Hi,

She had many worries—surgical safety, potential damage to the growth plate, recovery time, and infection risk.

I helped her look into the likelihood of each, searching the latest data and literature reviews I could find. 

What would happen if he didn’t get the operation? Was it safer to wait and see?

Ultimately, one thing became clear; there is no risk-free option. 

The active choice of surgery seemed fraught with hazards to her, the counter-option of doing nothing presumably being safer.

But doing nothing meant being unable to play football, knee instability, possible later arthritis, and the psychological toll all of that would take.

In medicine and life, inaction carries consequences - even the best case scenario is subject to entropy.

The question shouldn’t be which is the least risky option.

Rather, which set of risks are most acceptable to me?

Simon Carley speaks about the ‘Goldilocks moments’ in healthcare, balancing urgency with uncertainty.

If we wait until we have all the information we want before making a decision, the patient might die. If we act too early, we may be doing so in error. To act or wait both entail risks.

Every single treatment and decision in medicine is yoked with hazard of one kind or another. 

But the idea is to tip the risk:benefit scales so far in your favour that the decision makes sense, risks included.

There’s no risk-free option, only the ability to choose between them.

Clinical Things I've Learned

1. A middle aged female presented to the ED for the 4th time in a week with refractory migraines, driven to the point of feeling suicidal. CT non-con and venogram had been normal. Previous IV valproate, botox and occipital nerve stimulation in the past. Admitted after discussion with neurology colleagues for review. A review of different migraine treatments for me:
   
   
   1. Abortive treatments: Simple analgesics include paracetamol, NSAIDs, and aspirin 900mg. Triptans (oral, nasal or injectable) such as sumatriptan/rizatroptan/zolmitriptan can be taken in combination with the above. Anti-emetics when nausea is an issue include metoclopramide, prochlorperazine, ondansetron, chlorpromazine, and promethazine. 
   2. Preventive treatments: beta-blockers (propranolol, metoprolol), anticonvulsants (topiramate, valproate), and tricyclics. NICE first-line are topiramate and propranolol, with amitriptyline a second-line option.
   3. More refractory cases may be trialled with nerve decompression or stimulation of the affected nerves (eg greater occipital nerve, supraorbital etc), other neuromodulation devices, botox injections, and even hyperbaric oxygen as a possible option. 
      
      
      
2. A 32 year old dialysis patient presented with hypoxia and hypotension. Likely pneumonia with an element of pulmonary oedema from established LV dysfunction triggered an acute decompensation in this patient’s ‘cardiorenal syndrome’. She presented a difficult triad of pulmonary oedema, hypotension, and renal failure, where treating one may worsen the others.
    
   1. The definition of cardiorenal syndrome is broad; ‘any acute or chronic problem in the heart or kidneys that causes an acute or chronic problem of the other organ’.
   2. Cardiac failure impact on kidneys: fluid overload from cardiac failure leads to increased venous congestion around the efferent arterioles, reducing glomerular filtration. Reduced cardiac output and arterial filling, along with reduced renal perfusion, increase RAAS activation and sympathetic tone - this leads to a vicious cycle of sodium and fluid retention, and worsening renal congestion. 
   3. Renal failure impact on heart: failing kidneys retain more sodium and fluid, leading to fluid overload that strains the heart. Reduced renal perfusion leads to higher RAAS activation and sympathetic drive, which worsens hypertension and inflammation, impacting cardiac function. Dialysis can also trigger immune responses and worsen the pro-inflammatory state.
   4. Treatment is challenging, and modalities include diuretics, nitrates, inotropes (eg dobutamine), NIV and diuresis; tailored to the individual patient circumstances. 
      
      
      
3. A new review of contemporary management of traumatic cardiac arrest (TCA) and peri-arrest states provides a great overview that covers the essentials in TCA management. Short, up-to-date article and worth a read through; some reminders and pearls I took from it:
    
   1. TCA presents as a spectrum, and physiology can vary from low-output state in trauma (LOST) to no-output states (NOST). Characteristics of LOST include no palpable pulse but present electrical and/or visible cardiac motion on US. NOST presents with agonal rhythms and likely cardiac standstill. In a large study, patients with LOST had an 8.4% survical, whilst NOST had 0% survival.
   2. Aim for supradiaphragmatic vascular access; quicker time to coronary and cerebral circulation, and bypasses abdominal trauma if suspected. 
   3. Staples of haemorrhage control: direct pressure, haemostatic gauze, tourniquet (+/- 2nd tourniquet 2-3 inch above if haemostasis not achieved). Pelvic binder application. This is alongside blood product replacement and optimising vascular access.
   4. Generally, there is no place for fixed dose interval pressors. The author gives anecdotal thoughts that low dose (eg 100 mcg bolus) adrenaline may be considered as adjunct in certain situations.

From Elsewhere

Speaking of migraines, this medical malpractice issue is an interesting read that highlights the difference between wrong judgement and clinical negligence.

The crux of it is, that as long as your clinical decision making is sound and properly documented, you are generally unlikely to be negligent. Unfortunately, it is unavoidable that things are missed in medicine; we want to minimise unnecessary misses and learn from them. 

A medical registrar on Reddit had this to say regarding similar conversations:

"One thing that helped me cope with decision making was realising that if every decision I make has a sensible (and documented) rationale, there is really very little to worry about. You’re essentially untouchable if your approach your clinical work in this manner"

Similar idea to the Bolam Test back in my first issue of this newsletter. 

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"I believe craft is the outcome of numerous small actions, carried out endlessly and sometimes repetitively. But after a while, something emerges which is substantial and has its own unique character, however commonplace the activity that produced it"

- Judith Weir,

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