Hi,
 
I went to the Edinburgh Fringe last week.
 
Seeing how an individual could captivate an audience in a small space, unable to hide behind anything, left me feeling like an automaton. The creativity on display was awesome. 
 
It made me think that in any pursuit, we have to submit ourselves in a way to be moulded. You have to learn the culture, mannerisms, practices, techniques, and fundamentals. An obvious example is the military, where you need to be subsumed and shaped into a specific product. The same is true for pretty much any pursuit. 
 
You have to get good at the thing. But there’s also a pressure to fit in.
 
Medicine is similar; models of communication, attire, basic sciences, procedural memory - all these things have to be embodied over time. If push comes to shove, our individuality has to be secondary to this process. The outcome is what matters. 
 
No one cares that the pilot is a hilarious orator if they’re crap at flying planes.
 
But as you move along the mastery process, then more space opens up to bring your own individuality forward. 
 
Roger Kneebone describes this as developing your voice:
 
To be expert, your voice must remain recognisably yours, even when you are in situations you haven’t encountered before...To be effective, your voice must be authentic. You are drawing on aspects of yourself that are already there, not creating a new identity..
 
So whilst there’s something strangely alluring about becoming robotically skilled at your ‘thing’, this can come at the cost of your own voice within that space. 
 
The consultants I remember most vividly brought aspects of themselves to their work, eccentricities and all. 
 
Life is quite short, so it would be a shame to loose that.

Clinical Things I've Learned
  1. A recent ambiguous case of possible meningitis presenting primarily as a bacterial tonsillitis made me think a bit. Listened to a Curbsiders episode and read through NICE guidance and a good RACGP review. Some points to highlight for myself.

    1. Consider meningitis in a patient presenting with 2 or more of fever, headache, neck stiffness, and altered consicousness/cognition
    2. Most people do not need a CT brain prior to LP. There are some specific indications but the vast majority need prompt LP and treatment. 
    3. Give dexamethasone 10mg, along with antibiotics, to suspected bacterial meningitis, but not meningococcal disease (caused by neisseria meningitidis, with purpuric/petechial rash as a defining feature).
    4. Kernig and Brudzinski signs are probably pretty unhelpful clinical exams to do, with a very low sensitivity


  2. Does cricoid pressure matter in RSI? A literature review release just a couple of months ago thinks probably not: 
    "cricoid pressure—as it is currently performed—likely provides no benefit but probably does minimal clinically relevant harm"
    This seems to vibe with others’ thinking on the matter.


  3. E-bikes continue to wreck people with a nasty paediatric femoral shaft fracture I saw last week. Unfortunately they had an associated nasty tibial plateau fracture on the same side. 

    1. Most occur from high energy trauma such as road traffic accidents, with young males being the highest demographic. They are associated with other significant injuries so high suspicion for trauma elsewhere in the body should be maintained. 
    2. Femoral shaft fracture can result in 1-1.5 litres of blood loss, so haemodynamic compromise is a risk. 
    3. Analgesia: pull the limb to length with traction (kendrick splint, thomas splint etc) and perform a FICB / femoral nerve block. Queensland have a nice guideline outlining the two approaches in paediatrics
    4. Complications to consider: nerve injury is rare, but always document neurovascular status. Be mindful of possibility of compartment syndrome and fat embolism later down the line (usually much past the ED stay).

From Elsewhere
Two paragraphs from Jon Krakauer’s ‘Into Thin Air’, contrasting the expected but undelivered elation of summiting Everest, with the more prosaic and perhaps satisfying ‘small’ life satisfactions:
 
I understood on some dim, detached level that the sweep of earth beneath my feet was a spectacular sight. I’d been fantasizing about this moment, and the release of emotion that would accompany it, for many months.
 
But now that I was finally here, actually standing on the summit of Mount Everest, I just couldn’t summon the energy to care.
...
I was forty-one now, well past my climbing prime, with a graying beard, bad gums, and fifteen extra pounds around my midriff. I was married to a woman I loved fiercely—and who loved me back. Having stumbled upon a tolerable career, for the first time in my life I was actually living above the poverty line.
 
My hunger to climb had been blunted, in short, by a bunch of small satisfactions that added up to something like happiness.