Hi,

The following was offered up on Reddit to a poster who was voicing their concerns with the increased risk and responsibility as an impending qualified consultant. 
 
"Medicine is not for pessimists - almost anything can be made to seem fatal, so that a pessimistic doctor would never get any sleep at night due to worry about the meaning of their patients' symptoms.
 
Medicine is not for blind optimists either, who too easily embrace a fool's paradise of false reassurance.
 
Rather, medicine is for informed gamblers: gamblers who are happy to use subtle clues to change their outlook from pessimism to optimism and vice versa. Sometimes the gambling is scientific, rational, methodical, and reproducible (odds ratio); sometimes it is based on the vital but ill-defined framework of experience.
 
Of course, gambling inevitably results in losses, and in medicine the chips are not just financial. They betoken the health of your patient, the wellbeing of families, your reputation, and your confidence.
 
Perhaps the hardest part of medicine is the inevitability of making mistakes whilst attempting to help. But do not worry about gambling: gambling is your job. If you cannot gamble, you cannot walk the thin line between successfully addressing health needs, and causing over-medicalization. But try hard to assemble sufficient evidence to maximize the chance of being lucky.
 
Lucky gambling is a requisite for successful doctoring and the casino of medical practice celebrates the card counter. But the cardinal clinical virtue is courage: without it we would not follow our hunches and take justified risks."
 
- Trisha Greenhalgh

Clinical Things I've Learned
  1. ‘Dirty adrenaline’ is sometimes given in time-critical, peri-arrest situations, either as bolus form (such as 10mcg/ml syringe) or drip. Braham et al recently published a case series looking at dilute adrenaline infusions (1mg in 1000ml) through peripheral cannulae in the pre-hospital, rural australian setting. 

    Simon Carley at St Emlyn’s did a nice overview and takeaway: 

    “The study demonstrates that dirty adrenaline is probably safe, with few adverse events, and appears to improve survival in patients with fluid-resistant shock, particularly those suffering from septic shock. However, it’s small numbers and observational data so the level of certainty for safety etc is low.”


  2. Female with headache and 14 weeks pregnant, blood pressure 159/90 on attendance. Review of of NICE guidelines for pregnancy-related hypertension.
    1. HTN in under 20 weeks pregnancy
      1. if sustained >140/90 offer anti-hypertensive, target BP 135/85, aspirin often needed from 12 weeks.
    2. If HTN in over 20 weeks - all should be assessed for pre-eclampsia
      1. >140/90 - get patient to secondary care assessment
      2. >160/110 - all should be admitted to hospital for blood pressure control
    3. Pre-eclampsia typically occurs >20 weeks gestation, with BP >140/90 plus new proteinuria of 1+ on dipstick or other maternal organ dysfunction
      1. Key in ED is to diagnose, manage acute problems, risk stratify, and admit to appropriate area (HDU for severe pre-eclampsia)
      2. Some nice Trust guidelines on pre-eclampsia management


  3. Rebel EM discusses an approach to mitigating against procedural decay, with practical advice for how to maintain practical skills that are often only deployed in high acuity, low occurrence (HALO) situations. 
     

From Elsewhere
Seneca, on the virtues of reading:
 
We are excluded from no age, but we have access to them all; and if we are prepared in loftiness of mind to pass beyond the narrow confines of human weakness, there is a long period of time through which we can roam.
 
-----------------
 
Richard Sennett on the balance between security and taking risks:
 
Diminishing the fear of making mistakes is all-important in our art, since the musician on stage can’t stop, paralyzed, if she or he makes a mistake. In performance, the confidence to recover from error is not a personality trait; it is a learned skill.
 
Technique develops, then, by a dialectic between the correct way to do something and the willingness to experiment through error. The two sides cannot be separated.
 
If the young musician is simply given the correct way, he or she will suffer from a false sense of security.
 
If the budding musician luxuriates in curiosity, simply going with the flow of the transitional object, she or he will never improve.
 
 

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