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”Doctor please tell me what is likely to happen to me”
Although in theory doctors memorise probable outcomes, in practice most of them have forgotten them within hours of passing any exams!
In their defence it is said of Albert Einstein that “He never bothered to commit facts to memory. There were better uses he thought for the human brain”
In theory, doctors are expected to memorise the prognosis figures for many different complex situations. In reality, while some may be good at such feats of memory and calculation, the average doctor forgets such figures almost as soon as they have been learnt. Attempts have been made to incorporate such figures into commercial clinical computer systems but the cost of trying to do this independently on each incompatible system is far too great. Only when a) the data items in such systems have been standardised and b) when there is a single cost free source linking such figures to specific data will it be practical to expect computer systems to help clinicians by providing such information automatically.
It is intended either that any relevant information should be gradually made available as part of this volume of the EEPD; or that there should be a hyperlink from here to some other source.
Providing information about potential future risks and outcomes in medicine will always be an inexact art, but, as I often tell my patients, the fact that train timetables may often be inaccurate doesn’t mean we ignore them: some information, however unreliable, is better than none. One needs also to remember Aristotle’s comment that "It is the mark of the instructed mind to rest satisfied with the degree of precision which the nature of the subject admits, and not to seek exactness where only an approximation of the truth is reasonable"
As a result of needing to assess risk, medical textbooks are full of lists of the groups of patients at an increased risk of, for example, Pre-Eclampsia.
But it is more useful when such lists provide more detail as to the relative risk of each possibility, not only in general but also, for each individual expectant mother not only the general risk but also her particular risk taking into account any relevant data in her electronic record
At present, each doctor in need of this kind of detailed information has to do a personal literature search, and each computer system has to rely on independent competing commercial initiatives.
But it is possible to use a low-cost computer program to provide a crude but useful prognosis: an example is the iPhone App called “Bishops Score.”
Also, the PubMed Clinical Queries can be used in literature searching to help identify the most relevant published research.
The aim of this volume is to provide a link between the kind of data which should be present in any good perinatal computer system (e.g. Gestation, Pre-Term Rupture of Membranes etc); and the best available information from well documented sources; all such information being subject, through the internet and the EEPD website, to continuing peer review.
It is intended that this site should in the long term facilitate immediate individualised computer-generated comments, either on this web site or by providing links to any appropriate open-access electronic information.
As a totally fictitious example:
If the EPR contains the information “Gestation: 37 weeks + Spontaneous Rupture of the Membranes + No other relevant electronic data”: Then the computer should be able to provide any doctor or midwife with information such as Prognosis: “86% labour within 24 hours, 91% labour within 48 hours, 94% labour by 96 hours, 6% in this study did not achieve spontaneous labour at all.” (Basis: UK population in 2004. Source: BJOG N(N):pnn)”
This kind of assistance will only be cost effectively achieved on the basis of an internationally agreed set of flow patterned standardised, questions and all allowable answer options, such as is set out
in Volumes 4 and 5 of the EEPD.
Some commercial companies (e.g. UpToDate and Ebsco DynaMed) have attempted to provide partial access to some of the relevant probabilities, but these are expensive resources and, despite attempts at integration with clinical systems, will never be able to provide a sufficiently robust “one-stop shop,” even if everybody could afford to subscribe to them. Clearly the world needs a single free source of such correlated information.
If one already exists do contact the editor so that the EEPD can include a hyper-link
(Updated 15 Nov 2010)
Medical Textbooks and Guidelines frequently contain lists such as:
“The following types of patient are at an increased risk of post-partum haemorrhage:
1. ALL Caesareans
2. Previous Post Partum Haemorrhage
3. Significant Anaemia (Hb 100 g/L or less)
4. Grand Multipara (> 4 previous births)
5. Precipitate Labour (2 hours or less)
6. Prolonged 1st Stage (Active stage > 12 hours)
7. Prolonged 2nd Stage (Primips > 2 hrs, Multips > 1 hr)
8. Prolonged 3rd Stage (> 30 mins)
9. Manual Removal of Placenta
10. Possible Incomplete Placenta
11. Pregnancy Induced Hypertension as a separate cause of hypovolaemia
12. Low maternal booking weight indicating low blood volume”
(Taken from a typical U.K. hospital handbook for junior staff and midwives as used in 2007)
A. Rarely provide a reference to any peer reviewed literature to support the view expressed; and indeed seem more likely to be based on tradition or personal anecdotal experience rather than any more reliable basis.
B. Provide no indication as to the average risk of a P.P.H. if none of the above risks are present.
Instead, in making a professional judgement one needs to start with an estimate, however roughly calculated, of the degree of risk in a healthy primiparous expectant mother. For example there is likely to be some evidence somewhere that in such a situation, in the average district general hospital, if there are no other risk factors, the risk of a significant PPH is say 1 in 1000.
C. Provide no information as to the degree of risk which is present when any such factors are present. For example if there has been a Precipitate Labour of 2 hours or less, is the degree of risk in the current pregnancy about 1 in 2 or 1 in 20 or 1 in 300?
Yet managerial and professional decisions are frequently made on the basis of such unreliable anecdotal evidence.
To take a recent personal example: I had a patient who was having her third prostin for labour induction at 38 weeks with an unfavourable cervix. An Artificial Rupture of the Membranes was described as “Technically difficult but may be possible; Keen to avoid a C/S if at all possible”. The reason for her induction was documented as being the risk to her fetus of sudden infant death because of abnormal liver function tests. On checking, all her liver function tests were totally normal apart from a globulin level of 90 (Normal 6 - 32) Her Alkaline Phosphate was marked on the pathology report as abnormal since it was 229 (i.e. above what the pathology computer was programmed to regard as normal in a non -pregnant patient) - but in pregnancy the upper limit of normal is around 418.
Neither I nor, I am sure, the trainee had any idea of even a rough approximation of her true risk from induction at 38 weeks with an unfavourable cervix or of a sudden intra uterine death of the fetus. All that to guide us was a black and white “label” that she was suffering from abnormal liver function and needed urgent delivery, in her case as matters turned out, by a Caesarean Section after a failed induction.
If computer systems are to fulfil their potential, then it will be useful for such systems to provide a better basis for professional and managerial judgements, than is currently available. And if such systems are eventually created, someone somewhere, will have the task of linking data likely to be available in the electronic record with literature or audit information on the risk levels for a whole series of different potential problems.
This could be done separately for each different commercial perinatal system; but would be hugely expensive.
One of the propositions behind this volume of the EEPD is that such knowledge would be better documented once and thoroughly, with the benefit of an internet based peer review via the feedback to the Editors; as soon as practical by a Wikipedia approach.
Different computer companies could then make use of such standardised and documentation backed information to incorporate within their different systems.
Hopefully sooner rather than later this website can be converted to a modified Wikipedia style and someone somewhere in the world will, in time, be willing to become the long term editor of this volume!!!
Rupert Fawdry (Updated 16 Nov 2010)