slightlymoving

why can’t i rotate my photos in tumblr?

i spent this morning with the local ACAT (aged care assessment team). and i really enjoyed it. i think geriatrics and palliative care are two interesting areas of medicine that (in some ways) get overlooked.

as part of the morning we saw two potential clients for assessment. they had markedly different reasons for the assessment being requested. one was a 75 year old man with progressing dementia who is being looked after by his son - and the focus was primarily on respite care. the man had become more verbally abusive and difficult and the son needed a break. the second was an 80 year old woman who had had shoulder surgery and needed some assistance with ADLs when she returns home (which she was keen to do asap) from hospital.

there was a moment during the assessment with the woman where she talked about sometimes feeling lonely (her husband had died a few years ago), particularly in the early evening. she is able to occupy herself during the day by going to various groups, but now that she’s living on her own it’s the time between eating dinner and going to bed that make her saddest.

and, while residential care would offer her more social contact, she is not nearly ready for it and wants to maintain her independence as long as possible. it made me feel that we get so locked into the idea of couples and nuclear families that when it gets to this stage, we become limited in the possibilities. i’ve always been interested in co-housing, and it seems to me that having a situation where you live and share with more people than your immediate family would be beneficial at all stages of life. something to consider for the future…

yep. time has me by the short and curlies.

exams are looming.

and movember has started. so, if you want to support a great cause and donate to motivate me to grow my Mo, then here’s where to do it:
http://au.movember.com/mospace/74246

i’m sure you know what movember is. might be my last year for doing it. 3 years running now.

i should write something about the project jacob and i did on the weekend just gone, up at the natimuk frinj festival. but i just haven’t got the… time.

in medicine, there’s an incredibly embedded hierarchy and tradition that often means teaching methods are slow to change and knowledge acquisition is, in some ways, made a goal in and of itself. part of this system involves memorising long lists… of conditions, side effects, drugs, outcomes, risks, limitations, benefits, statistics, anatomical features… to name a few. some of these lists are useful and are worth having at immediate recall - but many of them are almost pointless to remember because of the detail, the lack of use, and the utility of them.

recently, at a grand rounds presentation, a young fresh-out-of-medical-school intern condescended half the audience by stating he was dropping the topic down to medical student level and briefly discussed the mechanism of action of steroids. he then proceeded to ask each student present to name one side effect of steroid. i think i was about 6th in line and when it came to me i couldn’t think of anything, so i said so. it caused a little uproar in the room, which was fascinating in a number of different ways.

firstly, there were a few encouragers, suggesting that i did know more side effects and could think of one. there was a call for nudging my neighbour to get a whispered answer - accompanied by some whispered answers. there was a scornful call of that’s just not good enough. and finally a plaintive voice saying it was important to know as it will be on the exams and you’ll get asked a lot as an intern.

amazing really, to get such a varied and active response.

for me though, it highlighted some of the things that concern me about medical education and the lack of thought behind such methods for consolidating knowledge. the assumption here is that the intern was attempting to help us learn and not simply assert a knowledge hierarchy - and i’d like to give him the benefit of doubt.

the main concern for me is about equating immediate recall with knowledge. if you can answer a question with a list then you show you know something - when of course, that’s not necessarily the case at all. i often see some students reeling off a list in answer to a question but most of the list having absolutely nothing to do with the situation at hand. i suppose it comes down to ways of thinking and working. a computer might be good at processing through lists to determine appropriate choices according to set criteria - but most humans are not. the best clinicians i see are attentive to their patients so that when they give them steroids, for example, they don’t reel off a long list of possible side effects (mind the buffalo hump won’t you) but engage with the patient about observing changes and symptoms.

a list will always be written down in a book. or on your iphone. or on wiki.

there’s more to this post but i’m a bit tired after that effort…

Jacob and I performed tonight. First time together since the start of the year.

We had a fairly short warmup time, which served to show us just how little stamina we have. And during the day we’d been discussing our practice and teaching and thoughts about improv process. Entanglement.

The performance went reasonably well and in reviewing I think that while we have a strong performance ‘muscle’ our dance and compositions ‘muscles’ have atrophied somewhat. I’m keen to see what happens over the next few nights…

Earlier in the day I’d listened to the Hon Nicola Roxon talk at GP’09 conference about national health reform. The Q+A that followed was interesting and was recorded as part if their ‘consultation’ process. I like to think that the reforms are being approach in an open and strategic manner, but it’s hard to tell right now.

Oh oh… Starting to mix my posts…

subtle title, i know.

but right now i can still smell faeces. this morning was my second major involvement in a MET call. i’ve been to a number this year but mostly just as an observer (or contributing in very minor ways). this time though, i participated and gave closed cardiac compressions to a man in his 60s who had gone in to arrest following thombolysis for an AMI. in the process of trying to help this man by breaking down the thrombus causing the MI (using retaplase for those who want to know), he’d gone into a reperfusion injury arrhythmia and was in VF. (as a side note, isn’t wiki great)

we’ve been going over ACLS and i knew this was a witnessed and monitored arrest so according to protocol he should have been given 3 defibrillation shocks as initial management followed by CPR. he did get two, but then there seemed to be a delay while waiting for a senior clinician. in the meantime cardiac compressions were commenced. he had no output (no pulse) and was being bagged and the monitor continued to show VF. once the senior was there another shock was given and CPR continued on… but then, despite staying in VF for the next 15 minutes it took that long for another shock to be ordered.

now, i know i’m not that experienced, but all evidence points towards early defibrillation being the only intervention that makes a difference to outcome in arresting patients. some reading on the efficacy of a MET if you’re interested. and he did get early defib, but not according to protocol. it’s possible a 3rd early shock would have depolarised the heart enough to get it back into rhythm… but then, i don’t know if the protocols are based on level 1 evidence - it would be difficult to perform a RCT or get ethics clearance.

so, this guy did eventually get back into sinus rhythm but was intubated, put on a ventilator and then transferred by helicopter to a major sydney hospital. he wasn’t looking good, and if you read that article above only about 17% of arresting patients survive to discharge. in the midst of the ACLS (oh, he wasn’t sedated initially and was reflexively/voluntarily responding to the pain of the cardiac compressions) he defecated.

the smell has stayed with me all day.

if you don’t want CPR, make sure you have an advanced care directive. have a read of this article for one doctor’s thoughts on CPR and why he doesn’t want it.