Hi,

Up until recently I viewed my job role chiefly as seeing patients. 
 
Acuity and volume were the main metrics I measured my performance against. 
 
On a recent night shift, whilst managing my own patient load, I noticed myself becoming increasingly agitated by what I perceived as interruptions to my supposed primary job of delivering patient care. 
 
Junior colleagues asking for advice, relatives asking for updates, printers misbehaving. 
 
‘Why am I feeling so agitated?’ I thought.
 
I saw all these tasks as interruptions and obstacles to my actual role; to deliver patient care. 
 
But it struck me, these moments will never go away; they are inescapably baked-in to the job. 
 
The job then, isn’t seeing patients per se; it’s solving problems. 
 
The junior colleague asking for help; the relative asking for an update; the broken printer; the colleague that’s upset with how someone spoke to them. I can’t run away from any of these, they’re all baked into the job. 
 
Working in the sandbox of an emergency department means accepting every problem that materializes within its walls. 
 
If I view my job as just seeing patients, every one of these problems will be interpreted as an irritating obstacle in the way of my ‘actual’ job.
 
Sick patients will always be the priority problem to trump all others. 
 
But equally, the broken printer won’t fix itself.
 
One solution to a problem might be punting it on to someone better qualified (I tried turning the printer off and on again). It might be asking someone for advice. 
 
Moving one level of analysis above ‘seeing patients’ lands me on ‘solving problems’. This encompasses the demands of the job, and reduces resentment when so-called distractions confront me with predictable frequency.

 

It’s worth re-considering what level of analysis works best for your current role. 

Clinical Things I've Learned
  1. Getting in Right First Time (GIRFT) has created an excellent interactive flowchart for suspected cauda equina syndrome (CES). Some points:

    1. The most common cause of CES is lumbar disc prolapse. Other rarer causes include haematoma, trauma, infection, tumour and spinal/epidural anaesthetic.
    2. A digital rectal exam is no longer necessary, but subjective peri-anal sensation should be documented
    3. Bladder scans have a useful positive predictive value, but poor negative predictive value; 60% of patients who underwent emergency decompressive surgery for CES had a post-void residual of <200ml


  2. I came across a new cause of headache last week in a patient with known Tolosa Hunt Syndrome;  inflammation (usually idiopathic) around the cavernous sinus and/or superior orbital fissure.

    1. Causes intermittent severe, unilateral periorbital headache with aassociated paralysis of one or more of cranial nerves within the cavernous sinus (CN III, IV or VI. The maxillary nerve of CN V is also in the cavernous sinus and may be affected).
    2. The average incidence is 1 case per million per year! Average onset age is around 40 years old. 
    3. CT will be poorly sensitive but may show thickening of cavernous sinus, whilst MRI is the gold standard test
    4. This diagnosis needs exclusion of other concerning pathologies such as cavernous sinus thrombosis, infection, ischaemia, haemorrhage etc. Treatment is with steroids.`


  3. Despite almost 100% specificity for subarachnoid haemorrhage, CT can occasionally lead to misdiagnosis due to the relatively rare phenomenon of pseudosubarachnoid haemorrhage; appearance of haemorrhage that isn’t really there.

    1. This is usually in the context of hypoxic brain injury, caused by displacement of edematous parenchyma into the subarachnoid space, displacement of CSF, and engorgement of superficial pial veins.
    2. It can be extremely difficult to differentiate true from pseudo SAH, but certain radiographic clues, MRI and lumbar puncture may help. It usually remains a diagnosis of exclusion in the first instance, given its clinically significant implications if a true SAH.

From Elsewhere
“At the end of your life, looking back, whatever compelled your attention from moment to moment is simply what your life will have been.
 
So when you pay attention to something you don’t especially value, it’s not an exaggeration to say that you’re paying with your life.”
 
- Oliver Burkeman
 
———
 
“Eighty! I can hardly believe it. I often feel that life is about to begin, only to realize it is almost over.”
 
- Oliver Sacks
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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.