• Monotonous single task factory work, usually 6 days/week, often 7 days. 
• Hours often from 7am up to 11pm (classed as overtime, which was ironic given it occurred more often than ‘normal time’) 
• Fitting in own chores sorting out home rice fields, sometimes until 3am (with work again next day)
• Looking after a young child alone (husband worked in construction far away, came home 1 week per YEAR)
• No A/C or heating in sub-zero winters and >40ºc summers
• No real friend network or family support

Thankfully she is now retired and deservedly more comfortable and autonomous.

Clinical Things I've Learned

1. A nice review on Craniocervical Artery Dissections (CAD) by Mayo Clinic highlighted some interesting points.
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   1. Most trauma-associated CADs are from minor trauma such as heavy lifting, whiplash, chiropractic adjustments, spotrs, increased valsalva (eg vomiting, coughing, sneezing)
   2. Any young person with sudden onset intractable, persistent head or neck pain should seriously be considered for the possibility of CAD
   3. Ensure non contrast CTH first if any neurological abnormality or suspicion of SAH to rule out stroke or SAH. After that, CT/MRI angiography of the head and neck are gold standard. 
      
      
2. When needing emergency IV access for volume replacement in resuscitation scenarios, the ease/speed/gauge of peripheral far outweighs central access. 16G in the ACF. The flow rates will be higher than central lines. 
   
   
3. CT imaging in acute first seizure presentations is not common practice in the UK. Patients get a First Fit clinic referral, and may or may not have follow up MRI/CT imaging. However a recent systematic review published in the EMJ questions whether this is the right approach
   -
   
   1. They found a high yield of intracranial abnormalities (such as tumours, infection, bleeds etc), with a number needed to scan between 10 and 19. Interestingly the findings of actionable findings decreased each year of published study, from 35% in 1994, to around 5% in 2023. Either way, the conclusion was that these patients should be scanned on their index ED visit.
   2. NICE guidance advises CT if an underlying structural cause is suspected.
   3. Royal College of Emergency Medicine recommends considering CT if prolonged wait for first fit clinic likely, or any red flags present.
   4. Generally, perform CT head if any red flags present or clinical suspicion of underlying intracranial pathology. Maybe this EMJ study will lower my threshold. 

From Elsewhere

Roosevelt's timeless middle finger to the armchair critics and encouragement to those that do:

"It is not the critic who counts;

not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better.

The credit belongs to the man who is actually in the arena,

whose face is marred by dust and sweat and blood;

who strives valiantly;

who errs, who comes short again and again, because there is no effort without error and shortcoming;

but who does actually strive to do the deeds;

who knows the great enthusiasms, the great devotions;

who spends himself in a worthy cause;

who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat."