Hi,
 
I’ve been heavily caught in the midwit trap recently. 
 
In an effort to better understand the fundamentals of acid-base balance, I’ve opened up a can of worms about chemistry, equations and formulae that I’m struggling to get out of. 
 
Whilst I’ve sunk tens of hours into reading and listening to a load of material on the topic, I’m starting to come full circle to how I viewed the topic right at the beginning. 
 
I’ve realised that I’m firmly midwit for a lot of topics.
 
Trying to better understand something gets me caught in the weeds, often for long periods of time. 
 
On many occasions I emerge out the other end with similar conclusions to when I had a limited understanding of the topic. 
 
Others have argued that in order to become the guy on the right, you should embrace being the one on the left. In a strictly outcome-oriented way, this may be true for many cases. 
 
There are definitely areas in life where I’m happy to be the guy on the left. 
 
But for the pursuits that matter, I think its worth trying to get through the midwit phase, even if its hard to emerge out the other side. 
 
I’ve worked with people on the right with certain topics; they give concise and suspiciously simple answers to questions, and refrain from massively pontificating before answering. But the difference is that they have gone through the quagmire of uncertainties to reach there, and can stand on a more solid foundation. 
 
If you can savour and enjoy somewhat the striving to get out the other side, then you are probably doing the right thing for you. 

Clinical Things I've Learned
  1. A neurodivergent patient presented to resus with seizures and a history of excessive drinking. Blood gas revealed a sodium of 117. They had drunk themselves into severe hyponatraemia by psychogenic polydipsia. Nice review on hypertonic saline. 
    1. Dipsogenic in those who consciously drink excess water in an effort to maintain ‘heathy’ lifestyle and psychogenic primarily in those with underlying neuropsychiatric conditions.
    2. Moderate (nausea, lethargy, confusion) and severe (coma, seizures) symptoms warrant treatment with hypertonic saline. Different protocols exist but generally 100-150ml of 3% NaCl as an initial bolus.
    3. Osmotic demyelination syndrome is the primary, devastating complication to avoid. Rates may be rarer than feared. Higher risk for ODS include liver disease, alcohol excess, malnutrition, hypokalaemia, Na <105. In these cases aim for lower Na rise target within 24 hr, such as 4-6 mEq/L instead of usual 8-10 mEq/L.


  2. A postpartum patient attended with vomiting, fevers and abdominal pain. Whilst they were ultimately diagnosed with pyelonephritis, a differential of endometritis was considered; a diagnosis I was quite unfamiliar with.
    1. Endometritis can be caused by bacterial vaginosis or STD (normally chlamydia or gonorrhoeae). It is the most common post-partum infection, normally polymicrobial from translocation of vaginal flora into the uterus.
    2. Post-partum can occur up to 6 weeks after labour, and is a clinical diagnosis of fever, significant lower abdominal pain, uterine tenderness, and foul-smelling lochia. Suprapubic tenderness is very common. Acute endometritis from STD has many overlap features with PID
    3. If untreated the fatality rate of post-partum endometritis is almost 20%!
    4. Its a clinical diagnosis and there are usually not ultrasound or CT features that can diagnose endometritis
    5. Maintain a low threshold for admission given possibility for extension to intra-abdominal infection / sepsis


  3. I was asked about whether we should give tranexamic acid to a patient with an upper GI bleed by a junior colleague this week. As it stands, TXA is still NOT recommended for either upper or lower GI bleeds, with increased risk of thromboembolic events shown in the 2020 HALT-IT trial for GI bleeds.

    Doesn’t stop it feeling odd to withhold TXA when someone is acutely haemorrhaging and you want to throw the kitchen sink at them. 
 

From Elsewhere
I’ve stolen this quote from Shane Parrish’s Brain Food Newsletter this week. I don’t know much about who its attributed to, but I like the idea of being protective of ideas in their infancy.
 
“I kept my idea a secret from anyone who could not directly help to move it forward. That was my gut instinct at the time, but it’s now one of the best pieces of advice I have to give. Ideas are the most vulnerable at the moment you have them; that’s also the time people are most inclined to run around seeking validation from everyone they know. Discouraging remarks will likely take you off course. You’ll either end up deflated or spend your time defending your idea instead of going for it.”
 
— Sarah Blakely