Hi,
 
I started at a new emergency department last week, in a major trauma centre.
 
Its the usual yearly ritual of logins not working, learning new names, and not knowing where anything is.
 
Alongside this, the patient presentations have been some of the sickest I’ve ever seen, and busier than I’ve had since I can recall.
 
The ambient pre-shift anxiety has edged up. 
 
I’ve fallen back on an old Jocko-ism and started to deploy the response of “good” as a default. Its a pretty blunt tool, but I find the simplicity of it has high utility.
 
"When things are going bad: Don’t get all bummed out, don’t get started, don’t get frustrated. No. Just look at the issue and say: “Good.”"
- Jocko Willink
 
Pre-shift anxiety? Good... better to be engaged than bored.
 
Huge surge in patient numbers? Good... see how efficient you can be. 
 
New pathology you’ve not seen before? Good... learn it and get better.
 
Patient kicking off being violent? Good... lets try to calm them down.
 
Its the bro-science method of engaging in paradoxical intention therapy, espoused by Victor Frankl, who stated that “The patient is encouraged to do, or to wish to happen, the very things he fears”.
 
Our lizard brain perceives ‘bad’ things by ramping up a state of anxiety, fear, and stress. But it often over-corrects for what it perceives as ‘bad’.
 
The ‘bad’ thing is getting hoisted upon you either way. Saying ‘good’ is a re-frame that shifts the sense of something being done to you, to actively doing something yourself.
 
Its a step toward dialling down the threat perception, and gaining a greater sense of control over the situation. 
 

Clinical Things I've Learned
  1. Major trauma patient with a large vessel injury and major haemorrhage the other day.
    -
    1. Target permissive hypotension, with different guidelines suggesting between 70-90 mmHg systolic. If traumatic brain injury, aim a higher systolic to ensure adequate cerebral perfusion. 
    2. Aim normotension when definitive control achieved - even if not achieved, some guidelines and practice advocate to aim toward a normal blood pressure within 2-4 hours. This is because prolonged permissive hypotension leads to end organ ischaemia, AKI etc. 
    3. In the haemorrhagic patient, key prognostic metrics are blood pressure, acid-base status, coagulopathy and temperature.


  2. One of the central truisms touted in medicine is ‘first, do no harm’. Makes a great deal of sense on the surface, but Justin Morgenstern questions whether this is so trivial as to be on the verge of pointless.

    “First do no harm” is a deepity because it is impossible to act in medicine without harm. That apparently profound statement is just wrong. Our best therapies all have significant harms”.


  3. Dizziness can be caused by myriad things, some of them benign, others extremely serious. GRACE-3 guidelines provides a brilliant, prgmatic overview to approaching this presentation in the ED.
    -
    1. Asking about dizziness vs light headedness vs vertigo is largely a waste of time. High inter-variability in reporting symptoms exists. Focus on triggers and timings to place the patient in a bucket of either continuous acute vestibular syndrome or episodic vestibular syndrome (which is either triggered or spontaneous).
    2. HINTS and Dix-Hallpike are better than any imaging modality in the correctly trained hands. 
    3. If suspecting posterior stroke, CT will only pickup around 25%. If worried about a bleed or other intracranial cause (very few ICH have isolated dizziness symptoms only) then a CTH is reasonable first step. 
    4. Bottom line: get good at HINTS, including who to use it on.
 

From Elsewhere
Getting better at something is largely about cultivating and shaping higher-fidelity, more workable mental maps and representations of the world we find ourselves in:
 
“In pretty much every area, a hallmark of expert performance is the ability to see patterns in a collection of things that would seem random or confusing to people with less developed mental representations. In other words, experts see the forest when everyone else sees only trees”
 
- Anders Ericsson