Hi,

We're back to normal service after a prolonged website migration over last week. 

Onto what I've been thinking about...

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Statistically, we're all quite average in our respective fields.

It’s more likely than not that we find ourselves within the bellcurve.
 
Although I want to get better at what I do, Mel Herbert, an Australian EM physician, talks about the power of being average. 
 
He encourages us not to fight statistics, and to accept that we are likely to be average within our field. 
 
The ability to be extraordinary then, comes from other non-technical qualities; working hard, being punctual, delaying gratification, learning from mistakes, remaining teachable, being truthful, and so on.
 
These are all traits that anyone can cultivate, regardless of technical ability.
 
It’s easy to think of the skilled colleague who is a nightmare to work with. The most competent person in the room may be a sociopath.
 
Conversely, someone may be technically average, but bring a solid work ethic, are reliable, and others are relieved to see them on shift. 
 
To me, this can be summarised in the following way:
  1. Despite probably being average within a group, it’s always possible to be a better version of oneself. 
  2. Leveraging other strengths of character is akin to applying a power law to otherwise ‘average’ abilities.

So even if considered technically ‘average’, it’s still possible to be extraordinary through leveraging and cultivating other valuable traits.

 

Clinical Things I've Learned
  1. The NCEPOD 2021 audit for inpatient care of out of hospital cardiac arrests (OHCA) gives a broad overview of UK cardiac arrest statistics and outcomes. It looked at 30,829 attempted resuscitations in 2018, out of hospital. Very useful background knowledge for discussions with family and patients across different contexts.
    1. Less than 1 in 10 (9.7%) survive an OHCA - compared to 1 in 4-5 in areas such as Norway and the Nethelands.
    2. Of those resuscitation efforts out of hospital, 51.5% were conveyed to hospital, and 56.8% of those conveyed achieved ROSC at handover.
    3. Only 2.8% of initial non-shockable rhythms survived to hospital discharge, whereas 29.5% of shockable initial rhythms survived to discharge.
    4. Unless there is an obvious non-cardiac cause, 59-71% of patients with OHCA will have had an acute coronary artery even
    5. There were no survivors in those with a duration beyond 39 minutes between OHCA and ROSC
    6. Survival was more common in a lactate level <6 mmol/l, but the highest lactate in a survivor was 19.8 mmol/L. Similar trends for pH.
    7. For those patients in which sustained ROSC took longer than 20 minutes to achieve, 9/143 (6.3%) survived
    8. The report recommends delaying neuro-prognostication of OHCA survivors until at least 72 hours after ROSC and effects of temperature management and sedation can be excluded


  2. Final bit of paediatric resuscitation related pearls for a while as I’ve just re-certified APLS (nice surprise to be put forward for instructor potential).
    1. Peri-arrest/rescue dose inotropes: calculate arrest dose (10mcg/kg = 0.1ml/kg of 1:10,000). Then dilute this down to a 10ml NaCl syringe. This gives 1mcg/kg/ml. Can then bolus 0.5-0.1ml as required.
    2. In the shocked infant (or any patient for that matter), don’t hesitate to use intraosseous access. The biggest reason for low use is likely unfamiliarity and reluctance. But it’s rapid and is classed as central (not peripheral) access, with all the benefits of being able to administer drugs requiring a central line. Just learn the landmarks, contraindications, and don’t faff around struggling with peripheral access.


  3. Tried to needle decompress a tension pneumothorax last week before going on to place a chest drain. I didn’t find that the anterior 2nd ICS space approach with a 14G cannula had any clinical effect on the patient.

    The literature suggests this is variably unreliable as a method of decompression (chest wall thickness, kinked cannula, occlusion of cannula with tissue etc). In future, I may move to finger thoracostomy + drain in the first instance. Planning to chat to other colleagues to see their own practice and thoughts. Further reading    . Would love to hear from others on this. 

From Elsewhere
"And I think it’s worse than just, oh, my best wasn’t good enough today, and I couldn’t, I couldn’t win. It’s no, our actions actually caused the failure.
 
We did the opposite of what we were trying to accomplish. And it hit the team really hard. And, and it reverberated for a very long time."
 
How to move forward when those meant to save do harm?
 
St Emlyn’s talks to Kevin Cyr, a SWAT commander, about learning through failure. 
 
A very candid talk about his team’s accidental shooting of a hostage, with lessons to take away across many fields. 
 
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"He is careful of what he reads, for that is what he will write. He is careful of what he learns, for that is what he will know."
 
- Annie Dillard
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All information in the Push-Dose newsletter is strictly for educational purposes only, and does not constitute professional or medical advice.