre... resveratrol....

In search of the counterintuitive

Ahhhhhhhhhh! My soul is almost almost a circle - not quite infinite-sided....

An unjust world is the best of all possible worlds!

Enhanced human cognition is a bandwidth issue

To the space between S & R!

Started following (twitter): CNN, NYT, 10Dowining Street, BBC Click....

Had your dose of reseveratrol today?

If we've spoken - I don't have "normal" conversations. What point normal? I'm looking 4 the shape of your soul; mine's probably similar....

Exercise is a good proxy for control

In celebration of commitment devices & mental accounts - Yay! Tversky! ;-)

I do not know the shape of my soul - & I think that I should.

Prayers complete; why do I pray? It's self management in the same way as meditation....

Can you imagine: doctors used to touch paitents!? They called it an examination!

Can you imagine: operations were done under inebriation!?

learnt tonite that manual evacuation of a rectum is verboten without an anaesthetic (?GA) = abuse....

SIGNIFY!

can an entire cohort lack balance?

What cure for a sensation junkie?

Discovered Google Dictionary

Reading an '89 journal: the entries do not recall the events. Memory is fickle

Portrait of an artist as an old man

In search of a magnum opus

Simpler: how broad & how deep are your stated / known preferences?

How rich are your articulated preferences?

Twitter spam is going to be a huge problem - and I'm not talking about me :)

In search of an affectometer: a device that measures physiological arousal+ambient temperature+geolocation and tells you what you are feeling

At some point life will be perfect - even if only for a day....

Chat better than email for updates too? multiple lines text & multi-updates at a time.

With blogger added to ping I'll have to do more housekeeping

HAPPY NEW YEAR!

BEST WISHES TO EVERYONE FOR 2009!

TIABIM

TIABIM: Taking into account and bearing in mind.

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!

What is the strategic purpose of an Emergency Department?

• It is a safety net to catch anything that may fall through the cracks of existing services
• It deals with accidents to reduce sequelae
• It seeks to resolve emergencies

 

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.

New Year Resolutions

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.

One Bin, One Queue

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?

Problems with our electronic patient system

• It isn’t used: data is not entered
• Data is entered incorrectly and not corrected
• Data is duplicated
• Patients are duplicated and episode data are allocated to one or another patient record rather than both
• It takes time and effort to learn
• Greater use requires greater bandwidth and storage
• Data integrity is an issue
• Authentication for entry, editing and access remains unsolved

The desert teaches many things:

• That life is constant flux – the landscape is always changing
• That life is both fragile and hardy and that it can persist in the most inhospitable environs
• That preparation and vigilance go hand in hand
• That necessity is a hard teacher
• That basics matter
• That nature is indiscriminate

 

GK Chesterton

"We have seen the truth and it makes no sense."

 

G.K. Chesterton

H5N1

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.

Problems

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?

Proposed Blink Communication chart

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

BBC AIDS Day

AIDS DAY

Proposed Predictors of longevity

 

·       Resting pulse and blood pressure

·       Exercise induced pulse and blood pressure variability

·       BMI

·       Fasting blood sugar

·       Health literacy

 

 

Audit

Audit (Definition)

Expertise

“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.

Medical Research

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.

Suture Patents 1984-2007

Suture Patents

Dangerous people

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.

 

BMJ Rapid Response

 

The role of the doctor is four–fold:

 

• To preserve health
• To manage disease: treat, mitigate or palliate
• To act as patient advocate
• To educate: self, colleagues, patients and the public at large

 

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.

 

EBM notebook

The evolving science of translating research evidence into clinical practice

Ian Scott, FRACP, MHA, MBBS

Today...

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.

Purpose

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?

On being clear

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.