Present

Some of my friends knew I actually bought two books as presents for the Christmas Quiz. During lunch before the grand round, SN asked, "Have you ever read those books ?"

"Of course. How else could I recommend them to the others ?" I replied firmly.

For those from the next generation, I would recommend the followings:

• The Elements of Style by Strunk & White (English writing)
• Sophie's World by Jostein Gaarder (philosophy)
• How to Make Friends and Influence People by Dale Carnegie (psychology)
  
• A Short History of Nearly Everything by Bill Bryson (natural science)
• The Wealth of Nations by Adam Smith (economics)
• The Intelligent Investor by Benjamin Graham (investment)
• Murder of Roger Ackroyd by Agatha Christie (detective story)
• Freezing Point (冰點) by Miura Ayako (三浦綾子) (fiction)
• Cobra by Buichi Terasawa (寺沢武一) (comics)
• 司馬遷 《史記》 (history)

Happy new year.

Idea

After the Christmas Quiz grand round, I told Vivian the questions I put up.

She pointed out coldly, "Fifteen pairs of hands ? Alas, the idea of your mentor's distinction viva really gets you."

As always, my wife was right. In fact, I told the story here not too long ago (see http://ccszeto.blogspot.com/2009/11/contd.html).

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And I have a deja vu feeling of a scene in The ABC Murders, when Hercule Poirot described his "dream crime" to Arthur Hastings:

"Supposing that four people sit down to play bridge and one, the odd man out, sits in a chair by the fire. At the end of the evening the man by the fire is found dead. One of the four, while he is dummy, has gone over and killed him, and, intent on the play of the hand, the other three have not noticed. Ah, there would be a crime for you! Which of the four was it?"

Alas, it didn't take long before Poirot met exactly this case in Cards on the Table.

PS. According to the chronology of Agatha Christie, both stories happened in 1936. The usual Poirot would actually try to find out who was eavesdropping when he was telling his idea to Hastings (who spent all his time with Poirot during the ABC incident and was back Argentina immediately afterwards - he had no opportunity of telling anybody else).

Shift

Contrary to her usual self, my friend TW appeared hot and upset with my blog recently (see her comments during Christmas).

In my opinion, however, the annoying bit of the policy was not the resulting delay or cost to human life (by consuming everybody's time) - but the blind of shifting the responsibility.

You see, the policy of checking allergy record was put up by extra-terrestrials and executed by creatures on Neptune, but it is the duty of those who work on the Earth to decide (sugar-coated in the term "discretion on individual basis") if a particular patient needs the injection urgently. The impression to any onlooker is, therefore, all delay is the result of wrong judgement by Homo sapiens and has nothing to do with mollusks living on other planets.

And, you see, that's the general principle: Professionalism and responsibility is the two side of the same coin, which should always go together with the right to make decisions. I am always against those s0-called professionals who claim the right to decide but do away with the whole of their responsibility (often by shifting just a tiny bit of the right to the others).

Contrary to my usual self, I am serious.

Legacy

My friend VW recently expressed his concern of global warming (see http://vwswong.blogspot.com/2009/12/warm.html).

His worry was quite simple. In short, although it is unlikely that the sea level could have a meaningful rise during our life time, it seems mostly likely that the level would rise by at least 5.6 meters in the next 1000 years.

I could not agree more. As a parent, I am always concerned with what type of world I leave for Euterpe and her children.

However, at the same time, another story in ancient China comes through my mind:

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文承閒問其父嬰曰：「子之子為何？」曰：「為孫。」「孫之孫為何？」曰：「為玄孫。」「玄孫之孫為何？」曰：「不能知也。」文曰：「... 今君 ... 厚積餘藏，欲以遺所不知何人，而 忘公家之事日損，文竊怪之。」
〔史記卷七十五孟嘗君列傳〕

按：文，孟嘗君田文也。

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Is there any difference between monetary wealth and a metaphysical legacy ?

Cost

You may think my argument yesterday was irrelevant because human life should not be quantified by the dollar sign.

I fully agree. Life is the time that we spend in this world - let's measure it in terms of time and do a cost effective analysis:

• As stated yesterday, the average delay is 6 hours.
• During this period, a patient needs to stay in the ward and wait. This is the duration of life that is consumed. (Let's take aside the humanistic cost of suffering. I also try my best and used the word consumed rather than wasted.)
• We admit 60 patients each day, and 40% of them need antibiotics. In other words, 6 days of human life is consumed for each effective day of the policy.
• Let's assume the average life expectancy of a patient admitted to our hospital and required antibiotic treatment is 15 years. (Given the age and prevalence of multiple diseases, this is probably a slightly optimistic number.)
• The inevitable conclusion is: The policy would only achieve zero balance on its cost to human life if it could avoid one death in every two-and-a-half years.

I shall leave it to your own judgement whether the policy could save life that often.

PS. Our case is, in fact, the classical scenario of hidden social cost. No one dies of the policy that seemingly saves lives, but everyone pays part of his time.

And time - in aggregate - is life.

Bed

You may think my major concern on delaying antibiotic treatment is the potential threat to some critical patients. That's not (entirely) correct.

In fact, our friends outside the solar system would say clinicians could always ask for urgent dispensing of a drug when they really feel necessary. (Of course I could not imagine what would happen if we say 80% of our patients are urgent and have a necessity.)

But, let's assume they are sincere and that few critical patients were safe, there remains the problem of indirect cost that may skip your eyes.

Let's consider the following estimation:

• The average increase in time lag for antibiotic is around 6 hours.
• The time lag would be translated into an equivalent prolongation of hospital stay. (Let's assume there's no detrimental effect of the lag.)
• Let's assume we admit 60 patients each day, and 40% of them need antibiotics. (Both are highly conservative estimations.)
• The prolong in hospital stay would become 6 extra patients staying in ward (60 times 40% times 0.25 day).
• Assuming daily hospital stay costs HK$3000, the extra cost is $18,000 per day.

Sophisticated administrators would argue that hospital beds are fixed cost and would not disappear even if that 6 patients were not staying. Yes, that's true if we have plenty of empty beds. On the other hand, if the hospital is always full, six extra patients for this particular reason inevitably means that the same number of other patients in need would not receive the care.

There's something more than the dollar sign.

Amenity

One hot topic that keeps coming up in our professional casual chat (the term is self conflicting, I know) is the ban on ward stock of all antibiotics, with the resultant delay in availability of antibiotic for patients admitted through the emergency department.

To be fair, the ban is not without a reason; there had been quite a number of mishaps in the ward because antibiotic was given to someone with a known history of allergy. The solution adopted was to make sure all dispensing must go through the pharmacy, who would check on the history of allergy - and do away with the drug stocking in ward.

Inevitably, the price to pay is there would be some delay in given the drug (using the jargon of our cardiologist, the "door-to-injection time") - even for the vast majority of the patients without a history of allergy.

I shall not give my opinion here. Nonetheless, I am impressed with the comment of Charles, the cynical friend of Coemgenus, when the two discussed the traffic jam indirectly caused by blocking the road for the investigation of a traffic accident:

"Considerations of safety may have a higher priority than amenity but can never override it absolutely as the latter is what enriches life. I would ask the police whether the benefit to them in investigation, whether it be to satisfy those affected, to prepare for intended prosecution, or merely to cover their backs, always justifies the extent of the disruption to the lives of others that it causes."

Go read The Unknown Motorist in Clinical Medicine 2009; 9: 635-636.