Hi,
 
“Neither growing old nor accumulating life experiences is sufficient for growing wise.” - Current Opinion in Psychology journal.
 
“Awareness, not age, leads to wisdom.” - Publius Syrus
 
 
There’s around 2000 years of time between the utterances of these two sentences.
 
I’ve long held the implicit assumption that greater experience affords greater competence and wisdom. 
 
From primary school through postgraduate medical training, there is a sense of a determined path, a climbing of the ladder, and steps closer to mastery. 
 
I’ve always valued competence, as it’s the answer to many practical problems; “ the building stands, the car now runs, the lights are on”.
 
But I’ve increasingly come to see that competence, although a pre-requisite, is not sufficient. A psychopath may be the most competent person in the room.
 
The road through medical school and training toward competence has always been inherently hierarchical. The lecturers and consultants are gatekeepers of knowledge, skills and opportunities, and there is a clear pathway forward (medical student → foundation doctor → trainee → etc etc). 
 
So it seems self-evident that those above in this hierarchy are more knowledgable, capable, and wise. 
 
Why would I ask more senior colleagues for clinical advice otherwise? Why would the medical students listen to me teaching? (maybe they have no choice...)
 
More than ten years of medical school and training have ingrained this sense of ‘those above’ being wiser. Generally, this holds true.
 
But by extension, I may subconsciously sense that my ‘wiser self’ is somewhere in the distance, over the horizon; if just for more time, training, repetition, exams, courses, assessments, I will eventually get there. 
 
With this, comes the persistent sense that I have never ‘arrived’.
 
But progression through training gives peeks through the cracks. You see newspaper scandals involving clinicians, mistakes made, or instances of questionable behaviour that undermine the assumption that wisdom is somewhere higher up the ladder.
 
“Awareness, not age, leads to wisdom.”
 
Receding on the approach like a mirage, wisdom doesn’t come from the passing of time.
 
We’ve seen enough evidence across our political, social and other institutions to know that the top of the hierarchy by no means guarantees wisdom. It’s the recognised phenomenon that most adults are just winging it and no one really has it figured out.
 
Medicine has taught me the following: pay attention, maintain a degree of scepticism, don’t ignore your instinct, hold firm beliefs loosely, and maybe it’s possible to be a little wiser in the here and now. 

Clinical Things I've Learned
  1. Pneumomediastinum; An elderly lady with chest pain and subcut emphysema presented to ED after a morning of severe coughing. She had an impressive pneumomediastinum with emphysema tracking into the neck and chest. Some summary points from this useful review:

    1. Overall a relatively rare entity. Most common in young males.
    2. Most present with retrosternal chest pain. 70% have subcut emphysema. Other symptoms include neck swelling, pain, and alterd voice and swallowing.
    3. 70-90% of cases are detectable on CXR. Look for ‘continuous diaphragm’ sign, mediastinal air streaks, air around the large vessels, deep sulcus sign, outlining of the heart border, possible pneumothorax, and subcut emphysema.
    4. Causes can be primary spontaneous, iatrogenic, traumatic, or non-traumatic (includes necrotising infection, airways disease, child birth, physical activity). Most common is alveolar rupture from increased valsalva pressure in coughing or retching. Oesophageal perforation is also common. 
    5. Generally a benign entity that just requires supportive management. Clinical judgement for who needs admission versus discharge.
    6. Tension pneumomediastinum is a rare complication, where air can cause tracheal or great vessel obstruction. This needs subxiphoid mediastinal drain placement by a thoracic surgeon

  2. There was a tracheostomy airway emergency in resus last week with a false tract in a longterm tracheostomy patient. This required the crit care team to perform oral intubation with a glidescope after removal of the tracheostomy. Some pertinent reminders about tracheostomy patients (very nice summary article).

    1. Tracheostomy tubes can be cuffed, uncuffed or fenestrated. The latter two allow some phonation but have a higher risk of aspiration. Speaking valves force exhaled air through the vocal cords; so MUST be used on only uncuffed or fenestrated tubes, otherwise the patient can’t breathe!
    2. It takes around 7 days for a stoma and tract to mature. Trying to switch a tube in this time risks premature closure, false passages and other complications.
    3. Exchanging a tracheostomy: have a same size and one smaller to hand, neck slightly extended, pre-oxygenate.
    4. Up to 50% of tracheostomies experience at least one complication. Paeds tracheostomy-related deaths are 10x higher than in adults(!) 
    5. Early tracheostomy complications include false tract, subcutaneous emphysema, bleeding (braciocephalic bleeding has high mortality), and RLA nerve injury. 
    6. Know if you are dealing with a laryngectomy as this will mean oxygenation/ventilation must take place via the trachea, not the oropharynx.
    7. Know the emergency algorithms


  3. Self reminder about the different types of venous access lines that can turn up to the ED.

    1. PVC: peripheral cannula with insertion and tip at a peripheral vein.
    2. Midline: insertion at arm, tip around axilla
    3. Central lines:
      1. PICC line - insertion at arm, tip at SVC
      2. Tunnelled line - Hickman, Broviac
        1. Inserted into IJV / subclavian with tip in SVC. The free-end is then tunnelled under the skin to exit around the chest as a freely accessible line outside the skin. 
        2. Generally for long term, more frequent or continuous access such as dialysis, TPN, chemotherapy, frequent phlebotomy.
      3. Implantable ports (Port-a-cath)
        1. Similar insertion as tunnelled line but the exit site is an implanted resevoir that sits under the skin. Access via a specific ‘non-coring’ needle.
        2. Generally for long term, intermittent therapies such as chemotherapy. 
    4. Tunnelled / implanted lines - thought to reduce risk of infection by increasing distance from insertion to exit site. Require heparin locks. 
    5. Heparin lock requires 2-5ml of 10-100u/ml heparin to be administered into the line to fill the lumen volume. For tunnelled lines. 

From Elsewhere
Found a physical training journal entry from my more idealistic self back on the 13th May 2007:
  • "Trust instincts; ability is higher than confidence
  • Know self and goals; forget what people say and don’t be influenced
  • Can train much harder; go past the pain, past reps
  • We are capable of a lot; we all need to believe in ourselves"
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All information in the Push-Dose newsletter is strictly for educational purposes only, and does not constitute professional or medical advice.