Hi,

“no matter what you do, don’t do it because of the rare diagnosis made, or TV-drama life-saving procedure in a speciality…you have to enjoy the bread and butter’.“
 
This is one of the best pieces of advice I received before choosing what to specialise in for medical training. I think it applies broadly to life as well.
 
As an onlooker, not yet established within a field, our impression of what it involves is biased toward the most attention-grabbing aspects. 
 
Shredding a guitar solo to a sold out stadium is not what ‘learning the guitar’ is made up of. 
 
Winning medals in diving is less than 0.000001% of the actual practice of diving. 
 
Many astronauts never make it out of earth’s atmosphere.
 
Despite the specialty’s name, a day in emergency medicine is not filled with life-saving interventions. Intoxication, head injuries, abdominal pain, overdoses and the such are much more common.
 
Before choosing to pursue something, consider what the actual ‘bread and butter’ is of that thing. Look behind what’s presented to you at a surface level, see what the day-to-day reality is. 
 
I think this is why some people become disillusioned with medicine. The documenting, administration, referrals, and book-keeping are all a significant departure from what we thought being a doctor meant when we decided to pursue medicine. 
 
Allow the highlights to draw you in, but always insist on looking behind them to what the true reality is. 
 
And understand that there is monotony and repetition to every pursuit, but one person’s boredom is another’s obsession.

 

Clinical Things I've Learned
  1. An 11 year old boy presented with knee pain after a tackle during football. His patella fossa was empty with a high-riding patella (patella alta), XR showed tibial tuberosity avulsion; he was admitted under orthopaedics for operative repair of complete patellar tendon rupture.

    1. A rare injury, affecting <1 in 100,000 people per year. Quad tendon rupture is twice as common. 
      Occurs from overloading the extensor complex of the leg, highest risk when knee in a flexed position >60º
    2. Ability to straight leg raise implies incomplete rupture, whereas loss of extensor mechanism indicates complete rupture  
    3. MRI used to differentiate partial vs complete rupture. US can aid bedside diagnosis.
    4. Partial tendon rupture is treated with knee immobilisation and orthopaedic outpatient follow up. Complete rupture normally operatively managed.
    5. Delays to surgery generally worse outcomes. All ruptures should initially be immobilised in a splint. 
      Partial rupture recovery around 6 months for full function, and 6-12 months for complete rupture.


  2. Two learning points from a patient presenting with severe HHS/DKA overlap syndrome last week.

    1. Serum sodium will usually rise significantly during treatment of HHS (this patient went 145 to 155 mmol/l in a few hours). This is due to relative hyponatraemia from initial hyperglycaemia → IV fluid hydration dilutes glucose and reduces serum osmolality → fluid shift into intracellular compartments → increase in serum sodium. This becomes an issue if osmolality is not concurrently falling during treatment. 
    2. SGLT-2 inhibitors have a health alert for a rare but devastating side effect of fournier’s gangrene; necrotising fascities of the perineum. 


  3. A puzzling case of headache, left sided spatial neglect, intermittent cerebellar signs and subjective confusion and a normal CT (eventually treated as encephalitis pending further investigations). Made me think about visuospatial neglect versus hemianopia in a bit more detail:

    1. Hemianopia is the loss of vision in a patient who generally remains aware of this defect, and compensates accordingly. Visuospatial neglect involves the inability to even attend to an area of space, let alone see it; the patient can’t see an area of space, even if the visual pathways are intact.
    2. Neglect can be visual, auditory, or tactile in nature. It often presents as a more generalised loss of awareness of space, rather than purely visual loss. 
    3. Neglect is usually left-sided; the right hemisphere is often dominant in spatial attention, covering for both right and left sides, whereas the left hemisphere will contribute to right sided attention. So a left hemisphere lesion will be compensated for by the right, but not vice versa. Most common lesion is a middle cerebral artery stroke affecting the parietal lobe.
    4. Visual neglect and loss often co-exist eg in stroke, making the differentiation difficult. No single test exists to diagnose, and patient history and observation must support testing.
    5. Inattention is generally a less severe form of neglect, where attention can be directed toward the affected side with some effort.

From Elsewhere
“My father has zero intellectual insecurities. . . . It has never crossed his mind to be concerned that the world thinks he’s an idiot. He’s not in that game.
 
So if he doesn’t understand something, he just asks you. He doesn’t care if he sounds foolish. He will ask the most obvious question without any sort of concern about it. . . . So he asks lots and lots of ‘dumb,’ in the best sense of that word, questions.
 
He’ll say to someone, ‘I don’t understand. Explain that to me.’”
 
- Tools of Titans, Tim Ferris
 
-----
 
“If you take risks and face your fate with dignity, there is nothing you can do that makes you small; if you don’t take risks, there is nothing you can do that makes you grand, nothing.
 
And when you take risks, insults by half-men (small men, those who don’t risk anything) are similar to barks by nonhuman animals: you can’t feel insulted by a dog.”
 
- Nassim Nicholas Taleb
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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.