Hi,

Whatever it is we are doing, its tempting to imagine that one day we’ll nail it, and everything will click into place and become second nature. 

The more time passes without arriving at this state, the greater our self-doubt can become. 

Maybe I'm just not cut out for this.

 

Predictably, my emergency department has been getting busier as we move into winter. 

As the EPIC (Emergency Physician in Charge), one of the consultants remarked how taxing these shifts can be. 
 
“I can find these shifts exhausting; I have to put on the right music on the drive to work, and do some self-talk before starting my shift”.
 
More than twenty years experience as a doctor doesn’t evaporate the pre-shift nerves and challenge of the job. 
 
Never ‘arriving’ or getting a full handle on something is much more likely an existential reality, rather than a reflection of personal insufficiency. 
 
It can be said for parenting, marriage, training, playing an instrument; anything that’s open-ended.
 
The apparent finished articles and people who have it ‘figured out’ all over the internet are a mirage. 
 
Accepting that it'll never all be figured out is paradoxically liberating. 

Clinical Things I've Learned
  1. Headaches in paediatric patients; the question is always ‘do they need a scan?’ A study over a 4 year period in Italy looked at 2077 children (pair with RCH Guidelines and NICE red flags):

    1. Almost 1/3 of all headache presentations had ≥1 red flag. The presence of red flags does not mandate neuroimaging, but should prompt a detailed history and examination.
    2. Around 0.3% of all headaches had a significant secondary cause (stroke, bleed, tumour, infection etc) - this is about 1 in 350. 
    3. The study found no correlation between life threatening headache and occipital headache or nocturnal wakening. 
    4. The most common diagnosis for headache was infection (42%, such as URTI) and primary headache (40%).
    5. If the child has an abnormal neurological exam, neuroimaging is likely to be indicated (PEM Playbook)


  2. A patient with resolved abdominal pain had an 8mm gallstone in their CBD found on CT. I had assumed, like renal calculi, that normal LFTs (U/Es equivalent to me), normal obs, and now asymptomatic could be discharged with safety netting.

    UK guidance is for admission for all CBD stones for offering ERCP extraction due to risk of complications such as pancreatitis, ascending cholangitis, etc. Patient was therefore admitted.

    NICE on CBD gallstones: “Offer referral for bile duct clearance and laparoscopic cholecystectomy — although they are asymptomatic, there is a significant risk of developing serious complications such as cholangitis or pancreatitis.”


  3. Was handed over an elderly patient with digoxin toxicity, serum level 2.5 ng/ml, which I've refreshed myself on since:
    1. Class V anti-arrhythmic - increases vagal tone by AV inhibition and increased inotropy.
    2. Recommended serum levels around 0.8 to 2 ng/mL. Toxicity increases when over 2.0 ng/mL. Can occur at lower levels if low body weight, advanced age, renal impairment, hypokalaemia
    3. Get a digoxin concentration on presentation and 6 hours
    4. Acutely can cause arrhythmias (ectopic beats, slow atrial fibrillation, and accelerated junctional rhythms, ventricular tachycardias) and hyperkalaemia
    5. Digibind indications include cardiac arrest, life threatening dysrhythmias, K >5, smptoms of dig toxicity and co-existent renal failure
    6. Disposition: Patients with falling serial serum digoxin levels, normal serum potassium and renal function, no gastrointestinal symptoms no evidence of cardiotoxicity at 6 hours can be medically cleared. (LITFL) 

From Elsewhere
What is the price of work?

Everything.  The price of work is everything.
 
But, the reason I’m telling you this story is because it doesn’t have to be.
 
Dr Andrew Tagg at DFTB writes candidly on his experience of burning out. Very much worth a read.
 
.....
 
Really enjoyed the Mr McMahon series on Netflix; another example of the reality distorting effect that some individuals possess.
 
Not to mention the controversies, genesis of pro wrestling and characters are all way more interesting than I imagined. 
 
 

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