Hi,

A few years ago I saw a video of Anthony Mangieri, a New York based pizzeria owner.
 
It’s shot 16 years ago from a small, modest space with only 2 other staff who run the entire operation with him.
 
He speaks obsessively about making pizza, obstinately enforcing traditional Italian methods, often to his own huge inconvenience. He had to smash half his walls down just to crane the wood-bake pizza oven in that he sourced from Naples.
 
Two days ago, I stumbled across a new video about him, filmed just last year.
 
At the age of 53, he’s now been making pizza for 38 years (yes, since 15 years old).
 
Despite working from a larger, more refined restaurant, and winning Best Pizzeria in the World and numerous other accolades, the goal is still the same; to make really good pizza. 
 
Pizza is the organising idea around which he practices his craft. It’s at once both insanely simple, but extremely nuanced and full of depth in the details. Even the menu only has 4 options. 
 
The flour, the oven, the buffalo mozzarella, the worktop; all the basic components have had decades of experimentation, refining, and practice. 
 
The actual pizza is 1% of what the work involves; he thrives in the process itself.  
 
Making pizza the way we do it is such a fleeting moment of happiness and perfection. And the more you do it, the more you're aware of all the imperfections in it. And so there's this constant, like, the next shot is going to be maybe the one that's like going to make me feel like, "Woo, we did it." - Mangieri
 
Anthony sees pizza through a different lens than most of us do.
 
What strikes me is if pizza can be pursued so meaningfully, then almost anything can.
 
You don’t need a rarified job, you need a rarefied approach to your work. - Cal Newport
 
Videos for reference:
2008 
2024 

 

Clinical Things I've Learned

  1. More of a mindset shift in hearing the last St Emlyn’s podcast discuss VT/VF arrests.

    Unlike a PEA/asystolic arrest, VF/VT should be approached with higher expectations of a successful outcome, and the default assumption that this can be reversed. It is a distinctly different entity to non-shockable arrests, and prognostic expectations and actions should reflect this. 

    Not to say don’t try with asystole/PEA, but that VF/VT should be really assumed to be reversible until significant efforts are exhuasted. 

    “If we go to a patient who’s in VF, they should survive that, and that’s the mentality we should be going in with”.


  2. An interesting case from Medical Malpractice Insights highlights the rare and tricky diagnosis of acute porphyria. Anaesthesier have a great summary.

    1. A rare, autosomal dominant disorder where precursors to Hb synthesis (porphyrins) accumulate and cause problems
    2. Think about in the 4 P’s: painful abdomen, polyneuropathy, psychological disturbance, port coloured urine. Especially in females, 20-40 years old, with any family history of similar problems. 
    3. Diagnosed by testing porphobilinogen (PBG) in the urine
    4. Treatment is with Haem arginate and supportive car


  3. The use of ankle reflex in pinning down causes of foot drop:
    Reflex arc is a stretch reflex, with afferent input via S1-2 fibres of the tibial nerve → spinal cord → input from descending corticospinal tracts (UMN) dampen and refine amplitude → S1 efferent nerve root stimulates gastrocnemius and soleus to plantarflex

    1. Normal reflex - common peroneal nerve injury likely
    2. Absent reflex - LMN lesion, any part of the reflex arc
      1. Peripheral (PNS) 
      2. Peripheral neuropathy: diabetes, hypothyoridism, mononeuropathy, vit/electrolyte disturbance, toxins
      3. Radiculopathy of S1 nerve root: eg disc herniation
      4. Guillain-Barré syndrome
    3. Central (CNS)
      1. Cord compression - CES
      2. Spinal cord lesions: transverse myelitis, tumors, infection
      3. Multiple sclerosis, motor neurone disease (mixed UMN/LMN symptoms)
      4. Muscle: Myopathies
    4. Increased reflex - UMN lesion
      1. Any pathologies affecting the brain or upper motor neuron pathways in the spine 
        1. Vascular; stroke, spinal cord infarction, aneurysm
        2. Inflammatory/autoimmune: transverse myelitis, MS, SLE, APS
        3. Trauma: traumatic brain injury, spinal cord injury
        4. Metabolic/endocrine: HHS, thyroid disease, 
        5. Infection: HIV, encephalitis, abscess, neurosyphilis 
        6. Neoplastic: tumour

From Elsewhere

"If you do not actively choose a better way, then society, culture, and the general inertia of life will push you into a worse way. The default is distraction, not improvement."
 
- James Clear
 
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More pizza-related inspiration:
 
“If you spend 30 years of your life doing something, you're going to start to find your own voice within that. It's like a real gift in a sense to be like, doing the same work for 30 years and be like, "This is so exciting. I can't wait to try to make today better." 'Cause I'm not stopping. I'm going to keep fighting to be good 'til I drop dead.”

- Anthony Mangieri
 
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Have a great Christmas
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All information in the Push-Dose newsletter is strictly for educational purposes only, and does not constitute professional or medical advice.