Hi,
 
I’ve been smacked in the face numerous times with knowledge and confidence gaps in medicine. 
 
These epiphanies sometimes announce themselves subtly - trepidation at the ‘dizziness’ patient next to be seen. Other times they appear dramatically, like an unexpected cardiac arrest in a side-room. 
 
Without a strong mental map, it feels like navigating unstable ground; I don’t know where the ‘edges’ are or what to expect.
 
One of the most productive things I’ve learnt to do is take note when I’m on this shaky ground. The next step is to make a borderline absurd, audacious pledge to myself: to ‘become an expert’ in that thing. 

Whether or not that’s a reasonable expectation, the notion of transforming something nerve-wracking into an area of expertise is massively motivating for me. It offers a sense of control. 
 
When I realised how bad I was at ECGs during a taught session, I signed up to ECG weekly, read through some books, and delivered some teaching sessions.
 
After feeling out of my depth during an unexpected cardiac arrest some years ago, I become an ALS instructor and aimed to get better at managing arrests. 
 
Confronting a weakness with a brazen commitment to ‘become an expert’ helps shift from ‘why am I crap at this’ to ‘I can get better at this’. Whether or not I become an expert is irrelevant, its the expectation shift in myself that matters. 
 
Striving to become a teacher of something that once felt overwhelming is a reliable step toward competency, and tentatively toward expertise. 
 

Clinical Things I've Learned
  1. Placed a seldinger chest drain for a pneumothorax in a peri-arrest patient with severe bullous-emphysematous disease last week. Following day Critical Care Reviews ‘paper of the day’ covered pleural procedures and pathologies (would recommend subscribing to CCR Paper of the Day):

    1. Hippocrates (460–370 BC) is often credited with describing the first form of pleural drainage using hollow reeds to drain empyemas
    2. Size of chest drain is typically measured according to the french system = Ch (Charriere, name of creator) or Fr (where Charriere lived)
    3. An RCT showed the 94% with a large but minimally symptomatic primary spontaneous pneumothorax treated conservatively achieved complete re-expansion within 8 weeks. This reflects new(er) BTS guidance that has shifted from size of pneumothoraces to more symptom-based, individualised management. 
    4. General haemothorax guidance states if >1500ml on initial drainage or >200ml/hr over 2-4h = indication for thoracotomy 

  2. Listened to EM Cases regarding post-tonsillectomy bleeds:
    1. Primary haemorrhage within the first 24 hours. Secondary usually occurs 5-10 days post-op, often due to fibrin clot sloughing off.
    2. Take even very minor bleeds seriously - they can herald impending major haemorrhagic bleeding
    3. Get help early: ENT, anaesthetics if risk of airway compromise
    4. Resuscitate: IV access and ABCD care. If active bleeding prepare for possibility of RSI & intubation. Suction ready.
    5. Temporise: IV TXA, lidocaine spray to oropharynx then apply gauze soaked in adrenaline and TXA applied directly using Magill forceps, consider nebulised TXA +/- adrenaline. If direct pressure poorly tolerated or ++distress IV ketamine may help to relax patient.
    6. Always need ENT review even if bleeding has stopped, as these are high risk of re-bleeds which can be catastrophic.

  3. Some APLS reminders on some of the unique anatomy and physiology considerations in paediatric trauma

    1. Highly elastic chest walls make rib fractures less likely, but also mean high forces can be more easily transmitted to internal organs resulting in more severe visceral trauma. Horizontal ribs, underdeveloped musculature, small FRC = low tolerance for chest injuries
    2. The Monroe-Kellie doctrine is different for infants, as their cranial sutures are still open. This means that infants can lose a significant volume of blood intracranially before neurological signs become apparent. 
    3. Younger ages are increasingly unlikely to experience c-spine fractures, being rare in young children. If they do, atlas and axial injuries are most frequent. Atlantoaxial rotary subluxation is most common. May present as torticollis.

From Elsewhere
It’s all in the mindset; quotations from people passionate about widely varying pursuits:
 
"It takes years, and years, and years to learn, and it takes 100% dedication and focus."
- Pizza chef Anthony Mangieri 

"It’s enjoyable, it’s challenging and there are so many problems I haven’t solved yet. I’m still learning.” 
- Master Bladesmith Bob Kramer

"I spend about 70 hours a week talking about pickles, trying pickles, thinking about pickles, figuring out what to pickle.”
- Alex Hozven, purveyor of pickles.
 
"Even at my age, after decades of work, I dont think I have acheived perfection. But I feel ecstatic all day, I love making sushi. Thats the spirit of the shokunin" 
- Jiro, sushi chef.  
 
Get after it. 

All information in the Push-Dose newsletter is strictly for educational purposes only, and does not constitute professional or medical advice.