We rushed a young patient to the OR who had blown a hole in the left anterior chest with a .357 magnum in an apparent suicide attempt. Before the shot, several medications including Xanax, Tylenol, Percocets and several other unknowns had been ingested.

After several hours of surgery – thoracotomy and laparatomy -and several units of blood and blood components, the patient makes it out of the OR but still in critical condition.

During the case, we find out that, this is young patient had attempted suicide a year earlier in a very similar fashion. The hospital stay then lasted 6 months and was very rocky.

So we are probably going to see the same course again.

I don’t mean to be callous but when do we say stop? When do we as a health system and society oblige those who do not value life at the expense of those who do. If any other trauma had come in, in that space of time, care would have been extremely hampered by lack of blood and blood products!

This patient is apparently severely disturbed and needs a lot of help.  Is this a measure of the psychiatric and social care this patient was receiving? From what we could tell, compliance was not a strength of this patient.

So, should there be a strike system for how many times one would be resuscitated after an attempted suicide? Maybe two strikes….

In an environment of scarce healthcare dollars, maybe we should use what we have wisely.

jnkdg

Got this picture of ischemic loops of bowel recently.

jnkdg

We live in the era of evidence-based medicine and one can get nothing done unless there is ample proof from a prospective randomized double-blinded study with ample power.

I have always wondered about the role of these studies and how important they really are. Many a time, I have seen clinical results that stray from the “evidence”. Also, studies can so blind practitioners that they fail to consider all the facets of a case. A good  example is the medicine service trying to give a patient with acute abdomen who is hypovolemic and tachycardic beta-adrenergic blockers! Then is the small factor of studies with small sample sizes. I won’t even touch on meta-analysis!

So, I was intrigued when I read about the work of John P. A. Ioannidis. One of his seminal papers is titled “Why Most Published Research Findings Are False” – http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1182327

In it he challenges the validity of conclusions made from several studies.

Maybe my paranoia about published studies may have some validity.

jnkdg

I strongly believe in bringing about change from the inside out. It is the only kind of change that is long-lasting. It does not matter if it is change in one’s personal life, in a relationship or an institution.

My institution needed to undergo significant changes. Most of the nurses and physicians knew this. Instead of involving the employees in this process, the administration opted to get consultants (expensive ones) to advise them on what needed to be done. In the last few years, there have been many changes including the exodus of many nurses and stinking morale. Many of the recommendations made by the consultants are coming back to bite the institution. I truly believe that, a series of townhall meetings between the hospital administration and employees would have yielded several very important insights into what needed to be done. Instead, a lot of money was spent on consultants whose exposure to our institution was probably only a few weeks long and  whose recommendations failed to take several important socio-economic factors into account.

Change from the inside out!

jnkdg