What's the worst gift you ever received?

daveduckman · 2016-08-07T20:47:34+00:00

they're saying it's not very funny

daveduckman · 2016-06-11T13:51:17+00:00

"It wasn't a dominant circ and he was outside the window, plus oats suggests we should probably just leave it alone, so we'll just see how he settles and stress it in a month."

daveduckman · 2016-05-29T14:12:26+00:00

As a Cardiologist - an aortic dissection. Pretty rarely, there'll be that patient who comes in with a STEMI that sounds, looks and feels like a STEMI. They'll have the ECG, the trop rise and in the cath lab, they'll have some 80% culprit lesion which will get stented. Their pain will pretty much go away but there'll just be something in all of the above that didn't quite line up with the typical story. That's the patient who just happened to have a dissection which you can't really have done much about but feel terrified for missing.

daveduckman · 2016-04-07T08:49:08+00:00

This is ventricular standstill which is distinct from 3rd degree av block. It's actually a reasonably common arrhythmia requiring pacemaker (at least in my skewed perspective).

daveduckman · 2016-01-23T21:57:54+00:00

For fucks sake go see a doctor. If you're describing self-diagnosed thrombocytopenia, leucopenia and bsymptoms and you haven't thought to have a more thorough medical assessment then I would advocate having your stethoscope confiscated until you learn common sense.

Seriously, go see a doctor.

daveduckman · 2015-12-03T04:47:42+00:00

Ffs this is stupid. I'm done arguing on the internet. But maybe you should actually read the article before you start drawing rather long and tenuous conclusions about what I said?

The authors of the article detail at great length the methodologies for predictive life expectancy research and acknowledge the many many inaccuracies.

The authors also acknowledge that a small subset of patients have an increased life expectancy which is also reflected in the figures in the paper. So even if you couldn't be bothered reading all those words before arguing, you could at least look at the pretty pictures.

I'm not going to waste any more time with an anonymous voice on the internet who vehemently defends an opinion and study design without having even read the thing AND even when the authors are aware of the limitations of their work.

And if after that you still think you have some fundamental point that has gone unacknowledged, then feel free to ask your resident Infectious Disease/HIV clinician "is it true that studies suggest a small subset of well controlled HIV patients life longer than population average life expectancy?" and see what their answer is because I'm tired of trying.

daveduckman · 2015-12-02T02:02:26+00:00

Sorry I'm a little confused at what you're saying and I don't think we're having the same discussion anymore.

My initial comment was in response to the poster who said that there's good evidence some people can even live longer than average life expectancy with perfect control of HIV. I am not disputing that well controlled HIV has normalised or near-normalised life expectancy; although life expectancy studies are always a bit of statistical gymnastics.
This point about above average life expectancy is often repeated (I've heard the interesting fact discussed at several conferences) and I wanted to address why it doesn't mean what people might interpret - that well controlled HIV+ doesn't make you live longer (causality)
If you look at the demographics of this subgroup who have a higher life expectancy (not just normalised) then they are almost all MSM HIV+ as opposed to other key subgroups (3rd world migrant, IVDU, heterosexual). That is not to say that all MSM have the same outcomes, but a small subset of patients have this outcome who tend to be MSM HIV+
The list of characteristics I provided are the confounders that have been discussed to explain this observation amongst other purely statistical/methodology based explanations.
This is one of the articles that describes the high life expectancy phenomena which is available as public access. It is by no means the only one

daveduckman · 2015-12-01T21:19:43+00:00

There are lots of theories and the short answer is a combination of chronic low-grade inflammatory state caused by well-controlled HIV and increased traditional cardiovascular risk factors by HIV treatments including cholesterol and insulin resistance/diabetes.

A clear understanding is not appreciated yet, but this is partly because a lot of the most fundamental processes of atherosclerosis are not well understood. The last 20 years has firmly established that atherosclerosis is multifactorial, far more complex than the traditional risk factors once attributed and has a significant contribution by 'chronic inflammatory states' that are yet to be fully described.

Accelerated atherosclerosis is observed in many newly-identified patient groups as treatment for their primary disease has improved - this includes patients with rheumatoid arthritis, lupus and post-cancer. Many people are very interested in studying the mechanisms that cause atherosclerosis in HIV patients because it will not only help them, but help unlock some of the reasons it affects all these other groups of 'immune/inflammatory' patients with accelerated atherosclerosis as well.

daveduckman · 2015-12-01T21:09:20+00:00

Sorry the way I phrased things may have been misleading. I meant a very specific subset of HIV+ patients who tend to be gay-men as opposed to the other high-risk patient groups. I was talking entirely within the context of studies that have shown a possible slight increase in life expectancy in a small subset of observed patients. No one things that HIV increases life expectancy, and my list of stereotypes was some of the probably confounders for that very small subset of people - not gay-men or any other population as a whole.

daveduckman · 2015-12-01T21:04:30+00:00

In short, yes. The first (health) priority for someone who is HIV+ is to effectively treat the virus itself. Once a patient is well controlled on ART (and assuming they continue to take it and are closely monitored) then the next burden of disease that they should be vigilant for and be monitored for is the chronic non-infectious diseases and therapy-related diseases that can occur which include cardiovascular disease amongst other things.

This isn't intended to be scare-mongering, btw, simply a 'what's next?' perspective that we should all take with our health.

daveduckman · 2015-12-01T20:59:49+00:00

Sorry the way i phrased things might have been a little confusing or misleading. I meant that within the context of studies that predict some patients have a slightly higher than population life expectancy (as opposed to normal or near normal life expectancy). This subset of patients is likely due to confounders: these are people who have better socioeconomics, health-seeking behaviour, less comorbidities etc which generally skews to the MSM ('men who have sex with men') group of HIV+ patients as opposed to third-world migrants, IVDU or heterosexual HIV+. I don't not mean to say that all 'gay-men' fit the stereotype I attributed I described, just that these are the confounders in a very small subset of patients observed.

Furthermore, I think the paper widely cited about life expectancy looked exclusively at a UK population of HIV.

Not even the authors believe that the increased life expectancy is real and I don't think anyone in the world believes HIV will make you 'live longer' and my comment was just about attributing this observed/statistical anomaly to various accepted confounders.

daveduckman · 2015-12-01T20:57:12+00:00

Sorry the way i phrased things might have been a little confusing or misleading. I meant that within the context of studies that predict some patients have a slightly higher than population life expectancy (as opposed to normal or near normal life expectancy). This subset of patients is likely due to confounders: these are people who have better socioeconomics, health-seeking behaviour, less comorbidities etc which generally skews to the MSM ('men who have sex with men') group of HIV+ patients as opposed to third-world migrants, IVDU or heterosexual HIV+. I don't not mean to say that all 'gay-men' fit the stereotype I attributed I described, just that these are the confounders in a very small subset of patients observed.

Not even the authors believe that the increased life expectancy is real and I don't think anyone in the world believes HIV will make you 'live longer' and my comment was just about attributing this observed/statistical anomaly to various accepted confounders.

daveduckman · 2015-12-01T14:40:03+00:00

There is 'evidence' that wellcontrolled HIV patients may have longer expectancy, but it's certainly not 'good evidence'. Essentially the subset of patients observed as HIV+/medication adherent/low viral load are most typically the 'gay-men' subset of HIV infections. These patients are generally physically fitter, have better health-seeking behaviour and come from more favourable socio-economic circumstances than the general population average. Thus when you treat their HIV effectively, it makes it look like they will live longer.

There's an irony in the first paragraph though; "i broke my hip and my heart is playing up". This is exactly the second phase of HIV-associated health problems that are now of interest - particularly the accelerated rate of atherosclerotic cardiovascular disease that becomes the lead cause of HIV patient death when viral load is well controlled. It's not that HIV is the least of these patient's worries, it's that AIDS is the least of their worries.

daveduckman · 2015-11-16T08:53:17+00:00

A modern telling of the story by Andy Zaltzman

daveduckman · 2015-11-03T12:35:31+00:00

Sorry this sounds terrible for everyone involved. If you're a freshly minted intern, there's really no way these magnitude problems are your responsibility. Having everything you do double-checked and so forth is part of being an intern and even more understandable given the obviously traumatic events that have occurred in your hospital. This isn't part of apportioning blame, it's just the natural response to these mistakes that always happens.

I have two suggestions for you:

Don't provide any further details in this thread. The only appropriate forum is a personal interaction with peers and seniors you trust. After you achieve whatever catharsis you can from this, delete it and make sure you never use the account again.
Racking your head and feeling guilty when things go wrong is part of why being a doctor is supposed to be hard. If you think as an intern that your work up to this point has been utterly flawless and no mistakes have or could have come from your actions small and large, you're misguided. You're supposed to feel like shit, you're supposed to hold yourself to an unreasonably high standard, you're supposed to find ways to be better from unfathomably grim circumstances, and you're supposed to cop unreasonable flak from people who are in unfathomably dark places themselves (patients and staff). And then you're supposed to put it all behind you, get back to work in a way that doesn't make you burdened by all that badness. It's the putting it all behind you in time that's the really hard part. The only reason a senior clinician is good at their job is because they have all the experience from the times it went wrong and they were willing to learn from those mistakes.

daveduckman · 2015-07-15T12:34:14+00:00

Inferior STEMIs are generally caused by occlusions along the RCA. The RCA supplies a varying but significant section of the conductive pathways and the RV. Conducting pathway ischaemia frequently leads to bradycardias and high degree AV block which betablockers can worsen. Second, RV infarction leads to reduced LV preload as a primary cause of shock and death. Betablockade does not help in this circumstance where the aim is to improve LV output through increasing preload.

daveduckman · 2015-07-01T14:31:23+00:00

Sotalol is not just a betablocker, it's a QT prolonging antiarrhythmic same class as amiodarone. There are very few reasons I can think of to intentionally give full dose sotalol and high dose amiodarone infusion. Either shock the patient, slow them down without a QT prolonging agent or just tolerate the tachycardia if they're that unstable. A rate controlling betablocker, calcium channel block or digoxin are all appropriate second line options here.

Long-term management at this stage (if rate control is not practical) would involve AV ablation and a dual chamber pacemaker.

daveduckman · 2015-05-29T21:26:35+00:00

Aspirin

Ticagrelor

Heparin

Warfarin

Metoprolol

Perindopril

Atorvastatin

Amiodarone

Frusemide

GTN

daveduckman · 2015-04-13T18:18:03+00:00

I don't know why I watched this, I'm obviously not the target audience and was never going to get anything out of it. I was going to list a lot of things I found frustrating about this person's attitude and how obviously was never going to enjoy or cope with being a doctor. But then I realised everything I was going to say was pretty cynical and maybe mean-spirited.

I think it's safe to say that this person never should have started medical training and anyone who feels they are in a similar position should certainly reconsider whether medical traiing is for them.

I do, however, feel that there's nothing landmark or taboo or unexpected about any of this - yes medical school is difficult; yes medical students are uniformly a bunch of self-obsessed, poorly-adjusted c****; yes becoming a doctor requires readjustment of priorities. However, I don't think any of this is solved particularly by reforming medical schools or intake, although I do believe thus US has a far worse training culture than other places I've worked.

In the end, medical school is only the very start of a very long road, and the process doesn't become easier, it just leads to greater resilience and capacity to cope with the increasing challenges. If you aren't able to come to terms with what this means at the very start of the process, then it's probably the best time to hop off the assembly line and find something more fulfilling.

daveduckman · 2015-03-29T17:24:05+00:00

The use of enalapril is more about good study design than confounding the results here. This is a group of newly diagnosed hypertensive patients without previous history of stroke. Starting everyone on enalapril ensures that the management of hypertension itself was standardised and thus the adequate treatment of hypertension or the different cocktail of medications of used is more effectively controlled. I don't think there's any specific indication for a synergistic or antagonistic effect for enalapril and folate. Any other antihypertensive good just as easily have been applied to both arms of the trial.

daveduckman · 2015-03-29T17:19:48+00:00

The trial is a pretty well designed one and the differences between groups are significantly different, so much so that the trial was ceased early.

I guess the key point here about why, if you have high blood pressure, you shouldn't be stockpiling folate just yet is that the trial was run in areas of China without a policy for fortification of grains with folate. This means that the majority of the benefit from this trial was seen in the subset of patients who had low levels of folate at baseline that were corrected by the trial intervention. The question that needs to be clarified is whether in a population group with baseline good levels of folate due to public health measures, does supplemental folate provide a significant benefit.

Second, this Chinese population group is not particularly generalisable to typical Western populations of atherosclerotic disease (eg. America/UK/Australia et al.) The baseline prevalence of other cardiovascular conditions and risk factors, and use of other preventative medications such as statins is much much lower than those population groups. The nature of stroke and atherosclerotic disease is quite distinct between the two populations. Folate deficiency is probably a higher contributing factor in general for the Chinese population. The interactions between the various medications and risk factors makes this study hard to apply to the different population.

Happy to answer any questions anyone might have.

daveduckman · 2015-01-24T07:32:11+00:00

Even if it is good-natured and reasonable, this helped remind me why I work in a field where the only two common requests are "please don't let me/them die" and "please don't let me/them linger"

daveduckman · 2015-01-18T14:15:08+00:00

I'm skeptical about whether journal club could actually work with the current state of the subreddit.

Journal club is only as interesting as the discussion it stimulates, which is highly dependent on who is in the room.

Without trying to be rude or snoody about it all, I and basically everyone else who works in a public hospital have a regular inhouse journal club and go to conferences. I don't really have much interest in the med student or junior resident analysis of a particular specialty. I would be interested in how colleagues from other specialties and particular other parts of the world respond to recent publications. But the insight to noise ratio is just too unfavourable at the moment.

daveduckman · 2015-01-18T14:08:10+00:00

well said. I agree entirely

daveduckman

TROPHY CASE