Controversial Ideas in Medicine

The nuff-nuff is the bane of our existence. That person who comes in complaining of tummy pain or feeling weak or some vague and inconsistent symptomatology completely without medical explanation and almost certainly psychological in nature. They have some tawdry and dreary sort of social background and probably reside in a slumlike place (oh boo-hoo). They have all sorts of medications for somatic relief. The endones and pethidines and maxolons and valiums. Not to mention the psychiatric pharmacopoeia of zolofts and efexors and zyprexas. Some of them drink and smoke too much (but not enough, sadly). We do all the tests (or just enough to satisfy ourselves) and find nothing while they abuse us for "not caring". So we send them home, kicking and screaming while they threaten "if you send me home I will be back here tomorrow" (which we know is true). And sit back exhausted but relieved that they've finally left. They are the bane of our existence, the nuff-nuffs. The bane. But would you know that:

• Schizophrenia and other psychotic illnesses
• Depression, anxiety
• Personality disorders
• Substance abuse

are all associated with greater rates of illness and mortality? Multiple presentations to hospital are a bad sign that there is something going wrong- whether it be physical or psychiatric. Or both for that matter. Even worse, as they say "you can't prove a negative"; in other words there are many for whom we do not find the real answer (even though it exists). Additionally, chronic diseases lead to significant psychiatric burden- people become depressed, anxious, sometimes even epileptics have psychological "pseudo-seizures". And the mentally ill just do not look after themselves properly. So what do you do when faced with the nuff-nuff? There is I suppose only one thing you can do - exclude organic pathology while treating the psychiatric disorder.

• Approach things with an open mind each time. Ask yourself "why" and be prepared for a complex answer. Sometimes people with worsening disease become anxious and depressed and present to hospital even without a need to. Sometimes it is a cry for help. Sometimes despite mostly being psychiatrically unwell or having a pathological personality there is genuinely a medical cause for the symptoms.
• Involve a psychiatric team early. Sometimes the diagnosis is psychiatric and this in itself is the main thing.
• Keep a high index of suspicion for both organic and psychiatric disease- nuff-nuffs get sick too (and sometimes die)
• Have a sympathetic but professional attitude; be caring but consistent and do not get too wound up in the transferred anxiety.
• Do not get angry, violent or abusive. Additionally do not take on their stresses as your own.
• Be as prepared for gratitude as for the potential to be verbally abused for your approach (and don't take it too personally)
• Exclude dangerous things
• Do what your duty of care towards your patient behoves you to do; do not discriminate on the basis of psychiatric illness.

Doctors are angered by these patients for more than one reason. We are educated to believe that only organic disease is "real" or "significant". But even more than that, being (often unconsciously) manipulated and having large amounts of angst and anxiety offloaded onto us - and then finding that the underlying cause is not what it seems- makes people feel betrayed or lied to (even if that is not the conscious aim of the patient). But why should we feel betrayed? A psychiatric diagnosis (even that of a somatoform or personality disorder) is still a medical - and pathological- condition that causes harm. Often the best thing we can do for these people is to acknowledge their underlying issues and refer appropriately. Sometimes that is all they have been hoping for.

Every speciality has its bugbear. Emergency departments have D-dimers (always positive if you spend more than 2 mins in a hospital, seemingly). Gastroenterologists have "melaena" (often just dark brown stool or even frank PR bleeding). Rheumatologists, chronic back pain (the worst thing you can do is admit them to hospital). And cardiologists have troponins. Good ol' troponin. Touted as "the" test for myocardial infarction (heart attacks to the layman), troponin has gone from being the wunderkind of cardiology to a much maligned villain due to its (sometimes) excessive sensitivity. "Why did they order a troponin?" I hear you cry. "Don't bother with it, it's just troponinitis." What is troponinitis? What is this entity which like "acopia" appears to have entered the everyday parlance of the hospitalist? It is, quite simply, a troponin higher than the 3 times the reference range which for whatever reason is not felt to be due to a myocardial infarct. Troponin is an enzyme that only occurs in cardiac muscle, and thus is only released during death or damage to cardiac myocytes. There is obviously a small baseline amount of damage that is normal wear and tear. The main worry with a very high troponin, then, is a large amount of cell death secondary to a clot or stenosis completely obliterating arterial supply to cardiac muscle - an acute myocardial infarction. Rises in troponin can also occur secondary to sepsis, uncontrolled tachycardia, pulmonary embolus, cardiomyopathy and other causes for cardiac strain. Additionally a troponin can be mildly elevated when it isn't been excreted by the kidneys- in renal impairment. So should we worry about a high troponin in the setting of sepsis, tachycardia or other causes? The key issues here are as follows. Is this:

1. A real myocardial infarction, and if so:
   1. Is this caused by thrombus (clot) post plaque rupture (type I MI)?
   2. Is this caused by cardiac failure/hypotension in the setting of fixed coronary artery disease (type II MI)?
2. Is this another condition causing a raised troponin, and if so:
   1. Does the raised troponin mean there is cardiac damage?
   2. If not, does the raised troponin have any significance?
3. Is there coexisting cardiac as well as other pathology?

Obviously the above must be evaluated in every patient. Additionally any test - including a troponin - should be ordered at an appropriate time when you have a high pre-test probability of an acute coronary syndrome. Thus, underlying risk factors (especially diabetes), clinical features- history and examination, an appropriate acute deterioration, etc. Now, for the controversial bits:

• It is possible to have a watershed infarct in the setting of fixed coronary artery disease where hypotension, tachycardia or cardiac failure is present (eg sepsis or arrhythmia)
• It is also possible to have clinically significant cardiac damage in those settings even without true infarction secondary to strain
• Raised troponin has been shown to be associated with a significantly worse prognosis in acutely unwell patients where another pathology is shown to be the cause

Which leads to my next conclusion:

A raised troponin in an acutely unwell patient, especially one with risk factors and evidence of haemodynamic compromise and/or heart failure should never be ignored.

"But what are you going to do about it?!" you say, incredulously. Watershed infarct without a thrombus? "Troponinitis" due to sepsis? What the heck are you going to do about that? Shouldn't we just stop checking the damned thing? Given that these patients have in fact had the possibility of thrombosis, fixed coronary atherosclerosis, severe cardiac strain/hypoxia or just very bad underlying disease the following should be done:

1. Follow up troponins to monitor trend - MI less likely if troponin persistently raised
2. Aspirin (if not contraindicated) and prn anginine
3. Optimisation of fluid status, strict fluid balance and daily urea, electrolytes and creatinine
4. A transthoracic echocardiogram to assess heart function and see if there is in fact evidence of either infarction or heart failure
5. Cardiologist review in all patients
6. Referral for percutaneous coronary intervention/angiogram:
   1. In patients with ST elevation and likely infarction and who are well enough for the procedure and do not have sepsis (risk of septicaemia and endocarditis)
   2. In patients who will benefit and are well enough for the procedure in whom there is high pre-test probability- as an elective procedure when well.
7. Therapeutic anticoagulation for 48-72 hours in patients with high pre-test probability of infarct with no ST elevation and no contraindication to anticoagulation
8. Addition of cardiac risk factor modifying agents and optimisation of cardiac failure medications
9. Treatment of acute illness, underlying problems and optimisation of chronic conditions
10. Discussion with the patient and family regarding diagnosis and prognosis

Of course, unfortunately the one thing that everyone will groan about is the fact that I have listed 10 things that need to be done for sick patients with "troponinitis". It is much easier to ignore it and do nothing- but that is a grave disservice to our patients and very contradictory to the actual evidence on the matter.

I had a fairly disjointed argument on the weekend with a would-be future political type. The crux of this segment was as follows: Him: "The states' power should be preserved because Australia is a federation of independent countries" Me: "But how exactly are Victorians benefited by keeping everything separate?" Him: "They should be separate as a safeguard to the federal government and because of history" Me: "But how does that benefit people?!" &c&c Australia is an odd country. It's one of the least population dense countries and continents in the world. 20 million people most of whom live in cities scattered along the coastline. A huge amount of empty space in which people do actually live, here and there. A great whopping big desert that we try and farm. Mostly developed and first world with one of the highest life expectancies  and best healthcare systems in the world... unless you live in a very remote Australia or are Indigenous. The biggest barriers to healthcare in Australia then?

• Geography
• Race/Indigenous status

Let me explain. There are country towns with a population of 300 which are inland and where the nearest tertiary hospital is greater than 5 hours away. By helicopter. Other towns with a population of 30,000 which have the biggest hospital by road for hours and are very strained. There are towns which are remote or even not that remote but where the closest big centre is in another state. Or where half the town is on one side of the state border and the other on the other side. This is problematic for many obvious reasons. Airlifting trauma patients is difficult. It is difficult to get patients from one state hospital system to another. There are funding issues. Doctors have to ... get this... apply for registration in both states (and pay an exorbitant fee) in order to perform the practicalities of working in a border town. The federal system in Australia is impractical precisely because of the size and geography of the country. Rather than facilitating healthcare in disadvantaged areas by tailoring policy it results in an ad hoc patchwork system where interhospital transfer (something crucial in remote areas where services are difficult to access) is exquisitely painful to organise and results in avoidable delays in getting sick patients appropriate care. The states and their laws are divided by history and accident rather than logic or relevance to modern Australia and its issues. As far as I can tell it only offers disadvantages to its citizens in its current incarnation. Perhaps in a much smaller and more highly populated country the state system would make more sense because it would just be a matter of there existing a protocolled system for treating and transferring patients. However, when you have little choice where to go and what to do and time is critical... it is inefficient, bureaucratic, and furthermore harmful. Conclusion: Whatever you do, just don't get sick in Broken Hill. Or chased by drunk guys because you're a drag queen from Sydney. Whatever.