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COVID-19, negative nasopharyngeal swab, clinical positivity. 8th of February, 2021 ANTE·MERIDIEM 12:21

I was in the interesting situation over the last few days of dealing with a patient with a recent hospital admission (discharged two weeks previously in the context of a distinct clinical problem), brought in by ambulance with a decreased level of consciousness, dyspnoea, and bilateral pneumonia on chest X-ray, CURB-65 of five. With our pre-test probabilities as they are, he almost certainly has COVID-19, and he improved dramatically on Airvo® treatment (high-flow nasal cannula), after iv dexamethasone, iv antibiotics, and a failed trial of CPAP. His nasopharangeal swab was negative for COVID-19 (and it was correctly done, I was in the room as it happened), and I write this post to document that the man had a urea of about 48 mmol/litre (about 7 times the upper limit of normal) and was dry as a bone, with skin flaking and dry mucous membranes. From my assessment, the reason the nasopharangyeal swab was negative was because the man was secreting nothing at all from his upper airway, because he had little to no fluid to help with that secretion process, as is not shocking with a severe acute kidney injury.

Free Kirk o Scotland (1843—1900) 7th of April, 2020 POST·MERIDIEM 07:43

https://en.m.wikipedia.org/wiki/Free Church of Scotland (1843—1900)

“The first task of the new church was to provide income for her initial 500 ministers and places of worship for her people. As she aspired to be the national church of the Scottish people, she set herself the ambitious task of establishing a presence in every parish in Scotland (except in the Highlands, where FC ministers were initially in short supply.) Sometimes land owners were less than helpful such as at Strontian, where the church took to a boat.”

An individual I used to know well grew up speaking a Turkic language in Iran, together with good Persian. Neither of those have grammatical gender, something that contrasts with classical Arabic and with many European languages. This person was very much on board with the idea that languages either had grammatical gender or did not, and was very irritated by the standard English-language habit of referring to ships as ‘she’ and the less standard habit of referring to individual vehicles as ‘she’.

The above paragraph describing the circumstances of one of the presbyterian churches seems calculated to enrage my acquaintance. As a non-Scottish English speaker, it is only remotely comfortable to read for me because of my German, and I would be irritated if the gender differed from that of Kirche in German. I write this entry to document my surprise at this sort of consistent use of grammatical gender for the word church in English.

RCEM Learning Podcast. 6th of December, 2018 ANTE·MERIDIEM 12:35

I worked as an SHO in the Mater Emergency Department in Dublin from July 2014 when Andy Neill was a registrar there, and my thinking then was ‘this man is clearly great as a doctor, I am glad of any input from him on almost any presentation, my one concern is not to overload him with questions, I’d prefer him not to burn out while I’m here.’

The Irish secondary care system is, let me phrase this diplomatically, uneven, and when I was working as an SHO in non-central-Dublin hospitals the guidance from registrars was of limited benefit to the patient or to either of the doctors. There was no whisper of this situation from Andy, and from most of the registrars in MMUH.

The correct specialty (in terms of benefit to patients and long-term quality of life for the doctor) for most of the doctors most of the time in the Republic is General Practice. And so I applied for the training scheme, and have been in Donegal since July of 2015; I thoroughly recommend the Donegal Specialist Training Scheme in General Practice, I have spoken at length with trainees across the Republic and the North about their schemes, and in terms of almost anything objective, the Donegal scheme comes out best.

But; the first specialty I worked in post-intern-year, early 2013, was Emergency Medicine. And, well, I really enjoyed it. I enjoyed how general it was, I enjoyed randomly having to deal with an Afghan refugee where my Persian was of some use, knowing that نقرس is gout was of actual help to the patient, I enjoyed managing patients well through French without issue when the triage nurse in Blanchardstown (closest hospital to the airport!) was worried about the need for an interpreter but hadn’t actually organised an interpreter on triage. I even enjoyed that anyone who had put up with the fourteen hour wait was actually sick enough to need to be in hospital, and so I knew how to manage them from my intern year! I didn’t know much about sprained ankles or migraines, but I did manage to learn it.

And I still like it. Five years later, I am still consistently seeing ED patients a proportion of the week and enjoying it, there is no prospect of me stopping ED work in the medium term. I’m not doing it in Dublin, but that is mainly a constraint of my registration rather than an explicit choice.

Which is a roundabout way of saying I listen to the RCEM Learning podcast because I enjoy it and it is relevant to my day-to-day work. I write this post today because I now contend that it is a high point of human learning.

I attended some local teaching in Donegal yesterday from a medical specialist, about one of her areas of interest and the appropriate management and approach to referral; and it reminded me of how bad medical teaching can be. She used data from the US population that differed importantly from the Irish population to make decisions; she appeared to have no insight into the day-to-day pattern of presentations to GPs in general and how her recommendations would impact on her clinic numbers, when making a presentation to GPs in large part advertising her service; practicality and pragmatism were at no point involved in the presentation. It was as bad an experience as any of the bad presentations involved in my experience of Computer Science lecturers, and those fellows had the theory of mind of a four-year-old Sheldon Cooper.

Nothing like the above ever happens with the RCEM Learning podcast, of which Andy is the backbone. Doctors’ weaknesses of understanding are usually with formal statistics; the RCEM Learning podcast gets this right consistently. Practicality and pragmatism are front and centre. The variation in speakers, from the UK to ourselves to Australia, a little bit the US (certainly not a massive cultural variation, but a big variation in how health care systems are funded and how the associated incentives play out), mean that the decision-making cul-de-sacs that give bad outcomes for economic reasons are mentioned as avoidable.

I listen to lots of North American podcasts relevant to Emergency Medicine, and they’re great, much better than our medical specialist above. RCEM Learning still edges in front of all of those I listen to. If you are a doctor who drives and has anything to do with Emergency Medicine (whether working in it, taking referrals from it, or making referrals to it), make your car handle podcasts in some way, and listen to the RCEM Learning. podcast when it comes out. You will make better decisions, you will have a better understanding of the decisions made when you refer, and you may incidentally start rhyming ‘now’ with the French word for ‘eye’, which will be entertaining for everyone.

Thran. 23rd of October, 2018 POST·MERIDIEM 11:53

Thran /θræn/ (th of thin, rest of the word as in ‘ran’) is a word used in this part of the world to mean “stubborn, obstinate.” This little vignette on Reddit, about the roads I drive to do my grocery shopping, prompted me to look it up. To my surprise it’s not in the second edition of the OED, but from the Scots dictionaries it is likely the same word as ‘thra,’ which is. For your edification, here is the OED2 entry.

thro, thra, a.¹ (adv.) Obs. Forms: 3­4 Þra, (5­7 Sc.) thra, 4­5 Þro, thro, throo (5 throe).
[ME. a. ON. Þrá-r ‘stubborn, obstinate, unyielding, refractory, persistent, zealous, eager, keen’, adj. cognate with Þrá n.: see prec.]
1. Stubborn, obstinate, persistent; reluctant to give way, or accede to a request.
(The spelling throw in quot. c 1500 is app. due to confusion with other words.)
a1300 Cursor M. 5803 (Cott.) King pharaon..es ful thra [Trin. Þro], Lath sal him think to let Þam ga.
13.. Ibid. 28092 (Cott.) Vn-buxum haf i bene, and thra A-gayn my gastly fader al-sa.
c1400 Destr. Troy 5246 þat were Þro men in threpe, & thre-tyms mo.
?a1500 Chester Pl. (Shaks. Soc.) II. 11 In this place, be you never so throe, Shall you no longer dwell.
c1500 Smyth & his Dame 317 in Hazl. E.P.P. III. 213 Be thov neuer so throw, I shal amende the sonne, I trow.
c1560 A. Scott Poems (S.T.S.) xiii. 31 Than be not thra ȝour scherwand to confort.
1603 Philotus xl, Scho is sa ackwart and sa thra, That with refuse I come hir fra.
b. Of a corpse: Stiff, rigid.
a1400­50 Alexander 4452 Graffis garnyscht of gold & gilten tombis Thurghis to thrawyn in quen ȝe Þraa worthe.
2. Stubborn in fight, sturdy, bold; fierce. Also fig.
c1320 Sir Tristr. 777 þei Þou be Þro, Lat mo men wiÞ Þe ride On rowe.
?a1400 Morte Arth. 3757 They..thristis to Þe erthe Of the thraeste mene thre hundrethe.
c1400 Ywaine & Gaw. 3570 Thir wordes herd the knyghtes twa, It made tham forto be mor thra.
c1400 Destr. Troy 6422 Merion..With Þre thousaund Þro men Þrong hym vnto.
Ibid. 6446, 6462, etc.
c1470 Henry Wallace ix. 846 Wallace with him had fourty archarys thra.
1513 Douglas Æneis viii. xii. 128 And Gelones, thai pepill of Sithya, In archery the quhilk ar wonder thra.
1535 Stewart Cron. Scot. (Rolls) I. 250 The Albionis, thocht tha war neuir sa thra, Out of the feild on force wer maid to ga.
3. Angry, wroth, furious, violent.
13.. E.E. Allit. P. A. 344 Anger gaynez Þe not a cresse, Who nedez schal Þole be not so Þro.
c1375 Sc. Leg. Saints ii. (Paulus) 504 As he, Þat firste wes cristis fa, And in thra will his men can sla.
c1380 Sir Ferumb. 3968 Wan Þay come to Þe dupe Ryuer, þat wilde was & thro, Entrye Þanne ne darst hy noȝt.
c1400 Destr. Troy 147 He bethought hym full thicke in his throo hert.
c1440 Bone Flor. 2075 Sche dyd me oonys an evyll dede, My harte was wondur throo.
c1475 Sqr. Lowe Degre 1017 With egre mode, and herte full throwe, The stewardes throte he cut in two.
4. Keen, eager, zealous, earnest.
a1300 Cursor M. 14392 (Cott.) Ful deueli war Þai Iuus thra þair blisced lauerd for to sla.
c1320 Sir Tristr. 615 Rohand was ful Þra Of tristrem for to frain.
c1350 Will Palerne 3264 þre M. of men Þat Þro were to fiȝt.
1400 Destr. Troy 470 Mony thoughtes full thro thrange in hir brest.
c1425 Wyntoun Cron. v. vi. 1198 Sancte Gregor..Made special and thra oryson Þat God walde grant his saule to be..fre.
?a1500 Chester Pl. (E.E.T.S.) 451 Falsehed to further he was euer throe.
[1775 John Watson Hist. Halifax 547 A person is said to be thro about any thing, who is very keen or intent about it.]
b. fig. Of a thing: Ready, apt, disposed.
a1425 Cursor M. 16560 (Trin.) þei..cut Þis tre in two..What Þei wolde Þerof shape: þerto hit was ful Þro.
B. adv. Obstinately; vigorously; boldly.
a1425 Cursor M. 5997 (Trin.) ȝitt Þe kyng hem helde ful Þro For wolde he not lete hem go.
c1450 St. Cuthbert (Surtees) 6032 Oxen twenty and twa War drawand Þis bell full thra.
c1470 Golagros & Gaw. 60 The berne bovnit to the burgh..and thrang in full thra.