Hi there,
 
My brother is a furniture maker. 
 
He was telling me about a young work experience student who had been shadowing him recently; he’d really enjoyed having them around. 
 
He told me how they had been persistent in joining despite my brother having to cancel a number of times, how they showed genuine interest in the craft, that they were punctual, polite, and had even gifted him a card and bottle of wine after their time with him. 
 
This student had clearly left a lasting impression and, as a result, my brother was happy to go out of his way to help them out.
 
I contrasted this to a student I had following me when I worked on ITU.
 
They showed little interest in being invited to watch a critical procedure, gave a cynical attitude when spoken to, and left early before the day was over. The consultant who had gone out of his way to deliver personalised bedside teaching was disappointed to say the least. 
 
No matter what field, being a good student is a skill. It also accelerates your learning and opportunities, as others are pleased and eager to help.
 
People who are good at a craft, generally, find great satisfaction in mentoring others. 
 
If you can hone the skills of a good mentee, you gain access to years of expertise and experience. 
 
Being prematurely cynical only kneecaps your progress before you’ve barely begun. 
 
Subjugate the ego to being a pleasure to teach and you can open doors. 
 
 

Clinical Things I've Learned
  1. I had a case of angioedema of uncertain aetiology this week. These presentations can range from just a bit of lip swelling, to life-threatening airway compromise. Very much worth a read of this review article, which provides a great summary to approaching these cases in the emergency department. Pair with EMCrit’s summary. Some take-homes:

    1. Histamine-related is most common, and generally responds to anti-histamines, corticosteroids +/- adrenaline. Generally it is more rapid onset, more commonly has urticaria, and may present as anaphylaxis. 
    2. Non-histamine angioedema is most commonly bradykinin-induced, and includes hereditary angioedema, acquired angioedema, and ACEi-induced. Can be rapid or slow onset, less commonly presents with urticaria, and may have abdominal angioedema symptoms (pain and/or swelling). 
    3. 1g tranexamic acid, FFP, and C1-inhibitor concentrate are treatment choices for bradykinin-induced angioedema. Histamine-related treatments will not work if it is bradykinin-mediated. 
    4. If no involvement of tongue, larynx, no threat to airway - can discharge after period of observation (≥2-6 hours)


  2. Amal Mattu at ECG Weekly reminds us that AV dissociation and complete heart block are not the same thing. AV dissociation simply refers to the loss of relationship between atrial and ventricular activity. This may include ventricular tachycardia, junctional escape rhythms, or some form of heart block. All cases of heart block include some AV dissociation, but not all AV dissociation are complete heart block. 

    At times, P waves may be ‘captured’, resulting in a capture beat showing conducted ventricular contraction; this is not complete heart block, because there is some conduction from the atria to the ventricles. 

    Also worth remembering that in AV dissociation, the P waves may not be completely regularly spaced, due to sinus arrhythmia.


  3. It should be remembered that Cerebral sinus venous thrombosis is actually a form of stroke (quite rare at 0.5-1% of all stroke admissions). This is an excellent and brief review article that highlights some important aspects of CSVT:
    1. Presentation is often vague, but 70-90% have headache, and 40% may present with an acute stroke-like syndrome. 
    2. Maintain high clinical suspicion in those who present with new-onset and persistent headache, worse with the Valsalva manoeuvre, and not improved with regular analgesia. Especially in pregnant, obese, young adults, or those on oestrogen containing contraceptives. 
    3. No lab test can rule in/out (including d-dimer). Non contrast CT can show signs (such as oedema, reduced white/grey differentiation), but CT or MRI venogram are imaging modalities of choice. 
    4. AHA/ASA/EFNS all state that anticoagulation is the treatment of choice, and indicated even in the presence of haemorrhage associated with CSVT. Obviously such management decisions should be MDT-drive with neurology/stroke input. 

From Elsewhere
Carl Jung, the influential psychiatrist, on the value of knowing yourself:
 
"The world will ask you who you are, and if you don't know, the world will tell you."