Understanding acute illness vs counting Andy Murray: it’s not Cricket!

I am not sure whether you have followed the tennis last week? Intriguing sport. Andy Murray ( beaten by his own leg. Many beaten by their nerves. I am still curious about the way that results are being managed 15:love. 30: love, 40:love. So I started to read up on it and it turns out that the origin is not very clear at all. It has probably something to do with medieval french counting of time in quarters (15, 30, 45) but the explanation is even more confusing than the numbers given that at the time that the counting is meant to have been invented they might not have used minutes.

So scoring is tennis is confusing. And I haven’t even started to talk about Test Cricket yet. As a German this is something that even after watching England playing Australia in Sydney I am struggling with, and that has little to do with the fact that it was a sunny day and that they allow pints in the stadium.

The numbers in acute physiology are equally intriguing and confusing. In septic shock, in really, really bad infection we believe that blood pressure is lowered due to loss of volume from the circulating blood from the circulation through the vessel wall into the interstitial space. So blood pressure goes down, but the diastolic pressure might be initially preserved. But at the same time vaso-constriction can be impaired due to release of cytokines such as tumor necrosis factor alpha, Interleukin 6 and others. Central venous pressure that is measured in big veins in the neck or groin goes down and the amount of blood that is pumped around each minute probably goes up in the first phases of this condition. Similar findings are found in conditions where fluid is lost from bleeding or the runs …

The measurements of septic or ‘hypo-volaemic shock are in stark contrast to those in cardio-genic shock where where shock is caused by a problem with the strength of the heart: The blood pressure goes down, but vaso-constriction sets in and the central venous pressure goes up and the amount of blood that is pumped around the body to deliver oxygen per minute often goes down, leading to blue finger tips and tongue.

In both conditions we might find increased level of lactate, but changes in the activated partial thromboplastin time are more common in septic shock. And when most nurses and doctors struggle with this then it is clearly completely impossible for patients to understand.

Except if might not be:

When a colleague of mine who is a mathematician was admitted to hospital with severe abdominal pain he was inclined to shrug it off. A bit of a stomach cramp can’t be that bad. His first set of vital signs were not that bad. Given that he has worked with me on research in this area he felt entitled to review the numbers at the end of his bed. The overall NEWS score on admission was Zero, the lowest it can be. This means that all vital signs such as blood pressure, heart rate, speed of breathing, temperature etc were in the normal range. The surgeon came to see him. He examined the abdomen and reviewed the laboratory tests. He looked concerned. My friend wasn’t. And when the surgeon spoke about the possible need for surgery if things would not improve my friend was quite confident that there was not much to worry about.

He had a reasonable night in the circumstances. The nursing team kept an eye on him. And re-checked his vital signs. At 7:30 in the next morning the next set was due. And my friend noted to his horror, that his Early Warning Score was not longer Zero, over night it had started to shift and had crept up to 3. He remembered the figures from our study. So when the surgical team came back to suggest to take him to theatre to have a look into his belly he agreed at once. His appendix turned out to be fairly inflamed but had not ruptured and was taken out!

Now obviously he is a mathematician, he has studied in Cambridge and this might be straight forward to him.

But if you remember my blog from last week: I was speaking to one of my patients the other day“The only game you don’t want to score in!” – It might be NEWS to you but it is no longer to your patient… : he is my age but has quite significant lung disease. He was helping me with the OSCE examination of our first year Physician Associates and we were talking about what the students were expected to examine. When we came across his respiratory rate he knew! He even knew about the values of the Early Warning Score. ‘NEWS, yes, that is the one you don’t want to score on.’

So the only real difference between understanding Andy Murray scoring at Wimbledon and patients understanding the scoring of the severity of their illness is the direction of the score!

Even in the confusing system of tennis there is a simple over arching rule that holds true: the higher the score the better. And in physiology it is the other way around: the higher the score the worse.

So maybe physiology isn’t that complicated after all and certainly not as bad as scoring in Cricket!



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