Risk/Reward ratios in Medicine

Warning: medical post with an unhappy ending.  Also, statistics.  (eeek!)

Streptokinase.  Credit: Wikipedia

  Recently we had a patient who had a heart attack.  Actually, that's quite common - we often have several in a week.  Absent good reasons not to, we typically treat with streptokinase.  Streptokinase (SK) is an enzyme made by some bacteria (see if you can guess which!) that has an impressive ability to dissolve blood clots.  This makes it useful to dissolve blockages, say, in one of the heart's own arteries (aha! a heart attack).  Miracle, no?
   Well, it's not specific to the coronary arteries, so it can cause blood clots to dissolve everywhere in the body.  There's a constant balance in your body between the clot-dissolving system (which keeps your blood vessels from solidifying) and your clotting system (which keeps you from bleeding from every pore).  SK massively shifts the balance in favor of clot-dissolving.  You can imagine some of the other risks, but the most serious risk is intracranial hemorrhage (a huge, bleeding stroke, often lethal, always horrifically destructive).

The generic risk of dying from a heart attack is roughly 12%.  The risk of intracranial hemorrhage from SK is approximately 0.5%.  Giving SK reduces risk of death by about 4%.  To put that in easier terms:
For every 200 patients I give SK to...

175 patients will receive SK who would've lived anyway. though I like to think they'll have less heart damage.
8 will live who would have died.
16 will die anyway, despite SK, and...
1 will die who might otherwise have lived.

Well. The patient I began with was the one.

Sometimes you know who it is you saved.  In August, and again in September, I had two patients in cardiogenic shock whom I nursed through the night until the SK had its effect and the heart started working again.  Other times you just don't know and you have to trust the statistics that say you've done some invisible good.  But you always know which ones your treatment harmed.

Minority Report

A swiss friend invited the kids over to make special breads for St. Niklaus eve (Dec  5th)

    Last night I took care of an older gentleman (with a heart attack).  His wife related an interesting story.

   Many, many years ago, they were married.  Then he left and moved to India for 20 years.  There, he met and also married another woman.  A few years back he returned  again to Bangladesh and moved back in with his first wife.  She looked me straight in the eye and, clearly imagining what I might be thinking, said. "What should I do? This is Bangladesh."  Her tone was even and completely unaffected.  It wasn't even resigned - just matter-of-fact.

   The subtext was, "What? He's my husband.  He is my standing in society.  No, equality is not a thing to be expected.  Without him I have nothing.  So, I accept that he had/has another wife."

   I knew polygamy existed in BD; this is merely my first up-close exposure to it.  I came home and discussed it with our house helper (who is christian - a small minority here).  She said, "Yeah.  Muslims have too many wives.  1, 2, 3. sometimes more!  Christians and Hindus don't."  That makes it sound like it's everybody - it's not, but it's around.
   What struck me about her comment was the exact same matter-of-fact tone.  Living in a society where you are a small minority (or a powerless group) you can have an identity or set of rules that are completely different from that of society at large, yet you must accept the larger society's rules as fact.

  This is probably how minorities have felt throughout time, from first-century Corinth to modern-day Bangladesh. 

Snapshots

Geek is Chic.  Thanks, Erika!

Sisters.

Just give up now, you're going' down!

I've just finished a few weeks in the hospital of intense every-other call.  Now I'm taking a few days of time-off to spend with Laura, the children and my parents.  The contrast makes me realize just how hard I was working.  I'm not entirely certain I was easy to live with or always present for the children.

But having these days is lovely.  We played frisbee this afternoon and yesterday I kicked a soccer ball with AE (who is surprisingly good!).  I had the chance to look up and around once or twice and to look down at a face that's smeared with a bit of mud and a big smile.

Pachyderm

What nobody's talking about.

A night in the life...

Two call nights ago, after I got home at 9:20pm, I received no further calls all night.  Last night was a another kind of night:

22:30 - go to sleep.

23:47 - the phone rings.  Walk through the fog to the hospital to see a patient with a tender abdomen and discuss the case with the junior doctor.  Order an abdominal Xray (we have no CT scan).

Get called to see two other patients.

Look at the film on a lightbox.

Film shows dilated bowel loops everywhere.  Clinical impression before was probably ileus (temporarily paralyzed intestines after surgery), Xray is consistent.  Discuss why repeating the exam hourly is better than having a CT scanner - you feel the change in abdominal tension and sense whether the pain is increasing or decreasing: "Your hands are better than a CT."

Walk home through the fog at 01:17.  Lay down under the net, but sleep is taking a while...

02:30 - ...nope.  Eyes closed, but no sleep.  Phone rings.  35 year old with very low oxygen levels despite administering more oxygen.

Run while zipping up jacket.

02:37 - teach junior doctor how to intubate (put a breathing tube in the windpipe).   Impressed: junior manages it first try!  Patient extremely ill - frothy pink secretions are bubbling up the tube: Diffuse Alveolar Hemorrhage (DAH) likely.  Requires constant suctioning to keep clear.  

02:45 - a little more story, apparently was drinking some homemade rice alcohol.  Quite a lot of it.  suspect it was adulterated with other chemicals - some pesticides cause DAH.

02:50 - troubleshoot suction machine.

03:12 - one of the guards looks in to see what the excitement is.  Stays to watch a few minutes.

03:30 - patient temporarily stabilized.  Bedside ultrasound confirms it's not the heart, so DAH it is.

03:52 - check on guy with the tender belly.  Improving.

04:00 - DAH again.  Trouble with secretions clogging the tube.  Attempt re-intubation with larger bore tube - won't fit, revert to original tube.  more suctioning.

05:00 - eventful hour.  Patient quite unstable - now on IV pressors to keep blood pressure up.  Having trouble maintaining saturation even with ventilation.  This bodes ill.

05:15 - realize two patients on the ward can see through the door into the ER and have been watching us work the last few hours.  They appear fascinated.

05:32 - we can do no more than we're doing.  As I head home to sleep for an hour or so, I hear the mosque turn on it's PA system and begin the 5:30 Azan (call to prayer).

08:00 - patient with chest pain rolls in, swallow the last of my coffee...