> I agree that SOME of these patients will indeed be their first
> presentation of "stable" angina, but some of them it will be unstable
> angina...thinking about the biology of this there is no way we can tell
> on a single episode whether her stable atheroma has now reached a
> critically narrow stage or whether she had a small plaque rupture this
> morning and formed a clot which she then lysed...if it is the latter
> then she is at extremely high risk of having an infarct later on today
> or in the near future. The only way of ensuring this woman has an
> exercise test to assess that risk is to admit her. Also you need to do
> at least a 6 hour troponin if not a 12 if you do one at all otherwise it
> will be a falsely reassuring test.
> --
> Sam Waddy
Reminds me of a conversation with another medical SHO from a teaching
hospital, criticisng me/ being staggered at my gross incompetence for
diagnosing asthma by trying empirical treatment. Felt the only approach was
to perform a "bronchial challenge" whatever that is!
I agree with Adrian's sentiments. We work in an underfunded, understaffed
and under resourced health environment. Every day is a "major incident" and
our patient care is designed to do the "most for the most" in as reasonable
and safe a manner as time and resources allow.
I also agree that Sam's approach may be desirable. If this patient presented
in the US (with the right health insurance of course....) I wouldn't be
surprised to see her tipped out of hospital 6 hours later following an
exercise test and coronary angiogram, with full prognosis and management
plan established.
We are forced to work to Adrian's values, but perhaps should be canvassing
public and government to move towards Sam's vision. That would be more
effective than arguing over workload and money, just show the public how
compromised every day in the NHS really is!
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