Limping Grand daughter.
Plastic PPRuNer
Oooh! I loved Davaar's story! Reminds me of a classic Poe story that horrified me as a child - "The Facts In The Case Of Mr Valdemar" - ".....there lay a nearly liquid mass of of loathsome, of detestable putrescence".
Let me tell you another story that a friend told me who'd heard it from a real pilot. Once upon a time there was an aircraft, a 747 Classic to be precise, that led an entirely blameless life until one day when the Flight Management Computer started to misbehave. Whatever destination you entered, it would obediently follow for a while and then start drifting off. If you reset it, it would behave for while and then this strange behaviour would start again. This was most upsetting for pilots and the company and many things were tried to correct it. After much harrumphing the engineers replaced the entire unit, but to their surprise the navigational drift in the FMC persisted! Much consternation! Further data analysis revealed that the aircraft keep trying to pursue a heading of 45°24' N 75°40' W ! Most mysterious! But as luck would have it, the A/C was due for a D check and was trundled of to a hangar where everything was taken apart from inspection. After everything was stripped down and inspected, a most strange thing was found! Behind a blank panel in the avionics bay they found the dead body of a Canadian beaver! This was removed, the D Check completed and the aircraft returned to service. Now the FMC behaved perfectly and the aircraft obediently went wherever it was told with no more fuss.
The only explanation that they could come up with was that the beaver had stowed away to get home but expired enroute. However it's corpse still wanted to go home and was somehow mysteriously influencing the FMC! Isn't that amazing!
Let me tell you another story that a friend told me who'd heard it from a real pilot. Once upon a time there was an aircraft, a 747 Classic to be precise, that led an entirely blameless life until one day when the Flight Management Computer started to misbehave. Whatever destination you entered, it would obediently follow for a while and then start drifting off. If you reset it, it would behave for while and then this strange behaviour would start again. This was most upsetting for pilots and the company and many things were tried to correct it. After much harrumphing the engineers replaced the entire unit, but to their surprise the navigational drift in the FMC persisted! Much consternation! Further data analysis revealed that the aircraft keep trying to pursue a heading of 45°24' N 75°40' W ! Most mysterious! But as luck would have it, the A/C was due for a D check and was trundled of to a hangar where everything was taken apart from inspection. After everything was stripped down and inspected, a most strange thing was found! Behind a blank panel in the avionics bay they found the dead body of a Canadian beaver! This was removed, the D Check completed and the aircraft returned to service. Now the FMC behaved perfectly and the aircraft obediently went wherever it was told with no more fuss.
The only explanation that they could come up with was that the beaver had stowed away to get home but expired enroute. However it's corpse still wanted to go home and was somehow mysteriously influencing the FMC! Isn't that amazing!
This implies as I read it that patient = population. There I disagree. The first is people, the second is statistics.
One startling difference I noticed in the transition from Secondary to Primary, was that at one time I may have spent days, sometimes weeks, devoting a whole load of resources at one time, to only perhaps only one or two patients. (Totally necessary at that time.)
It did take a while to adapt to primary care, but I soon came to realise, that my responsibility wasn't just to the patient sat in front of me, nor to those sat outside in the waiting room. My team, and I, were actually responsible for the health of the 15,000 patients who we served in our community.
Our patients were dying of diseases, the mortality and morbidity of which, could be reduced by effective, systematic care, which, sometimes doesn't exist.
(Remember the "Rule of Halves," for patients suffering with hypertension.)
We have the magic bullets to treat diseases and prevent diseases, and the evidence to support these interventions, but unfortunately, we continue to deliver the magic bullets in a haphazard unsystematic way.
We have to think imaginatively (whether that means expanding the roles of nurses, pharmacists, prescribers, health care assistants), if we are to make a real difference to our populations, and patients, health.
The medico-legal arguments against expanding roles of "para" medics is an interesting one, and not my area of expertise. I'm not aware of any evidence to suggest safety has been compromised by professionals exploring their boundaries.
Last edited by gingernut; 16th Aug 2006 at 12:26.
Plastic PPRuNer
Interesting post gingernut.
"Approximately 3.3 million (30%) deaths annually were due to heart disease, 2.3 million (21%) to cancer, 1.5 million (14%) to stroke, 0.9 million (8%) to chronic respiratory diseases, and 0.8 million (7%) to violent causes (i.e., intentional and unintentional injuries). An estimated 1.5 million (14%) deaths annually are attributed to cigarette smoking." Recent WHO figures for the Developed World.
"Clearly, heart disease and cancer exact a tremendous toll on public health, together causing over half of all deaths in the United States each year. However, homicide among black males and unintentional injuries among white and black males cause the greatest years of potential life lost before age 65."
What's changed? Well, infectious diseases are almost off the map, though RVD (retroviral disease, a nice way of saying AIDS) pushes the figures up a bit.
Where are TB, cholera, diphtheria, polio, puerperal fever, typhoid, typhus, pneumonia, tetanus, gastroenteritis and septicaemia?
It is important for people to realise that the major determinants of decreased morbidity and mortality since the nineteenth century come not from medicine, but from improvements in public health: Better sanitation, sewers, water closets, Clean Air Acts, Safety in the Workplace, literacy and numeracy, regulation of food production and adulteration, safety glass, fire-resistant nighties, better housing, less overcrowding, mass miniature X-rays, slum clearance, minimum wages and National Insurance, pensions, electrical/mechanical/heating safety regulations, and building codes to name but a few.
Enter obesity and all it's sequelae (diabetes, cardiac disease, stroke), homicide, motor vehicle accidents, drug abuse, depression, anxiety and the accidie of modern society.
Yes, we do have _some_ magic bullets (the recent virtual elimination of peptic ulcer disease by treatment of helicobacter pylori springs to mind), but the magic bullets we need now (apart from for cancer) are largely those that will change negative patterns of human behaviour rather than anything else.
Doctors are involved with disease, not health - we're not very good at health because that isn't our job. Yes, we can participate in screening programs. Yes, we can promote health by encouraging healthy behaviour when we meet our patients, but there's little we can do before they get sick. That is the job of government and the community.
Disease is the doctors problem. Health is the wider community's problem.
And there's the rub. To make much further impact we have to change people and people's behaviour, which is a far more difficult thing. Much of mankind's foolish behaviour is intrinsic to being human - to change this is no small thing. Aggression and competition are particularly male components of behaviour - how can we curb and channel these without demonising these energising principles? Nurturing and the desire to have children are particularly female components - how can we attune these to 21st century realities without desexing women? The impulse towards pleasure is universal - how can we ensure that this powerful urge is exercised in a responsible way?
The current European belief that such changes can be legislated into existence is absurd. The ever increasing crop of laws that would seek to regulate the smallest corners of our lives brings the law itself into contempt and worsens our problems. The absence of codes of Good Citizenship, the cult of the individual, the abolishment of the doctrine of personal responsibility and the idea that it is always someone else's fault erode our society and make improving public health in the larger sense almost impossible.
I am encouraged (for my society) by the emphasis my son's South African school places on manners, fairness, kindness, tolerance, responsibility and hard work as being the pillars of our nation.
I quite agree, but I think you are addressing the wrong problem. All these things are admirable but target only a small part of the health equation.
Safety is compromised when doctors step outside their areas of competence and this is not a rare occurrence. Paramedical personnel are no different. That is why the General Medical Council, the Nursing Council and the Midwives Council have very strictly defined regulations about what you can and cannot do. Stay within these bounds and you need have no fear. The scope of practice of some other paramedical groups is far less well defined and the chance of finding oneself in difficulties if one "explores their boundaries" is correspondingly greater. These are matters of legal responsibility defined by Acts of Parliament and are determined by the electorate - they really have nothing to do with doctors.
A fascinating discussion.
"Approximately 3.3 million (30%) deaths annually were due to heart disease, 2.3 million (21%) to cancer, 1.5 million (14%) to stroke, 0.9 million (8%) to chronic respiratory diseases, and 0.8 million (7%) to violent causes (i.e., intentional and unintentional injuries). An estimated 1.5 million (14%) deaths annually are attributed to cigarette smoking." Recent WHO figures for the Developed World.
"Clearly, heart disease and cancer exact a tremendous toll on public health, together causing over half of all deaths in the United States each year. However, homicide among black males and unintentional injuries among white and black males cause the greatest years of potential life lost before age 65."
What's changed? Well, infectious diseases are almost off the map, though RVD (retroviral disease, a nice way of saying AIDS) pushes the figures up a bit.
Where are TB, cholera, diphtheria, polio, puerperal fever, typhoid, typhus, pneumonia, tetanus, gastroenteritis and septicaemia?
It is important for people to realise that the major determinants of decreased morbidity and mortality since the nineteenth century come not from medicine, but from improvements in public health: Better sanitation, sewers, water closets, Clean Air Acts, Safety in the Workplace, literacy and numeracy, regulation of food production and adulteration, safety glass, fire-resistant nighties, better housing, less overcrowding, mass miniature X-rays, slum clearance, minimum wages and National Insurance, pensions, electrical/mechanical/heating safety regulations, and building codes to name but a few.
Enter obesity and all it's sequelae (diabetes, cardiac disease, stroke), homicide, motor vehicle accidents, drug abuse, depression, anxiety and the accidie of modern society.
Originally Posted by gingernut
We have the magic bullets to treat diseases and prevent diseases, and the evidence to support these interventions, but unfortunately, we continue to deliver the magic bullets in a haphazard unsystematic way.
Doctors are involved with disease, not health - we're not very good at health because that isn't our job. Yes, we can participate in screening programs. Yes, we can promote health by encouraging healthy behaviour when we meet our patients, but there's little we can do before they get sick. That is the job of government and the community.
Disease is the doctors problem. Health is the wider community's problem.
And there's the rub. To make much further impact we have to change people and people's behaviour, which is a far more difficult thing. Much of mankind's foolish behaviour is intrinsic to being human - to change this is no small thing. Aggression and competition are particularly male components of behaviour - how can we curb and channel these without demonising these energising principles? Nurturing and the desire to have children are particularly female components - how can we attune these to 21st century realities without desexing women? The impulse towards pleasure is universal - how can we ensure that this powerful urge is exercised in a responsible way?
The current European belief that such changes can be legislated into existence is absurd. The ever increasing crop of laws that would seek to regulate the smallest corners of our lives brings the law itself into contempt and worsens our problems. The absence of codes of Good Citizenship, the cult of the individual, the abolishment of the doctrine of personal responsibility and the idea that it is always someone else's fault erode our society and make improving public health in the larger sense almost impossible.
I am encouraged (for my society) by the emphasis my son's South African school places on manners, fairness, kindness, tolerance, responsibility and hard work as being the pillars of our nation.
Originally Posted by gingernut
We have to think imaginatively (whether that means expanding the roles of nurses, pharmacists, prescribers, health care assistants), if we are to make a real difference to our populations, and patients, health.
Originally Posted by gingernut
The medico-legal arguments against expanding roles of "para" medics is an interesting one, and not my area of expertise. I'm not aware of any evidence to suggest safety has been compromised by professionals exploring their boundaries.
A fascinating discussion.
Last edited by Mac the Knife; 16th Aug 2006 at 19:15.
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Originally Posted by Mac the Knife
Safety is compromised when doctors step outside their areas of competence and this is not a rare occurrence. Paramedical personnel are no different.
Case referred to my clinic for management of musculoskeletal symptoms this week.
Patient falls off bicycle. Rear of helmet smashed by fall and patient sustains cut to back of head / neck at foramen magnum level.
Patient goes to hospital A. Glasgow Coma Scale (GCS) normal so patient sent home without further investigation. Patient wakes 3 or 4 days later in pool of blood and vomit.
Patient taken to hospital B by sister. GSC still normal and some investigations undertaken but patient sent home with advice not to be alone ! Two days later Hospital B calls and tells patient to return immediately due to investigations showing blood on brain plus collapsed lung.
Patient goes to hospital C now that they are at home with parents. Now one week post head injury and hospital C admits patient for one week. Patient spends it asleep most of the time.
Patient has had a suspected brain stem injury and will take many months to recover. It would appear that none of the hospital staff this patient saw stepped outside of their competence here. The question is did they really live up to it ?
Plastic PPRuNer
Stepping outside your competence is completely different from negligence within it (which is what you describe).
The first is doing things you have not been trained to do and the second is failing to do what you have been trained to do.
I'm not quite sure why you are so resistant to the idea that physios and other paramedics may succumb to the temptation to step outside their sphere of competence. As I have tried to point out, none of us are immune to this.
You may personally feel that your own competence is sufficient to allow you to adventure further than your peers and you may be correct. However, if you get it wrong the courts are liable to take a dim view of it.
If you feel constrained by your role, why not study medicine? I have a surgical colleague who was a radiographer and my oncologist wife has two colleagues who in previous incarnations were a social worker and a laboratory technician respectively.
The first is doing things you have not been trained to do and the second is failing to do what you have been trained to do.
I'm not quite sure why you are so resistant to the idea that physios and other paramedics may succumb to the temptation to step outside their sphere of competence. As I have tried to point out, none of us are immune to this.
You may personally feel that your own competence is sufficient to allow you to adventure further than your peers and you may be correct. However, if you get it wrong the courts are liable to take a dim view of it.
If you feel constrained by your role, why not study medicine? I have a surgical colleague who was a radiographer and my oncologist wife has two colleagues who in previous incarnations were a social worker and a laboratory technician respectively.
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No one denies there are incompetent or negligent doctors out there. Fortunately they are the minority.
Should we train flight attendants to start flying aeroplanes because there have been a few crashes caused by 'pilot error'???????
Should we train flight attendants to start flying aeroplanes because there have been a few crashes caused by 'pilot error'???????
It is important for people to realise that the major determinants of decreased morbidity and mortality since the nineteenth century come not from medicine, but from improvements in public health
Health itself is an interesting concept. As a clinician, my idea of health is sometimes very different than that of the patient (or population) I serve. Joe Bloggs sat in front of me, may not be too concerned about the fact his diabetic control is far from ideal, he may be more concerned about avoiding hypoglycaemic attacks which could result from tighter diabetic control.
Simillarly, if you asked me what the indicators of bad health are, I'd probably suggest tight BP control, healthy Body Mass Index, not smoking, healthy diet, moderate alcohol intake etc. If you ask our population, (and we have), they're more concerned with not having dog sh*t on the street, having more parks and feeling safe at night.
I'd agree that there is some "locus of control" within the patient themselves, but I don't really want to get into a victim blaming argument, suffice to say that the oppurtunities for me, as a middle class educated white man, are different than those afforded to my population.
I have to disagree about the doctor/nurse practitioner/physio/pharmacist argument. The "letting the stewardess fly the plane," argument is one I've heard before, (many times), but I think the case for "para" medics expanding their role competently is more complex.
The case for "para" medics expanding their role has come about for various reasons;
-Shift in patterns of demand/supply
-Information technology
-Changes in disease management
If you wish I could expand on each of these determinents, but perhaps I could give an oversimplified example;
20 yrs ago, if you developed hypertension, there may have been a good chance that you could have been managed by a hospital team. Years later, the same patient could have been managed by a primary care physician. Following the rules allowing nurses to expand their role, (and prescribing rights), the patient would then be managed by a primary care nurse.
Today, if you are a patient of mine, with controlled hypertension, you would be actively managed by a health care assistant, who, very safely and competently, manages, systematically, your condition.
We work well as a team, I am extremely confident that she manages our patients "better" than I ever did. This frees up my time to manage more complex cases, and the shift nudges up the chain up to the level of tertiary care.
Incidentally, the decision to explore our boundaries doesn't totally come from within- I have no desire to change my profession, and I could have opted to stay put in a more "comfortable," area-probably leading to an easier life- I have several colleagues who have chosen this route. The desire to explore and develop, comes with wanting to make a difference.
Of course it has to be safe- this is paramount, the key to this, as you have pointed out is competencty, and there are various mecanisms in place to ensure this.
The case presented by flyingphysio is interesting.I can perhaps second guess the outcome of this. Either hospital A, B, and C will blame each over, suggesting area's of incompetence for its partners, or the ranks will close, with neither A,B or C commenting on each others performance.
Its difficult for me to comment on the clinical aspects- it's not my area of expertise, but from what I see about this case, is that there is a golden oppurtunity for each team involved in the care of this patient to reflect and learn from the incident. Is this likely to happen- No. (Nurses are worse in this aspect than doctors.)
The skills of the surgeon, physio, pharmacist and nurse, are all different- but I believe that the patient should follow the same care pathway, if he presented to any of these highly skilled, reflective clinicians with a presenting problem, if that clinician had the competences to deal with that situation. The bottom line, of course, is having the competency to know when you can't deal with that problem, or problms. Simplistic, I know, and I realise that patients (and their problems), don't always fit into neat little boxes, but I'm afraid the argument that clinical accumen saves life is rather dated and not reflected by the available evidence.
I think we (the health care system), have to get away from what's best for us, as professionals,and concentrate on what's best for the patient.
These are my views, feel free to disagree.
Have a good week, I'm off surfing :-) I'm sure its better for the mind& soul than all these crappy antidepressants we sometimes dish out a little too easilly, but perhaps that is a different argument.
Last edited by gingernut; 17th Aug 2006 at 15:10.
Plastic PPRuNer
Well, I DO disagree, fairly profoundly, on many points.
I'm not going to argue further, for I think that I have covered most of the issues in my previous posts. Anyway, I don't believe for a minute that anything I could say will cause gingernut to reflect more or deflect him from his mission.
Many years ago I worked as a GP down the Old Kent Road (a poor part of London). This was a salutary lesson to me, after several years of hospital practice. That was before the MRCPGP and all that. The senior partner told me, only half joking, "If they're sick, send them to hospital and if they're not sick, give them a certificate!". And indeed, the vast majority of patients that I saw were not sick in the sense that I was used to. Sprains and pains and scrapes, earache, rashes, the pill and the coil, gastritis, "back trouble", menstrual problems, coughs and colds, old age, school difficulties, maturity onset diabetes, pimples, the "drip", arthritis, tiredness, hypertension, enuresis and teenage pregnancies, teenage pregnancies. Never an osteosarcoma or a Horner's syndrome, only an occasional jaundice or rectal bleeding to sink your teeth into (except that lab results took weeks and we had no sigmoidoscope). It was a whole other world. We still did house calls, though I learned very quickly that trying to read an ECG by a 40 watt bulb at 2am in a dishevelled council flat reeking of cat urine was a largely fruitless exercise. Far better to call the emergency bed service and an ambulance. Still, I did beat the LAS to a couple of deliveries. None of my patients complained of their obesity and my advice about weight loss was usually greeted with wry amusement. No so my timid enquiries about alcohol use patterns in the patients who arrived reeking and demanding a "sustificate"! All the chron. brons. with their Old Holborn rollups and their Ventolin and their repeated courses of Amoxil....
And after a few months, the cheery greetings at the shops - "Hullo Doctor!", "My Ern's much better, thanks", "Them aintibioticts you gave me fer me' cold worked a treat!" A strange and wonderful life. No practice managers, occupational therapists, podiatrists, practice nurses, physiotherapists or social workers, you were on your own.
Could an experienced practice nurse have dealt with all this? I suppose so, with enough training, but by then he/she would be not far off a medical qualification and presumably would command a commensurate salary. The doctor could then (his contact with most of his patients having been removed) get on with the business of practice management, strategic planning and education. The doctor has become an administrator and the nurse a doctor. What has been achieved?
Still, with the dreadful state of medical education in the UK (I get lots of UK exchange students) and the continued assault on the independence and reputation of doctors by the press and government (coupled with an influx of even more indifferently trained doctors from the ex-Soviet bloc) this might not be a bad thing.
"I'd agree that there is some "locus of control" within the patient themselves, but I don't really want to get into a victim blaming argument, suffice to say that the oppurtunities for me, as a middle class educated white man, are different than those afforded to my population."
Possibly, but this is an extraordinarily negative, disempowering and patronising statement
"I think we (the health care system), have to get away from what's best for us, as professionals,and concentrate on what's best for the patient."
Speak for yourself gingernut. The canard that doctors do not have their patient's best interests at heart and are only interested in feathering their own nests is a vicious lie propagated by those who would see medicine relegated to the abject condition that it was reduced to in the USSR. The results are plain to see.
"I'm afraid the argument that clinical accumen saves life is rather dated and not reflected by the available evidence."
This breathtaking pronouncement at one stroke annuls the entire basis of medical education. If clinical acumen is worthless then why bother to train clinicians (of any kind) at all? But I sense that the removal of clinical responsibilities from persons who have graduated from medical school (one can't really call then doctors anymore) is gingernut's aim.
This is probably a bit unfair, but here goes. Recently I operated a teenage boy from Somewhereovia who had complained of ankle pain after gymnastics practice. Physiotherapy and rest produced some relief and this was continued. After 10 weeks swelling was obvious, a doctor consulted and an X-ray done. This showed an extensive distal tibial osteosarcoma. Despite chemotherapy and surgery he now has disseminated disease and his prognosis is very poor. Would an earlier diagnosis have changed this? Maybe. What price clinical acumen now?
Ah well...
I'm not going to argue further, for I think that I have covered most of the issues in my previous posts. Anyway, I don't believe for a minute that anything I could say will cause gingernut to reflect more or deflect him from his mission.
Many years ago I worked as a GP down the Old Kent Road (a poor part of London). This was a salutary lesson to me, after several years of hospital practice. That was before the MRCPGP and all that. The senior partner told me, only half joking, "If they're sick, send them to hospital and if they're not sick, give them a certificate!". And indeed, the vast majority of patients that I saw were not sick in the sense that I was used to. Sprains and pains and scrapes, earache, rashes, the pill and the coil, gastritis, "back trouble", menstrual problems, coughs and colds, old age, school difficulties, maturity onset diabetes, pimples, the "drip", arthritis, tiredness, hypertension, enuresis and teenage pregnancies, teenage pregnancies. Never an osteosarcoma or a Horner's syndrome, only an occasional jaundice or rectal bleeding to sink your teeth into (except that lab results took weeks and we had no sigmoidoscope). It was a whole other world. We still did house calls, though I learned very quickly that trying to read an ECG by a 40 watt bulb at 2am in a dishevelled council flat reeking of cat urine was a largely fruitless exercise. Far better to call the emergency bed service and an ambulance. Still, I did beat the LAS to a couple of deliveries. None of my patients complained of their obesity and my advice about weight loss was usually greeted with wry amusement. No so my timid enquiries about alcohol use patterns in the patients who arrived reeking and demanding a "sustificate"! All the chron. brons. with their Old Holborn rollups and their Ventolin and their repeated courses of Amoxil....
And after a few months, the cheery greetings at the shops - "Hullo Doctor!", "My Ern's much better, thanks", "Them aintibioticts you gave me fer me' cold worked a treat!" A strange and wonderful life. No practice managers, occupational therapists, podiatrists, practice nurses, physiotherapists or social workers, you were on your own.
Could an experienced practice nurse have dealt with all this? I suppose so, with enough training, but by then he/she would be not far off a medical qualification and presumably would command a commensurate salary. The doctor could then (his contact with most of his patients having been removed) get on with the business of practice management, strategic planning and education. The doctor has become an administrator and the nurse a doctor. What has been achieved?
Still, with the dreadful state of medical education in the UK (I get lots of UK exchange students) and the continued assault on the independence and reputation of doctors by the press and government (coupled with an influx of even more indifferently trained doctors from the ex-Soviet bloc) this might not be a bad thing.
"I'd agree that there is some "locus of control" within the patient themselves, but I don't really want to get into a victim blaming argument, suffice to say that the oppurtunities for me, as a middle class educated white man, are different than those afforded to my population."
Possibly, but this is an extraordinarily negative, disempowering and patronising statement
"I think we (the health care system), have to get away from what's best for us, as professionals,and concentrate on what's best for the patient."
Speak for yourself gingernut. The canard that doctors do not have their patient's best interests at heart and are only interested in feathering their own nests is a vicious lie propagated by those who would see medicine relegated to the abject condition that it was reduced to in the USSR. The results are plain to see.
"I'm afraid the argument that clinical accumen saves life is rather dated and not reflected by the available evidence."
This breathtaking pronouncement at one stroke annuls the entire basis of medical education. If clinical acumen is worthless then why bother to train clinicians (of any kind) at all? But I sense that the removal of clinical responsibilities from persons who have graduated from medical school (one can't really call then doctors anymore) is gingernut's aim.
This is probably a bit unfair, but here goes. Recently I operated a teenage boy from Somewhereovia who had complained of ankle pain after gymnastics practice. Physiotherapy and rest produced some relief and this was continued. After 10 weeks swelling was obvious, a doctor consulted and an X-ray done. This showed an extensive distal tibial osteosarcoma. Despite chemotherapy and surgery he now has disseminated disease and his prognosis is very poor. Would an earlier diagnosis have changed this? Maybe. What price clinical acumen now?
Ah well...
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Originally Posted by Mac the Knife
I'm not quite sure why you are so resistant to the idea that physios and other paramedics may succumb to the temptation to step outside their sphere of competence. As I have tried to point out, none of us are immune to this.
Originally Posted by Mac the Knife
If you feel constrained by your role, why not study medicine?
Originally Posted by Mac the Knife
This is probably a bit unfair, but here goes. Recently I operated a teenage boy from Somewhereovia who had complained of ankle pain after gymnastics practice. Physiotherapy and rest produced some relief and this was continued. After 10 weeks swelling was obvious, a doctor consulted and an X-ray done. This showed an extensive distal tibial osteosarcoma. Despite chemotherapy and surgery he now has disseminated disease and his prognosis is very poor. Would an earlier diagnosis have changed this? Maybe. What price clinical acumen now?
On a postive note, I am glad you have moved on from the Old Kent Road. I was worried by your desire to get your teeth into some rectal bleeding !!
Keep up the good work in your field.
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Hmm, one wonders whether the GPs down the Old Kent Road would have known to send the kid off for an X-ray either. My recollection of that lot was a recorded message saying "The Surgery is closed, if you are sick call 999, if you are not then make your way to Guy's casualty", Some great pubs down there though, and once they knew you were from The Hospital extremely hospitable. The patient population were all salt of the earth. When you see the top heart surgeon in the country get called out of bed at 2am to fix an old docker's ticker at no cost to the patient, you realise how good the NHS can be. I think Thatcher later decided to shut his department down for a few months, he was doing too many operations and spending too much money.
Those who say specialists shouldn't have extensive medical training should sit in an outpatients clinic in an area where the GPs aren't too good. The referrel letter says "Dr Doctor, Please advise", and if the specialist didn't know a lot about medicine outside his speciality, the patient would never get a diagnosis.
That lot will have retired by now, and I am sure it's all changed for the better. I am sure Mac was a good one
Had a good friend die of osteosarcoma, surgeon too and he never caught it in time, thought his knee was sore from playing sport. Nasty thing to get, kills quickly and ibuprofen doesn't fix that sort of thing.
Those who say specialists shouldn't have extensive medical training should sit in an outpatients clinic in an area where the GPs aren't too good. The referrel letter says "Dr Doctor, Please advise", and if the specialist didn't know a lot about medicine outside his speciality, the patient would never get a diagnosis.
That lot will have retired by now, and I am sure it's all changed for the better. I am sure Mac was a good one
Had a good friend die of osteosarcoma, surgeon too and he never caught it in time, thought his knee was sore from playing sport. Nasty thing to get, kills quickly and ibuprofen doesn't fix that sort of thing.
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[QUOTE=Curious Pax]As Belfast Child mentions it could be Perthes - although 3 is young that is the age when my son was diagnosed with it. If it is that then young is good as they seem more likely to recover without intervention.
Perthes is where the ball at the top of the thigh bone that fits into the hip bone crumbles - sounds frightening at first, but the bone slowly grows back, and the child is monitored with x-rays to ensure that the new bone is developing with the correct shape. Diagnosis is also easy because an x-ray of the hip shows it clearly.
Legg Perth's on a plain film usually shows stippled epiphyses and has similar plain film findings to MED multiple epiphyseal dysplasia[sometime presents with mild retardation, but the phenotype is morbidly affected, also in the same Diff Diag category is Hurler's syndrome. ref. Harrold Rosenbaum's, 100 pearls in clinical diagnostic Radiology
sorry, no time now to read through, but from the first post I feel that your GP needs to look more carefully, and definitey enlist the assistance of both Pediatric ortho and neuro as a start. THIS MUST BE THOUROUGHLY INVESTIGATED FIRST!! b4 talking of factitious disorders
I'm not gonna add more[ I don't have enough info] and because this is a sensitive topic and I don't wish to speculate.
my heart goes out to the little miss, may all be well.
rhov
Perthes is where the ball at the top of the thigh bone that fits into the hip bone crumbles - sounds frightening at first, but the bone slowly grows back, and the child is monitored with x-rays to ensure that the new bone is developing with the correct shape. Diagnosis is also easy because an x-ray of the hip shows it clearly.
Legg Perth's on a plain film usually shows stippled epiphyses and has similar plain film findings to MED multiple epiphyseal dysplasia[sometime presents with mild retardation, but the phenotype is morbidly affected, also in the same Diff Diag category is Hurler's syndrome. ref. Harrold Rosenbaum's, 100 pearls in clinical diagnostic Radiology
sorry, no time now to read through, but from the first post I feel that your GP needs to look more carefully, and definitey enlist the assistance of both Pediatric ortho and neuro as a start. THIS MUST BE THOUROUGHLY INVESTIGATED FIRST!! b4 talking of factitious disorders
I'm not gonna add more[ I don't have enough info] and because this is a sensitive topic and I don't wish to speculate.
my heart goes out to the little miss, may all be well.
rhov
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Great thread. Why such erudite types as mac waste time posting on an aviation website defeats me.
But CC,a digression; did you know that cheetahs whistle? They sound like songbirds. Had some as 'passengers' once.
Hope the girl gets better.
But CC,a digression; did you know that cheetahs whistle? They sound like songbirds. Had some as 'passengers' once.
Hope the girl gets better.
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Originally Posted by Re-entry
Why such erudite types as mac waste time posting on an aviation website defeats me.
I hope the little girl is doing well and her problem has been properly diagnosed and treated by now.
Está servira para distraerle.
Thread Starter
A timely reminder that I have been remiss at posting an update on this thread. I have been quite astounded at the number of replies it has generated, at the depth of knowledge made available and at the concern of many of those who have posted, many thanks to all of you.
I understand that the little girl has now almost ceased to limp but that no one is any the wiser as to why she started doing so in the first place. As far as I can determine, at second hand; the GP has decided to adopt a watch and wait policy and that no X ray has been taken. I am not qualified to pronounce on the wisdom of this but the 'panic' would seem to be over, at least for the time being.
I should be seeing the prime grandparent sometime in the next few days and will post any appropriate update as it may come to my attention.
Again, many thanks to one and all. The input was most appreciated and I rather suspect that the poor old GP in question was somewhat rocked and shocked at the idea that there are people on the internet who actually do know what they are talking about. Perhaps as a consequence of this enlightenment; he will view my opinions with greater respect the next time I attempt to discuss some of the finer points of Septo-Hippocampal Dysfunction with him!
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Originally Posted by Mac the Knife
What's changed? Well, infectious diseases are almost off the map, though RVD (retroviral disease, a nice way of saying AIDS) pushes the figures up a bit...TB, cholera, diphtheria, polio, puerperal fever, typhoid, typhus, pneumonia, tetanus, gastroenteritis and septicaemia
1.Emerging an reemerging infectious disease IS STILL a SERIOUS and worldwide threat.
2. RVD is not HIV/AIDS which is caused by a specific retrovirus, it's not HTLV ETC.
3. mostly in the southern hemisphere, but who cares those things aren't HUMAN
, but with IATROGENIC antibiotic abuse multidrug resistant strains of every thing are popping up [Ceftriaxone for all !!! 
] everywhere, and because of aviation/shipping; no-one is safe. and as Far as HIV goes well when the water here continues being treated incorrectly[ i.e NOT ozonated] well let say it in the form of a hint CRYPTOSPORIOSIS 
We all have NO CLUE
TURBOJETS ONLY
rhov
edited to add: Question my medical mind all you like [anyone]
but remember RHOVSQUARED IS CRAZY... and I'M MY MOTHER'S SON AND I'M NOT AFRAID OF ANYTHING
Está servira para distraerle.
Thread Starter
Just an update on this for the information of all those who have so kindly posted advice.
Apparently the child has stopped limping and the 'specialist', by which I presume the grandparent means a pediatrician, has diagnosed a 'viral hip.'
This doesn't mean much to me other than to convey the impression that the specialist hasn't a clue. Perhaps I am wrong in so thinking.
Anyway, all now seems well and many thanks again. Quite a thread and long may it continue!
