Hope: from Home Birth to Hospice

Home birthing and hospice care.  Birth and death, aside from taxes, the only certainties in life!  These may not seem to be related topics, but they are.  Stay with me and I shall explain.

Let us start with home birth.  There has been a bit of banter in Broome and online about the modern controversy associated with “home-birth” for women in places like Australia.  [ Ed: If you want to start a twitter argument – this is a pretty good opening gambit! ]  In some countries this is the norm.  However, in most of the developed world the vast majority of babies see their first light in the labour ward or operating theatre. [ ~1 % of American women birth at home, although up to a third do so in the Netherlands. In Australia it is more like 0.5 %]

Australia has excellent antenatal and Obstetric care.  We have really great outcomes – amongst the lowest maternal mortality rates in the world. (equal 6th)   And yet…. there exists a group of women who wish to opt out of this world class care.  They want to give birth in their own home, surrounded by family and a caring midwife.  They argue that being born is a ”natural” phenomenon that need not be medicalised or confined to a hospital.

This bothers us… the doctors.  It flies in the face of logic.  Why take the risk of disaster?  We see the cases where things go very wrong.  Surely these women just need to know the stats?  We have all seen or heard of Coronial cases resulting from home birth. We can explain to them how critical interventions will not happen in time if they need to catch an 11th-hour ambulance across town – surely they will see reason?  But no, they do not.  In fact these sorts of discussions tend to polarise things further and create an atmosphere of opposition.  What is going on here?

OK let us now jump to the other end of the roller-coaster ride.  Dying.  I have been reading a lot of excellent posts and podcasts about the interplay between Critical Care and Palliative care.  Recently Dr David Anderson ( @expensivecare ) wrote this piece: DNR: Who decides? .  There have been discussions by my American colleagues in which they despair over the near universal family response there: “We want you to do everything to keep him alive.”  Read this excellent article recently on KevinMD by Dr Jarman ( @DocJarman ) on “Why Intensive Care is a Myth.”   We seem to have a problem.

We have a disconnect between our doctorly understanding of the dying process in the modern medical paradigm and the beliefs and expectations of our patients and their families.  When doctors are surveyed they almost universally say they would decline aggressive care in the the final phases of their illness.  However, we know that the majority of patients will opt for what we see as futile care – be it CPR, chemotherapy or “hail-Mary surgery.”  What is driving this?  Why do our patients and their families request treatments that we would never accept at the end of life?  It is often hypothesised that ‘Joe Public’ overestimates our ability to “bring Dad back” from watching too many episodes of E.R. [Jones, Acad EM 2000] – but I don’t buy that explanation.  There is something more personal and fundamentally human going on when families decide on what they or their loved ones want “if the worst happens.”

For me there is a common theme here.  The desire to give birth at home or the wish to “do all we can” at the other end of life are both manifestations of our patients wanting to wrest back control over the most fundamental moments of their lives.  The humans that we treat are yearning for CONTROL in a time where things seem to be anything but controlled.  We offer the illusion of control with our hospital machines, language and powerful medicines… and yet we know at our core that we cannot control these situations completely.  They scare us too.

So next time that you have that difficult conversation with a family or discuss the expectations of an excited, young mother-to-be.. remember this: they want control.  Whether that means choosing the “lighting in the labour ward” or when they have had “enough medicine” we need to be champions of our patients autonomy.  The ‘irrational’ fears, demands and expectations we see every day are those of our making.  We have stripped much of the control from our patients and this has resulted in anxiety and opposition. So try, just try, to offer real control to your patients and see how it goes.  Go on…  what is the worst that could happen?

Casey

PODCAST: The Guru vs. the Gump [Contraception]

Yes – after a number of months away from the Broome Docs podcast we are back.  The podcast has been on the back burner whilst I have been prepping for SMACC in Dublin and podcasting away over at Primary Care RAP.

This is an older file from the archive that has been neglected.  I have decided to drag it out for a few reasons:

  1. To keep you all amused
  2. As a bit of an experimental format
  3. to encourage my colleague – Dr Penny Wilson to do more excellent O&G podcasting on bits’n’bumps

Here is the link:

DIRECT DOWNLOAD here

DISCLAIMER:  the questionable humour in this podcast is entirely tongue-in-cheek, not that funny and should be ignored.  Please not angry emails>!

Casey

Clinical Case 131: the Latent Lover’s Headache

Hi there.  Just back from a great break in beautiful Vanuatu.  Seriously amazing place to visit and explore.  The beauty: death ratio is in balance!

I have a case for you today which has come up a few times recently.  It is certainly something that does occur in the ED, but most GPs deal with this dilemma on a regular basis.  Let us dive right in.

Our patient is a 28 year old chap – lets call him Trent.  Trent works in the local sausage factory as a quality control supervisor.  He is usually fit and healthy with no real family history or chronic problems.  He does a bit of exercise, doesn’t smoke and has a few beers at the weekends.  Trent has recently gotten married and life is sweet.

You are working away in your busy GP rooms – Trent is your next patient.  You last saw him for some travel immunisations prior to his honeymoon.  He is a very infrequent attender to your practice…

Here is how the consult goes:

Dr: Hi Trent, hows things?

T: Well Doc.  I’m OK.  My wife has told me I need to come and ask about this headache I got the other day.  I’m not too worried though…

Dr: tell me about it.

T:  Well its a bit embarrassing.  We were sort of fooling around – you know.  Getting intimate.  And half way through I got this sudden headache.  It was like somebody whacked me over the ear with a cricket bat.  It was really full on! One second I was fine, then I was almost knocked out.  Could hardly think.  I was rolling on the floor in pain for half an hour.  It felt like my  head was gonna explode.  Everything was a bit grey for the rest of the night

Dr: Wow. That sounds bad.  When was this. what happened?

T: Oh it happened 2 nights ago. About 48 hours I guess.  The pain eased off a bit after half an hour, but it was still there when I woke up the next day.  I was feeling rubbish and took the day off work.  It went away over the day – so I didn’t bother going to the ED.  But Sheila thought I should get a check up…. just in case.

                  OK, Freeze it there.

Think about how you would approach this case if you were working in ED and Trent presented immediately after the headache began – say 2 hours.

Now put yourself in a GP clinic 2 days later, he is now essentially asymptomatic, with a normal set of Obs, Neuro exam and really seeking reassurance.

What to do?

Here are my questions for you….

Q1:  Does Trent need a work up for subarachnoid haemorrhage / other malignant brain / vascular problems? i.e.  should he get imaging +/- LP today?

Q2:  Does the fact that he is now well, asymptomatic and alive decrease the odds that he has a SAH?

Q3:  If he told you that the headache started immediately after orgasm, rather than in the earlier phase of coitus, would it change your approach?

And just because I am a nice bloke I will add this image to help you visualise the relative usefulness of the investigations for SAH over time.  BEWARE: this is based on some seriously good and some not so good literature [and the graph may not be entirely to scale!!]

Sensitivity of Ix for SAH vs Time

Sensitivity of Ix for SAH vs Time

Clinical Case 130: Painful Palate Puzzle

OK crew.

Today I have a super quick clinical case for you.

42 year old man presents to the ED with a week history of pain in the palate.  He says he thought it was referred pain from a “sinus infection”.  He has had a series of these “sinus infections” recently and his GP has treated them with oral Amoxicillin / Clav…  not getting any better. We can debate if this is a good use of antibiotics, but just agree it is ‘clinical equipoise’ for now! (Check out the NNT take on this from 2013 here,  Cochrane agreed in 2012.. but they are looking at it again right now).

The antibiotics didn’t really help after 5 days.  He went to another GP who prescribed another antibiotic…  But today, on day 7,  he has a new symptom.  He has noticed a painful lump on his hard palate.  He cannot recall feeling it before.  It just “appeared” over the week as he was struggling through the pain of his “sinus infection”.

A cursory ENT exam shows all to be normal.  He does have some fullness and percussion tenderness over the left maxillary sinus.  But there is a definite lump on the palate:

The lump is firm, tender but not particularly hot.  It is bang in the midline:

palate lumpOK

Q1: spot diagnosis – what is it?

Q2: what imaging will you request if any?

Q3: what is the treatment ?

Casey

 

Pneumonia Ultrasound Diagnostic Strategy

In June I will be travelling to the Emerald Isle to attend and learn at the SMACC Conference in Dublin.  One of my jobs whilst I am there is to help out on the SMACC Mini workshop – I will be talking about using lung US to diagnose paediatric pneumonia.  Clearly, I am a self-confessed sonophile. I think that we can get a lot of information in quick time by using the bedside scanner to interrogate the lungs.  BUT, there is always a BUT…  what we do with this information is most important.  Lung ultrasound is really very simple, technically easy and there are not many subtle anatomical findings to keep you guessing.  However, when we interpret our scans we need to know a few things:

  1. What is the clinical question?  Are we “Diagnosing” or “excluding pneumonia”, “Septic screening?” or “differentiating pneumonia from bronchiolitis?”
  2. Do the findings represent “hard” or “soft” signs of pneumonia – could the signs be false positives?
  3. What is the plan – are we going to act on our findings? Hit then with antibiotics? OR get more tests?

Dr Rory Spiegel posted a great critique of the recent evidence around lung US for pneumonia at EMNerd this week. “A Case of Shadows II”   His post has prompted me to respond by explaining how I think we should use this tool in the light of our current evidence.

If you read the abstracts you will come away with a somewhat “black n white” view of the world.  However, there are a few shades of grey.  You will read impressive numbers – a positive likelihood ratio of 15, a negative LR of 0.06…  this is a great test! It discriminates in both directions.  BUT… here’s the next BUT… you need to know what these investigators were calling “pneumonia” and what was not.  If you have done any lung scanning you will  know that there exists a spectrum of findings -ranging from hard to soft.  So where on this spectrum can we “call it”?

  • Hepatisation with dynamic air bronchograms
  • Hepatisation with static air bronchograms
  • Large subpleural consolidations
  • Sub centimetre sub pleural consolidations
  • Unilateral B-lines
  • Unilateral effusion

 

Classic hepatized lung with “shred sign” of adjacent B-lines

Basal pleural effusion

The diagnostic characteristics of these signs are not all equivalent – as you go down the spectrum they become less specific [and more sensitive].  This does not make them useless – just less potent as far as diagnosis goes.

There is also a real risk of over-diagnosis  if we start overcalling pneumonia based on the softer signs.  So how do we integrate this “new test” into our practice?  I reckon we need Bayes.  We need to be smart about how we use the information that US provides.

Lets start with a case.  Here is the pretest- probability guesstimation:-  we are not great at picking pneumonia clinically – however if we have a child with fever, cough, tachypnoea and unilateral auscultation changes then I would guess that we are at about 50% at least.  So lets whip out the nomogram!  If we start at 50% and have a hard sign (e.g. dynamic air bronchograms) – +LR around 15 then we are up to about a 94% post-test probability – this is a slam dunk, I think we would all start treating this kid.  If we were to see only a softer sign such as focal B-lines and a tiny unilateral effusion then our +LR is weaker ( wild guess would be about 5??) That still gets us to a post-test probability of 83% – and I would start antibiotics at that level. [Editorial note: these numbers are completely fictional.  Based on my own experience and reading.  We need to have studies that exam these signs].

If you decided that the chest wasn’t convincing on auscultation – then your pretest risk might be lower – let us call it 20%.  In that case a soft +LR of 5 would only get you to 55% post test… maybe not good enough to call it over the “treatment threshold”.  We need more data.

So lets consider another scenario.  2 year old girl with fever, poor perfusion and tachycardia.  No localising signs on examination.  We are definitely going to start empirical antibiotics based on her risk of sepsis.  But we want to run a “septic screen” to find the source.  In this case our pretest probability is lower.  Maybe 10 or 15% chance of pneumonia.  So a CXR probably has a sensitivity of 70%, is that good enough?  Our lung US can have a whole range of sensitivities.  If we draw the line at “completely normal” – i.e.. none of the hard, soft or indeterminate signs listed above then the data suggests a sensitivity of high 90s.  So our strong -LR in this setting allows us to get our post-test probability down, well below 1%.  We need to look elsewhere for the source, maybe she needs an LP?

Now – a tougher case.  A 12 month old boy who has been admitted with bronchiolitis fro 48 hours.  He was initially improving with supportive care, but today has developed increased fever, tachypnoea and oxygen requirements.  He isn’t following the usual branch curve.  Has he developed a superinfection / pneumonia?  Lets scan his lungs…. We expect to see bilateral, small (sub centimetre ) sub-pleural consolidations.  Maybe symmetrical, small basal effusions.   So here we need to be choosy.  I would ignore any of the softer signs listed above.  There is a low signal:noise ratio here.  For our scan to be useful we would need to see a hard (very specific) sign of pneumonia – such as a larger  area of hepatisation with air bronchograms to allow us to make a call.  In terms of post-test probability, out treatment threshold need to be considered.  Given the clinical situation is the best option to start antibiotics.

Lung ultrasound is a test.  Like all tests it has imperfections.  It is not a binary phenomenon – there are a range of “cut off points” that you can use to enhance its ability to rule in or exclude pneumonia.  Unlike a numerical test like troponin or D-dimer it is not as simple as shifting the magical “normal range”.  We need to understand the relative potency of all of the possible findings and use these to our advantage depending on our goal.

So go on!  Use lung US in your practice. Use it wisely.

  1. Think about the context of your patient, estimate the pretest probability.
  2. Decide if you want a sensitive or specific test – what are you trying to do?  Rule in or out?
  3. Scan and interpret you findings – is it negative? Or maybe soft? Hopefully you find some hard signs.
  4. Understand how to apply these findings to the patient
  5. Premeditate your treatment threshold – at what level will you be starting treatment?

The best thing about lung US is that you can play around with it and only waste a few dollops of gel and your own time.  There is no real inherent risk in the test itself – no radiation or the need to bother the nice radiographers!

I hope this all makes sense.  Let me know if not!

Cheers

Casey

 

 

2000px-Fagan_nomogram