Hi,

An attractive aspect of emergency medicine is treating a patient for a discreet episode.
 
Once a patient is discharged or admitted, it’s onto the next one - no need for repeat visits, phone calls or outpatient clinics. 
 
But the benefit of no continuity is also a major drawback.
 
How do I know if I’ve actually done a good job?
 
The only way to close the loop is to follow up the journey of individual patients.
 
Otherwise, being wrong feels the same as being right.
 
This is a major blindspot.
 
Obstacles can hinder this; the IT systems we work with, keeping patient details securely, remembering to follow up, and ego.
 
It’s less friction, and less of a threat to the ego to just treat and forget. 
 
But the major benefit of following up are the free lessons; instances where there is minimal harm to patients but high yield learning to integrate.
 
Seeing patient journeys deviate from expected trajectories, errors picked up by inpatient teams, returns to the department, or other unexpected outcomes allow us as practitioners to refine and adjust the mental maps of our practice. 
 
Otherwise I’m just sketching out a map without checking it actually matches the real terrain - walking blind until I eventually end up lost and in serious trouble. 
 
When this happens, I run the risk of very costly learning.
 
Taking the effort to follow up provides the free lessons that, hopefully, reduce costly lessons; those where the patient really suffers harm. 
 
Without chasing feedback, being wrong feels the same as being right. 

Clinical Things I've Learned
  1. A patient presented with loose, watery diarrhoea, cramps and nausea. She had been taking Mounjaro, an SGLT-2 inhibitor. After excluding other causes, it was thought this was contributing to her symptoms. 

    Abdominal symptoms such as cramps, nausea, diarrhoea, constipation and bloating affect more than 1/10 people taking Mounjaro. As an SGLT-2 inhibitor, people are also at risk of euglycaemic DKA - this requires the same treatment as standard DKA.


  2. A reminder that for any pregnant patient, or those presenting up to 6 weeks after birth, a modified early warning score (MEWS) should be used. A patient I saw had a NEWS that almost doubled when calculated using MEWS parameters - this massively changes risk stratification and decision making. 
     
    This is because pregnancy physiology is different, and there are additional parameters included such as significant vaginal bleeding, reduced urine output, increased pain etc.
     
    In these patients, HR and cardiac output is normally higher, BP lower, and increrased RR often a more early and sensitive sign for deterioration.


  3. I read about a new condition I’d never head of before: Dietl’s syndrome - episodic abdominal pain due to intermittent renal pelvis dilation secondary to delayed ureteric drainage. It’s Not Cyclic Vomiting Syndrome Until Dietl’s is Ruled Out. 

    1. Can occur in adults, but more common in paediatrics
    2. Symptoms include cyclical nausea/vomiting, abdominal pain, urinary symptoms and haematuria.
    3. The pain is due to intermittent hydronephrosis, often caused by overhydration, stretching the renal capsule from delayed ureteric drainage. This can also occur from lumen blockage, vessels crossing the PUJ, and ureteric polyps, for example.
    4. Diagnosis can be made by many imaging modalities - but this is a very strong case for bedside ultrasound to look at hydronephrosis at time of acute symptoms
    5. Curable with surgical intervention - pyeloplasty
       

From Elsewhere
“There are two pernicious effects of the lack of feedback. We leave a ton of learning on the table.
 
Those cases are lost, never to be learned from again.
 
The second is that it actually breeds overconfidence.
 
For the huge number of patients we never hear about again, the brain operates under a simple rule: No news is good news.”
 
- Dr Gurpreet Dhaliwal
 
-----
 
“...begin early to make a three-fold category: clear cases, doubtful cases, mis- takes. And learn to play the game fair, no self- deception, no shrinking from the truth; mercy and consideration for the other man, but none for yourself, upon whom you have to keep an incessant watch. . . .
 
It is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way, can you gain wisdom with experience” 
 
- William Osler
 
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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.