Hi,

This year's UK cohort of medical graduates will be finishing their first month as a doctor in a week, and working with some of them this month has made me reflect on when I began.
 
Gaining procedural competence in any high risk field is a delicate balance.
 
A frightening realisation is that doctors only get better by seeing higher volumes of patients. 
 
There will always be the first time that a doctor does a procedure to any patient. 
 
Ways to smoothen out this transition include simulated training, mental rehearsal, chunking parts of the procedure, and maintaining expert supervision. 
 
But all of these things can never replace that actual moment when you have to do a procedure on a real patient.
 
Its not an option to not train new doctors, because they are the surgeons, anaesthetists, interventional radiologists, emergency medics etc of the future who must be good at their craft.
 
So whilst a patient is directly helped by a procedure done to them, they are also indirectly aiding future patients in refining the practice of that clinician. 
 
When supervising these, its a delicate balance between maximising exposure and learning for the doctor, and minimising risk of harm to the patient.
 
Whilst we want to absolutely minimise risk, stepping in too early deprives growth and learning of the clinician.
 
I vividly recall a central line I was struggling with, and the sense of appreciation I had when the trainer gave me the space to successfully place it. By not stepping in and taking over, I came away from that experience with a massively upgraded sense of clarity and confidence in how to navigate similar challenges in future.  
 
There is a massively increased sense of ownership, embodiment and confidence when given the space to navigate through a new experience.
 
The art is in balancing this space against the potential risks associated. 

 

 

Clinical Things I've Learned
  1. Diagnosed a case of Cannabinoid Hyperemesis Syndrome (CHS), for which RCEM has a helpful guideline (and good patient info leaflet included). 

    1. Symptoms may not be temporally related to cannabis use, and may sometimes even be helped. May develop CHS after years of use, and may have weeks or months between episodes.
    2. Ensure other pathologies ruled out, and screen for hypoglycaemia, AKI, electrolyte disturbance, and metabolic alkalosis/acidosis.
    3. Often quite resistant to anti-emetics and analgesics in ED, but follow normal practice in the first instance. IM haloperidol or 0.1% capsaicin cream applied to abdomen may be considered in refractory nausea and vomiting. Obtain ECG to check QTc prior to haloperidol. 
    4. Only stopping cannabis will prevent further episodes.


  2. Saw a presentation of painful bartholin’s cyst/abscess, which I’d never encountered before. EM Docs does a good case for this. NHS Wales is a bit more specific to UK practice (I'm not going to be sticking in word catheters myself).

    1. Occurs if bartholin’s gland obstructed (which lubricate distal part of vagina), with mucoid secretions building up to form a cyst. If becomes infected it becomes an abscess.
    2. Found normally unilateral at the 4 or 8 o’clock position. Cyst is typically soft and non tender. Abscess/infected cyst is usually painful. May be draining purulent fluid 
    3. Management: if >40 yo then consider excluding malignancy. If asymptomatic, no treatment needed. Otherwise, analgesia, hot compresses and baths. Incision and drainage if significant symptoms/abscess. Antibiotics if evidence of systemic infection


  3. Variation in Bell’s Palsy presentation can be deeply confusing. Patient I saw had attended 2 days prior with facial drooping and forehead sparing. CT scan normal, given aspirin and a TIA clinic referral (sadly self-discharged declining admission). I saw him 2 days later and presenting full blown facial nerve palsy with forehead sparing. I don’t know the rates of variance but obviously if forehead sparing it is a stroke until proven otherwise. Other useful points I reviewed.
    1. Eye care is vital. Hourly lubricant drops during day and ointment at night. If unable to close eye have two options: tape eyelid directly shut with likely irritation to delicate eyelid skin over proceeding weeks-months. Gauze firmly taped over eye but with risk of abrasion to cornea if eye lid opens. I’d love to know if other alternatives out there.
    2. Prednisalone if presenting <72h since symptom onset; either 50mg for 10 days or 60mg for 5 days with tapering course. Check ears if any evidence of Herpes Zoster (Ramsay-Hunt syndrome) which may benefit from acyclovir if indicated. 
    3. Some people never fully recover from Bells. Education, leaflets and pointing to resources is key to this condition
 

From Elsewhere

Carrying on the theme of experts and mental models from last week:

"A large part of the difference between the experienced decision maker and the novice in these situations is not any particular intangible like judgment or intuition.
 
If one could open the lid, so to speak, and see what was in the head of the experienced decision-maker, one would find that he had at his disposal repertoires of possible actions, that he had checklists of things to think about before he acted; and that he had mechanisms in his mind to evoke these, and bring these to his conscious attention when the situations for decisions arose."
 
- Scientist Herber Simon