Hi,

Despite best efforts, things often don’t go according to plan.
 
There are many presentations to the emergency department that are commonly unsurvivable. 
 
Stretched resources can negatively affect staff, patients, yourself.
 
There may be instances where mistakes lead to severe consequences.
 
All these things can cause us to suffer in different ways; mentally, physically, emotionally and so on. 
 
One of the most important principles that I read from Dan Dworkis is to commit to never waste suffering. 
 
"To waste suffering is to allow poor outcomes to happen without learning from them.
 
It is to believe that nothing could be changed or improved at the end of a hard case, either internally or externally, to better prepare you and your team for tomorrow’s emergencies. In a sense, it is to be defeated, to give up."
 
Some of my most valuable lessons have come from refusing to waste the suffering that accompanies difficult cases. Instead of trying to move swiftly on from them, there is usually learning to be found that can leave a deep and lasting impression, for the better.
 
I absolutely love this re-frame, because it brings a sense of hope and self-determination to what usually feels like loss of control and tragedy.
 
It's also a way of honouring those who have suffered in an event; whether that's colleagues, friends, patients or yourself. 
 
There’s an optimism in being able to take something meaningful from these experiences and use it to improve future outcomes.
 
After processing a difficult event, the commitment to never waste suffering offers a silver lining in these inevitable moments.

Clinical Things I've Learned

  1. The SHED study that looked at Subarachnoid Haemorrhage (SAH) in 88 emergency departments across the UK over 3 years (3663 patients) had some interesting findings:

    1. Cohort were ≥18 years old, GCS 15, non-traumatic acute headache reaching maximal intensity within one hour. Of these 3663 patients, 6.5% were diagnosed with SAH.  
    2. 56.1% of these SAHs were classified as aneurysmal, the rest as non-aneurysmal or unclear.
    3. It highlighted the difference between aneurysmal and non-aneurysmal bleeds; something I hadn’t fully appreciated before. There were zero patients with non anuerysmal bleeds who went onto have active neurosurgical intervention. This is likely because they are much less severe bleeds, often venous rather than arterial. So it begs the question, is admission, LP/CT angio and prolonged hospital stay really justified and of sufficient benefit for non-aneurysmal bleeds?
    4. The post-test probability of aneurysmal SAH after a negative CT up to 24h is 0.1%, and 0.5% for all SAH including non-aneurysmal. Although the sensitivity for CT reduces over 24 hours, aneurysmal bleeds are likely easier to see, and possibly present earlier, hence such a low post-test probability for aneurysmal SAH.
    5. If you were referred for LP after a negative CT brain in this paper, the chances of a positive result were 2.4%. 


  2. Duct-dependant heart lesions in shocked neonates. Some APLS nuggets:

    1. Most present in 7-10 days of birth, but consider in all shocked neonates.
    2. Left sided lesions can present with severe cardiogenic shock, normally sats are ok (aortic stenosis, aortic coarctation, hypoplastic left heart). Right sided lesions present with cyanosis unresponsive to O2 (think ToF, pulmonary and tricuspid atresias).
    3. Take blood pressures and SpO2 from the right arm (pre-ductal), aiming for >75% saturations.
    4. Neonates may present shocked, absent/weak femoral pulses, abnormal ECG, upper/lower limb SpO2/BP discrepancies, and with hepatomegaly.
    5. If suspecting shock or cyanosis due to duct dependent lesions, start prostaglandin until formal echo confirms or refutes diagnosis.
    6. Side effects of PG include apnoea, hypotension due to vasodilation and pyrexia


  3. Its important to remember when talking to patients that we often cannot give a definitive diagnosis for their symptoms.

    In chest and abdominal pain presentations, around 30-60% are ultimately discharged as ‘uncertain aetiology’.

    The body is a strange thing, and sometimes forcing yourself to give a diagnosis is more harmful than admitting ‘I don’t know what is causing your symptoms, but I’m confident it isn’t anything requiring specific medical treatment and should resolve with some time on its own.’

From Elsewhere

Don't wait for everything to fall into place. Don't assume you'll know better in future. Don't think others 'ahead' of you are wiser.
 
“Awareness, not age, leads to wisdom.”
 
- Publius Syrus
 

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