Mon pays

Working on Skuttler

So I’ve been putting a bit more work into my side-project, Skuttler. This is a little promotional and explanatory video I made using Blender. Let me know what you think!

March 22, 2012 | Leave a comment | Tags: Skuttler

Risk-aversive behaviour

For the past little while, I have been studying for my Health and Physical Assessment midterm, which was this afternoon. Up until Tuesday, our prof let us believe that any one of the six assessments we had been taught were examinable. On Tuesday, she let us know that it would be a random choice between only two—the head/ears/eyes/nose/throat assessment and the musculoskeletal assessment, which was a pleasant surprise!

But let’s imagine for a moment that the exam actually was a random assignment to one of six assessments, like we originally thought. Let’s also pretend that you were choosing between two imaginary strategies for studying for an exam like this.

The risky strategy

Using this strategy, you will be completely prepared, and guaranteed a grade of 100% on your exam, as long as you don’t happen to be randomly assigned to the neuro assessment, and in the case that you do draw the neuro assessment, you will be totally unprepared and receive a mark of 0%.

The conservative strategy

Using this strategy, you will be 80% prepared for all six assessments. No matter which assessment you are assigned on exam day, you will receive a mark of 80%.

If you were perfectly rational, you would have most reason to choose the “risky” strategy. This is because the expected grade outcome from making a decision guaranteeing a grade of 100% 5 times out of 6 is 83%. Another way of saying that is that if you were to write a large number of exams using the risky strategy, you would expect, over the long run, to get an average grade of 83%. The expected grade outcome for the conservative strategy is, of course, 80%, for the same reason.

The common objection is, But what if I choose the risky strategy and happen to be randomised to the neuro assessment? The answer to that question is, That would suck, but you would still have made the correct decision. Decisions should be evaluated ex ante, not ex post. To adopt a rule for one’s decision-making that endorses the conservative strategy is to adopt a rule that cheats oneself out of an average of 3% per evaluation.

What’s interesting about this result is that if you were to ask any of my classmates (I asked a convenience sample already), they would unanimously say that they prefer the conservative strategy, even after explaining (and them agreeing) that such a choice is irrational. This means that, in at least this case, nursing students at McGill are willing to give up 3% of their grade for nothing but the certainty of knowing what their grade will be beforehand. This is what economists call “risk aversion,” and there are more scientific ways to measure it.

I think I’d roll the dice and go for the 100%.

March 16, 2012 | One comment | Tags: Decisions analysis Nursing

Tricky exams for health practitioners

A couple years ago, I read a story about a medical student who was tricked by his professor. In this story, the professor asked the student to assess a patient’s retina, and told the student that he should expect to see a certain pattern of blood vessels on the retina. The medical student examined the patient’s eye and agreed, claiming to have seen it as well. Much to the embarrassment of the medical student, the professor then revealed that he was examining a glass eye.

I’m scared to death of this sort of thing happening to me.

Today I had a mock exam in my physical assessment class. Because it’s an exam situation, we’ve been told that we’re supposed to expect a normal, healthy standardised patient (SP), and so if we’re nervous and can’t actually find a pulse, for example, we can just say a pulse rate that would be normal for a healthy adult. I happened to be randomly assigned to the head/ears/eyes/nose/throat scenario, and one part of this assessment is examination of the SP’s tonsils.

I looked inside my SP’s mouth with my penlight to look at his mouth, tongue, the insides of his cheeks and his tonsils. The tonsils are supposed to be just visible around the sides of the back of the throat, and sometimes they’re not visible at all. I couldn’t see the tonsils, but rather than just writing down “tonsils +1,” I took the tongue depressor out and asked, “Have you had your tonsils removed?”

I felt like I dodged a bullet when he said, “Yes, they were removed three years ago.”

March 14, 2012 | Leave a comment | Tags: Nursing

Pathology midterm results

My pathology midterm was three weeks ago. I went to the exam feeling cautiously optimistic, but when I started talking to my classmates in the hall before the exam, my confidence was shaken. I wrote the exam in my usual way: I answered the questions as quickly as possible and then left before I had a chance to turn correct answers into wrong ones. I didn’t feel very good about my performance afterward. I felt a little bit better when a classmate mentioned that she also had a lot of 5′s in a row, but I still had no idea how I did, and I feared the worst. I mean I actually was afraid of receiving a failing mark.

Yesterday I finally decided to check my grade online. I did really well. Unexpectedly well. Suspiciously well.

This, on the one hand, is great news. Who doesn’t want a good result on a challenging exam? The only problem is that it was a multiple choice exam and so I don’t know whether I just happened to guess the correct answers, or if it wasn’t as difficult as I made it out to be in retrospect. I don’t know if I was adequately prepared, or if it was just a stroke of luck.

To be certain, there were a number of questions I wasn’t sure of, but then, because of the structure of the exam itself (it was multiple multiple choice) I was able to narrow down most questions I wasn’t sure of to two or three options.

I suppose in the big world of academic problems that I could be having, this one’s not so bad.

March 7, 2012 | 4 comments | Tags: McGill Nursing

Free online game theory course

So a few months ago I signed up for a free online course in Game Theory, taught by two professors at Stanford. I like Stanford. Ever since I discovered the Stanford Encyclopaedia of Philosophy as an undergrad (the one website that philosophy profs will allow you to cite in your papers), I had a profound respect for this institution’s free online offerings.

The course isn’t for credit at all—there’s just video lectures, and “quizzes” integrated into the videos. I guess I’m sort of interested in it because it relates to my thesis subject. Ever since I wrote my thesis on it, I find the whole idea of collaborative enterprises fascinating, and I would love to be able to more rigorously analyse what regulations would make a complex system with multiple stakeholders work best.

The course was supposed to start in “late February 2012,” so I waited until today—I was going to send the professors an email, since February 29th is about as late in February as you can get. So I opened up the site for the course to find a contact email address, and found the following message:

Regarding the start-date of the Game Theory Online course: The University is still finalizing policies to cover its new online courses, and so there has been some delay in the launching of the courses. We anticipate being able to launch the course soon, and will keep you informed of any news on the starting date. Matt and Yoav

I’ll let you know if anything interesting comes of this. Let me know if you sign up for the course yourself. :)

February 29, 2012 | 2 comments | Tags: Bioethics Exciting Memories Philosophy Thesis

It’s midterm week and what is wrong with Google Docs?

It’s midterm week right now, so I’m behind in my blogging. Apologies! I promise I’ll write a whole lot more when I get back.

Google Docs preferences

In the meantime, here’s a little bug I’ve found in Google Docs, and it’s one that has come up recently, because I have been actively using this feature, and I’m not sure how it broke.

Google Docs has a great feature: automatic substitution. When you type “(c)” and then hit the spacebar, Google Docs immediately changes your “(c)” into a “©” like magic! There was one substitution I was using all the time, namely, the “–>” into “→” substitution.

I specifically remember having used it in January extensively in my notes.

If anyone has a tip or a clue as to how to fix this, that would be appreciated. Google’s documentation is lacking. I’ve done a few searches, and found nothing helpful.

Failure to replace

I’ve checked my Google Docs preferences (see previous image) and the other substitutions work fine, but no matter what I do, I can’t get it to change my “–>” into a “→”.

February 15, 2012 | 3 comments | Tags: Buggy software Grad school McGill Nursing

How to break Endnote X5, Visual Basic and Microsoft Word

As many of you know, my old computer Fermat recently died. After a respectful period of mourning, I got a new one. Its name is “Gödel.” (I name my computers after mathematicians, in alphabetical order, starting at E. My first computer was named “Euler,” my second was “Fermat,” and so this one had to be “Gödel.”)

This week, when I opened up Microsoft Word to work on an assignment, I noticed something funny—the Endnote toolbar was missing. Endnote is the reference manager software that I use on pretty much all my school assignments.

I had this problem before, when I first installed Word on Fermat. The problem was that I installed Word after I installed Endnote. I thought it was the same problem, so I reinstalled Endnote. This didn’t help.

So I tried Googling the problem. I tried using the Endnote “customizer,” but that didn’t work. I tried repairing the disc permissions. Eventually, I called Thomson-Reuters technical support who had me go through all the steps I already found on the internet, and eventually told me that I had to re-install Word.

So, I did a full uninstall of Word and a complete reinstall, which was more difficult than expected, because my computer no longer has an optical drive.

I reinstalled Word and Endnote, but to no avail. My reference manager was still unavailable.

I called Microsoft technical support, who had me do all sorts of things—making new users on my computer, shift-restarting, repairing disc permissions again. This was also fruitless, except that they were able to identify that it was a problem with Visual Basic, which is necessary for Endnote-Word integration apparently.

They told me that my installation of Word was corrupted somehow, since Visual Basic was not able to access the folder for Visual Basic macros. They thought it might have something to do with my anti-virus software, and told me to reinstall with my anti-virus turned off.

I did this, but it didn’t help at all.

So I tried thinking about what was different between Gödel and Fermat: Fermat was running Mac OS X 10.6, and Gödel was running 10.7, but that was the only thing I could think of, until I realised that I had named my hard disc “Gödel”—including the two little dots over the O. I renamed the hard disc to “Godel,” and started Word.

Endnote worked immediately.

So the moral of the story is, if you want to break Visual Basic in your installation of Microsoft Word, just put a non-standard character in your hard disc’s name.

February 8, 2012 | 5 comments | Tags: Buggy software

The fifth vital sign is …

If you ask a nurse what the four vital signs are, you’ll get a fairly standard response:

• Heart rate, e.g. 60 bpm
• Blood pressure, e.g. 120/80 mmHg
• Temperature, e.g. 36ºC
• Respiratory rate, e.g. 12–20 per minute

But the “fifth vital sign” has been defined by different teachers that I’ve had in at least four different ways. I have had at least one nursing professor tell me explicitly that each of the following is the “fifth vital sign”:

• Pain, e.g. 2/10 (PQRSTU)
• O2 saturation, e.g. 97%
• Alertness and orientation
• Comfort, appraised subjectively by the patient

Has anyone else been told by a nursing professor that something else is the fifth vital sign?

January 27, 2012 | Leave a comment | Tags: Nursing

Weird thing to find in my readings for “Health and Physical Assessment”

My textbook for “Health and Physical Assessment” is called Physical Examination and Health Assessment (first Canadian edition) by Carolyn Jarvis. I’ve only done two readings from it, and it’s mostly what I expect. Largely, it’s written in a very scientific tone. It’s a textbook about anatomy, some common forms of illness, and techniques on how to assess a patient.

What’s surprising is something I found right in the middle of chapter 18, (thorax and lungs). The author uses an emotive, almost poetic voice to describe the baby’s first breath:

Breath is life. When the newborn inhales the first breath, the lusty cry that follows reassures anxious parents that their baby is all right.

(Jarvis, C. Physical Examination and Health Assessment. First Canadian Edition. p. 442)

The chapter continues immediately afterward in its characteristic, professional manner for the rest of the chapter, as if nothing happened. I read it, and had to go back to make sure that I didn’t imagine it. I don’t even know what they’re trying to get at with the whole “breath is life” thing. It’s almost philosophical, but then there’s no content there.

Just weird, that’s all.

January 18, 2012 | 2 comments | Tags: Culture Nursing Weird

Sometimes trying to understand nursing can be realwise doubleplusungood

Before I start on this rant, I want to clarify that I’m not suggesting that nursing be “medicalised,” or that the role of nursing be expanded to include diagnosis and treatment of illness. In fact, I think it’s a good thing that there is a discipline for caring for patients, namely nursing, and a separate one for diagnosis/treatment, namely medicine. These are different and complimentary roles, and I wouldn’t want to be burdened with the responsibility of diagnosing and treating the illness as a nurse. After all, if the nurse is busy doing diagnosis and treatment, who will be doing the nursing?

That said, I’m confused about something that’s come up a number of times in different contexts in nursing school—it’s the fact that nurses have to pretend that they don’t know what’s going on if anyone asks, but they are responsible for acting as if they do. A nurse is not allowed to diagnose an ear infection, a broken leg or a heart attack for example. If a nurse did that, she would be overstepping what she is licensed to do.

I think an example will help to clarify: It is well within a nurse’s responsibilities in certain contexts to triage patients in order of medical priority. Imagine a case in which three patients arrive at the emergency room to be assessed and prioritised by the intake nurse. One patient has the signs and symptoms of an ear infection. The second patient has an obviously broken leg. (Imagine the patient is in extreme pain and the leg is bent at a 90º angle half-way down the shin.) The third patient has all the tell-tale signs of a heart attack, like chest pain, distress, tingling down the left arm, light-headedness, etc.

In such a case, the nurse would be responsible for making sure that the third patient (the one with the heart attack) was given priority and taken to see a doctor immediately. The nurse would then refer the patient with the broken leg to radiology or something, and then a doctor would have the bone set and put in a cast. The first patient, the one with the ear infection, would have to wait until the others were treated before getting what she needs—probably just a prescription for antibiotics. If the nurse gets the order of priority wrong, she will be held responsible for the consequences.

The confusing part about this whole process is that a nurse has to simultaneously think about balancing the medical priority of the three patients while being careful to remain intentionally agnostic about what it is exactly that is afflicting each of the patients.

The nurse can’t just say, “You have an ear infection,” or “You have a broken bone.” Those are diagnoses. Doctors make diagnoses. Nurses can’t make diagnoses. But the nurse has to prioritise and execute her practice as if she did know that the one patient was having a heart attack and the other was having an ear infection.

This is of course, something of a simplification. In certain contexts, nurses can make what are called “nursing diagnoses.” Unfortunately, this concept doesn’t clarify anything for me. I asked a professor of mine to give me an example of one. She said that a nurse could pronounce a nursing diagnosis of “failure to oxygenate” in the circumstance that the patient was having difficulty breathing, complained of shortness of breath and had an O2-sat of 60% or something. The problem with the concept of a “nursing diagnosis” (at least for me) is that I would be more likely to call “failure to oxygenate” a “sign” (an externally observable indicator of the state of a person’s health) rather than a “diagnosis.”

But the point remains that after assessing a patient, if the patient asks, “Am I having a heart attack?” a nurse would have to respond with something like, “Due to the legal constraints on my licensure as a nurse, I can neither confirm nor deny that you are having a heart attack,” but at the same time, she would need to act as if she knew that the patient was having a heart attack and prioritise her care accordingly, on pain of legal repercussions.

I think I’ve heard of this before.

To know and not to know, to be conscious of complete truthfulness while telling carefully constructed lies, to hold simultaneously two opinions which cancelled out, knowing them to be contradictory and believing in both of them, to use logic against logic, to repudiate morality while laying claim to it, … to forget, whatever it was necessary to forget, then to draw it back into memory again at the moment when it was needed, and then promptly to forget it again, and above all, to apply the same process to the process itself—that was the ultimate subtlety; consciously to induce unconsciousness, and then, once again, to become unconscious of the act of hypnosis you had just performed. Even to understand the word ‘doublethink’ involved the use of doublethink.

(Orwell, George (1949). Nineteen Eighty-Four. Martin Secker & Warburg Ltd, London, part 1, chapter 3, pp 32)

Ahh, that’s what it is! Doublethink! Now I remember. This is, as they say, realwise doubleplusungood.

It might be crimethink to say this as a health care professional (am I allowed to call myself that yet?), but I guess I just have an intuition that the world won’t end if nurses are allowed to actually diagnose certain things under certain circumstances. I’m not saying that because I would want to change the role of nurses or to take territory away from doctors, but rather because I want to allow nurses to be able to execute their own practice—that of caring for the patient—without having to go through all that doublethink.

So, how does my claim that nurses should be able to diagnose certain things square with my original disclaimer that I don’t want to change the role of nurses? Here’s how I make it fit in my head: There are some things (like an obviously broken leg) that a nurse would be more than qualified to identify and yes, even diagnose without any further training. (There are other things that a nurse is not capable of diagnosing, and I’m not suggesting that nurses be trained to be able to diagnose cancer or anything so extreme as that.)

When would a nurse go about making a diagnosis? Only when it is necessary for her to do in the context of her role in providing care for the patient as a nurse.

For example, after an assessment, a nurse often needs to perform certain interventions as a part of her role. These may include referring to other practitioners, engaging in conversation, providing education, reflecting strengths, or assigning priority, as in the triage example above. For these interventions, it is often tricky to come up with a rational way to justify one’s actions without reference to the patient’s illness. I would much rather be able to say “the reason for this intervention is the patient’s infection” than “the reason for this intervention is something that I’m not legally allowed to say much about.”

January 14, 2012 | 3 comments | Tags: Grad school Medicine Nursing Politics