Hi,

Rotational training in medicine is disruptive; moving miles between hospitals for years on end becomes a grind. 
 
Many doctors prefer the idea of completing all training in one hospital, which has obvious advantages.
 
But rotating hospitals has up-ended one of my previous held convictions. 
 
“Work hard and you’ll be successful.” 
 
On the whole, this generally holds true (arbitrary catastrophes aside).
 
After studying swimmers across all levels in 1983, Chambliss published “The Mundanity of Excellence”. He found that, although necessary, effort alone was not sufficient for success:
 
“It is not by doing increasing amounts of work that one becomes excellent, but rather by changing, the kinds of work.”
 
Olympic champions don’t just attend more practices or move their arms faster, they do things differently. 
 
The attitude of the coaches and athletes, the standards, expectations, habits, techniques, and way of doing things is what drove success. 
 
Hospitals are the (chronically underfunded) swimming teams within healthcare.

Each department has a unique atmosphere, set of standards, and culture that influences the ‘success’ of patient care. The opportunity to rotate through them has exposed me to different ways of swimming (or drowning) in the emergency department. 
 
Sufficient work volume and time under tension is a pre-requisite to improving, but the manner in which the work is done can make a huge difference. 
 
I used to believe I could white-knuckle swim myself upstream toward success, regardless of the environment. 
 
But it matters where you place yourself, who you surround yourself with, how you view what you do, the attention to detail, the habits you cultivate; all the qualitative aspects of what you do.
 
Sometimes just doing more isn’t enough, and a change in the qualities and way of doing things is called for. 

 

Clinical Things I've Learned
  1. Posterior sternoclavicular joint dislocations have been added to my growing list of rare but terrifying conditions. A missed minor injuries case was discussed in a recent course by an EM consultant, with an emphasis on the inability to rule it out clinically or with x-ray. An interesting case review with some pearls: 

    1. Posterior SCJ dislocation can cause injury to the aorta, trachea and other mediastinal structures. For this reason they are often potentially life-threatening injuries. 
    2. Diagnosis is often delayed due to their rare, non-specific, subtle presentation, as well as lack of standard radiographical findings.
    3. Keep a high index of suspicion, especially if pain out of proportion to the area or significant bruising. If compression of mediastinal structures is involved they may have airway obstruction, aortic injury or other mediastinal compromise. This requires emergent closed reduction.
    4. Reduction involves anterior traction applied to the medial clavicle using sterile towel clamps inserted percutaneously along with longitudinal traction of the ipsilateral arm. 
    5. CT scan is the imaging of choice if this injury is suspected.


  2. Absorbable sutures appear to be non-inferior to non-absorbable for facial laceration repair, with comparable aesthetic and clinical outcomes (here). This was echoed by a maxillofacial registrar I listened to last week, who was involved in an RCT looking at absorbable vs non-absorbable sutures in 200 patients presenting with facial wounds to the emergency department.

    It seemed early complication rates were significantly higher in the non-resorbable group at the one-week follow up.

    I’m going to start using absorbable sutures on face wounds as this reduces the need for patients to attend for suture removal, which can be difficult to arrange, particularly in those prone to poor follow up. 


  3. The chaps over at Anaesthesier wrote a great summary on when to use bicarbonate . This is often a point of debate and contention, but definitely worth a read. Some key points:

    1. In many cases, it just fudges the numbers without addressing the underlying cause. 
    2. Salicylate and TCA toxicity are definite times to consider bicarb (see indications). Other times to consider bicarb are severe normal anion gap metabolic acidosis (NAGMA) and hyperkalaemia with impending risk of arrhythmia. Aside from these, there likely aren’t many other indications for bicarbonate. 
    3. Giving bicarbonate can lead to raised lactate, hypocalcaemia, and raised pCO2.

From Elsewhere
“But of course there is no secret; there is only the doing of all those little things, each one done correctly, time and time again, until excellence in every detail becomes a firmly ingrained habit, an ordinary part of one’s everyday life...
 
...“What these athletes do was rather interesting, but the people themselves were only fast swimmers, who did the particular things one does to swim fast. It is all very mundane. When my friend said they weren’t exciting, my best answer could only be, simply put: That’s the point.”
 
Daniel Chambliss 
 
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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.