mikecsh

I work as a doctor (in the UK) in a hand injury clinic and see tens of hand and finger injuries a day, including a lot of fingers slammed in doors.

Whilst you are correct that trephining a nail (making a hole) to relieve the subungal haematoma (blood under the nail) beneath isn't a very skilled procedure, that's not why we see these patients. Most of the time, it is a simple straightforward injury requiring simple treatment. But a significant amount of the time there is an underlying open fracture of the distal phalanx (bone at end of finger) which can lead to a severe, potentially finger-threatening infection. There are also often nail bed injuries which without repair will lead to nail deformities.

There are a lot of injuries I have seen with delayed presentation where patients felt they knew what to do and wanted to save themselves the time of visiting the hospital (as there is no additional financial cost to healthcare in the UK). Many of these delays have led to severe infection requiring hospitalisation and surgery which would not have been required if they had visited promptly, or presenting past the point where we can fix e.g. a mallet finger, displaced fracture, etc.

As in all fields, there is a danger in not knowing what you don't know.

We never rely on patients telling us their blood tyoe, or even past lab results. A test must have been performed recently (in my hospital it’s within the last seven days) for the blood bank to dispense blood.

If there is a major haemorrhage the patient will receive the universal donor (O-) while the test for definitive blood type is performed.

Also used in medicine for determining management of paracetamol (acetaminophen) overdose.

Your comment reminds me of illegal numbers [1] where a number is illegal because of the information it represents.

[1] https://en.m.wikipedia.org/wiki/Illegal_number

Which compiler is this?

Indeed - see Poiseuilles equation [https://www.openanesthesia.org/poiseuilles_law_iv_fluids/]

During a cardiac arrest the primary problem is a pump failure - blood is not flowing through the vasculature. A trickle of oxygen into the wrist will not help if the blood is not being circulated.

> Maybe in the form of a cuff that you clamp over someone's wrist that can use computer vision to identify veins and automatically insert the needles and run the machine.

There's a reason they put the lines in the femoral vessels - these cannulas are like hosepipes - you need to access the large vessels to get sufficient blood flow through the whole circulation.

I’ve never understood why people ever feel the need to point out whether a pun is intended or not. I never see (rhyme intended) for example, so why puns? To me it tends to disrupt the flow of the prose

Do you not have access to beta2 agonists such as salbutamol?

This condition is called situs inversus. There’s another similar one called dextrocardia where only the heart is on the wrong side (literal meaning is “right sided heart”).

I wonder whether you would have such strongly held opinions if you had more experience of medicine, disease, and end of life.

Palliative care is an incredible specialty. Something I wish more patients understood is that palliative care is not just end of life care. Their remit is the alleviation of symptoms and pain at any stage of a life limiting illness. In the UK many people consider palliative care to be synonymous with end of life care for cancer patients and are unwilling to be referred to them. This can lead to unnecessary suffering. Perhaps a re-brand is in order.. :/

Wow, thanks for the treasure trove of links!

Reminds me of old-school chorded keyboards[1] that allow you to type via key combinations from a small number of keys.

[1] https://en.wikipedia.org/wiki/Chorded_keyboard

We call it an “inco pad” here.. inco being from incontinence, but they’re useful in far more situations than just incontinence!

Is the application on the tablet showing test data or is that a live demo of the machine with the gentleman in the video?

I agree with this completely; not being able to understand a patient's medical history often makes it much harder to treat them effectively. Especially in an emergency setting.

That said concerns about the sensitivity of information are absolutely valid and should be at the forefront of EMR systems.

In my experience (UK) access to records is reasonably well restricted to relevant staff. Access is audited in efforts to identify unauthorised access and this is taken extremely seriously; for example opening records for patients not under your direct care with no valid reason.

Further, for particularly sensitive information such as some psychiatric histories, or medical photography of sensitive areas, this is kept behind a secure area within the EMR systems, not generally accessible. Opening it requires signing a declaration that you have either discussed it with the patient and gained consent, or that you do not have consent and you are opening it in the patients best interests in an emergent situation as they are unable to consent (e.g. history of depression with paracetamol (acetaminophen) overdose brought in unconscious by ambulance.

The problem with this is that a very small minority of patients are that diligent or reliable, for various reasons (dementia, forgetfulness, disinterest, mental illness, low IQ, substance abuse, not realising the information is required, brought in by ambulance unconscious and peri-arrest, etc.).

Here in the UK patients do have responsibility for some records - notably anticoagulation records and maternity / child health records.

I have seen literally one patient present with their anticoagulation record. I have lost count of the number of patients who come to appointments without their maternity notes or child health notes.

Even trying to get an accurate medication history from a patient is near impossible and we end up having to look at past hospital discharge letters, call their GP, or look on shared record systems to try and piece together what they are taking.

I'm all for patients "owning" their records but they must be held in a way that is accessible when needed regardless of human variabilities.

In the UK patients pay a flat charge for a prescription which is around £10. For that reason I rarely prescribe something like ibuprofen or paracetamol outside of the hospital. I will always tell the patients to buy it themselves over the counter for around £0.16, unless there is a good reason to deliver it via a prescription.

In a discussion of NHS vs private practice, the fact that some (certainly not most) NHS-employed doctors also do private work, has no baring on the incentives placed upon them within their NHS employment.

I am certainly not saying the NHS system is perfect, and all private medicine is bad, so if that is the impression you got then perhaps I was unclear.

In almost every single clinical situations within an NHS hospital that I have seen or can think of, the clinicians treating you will not receive any extra money, bonus, promotion, etc. for the treatment they provide you or do not provide you.

I have lived in countries with more private systems, where there is a direct relationship between what treatment/investigations you receive and what money ends up in the doctors pocket. For example, a private doctor in HK referring for not-strictly-necessary-but-ultimatelhy-clinically-justifiable MRI scans at a private MRI clinic which, provides a percentage of the (expensive) scanning fee back to the referring clinician. Contrast that in the NHS, no one gets given money for sending a patient for an MRI scan, and in fact, if it isn't going to change the management of the patient, the request is likely to be refused to constrain resources. In the HK system, neither the doctor nor the MRI provider is incentivised to not do the scan, quite the opposite.

The NHS system is not perfect, but pointing out different the pros and cons of different incentivisation structures that do have an impact on patients is not something that is a "meme that needs to die"…

And this certainly isn't the case in the NHS in the UK where doctors have no financial incentives interfering with their clinical decisions (barring saving the service money). What you describe is a pitfall of private medicine.

> yet scant data indicates that it helps

But this is not the case. In the UK, these observations are entered into a proforma by the nursing staff which allows them to calculate a "National Early Warning Score". Based on the patients score, the nurse has to escalate to an appropriate team and the doctor on the appropriate team has to take the referral.

Not only does this help identify deteriorating patients, but it helps to fight human factors like "I don't want to call such and such a doctor because they are always rude on the phone so I'll just leave it and hope it gets better"

In terms of actual data, we have a national body (NICE) that provides guidelines and recommendations based on appraising the available data and research. For NEWS scores, see:

For an overview: https://www.nice.org.uk/guidance/cg50/chapter/1-Guidance#phy...

For the full report and evidence used to compile the guideline: https://www.nice.org.uk/guidance/cg50/evidence/full-guidelin...

I think this hits the nail on the head. There is a huge information gradient between most patients and the doctor and perfectly bridging that gap takes more [time|money] than any system is willing to support.

I think about this when it comes to providing a patient with "informed consent" for a particular treatment/operation. What does "informed" really mean in this case? A brief overview of the main risks and a couple of statistics? Or a thorough understanding of the pathophysiology of the disease and the trial data supporting the therapy? How long is a piece of string?

> its that they knew nothing

That does sound rather concerning if that's the case!

As a medical student about to sit my final exams, I have shadowed hundreds of doctors of different grades and specialties in many different hospitals and family practices, and I don't recall ever seeing a doctor not review the notes before seeing a patient. Often here in the UK at least there is a large amount of time pressure and it would certainly be desirable to have more time to review further back, in more detail, etc. but given in general practice there is a 10 minute slot per patient, there are systemic limits on this (that would be nice to address).

On the other side, trying to figure out what is going on with patients is much more complex than catching up on notes and trying to get a "delta" update from them about what has changed in the shortest space of time/words as possible. The number of times I have taken a history from a patient and then less than half an hour later observed them add hugely important extra details that were omitted previously is pretty large. Often, it is far more helpful and illuminating to ask a patient to tell you what has been going on in their own words, even if you think you have read it all in the notes. I have often seen more senior clinicians pick up subtle clues that were missed by more junior clinicians, or ask a pertinent question that was not asked before.

And finally, on a more pragmatic basis, doctors take a lot of risk on board whenever they treat a patient. Patient's get tired of people asking them if they have any allergies for example, but when it's your name on the prescription, and your ability to sleep and your license on the line, you may well decide to ask the patient again rather than rely on what some previous clinician in some previous setting has written down on the patient's file. In a similar vein, a lot of practice is not black and white. If a junior with limited experience writes that a particular clinical sign is positive in the notes, you may well want to repeat that examination to re-assure yourself before you allow it to guide your treatment.

None of this is excusing unpreparedness or poor practice, but hopefully shines a little light on some reasons why it seems like there is so much needless repetition.

In addition to this, many doctors want to re-take the history from the patients and re-examine them for themselves, rather than rely on a brief handover or potentially sub-optimal notes from another doctor. Clinical signs can be subtle, as can points in a patient's history that may point to a diagnosis. I see patients often frustrated at being asked the same questions by each doctor they see, but most of the time this is in their best interest.

In the UK (not an insurance-based system), many GPs ("family doctors") will aim to take a BP reading if there is time. This is partly because there is a system called the Quality Outcome Framework that incentivises practices to do so, but the route of it is that those incentives are in place because high blood pressure is extremely common, under-diagnosed, and has huge health consequences if left untreated, which in turn is extremely expensive for a national health service. A BP check is quick, simple, and cheap, and can help to identify problems early on when simpler interventions can stave off bad outcomes.

> Speakers are something that NEED to be repaired.

I get the landfill argument, but I have not needed to have any of the speakers I have owned over the last 25 years repaired.

How much cheaper was your Hackintosh setup?

> Based on similar techniques, many single-gene disorders are effectively cured.

This is a bit of a leap. In principle (some of) the technology "is there" but there is a huge amount of complexity in the steps 1 through 5!

> Yet doctors can't engage in this work without going through the lengthy drug trial process.

I think it needs to be said that the "lengthy drug trial process" exists for extremely good reasons. Were a treatment to be shown to be so incredibly effective during the trial process, based on pre-defined statistics monitored by an independent data safety monitoring committee, the trial would be stopped as it would be unethical not to provide all patients with the clear benefits. (recent example: https://www.ncbi.nlm.nih.gov/pubmed/29132880)

> So instead, they recommend much riskier treatment options including some that would complicate future gene-therapy attempts.

I believe it is unquestionable that doctors should be advocating treatment based on the best available evidence, and that the process for obtaining said evidence is a thorough and rigorous as possible, otherwise great harm can be done (classic example, thalidomide).

I would question the doctor that routinely recommended an experimental treatment which has not been shown to be efficacious over a "risky procedure" which has been shown to have $X efficacy.

Making patients aware of trials which may be of benefit to them is a valid and valuable part of medical practice, which is not always done very well. This is improving (in the UK at least) with greater numbers of research nurses and the use of databases such as https://www.ukctg.nihr.ac.uk.