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Archive for September, 2014


7 Sep, 14 | by tomfardon

I’m not at the ERS, I’m in sunny Dundee, but due to the wonder of social media, we can all follow the goings on in Munich on the Twitter hashtag #ers2014. If you want to see what’s happened on this first day click here

Of great interest – those COPD patients with an increased Eosinophil count respond best to inhaled corticosteroids. More to follow on this topic, I’m sure. On my acute medical ward round yesterday I was bemoaning the lack of a space on the clerking pro-forma for eosinophil count; it seems chest physicians are the only people interested in eosinophils.

Conference Time

6 Sep, 14 | by tomfardon

There’s a thread over on on the Doc2Doc website about the ERS over in Munich. A couple of trainees asked about what to do and where to go – one of the more senior members over there thinks that conferences have become bloated, oversized, and are now so big that they have become too large to function effectively.

The ERS is a massive meeting – 24,000 delegates at Barcelona last year, and probably as many this year. But such a large meeting will draw big name speakers, and thus quality of presentations. There’s too much to see, of course – not possible to be in every place at once – and some of the sessions are so big that it’s very daunting to get involved in the discussions.

I fondly remember going to CHEST in 2004, in Seattle. Seattle is a great city – well worth the flight across to the West coast, I think- but the meeting was organised in a very different way to the giant ERS/ATS norm of today. Each session was very small, often only 12 or 15 people, of which 6 would be presenting. It lead to a very lively discussion in every session, between the people who were either really interested in the topic, or the real experts in the field. In some ways it’s like the spoken poster sessions at the Winter BTS.

There’s still the question of whether 20,000 people should get onto planes, and fly all the way to Munich for a conference that could be broadcast over the internet. The TED talks very successfully broadcast all through the year – we even had a TED-Med broadcast from Dundee recently, and we’re thinking of having a TED-Ed session later in 2015. The cargo footprint of the ERS must be astronomical – but the boost to the local economy of Munich, and Barcelona last year, Amsterdam next year, cannot be ignored.

I have a Maltese colleague who works in Dundee with me, but trained in the North East of Enlgand; he arranges one night out with his Maltese colleagues, one with his Liverpool colleagues and one with the Dundonians – hard to get together with so many people without meeting up at a conference.

I’m not going to the ERS this year – I was at the ATS this year, and the ERS last year, not to mention the excellent Summer BTS in York. But if you are in Munich, remember to visit the Thorax stand – there’ll be plenty of chat from our Editors, and a free copy of Thorax, probably.

Finally – do you want to be the next Editor in Chief of Thorax? We’re looking for one, or two – see the Journal Website for more info. If you don’t fancy the big seat, do you want to write a Thorax blog? Drop me a line – we’re looking for guest bloggers!

Should we have a Dr House?

5 Sep, 14 | by tomfardon

You’ve seen House, right? Prince George from Blackadder III plays a misanthropic “diagnostician” in a fancy Boston Hospital, taking on the hardest cases, those without a diagnosis, and works out what’s wrong through a range of tests carried out by his underlings, a whiteboard that *always* has sarcoid on it, and by being quite rude to the patient, relatives, and anyone else within earshot. He’s addicted to narcotics too, seemingly.

It strikes me that Gregory House is all well and good, reaching diagnoses that no-one else can make, devoting hours and hours to cogitation and diagnostician-ing, but he only has 1 patient at a time. The Royal College tells us we should have 25 in-patients each, and we have a variable out-patient workload. Greg has an out patient clinic to do, once an episode, but I don’t think he follows people up much. If I had only 1 patient at a time, I’d like to think that I’d be able to bury myself in the case, and come to a diagnosis, whether it’s Sarcoid or not.

Do the general public watch House and have the expectation that their doctors should be like him? I don’t mean grumpy, walking with a limp, and doped up on Vikodin – do they expect that we have as much time to dedicate to a single patient? Not to mention that the underlings seem to do all the tests, from gram stains to brain biopsies, via bronchoscopies and interventional radiology. I can do one of those tests, and ask experts for their opinions on the rest.

TV drama silliness aside, it makes me think – how many of my patients do I know really really well? How many do I see in clinic and know in depth the tests they’ve had, not had, the results, trends, discrepancies? Some. But not all – that’s unrealistic. But what if we had a special team of doctors, a ‘special ops’ unit, headed by a ‘House’? The team has a small number of the the most complex patients, and they know everything about that small number of patients, in depth. But that’s ICU, isn’t it? So House-UK is an intesivist? But intensivists are there for the intubated patients, in most places I’ve worked – although outreach ICU is more and more commonplace. So perhaps House-UK is an HDU doctor? HDU patient are awake, sick, complex – ideal House-fodder.

I’m on call for our HDU tomorrow, all weekend, in fact. Maximum of 6 patients, 2 to 1 nursing, and me. Not so many gram staining, colonoscopy-ing, brain biopsy-ing underlings, though. So I can play House-UK tomorrow? Consider sarcoid for every patient? Perhaps. But I’ll have all of the chest ward to see afterwards!

We chest physicians get a lot of ‘grey cases’ through out in patient, and out patient books, many with multi system disease that just happens to involve the chest, or, often, they come in with a co-incidental chest infection, or ‘breathlessness’ due to their unrecognised metabolic acidosis. We’re all Dr House to some degree, facing challenging cases in our clinic rooms, an on our weekend ward rounds. I rely heavily on second, and third opinions – formal, and informal multi-disciplinary discussions, sometimes in organised meetings, other times over a caffeinated beverage in the Drs’ Mess. None of us are Dr House, and none of us want to be – I hope our patients don’t expect us to be. A difficult case takes multiple brains, and takes time to get through.

My HDU ward round tomorrow will be the start of a weekend of ‘diagnostician-ing’. Perhaps I should get a white board, and write sarcoid on it?

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