Hi,

I've seen a few retirements from the NHS over recent years.
 
A few years ago, it was the last day on the ward for one of the senior nurses. A side room had been set up with snacks, and staff would stop by throughout the day to offer their well-wishes.
 
At the end of her shift she announced her leave, and people waved from their desks, with a few hugs shared.
 
As soon as she disappeared around the corner, everyone snapped back to their work.
 
I remember thinking how stark it felt - some thirty odd years given to one place, then the next minute, you’ve left. 
 
Meanwhile the machine churns on. 
 
I’m sure there’s a sizeable cohort of people who experience a crisis of identity at such a time, even among those seemingly thrilled to be finishing. 
 
To get good at something requires shaping your identity around it to some degree. You have to mould yourself into the craft, adopting it as part of your identity to excel. 
 
The more of yourself you give to the work, the better you become, and the more you are rewarded. You learn that progressing to the next level often means giving even more of yourself to the pursuit.
 
Before long, it’s easy to conflate who you are with what you do—especially for those who feel the need to justify their existence through action.
 
But as you start to reach a peak of something, the fall from the top can be brutal.
 
If the thing you do was taken away from you, what’s left? 
 
One way to guard against this is to use the pursuit not just to achieve, but to develop you character and traits, the more non-fungible aspects of who we are.
 
Commit to the craft fully, but hold it lightly, to simultaneously build something more enduring and innate, beyond titles or roles.
 

Clinical Things I've Learned
  1. A 40yo female presented to resus with possible thyrotoxic storm: AF in rapid ventricular rate and signs of right sided heart failure worsening over a period of a few weeks. Formal echo showed pulmonary hypertension, and she was diagnosed with Grave’s disease following TFTs the next day. RCEM provide a great overview. Some points regarding acute thyroid storms:
    1. Always remember to check TFT in a younger person presenting with AF or tachyarrhythmias. 
    2. Abdo pain, agitation, hyperthermia, tachyarrhythmias, tremor, etc? The first challenge is to consider thyroid storm: it is rare but has a 10-30% mortality rate
    3. Agitation: give benzodiazepines
    4. Tremor and arrhythmias: beta blocker (diltiazem/verapamil if intolerant). Propranolol has added effect of preventing T4 → T3 conversion, useful non-cardioselectivity effects for tremor, agitation etc. Other BB options are esmolol or metoprolol.
    5. Steroids - hydrocortisone to treat any hypoadrenalism and reduce T4 → T3 conversion
    6. Pyrexia: cooling measures
    7. Thyrostatic agent: Propylthiouracil PO

  2. Bodycam footage of a cardiac arrest attendance by pre-hospital clinicians gives an amazing overview of arrival on scene through to ROSC and RSI in the ambulance. Impressive aspects that stand out for me: 
    1. Calm, concise communication; no excess info, whilst everyone is cool-headed and talking as if just catching up with each other The atmosphere remains very cohesive and controlled.
    2. Role switching occurs very organically, with individuals stepping into and out of different roles in a fluid manner
    3. Familiar with equipment; the speed that they set up infusions, get ready for RSI, attach monitoring etc is testament to how well they know their gear.

  3. When checking an ECG for a seven year old patient, I had to be reminded of normal paediatric ECG variants when it looked like they had right strain pattern. Normal paediatric ECG variants may include:
    1. Apparent right heart strain: V1-V3 TWI (juvenile T wave pattern), RAD, RSR pattern in V1
    2. Persistent juvenile T wave pattern can occur in older children / young adults. Dr Smith looks at this in more detail and differentiating from the dangerous ARVD which can appear very similar 
    3. Marked sinus arrhythmia
    4. Short PR interval and QRS duration
    5. Q waves in inferolateral leads 
 

From Elsewhere

"There will be time next year, or the year after. But by hyping up the dangers of failure in action, we underrate the seriousness of the dangers lurking within passivity.

In comparison with the horror of our final exit, the pains and troubles of our bolder moves and riskier ventures do not, in the end, seem so terrifying.

We should learn to frighten ourselves a bit more in one area to be less scared in others."

- The School of Life. On Confidence 

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