Hi,
 
I saw Michelangelo’s David in Florence last week.
 
After allowing the initial awe to settle, I had space to really look at it. 
 
There are many reasons for humans to be drawn to it over the last half a millennium; the scale of David; the technical mastery; the biblical story behind it; the uncanny pose of the statue, and so on. 
 
These things did hit me. But as time passed, I began to notice things that escaped initial inspection. 
 
The subtle sweep of the vastus medialis and lateralis muscles outlining the legs.
The extensor carpi radialis of his left forearm.
The slight protrusion of the external jugular vein. 
 
The level of detail and execution, such as the disproportionately large hands, gives David a super-real presence that all people can appreciate. 
 
Many of the details are so slight as to escape conscious noticing, but are crucial in the final impression. 
 
This requires such a high level anatomical understanding, not expressed in showy exaggeration, but hinted at in a subtle shadows here and there. 
 
It’s taken me a full medical degree and years of working as a doctor to even notice and appreciate the anatomical fidelity here.
 
To be able to produce it, in harmony with all the other elements of David, is quite unimaginable to me.
 
When people are paying millions of dollars in art auctions for a banana duct taped to a wall, I feel we may have lost our way a bit.
 
I’m willing to bet, the difference in mastery means only one of these will be viewed for centuries to come.
 
There are no shortcuts.

 

Clinical Things I've Learned

  1. I learned about a new condition at an M&M last week: Lemierre syndrome. Recommend reading this fascinating case report.

    1. Lemierre syndrome describes thrombophlebitis and bacterial infection of the internal jugular vein, usually caused by anaerobic bacteria. 
    2. Normally occurs from primary infection such as respiratory or ENT infection, which then tracks into the lateral pharyngeal space before producing septic thrombophlebitis of the IJ vein. 
    3. This can result in septic emboli showing to other more distal organs such as lungs, liver, joints, brain etc. 
    4. Presentation may involve fever, neck mass/tenderness, pharyngitis/peritonsillar abscess, trismus, CN X/XI/XII palsy, trismus, and septic joints from distal emboli.
    5. Requires CT neck with contrast. CT or CXR to check for pleuropulmonary involvement. 


  2. An interesting systematic review / met-analysis (11,811 patients) concluded that rapid correction of hyponatraemia (8-10 mEq/24h) had a reduced mortality and hospital LOS than slow or very slow correction (6-10 and <4-6 mEq/24h, respectively).
     
    This needs RCT work to verify but it looks like the fears of osmotic demyelination syndrome may be over-exaggerated.  8-10 mEq/24h also doesn’t seem massively different or rapid vs targets in clinical practice here either.

    Justin over at First10EM makes an interesting point about the balance between avoiding rare but devastating complications and under-treating patients in medicine.


  3. On night shift, a young male brought in acutely agitated requiring police and security to hold down. 4mg lorazepam IV had no effect, more settled after IM ketamine. Good to review the RCEM Acute Behavioural Disturbance (ABD) guideline for some extra pointers:

    1. Continued exertion under restraint is dangerous to the patient due to hyperthermia, metabolic acidosis, and catecholaminergic surge.
    2. Indication for rapid tranquilisation: lack capacity to refuse treatment, are non-compliant, and pose risk to self/others OR need further assessment/treatment.
    3. Lack of evidence in literature to recommend specific drugs according to severity of ABD. However, in severe ABD, ketamine (4mg/kg IM or titrated IV) and droperidol (5-10mg IM) are robustly recommended as first line agents. Alternative regimes also discussed in the gudeance.
    4. Intubation points: ketamine recommended induction agent. Avoid suxamethonium due to possible hyperK+. Avoid opiates due to possible hypotension. Avoid fentanyl in suspected serotonin syndrome as this increases serotonin release. Ventilate adequately to compensate for likely met acidosis.

From Elsewhere

This quote spoke to me as someone who has been there numerous times:
 
“Just occasionally though, just once every so often, you will wake about 3am and wonder…., ‘I wonder if that patient was the one that slipped through the net?’, or ‘I wonder if I might call them tomorrow to check they are OK?’ I’ll give a pound to any emergency physician who has never woken with such thoughts, and I’m pretty certain that the pounds will stay in my pocket.”
 
- Simon Carley
 
———
 
“They do not know the darkness and the heartaches; they only see the light and joy, and call it "luck". They do not see the long and arduous journey, but only behold the pleasant goal, and call it "good fortune," do not understand the process, but only perceive the result, and call it chance.”
 
- James Allen
 
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