Thoughts on Poker and Medicine

While listening to Simon Carley on risk at #SMACC2013 I had one of those thoughts.

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First I hope any serious poker players can forgive my over simplifications of a wonderful game. I also hope everyone can forgive my extreme stretching of this metaphor.

 

So why is medicine like a poker game?
It’s about prediction and probabilities, sometimes we are accurate and can be quite sure of ourselves but sometimes we get caught out by a surprise card or unlikely diagnosis.

In emergency medicine we often concern ourselves with the dangerous diagnoses, most poker players consider these options and likelihood their opponent will draw them. If you have played against a person/disease many times you can be more confident that you will be able to  judge their strength or recognise their tells.

In both luck plays a role that both doctors and card players are uncomfortable with. Everyone will have a “bad beat” where you are confident that you have the correct response or reaction but something unlikely/rare happens and you lose. This leads to both groups having superstitions and sayings which are similar.

“You play the man not his cards” sounds a lot like “It matters more which patient has the disease than which disease the patient has”

Like poker, medicine can be played at a number of stakes. Is it a life and death situation or just trying to rid someone of a minor irritation.

Texas Holdem

Medicine is most like Texas holdem (heads up).
I’ll explain why with an explanation of how it’s played and the similarities.

Heads up poker is played against one other person. You have your own cards and there are a number of communal cards which you make your best hand from. In this way a poker hand reflects a medical consultation information is slowly revealed and you attempt to gauge your position and certainty.

The rounds are as follows:

Pocket cards:

File:Pair of Aces.jpg

Firstly you are given two cards, an initial impression. You know from a glance if this patient is sick or not. Your system 1 is firing on all cylinders. You may get an instant diagnosis from the end of the bed, ?pocket Aces.

But you also know when you don’t have an idea. You know it will be hard or perhaps you just don’t want to play this hand.

Everyone makes their bets, some times this is easy. The patient is dry start some fluids, pain relief/Raise. Other times you don’t want to initiate much treatment until you have more information/Check.
In medicine you can’t really fold. unless you take the next chart (don’t be this person).

 The flop:

Three cards are turned over. This equates well with the history, it’s where the money is. Based on what you know about the patient and you impression most times you can have a very good idea about how you are placed. But there is some difficulty. Many diseases are difficult to tease out, are you being bluffed by your opponent. Previous experience with the opponent/disease can help you here. Are they likely to play passively or do they often show their strength?

The Turn:

This is the physical exam. (might be giving too much credit here)

This adds to what has come before. The reaction to this, tells/focal signs often increase your confidence in your diagnosis. But again it can leave you feeling unsure. But often it makes minimal difference, your impression can remain unchanged based on presence or absence of some signs. This is also often when you take a little time to think of any other possibilities you may have forgotten, a few extra questions whilst examining.

 The River:

 The investigations. Everything is back, all the information you are going to get is there.

This confirms or refutes your previous thoughts. You often know where you stand are you “the nuts” ?

But everything can change and swing based on one investigation/the final card. Is the bloody D-dimer positive? 

Then the final rounds of betting, are you all in for one diagnosis or are you still unsure of yourself? Often you know your badly placed (Pt is sick) but you can’t be certain of why.

 Finally the hands are revealed; in medicine like in poker you may never find out if you were right. Your opponent may never reveal their cards.

The best you can hope for is to learn from your mistakes, minimise your losses and be ready to play again.

But remember, in the end the house always wins.

 

 

#KeeweePatient

I was working nights and had that sorta grumbly tummy you can get where your just not right but nothing to worry about. Took a couple panadol and carried on. Slept alright the following day but pain was getting bit more so did what most doctors do and took some codiene and carried on.

Nightshift was ok few to see but not super busy. But as it carried on i started feeling worse. hot and cold. got up from chair and felt light-headed and very nauseated. Night nurse declared i was white as a sheet and was in no state to see patients. Thankfully one of the other docs who was oncall nipped in to finish my shift.

He put me in a sideroom and had a bit of a look at me. “could be your appy but you knew that didnt you?”

So had an ok sleep for a couple hours. woke up and had bloods.

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USS

Cool local ultrasonographer goes “you know we never really get a good view of these. lays probe on and there is an appendix.

Abdominal pain

Abdominal pain

Appendix was reported as “likely normal, some increased vascularity, clinical correlation is required”

Bloods showed mild neutrophilia and CRP of 56

Chat with surgeon went like this “Want it out?”

“Yes”

“Lets do that then”

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  Theatre

I have failed the #FOAMed team in that the nurse in theatre struggled with my phone so the video of my intubation is rubbish. =(

 Post op went pretty well, bit tender but got on with things.

Sympathy flowed from my medical friends…

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 Finally big thanks to everyone who was involved in my care.

Appendix:

Specimen:Appendix

Clinical Details
Nil. (Surgeons!)

Macroscopic
Appendix 50x10mm with fragment of mesoappendix 45x9mm.  Serosa is congested
and the wall is focally haemorrhagic and firm.  (mp/1/r; HEBL)

Microscopic
Sections show appendix with extensive mucosal ulceration and a moderate
transmural acute inflammatory infiltrate, consistent with acute
appendicitis.

Diagnosis:
Appendix:  Acute appendicitis

Dealing with difficult patients.

 We often have patients who are a little more worried about their standards of care than others. They often want some sort of commitment from you that you are going to do your best or that you are the right person to be treating them. I often find myself telling these patients, you know the rules and so do I. A full commitment’s what I’m thinking of, You wouldnt get this from any other doc. I just wanna tell you how I’m feeling, Gotta make you understand… Never gonna give you up, Never gonna let you down, Never gonna run around and desert you. Never gonna make you cry, Never gonna say goodbye, Never gonna tell a lie and hurt you. #RickRolled =)

Sorry thats what a friday afternoon does to my brain. hope you have a good weekend. I’m off to PRIME so will report back on that next week.

Multi-staged death.

Been mulling the wise post over at St. Emlyns about little white lies.  http://stemlynsblog.org/2012/09/little-white-lies-in-the-resus-room/

Then was having a discussion with a local vet about breaking bad news. He told me about his favourite method which he calls the multi-staged death.

So he will often get a cat/dog that has been hit by a car, usually arrive with a distraught owner who asks for him to do everything possible to save them. Firstly he explains its touch and go and that they should say their goodbyes and go home. Then he does what he can for the critter.

If it goes badly and they don’t survive or if the injuries are simply unsurvivable he initiates the multi stage death protocol. Sometimes  he will do this  after the animal has passed away.

(Stage one) First his nurse calls to tell them it’s not looking good. This gives them an early warning about the likely outcome.

(Stage two) A short while later he calls to tell them he’s going to take their pet to theatre and he will “Do what he can” further preparation of owner.

(Stage Three) Then finally he calls back and breaks the bad news that despite all the best efforts the injuries were not survivable. Gives closure, they feel all that could have been done has.

He swears by it as being a great way to prepare the owners for the likely outcome and is much better than the “Will call you when its done, either way” approach of his practice partner.

Now im not advocating this approach for patients but found it an interesting approach. Thoughts?

 

Late presentations “Hard Bastard”

Working in an isolated area with a reputation for hard “bastards” you see things presenting even later than you might imagine. Had this “Bloke” present to ED. (Not barry crump for clarification)

<—–Kiwi literature

 78 male. life long bachelor.

Presented with anorexia, lethargy and feeling “as weak as an Auckland accountant” Some clarification for those outside New Zealand, Auckland is our largest city almost half our population and residents are known less than affectionately as JAFAs  (Just another f#$%ing Aucklander)

So the had been off his food for a while and not eating any solids as was “difficult”. His main complaint was that he got tired when pushing his lawnmower.

 The patient last saw a doctor 25 years ago following a “small” accident with a chainsaw when working in the Forest.

He had stitched himself with twine as was 2 days walk from the bush-end. “It was only about 20 stitches”

He came to get the stitches looked at. Not a bad job according to the ED doc. Was going to be revised to some formal sutures but self discharged after theatre list was bumped to following day. Explained to me that the boys were going hunting and didn’t want to wait another day and miss out.

So this time he had a Biochem panel done which showed this.

 

ECG was as below.

 The following day with some potassium replacement ECG developed to this.

Pt left hospital a week later unfortunately with diagnosis of oesophegeal Ca with mets. Declined any further intervention, but accepted some fortisip for dietary supplementation and review in clinic in a months time as he didn’t have any trips into the bush planned then.

His plan “Ill hunt until I can’t walk, and then the boys can strap me to the back of the Ute(Pick-up truck) and ill shoot from there”