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    Could someone please explain how to check for a collapsing pulse in a CVS exam, and what it's a sign of? cheers
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    (Original post by Captain Crash)
    The problem is that once the implants burst, they cause pain and scarring and are nigh on impossible to completely remove. I'm not sure of the ability to predict bursting, but I imagine the move is one of cheaper prevention rather than have potentially thousands of new chronic pain cases. And that's before we even approach the psychological aspect...
    I was under the impression that the way forward was to USS/?CT/MR and remove any that show signs of leakage, but then to some extent you're back to the problem because if they have leaked, the op will likely have its own risks, scarring, and then there's the problem of asthetics - if for example somebody is left with asymetries or breast damage due to removal, is it now your fault? These people will be pissed of anyway, I would bet they're willing to sue the NHS, even if it does them a large favour.

    So, the solution here is you don't go near it, the people who have had it done privately, those private surguries largely still exist - get them to do all this downstream work. If the patient presents acutly with rupture, than the NHS can look at that. If you want to treat patients privately and it goes wrong, you take responsibility for that - your coustomer is not supposed to be my patient.

    I can see, and to some extent agree with your POV, I just don't agree with the softly softly approach - people take advantage.
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    (Original post by Isometrix)
    Could someone please explain how to check for a collapsing pulse in a CVS exam, and what it's a sign of? cheers
    Look up Corrigan's Sign/waterhammer pulse.
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    (Original post by Captain Crash)
    The problem is that once the implants burst, they cause pain and scarring and are nigh on impossible to completely remove. I'm not sure of the ability to predict bursting, but I imagine the move is one of cheaper prevention rather than have potentially thousands of new chronic pain cases. And that's before we even approach the psychological aspect...
    There are what, 40000 patients with these implants in the UK? If the rupture risk is 2% then that's 800 ruptures. I can see that these 800 women are not going to agree with me, but I'd say it was better to run that risk than to operate needlessly on the remaining 39200, given that the replacement procedure is hardly without risk of pain and scarring and infection and everything else that general anaesthetic brings with it. When you get breast implants, you take that chance that the implant might rupture - it's a recognised risk. If the women want to play the psychological trauma card, then I would suggest that unless they have evidence of impending rupture then they should perhaps pay for the replacement procedure privately.
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    (Original post by Becca-Sarah)
    There are what, 40000 patients with these implants in the UK? If the rupture risk is 2% then that's 800 ruptures. I can see that these 800 women are not going to agree with me, but I'd say it was better to run that risk than to operate needlessly on the remaining 39200, given that the replacement procedure is hardly without risk of pain and scarring and infection and everything else that general anaesthetic brings with it. When you get breast implants, you take that chance that the implant might rupture - it's a recognised risk. If the women want to play the psychological trauma card, then I would suggest that unless they have evidence of impending rupture then they should perhaps pay for the replacement procedure privately.
    Repped.
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    (Original post by Isometrix)
    Could someone please explain how to check for a collapsing pulse in a CVS exam, and what it's a sign of? cheers
    Aortic regurg. Feel the pulse at the wrist, quickly elevate the arm and feel for a collapsing or decreasing volume pulse.

    As with many of these eponymous signs, it is totally operator dependant with shoddy sensitivities and specificities, an unfortunate relic of the past when echos didn't exist.
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    (Original post by Becca-Sarah)
    There are what, 40000 patients with these implants in the UK? If the rupture risk is 2% then that's 800 ruptures. I can see that these 800 women are not going to agree with me, but I'd say it was better to run that risk than to operate needlessly on the remaining 39200, given that the replacement procedure is hardly without risk of pain and scarring and infection and everything else that general anaesthetic brings with it. When you get breast implants, you take that chance that the implant might rupture - it's a recognised risk. If the women want to play the psychological trauma card, then I would suggest that unless they have evidence of impending rupture then they should perhaps pay for the replacement procedure privately.
    Looking closer at the offer by the NHS to remove the implants, they said they will remove them if there is clinical need.

    Which is fair enough to be honest.
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    (Original post by digitalis)
    Aortic regurg. Feel the pulse at the wrist, quickly elevate the arm and feel for a collapsing or decreasing volume pulse.

    As with many of these eponymous signs, it is totally operator dependant with shoddy sensitivities and specificities, an unfortunate relic of the past when echos didn't exist.
    If you feel a collapsing pulse in a 20-30 something patient in A&E/AMU, you may not have time to echo them before they die. There certainly is still a place for it in modern clinical practice.
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    (Original post by Wangers)
    If you want to treat patients privately and it goes wrong, you take responsibility for that - your coustomer is not supposed to be my patient.
    Quite. However, the original NHS charter in 1948 allowed NHS consultants to use NHA facilities for their private patients - meaning complications can be turfed to the local DGH. Its disgusting and it needs changing, but unfortunately that's the way of the world atm.
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    (Original post by Captain Crash)
    Looking closer at the offer by the NHS to remove the implants, they said they will remove them if there is clinical need.

    Which is fair enough to be honest.
    There are discrepancies between the different NHS regions tho - Wales is going to replace them, whereas England are only removing?
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    (Original post by Captain Crash)
    If you feel a collapsing pulse in a 20-30 something patient in A&E/AMU, you may not have time to echo them before they die. There certainly is still a place for it in modern clinical practice.
    From studies, it has shown to have a pretty awful sensitivity for AR. Even it's specificity is not great (low 60s). That means, objectively, it is pretty useless for ruling out AR. If there are other suggestions from the H&E that it is a case of AR (I guess your getting at a Marfan's/Ehler Danlos/Syphilitic presentation of Aortic dissection here) then yes, it could be contributory to the overall global picture, but alone it is not reliable. We just have these relics back from the days where there was nothing else but clinical signs.

    I've never felt a collapsing pulse before, wouldn't know if it hit me in the face. And besides, what's the cutoff that determines a positive finding? A 'little' bit of collapse, as felt by me? A 'lot'? It is totally operator dependant.

    Loads of these clinical signs that we trot out in OSCEs are totally bogus.
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    (Original post by digitalis)
    From studies, it has shown to have a pretty awful sensitivity for AR. Even it's specificity is not great (low 60s). That means, objectively, it is pretty useless for ruling out AR. If there are other suggestions from the H&E that it is a case of AR (I guess your getting at a Marfan's/Ehler Danlos/Syphilitic presentation of Aortic dissection here) then yes, it could be contributory to the overall global picture, but alone it is not reliable. We just have these relics back from the days where there was nothing else but clinical skills.

    I've never felt a collapsing pulse before, wouldn't know if it hit me in the face. And besides, what's the cutoff that determines a positive finding? A 'little' bit of collapse, as felt by me? A 'lot'? It is totally operator dependant.

    Loads of these clinical signs that we trot out in OSCEs are totally bogus.
    Edited

    Some would argue, nowdays, we do tests like smarties going out of fashion. You can quote large scale studies all you like, but given number of times old school consultants are on the money, the signs are good, if you know what you're doing.
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    (Original post by Wangers)
    Edited

    Some would argue, nowdays, we do tests like smarties going out of fashion. You can quote large scale studies all you like, but given number of times old school consultants are on the money, the signs are good, if you know what you're doing.
    We do appropriate tests because they are precise, accurate, reliable and management changing. All you have to do to put this into perspective is to think back to a time when you and a mate had a listen to a chest and one heard crackles, the other one didn't. That is the flaw of clinical signs, they are operator dependant. A well calibrated CT will show the same thing, time after time again, all over the world.

    'You can quote large scale studies all you like' Yes, I will :confused: since that is actual scientific evidence, designed to stop old school consultants going about their business like they did when they qualified in the 70s and 80s. Or is it OK to keep giving cef and met 'because that's what the consultant likes' still? :rolleyes:

    Clinical skills are alright if they correlate with real life, that's fine. Caput medusae suggesting portal hypertension, fine. Scleral icterus suggesting jaundice, fine. Random stuff that was invented hundreds of years ago that actually doesn't correlate well with pathology (Homan's sign anyone) = bin that stuff ASAP.
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    And in terms of imaging, this is the way of the future.
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    (Original post by digitalis)
    Clinical skills are alright if they correlate with real life, that's fine. Caput medusae suggesting portal hypertension, fine. Scleral icterus suggesting jaundice, fine. Random stuff that was invented hundreds of years ago that actually doesn't correlate well with pathology (Homan's sign anyone) = bin that stuff ASAP.
    I swear that's actually dangerous.
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    Ah! I can feel an impending burnout, and I've still got a week left will exams!
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    (Original post by digitalis)
    We do appropriate tests because they are precise, accurate, reliable and management changing. All you have to do to put this into perspective is to think back to a time when you and a mate had a listen to a chest and one heard crackles, the other one didn't. That is the flaw of clinical signs, they are operator dependant. A well calibrated CT will show the same thing, time after time again, all over the world.

    'You can quote large scale studies all you like' Yes, I will :confused: since that is actual scientific evidence, designed to stop old school consultants going about their business like they did when they qualified in the 70s and 80s. Or is it OK to keep giving cef and met 'because that's what the consultant likes' still? :rolleyes:

    Clinical skills are alright if they correlate with real life, that's fine. Caput medusae suggesting portal hypertension, fine. Scleral icterus suggesting jaundice, fine. Random stuff that was invented hundreds of years ago that actually doesn't correlate well with pathology (Homan's sign anyone) = bin that stuff ASAP.
    But the issue is these days very often tests are done inapropriatly, and then results are not interpreted properly, after which people do down treatment algorithems. Modern technology is not as definitive as you make out, everyone has something abnormal with them which you will possibly find with your battery of tests, the point is to interpret them.
    "All you have to do to put this into perspective is to think back to a time when you and a mate had a listen to a chest and one heard crackles, the other one didn't."

    Yes, I do put that into perspective - it's called being a student. Just because you or I arn't experienced enough to spot and interpret clinical data, it does not mean that the methods are wrong.

    Let me guess, the US are big fans of the testathon? This combined with defensive medicine will be the downfall of clinical acumen.
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    (Original post by Wangers)

    Let me guess, the US are big fans of the testathon? This combined with defensive medicine will be the downfall of clinical acumen.
    Sadly they are - and ordering large batteries of test compared to using clinical skills to justify which ones is definitely not the way forward.

    Especially as tests on the whole are not harmless... albeit most have small chances of large damage.
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    (Original post by digitalis)
    Aortic regurg. Feel the pulse at the wrist, quickly elevate the arm and feel for a collapsing or decreasing volume pulse.

    As with many of these eponymous signs, it is totally operator dependant with shoddy sensitivities and specificities, an unfortunate relic of the past when echos didn't exist.
    Except of course when you don't have all the tests to hand. I rather like the history of medicine and all this stuff.
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    (Original post by Wangers)
    But the issue is these days very often tests are done inapropriatly, and then results are not interpreted properly, after which people do down treatment algorithems. Modern technology is not as definitive as you make out, everyone has something abnormal with them which you will possibly find with your battery of tests, the point is to interpret them.
    "All you have to do to put this into perspective is to think back to a time when you and a mate had a listen to a chest and one heard crackles, the other one didn't."

    Yes, I do put that into perspective - it's called being a student. Just because you or I arn't experienced enough to spot and interpret clinical data, it does not mean that the methods are wrong.

    Let me guess, the US are big fans of the testathon? This combined with defensive medicine will be the downfall of clinical acumen.
    I'll ignore the remark about America.

    Why is this such a difficult concept to understand? You have fundamentally missed the point about the student concept.

    If you put your Dean infront of 100 patients and get him to do the Homan sign, even he will get a crappy pickup rate of DVT. Even if he was an expert, it is still useless. It is not reliable. It is like me stroking my chin at the bedside, seeing a crow fly by and going 'Oh! That must mean you are having an MI!'

    If you put a square box of known dimension into a scanner, you will be able to measure that box again and again and again. Yes, I agree with you that it is then up to the clinical acumen of the clinician interpreting it to know what to do with that data, but the raw data is reliable and accurate.

    Medicine is a progressive science. As I alluded to in my previous post, I don't mind doing clinical examinations that are reliable and indeed they are helpful in diagnosis! The stuff that was made two hundred years ago based on obsolete basic science principles or dubious reliability-why are we still doing it? It is about as much science as Heston Blumenthal's cooking! If you really wanted to do the best for your patients, you should be looking at what you do critically-otherwise you're just doing a disservice.
 
 
 
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