Hi,
 
The human body is at once mesmerising and frustrating in its complexity. 
 
A lot of medicine can feel like a game of trial and error; ‘let’s give some fluid and check the blood pressure again’, ‘get the scan and see what comes back’, and so on. 
 
Whilst a lack of complete certainty is unavoidable in medicine, this way of thinking can lead to greater anxiety and cognitive overload. 
 
What if the blood pressure is still low after the fluid? What if the scan doesn’t show anything to explain the symptoms?
 
The open loops that this reactive way of practicing creates can leave things up in the air, without a clear way forward.
 
Better to adopt an ‘if this, then that’ framework. 
 
“Let’s give some fluid - if the blood pressure is still low after this bag then we’ll begin vasopressor support.”
 
“Let’s get the scan - if it doesn’t show anything, then we need to re-review the patient and discuss with X specialty.”
 
The aim isn’t to burden yourself with dreaming up contingencies for every possible outcome of a decision.
 
But having a clear idea of what to do next if an important action doesn’t yield the desired outcome can reduce open-ended ambiguity and reactivity.  
 

Clinical Things I've Learned
  1. Points of learning for those presenting with breathlessness in pregnant patients, from the RCEM Obstetrics for EM Physicians conferece.

    1. Never leave out a chest XR if you can’t be sure it is physiological breathlessness; radiation of a CXR is about equivalent to a week’s exposure to background radiation in London - the benefit outweighs the risk. 
    2. Physiological breathlessness occurs in about 75% of pregnancies, and more common the further along. However the respiratory rate should remain the same, and if this is raised, a pathological cause should be ruled out. 
    3. Thrombolysis for massive PE is not contraindicated in pregnancy, at term, or one day post c-section.
    4. Pulmonary oedema is generally treated the same as non-pregnancy, with furosemide administration. Causes to consider (with their varying treatments) include pre-eclampsia, cardiomyopathy, underlying cardiac disease, valvular disease and ischaemia. 
    5. For asthma - steroids and normal asthma treatments are safe in pregnancy. 


  2. The guys at St Emlyn’s appraised a recent paper looking at the long-term complication rates for intraosseous access. The fear of causing complications or longer term issues is probably a bit of a barrier to inserting an IO in the emergency setting. The paper looked at longer term complications like osteomyelitis, compartment syndrome and osteonecrosis.
     
    5012 patients (adults and children) were analysed, with fewer than 5 cases of these complications identified. This is reassuring and should encourage us to reach for the IO drill when clinically indicated. 


  3. This paper tried to decode the phenomenon of non-haemorrhagic vagal responses to trauma (blunt, penetrating, and iatrogenic - ie surgical). This is important, because it’s useful to know if your patient has dropped their heart rate and blood pressure in their boots because of blood loss or something else.
     
    Their conclusion? “it remains a major clinical challenge to differentiate these patients and avoid unnecessary intervention in those that are not bleeding in the hyperacute phase...this review has demonstrated that it is not clinically possible to confidently diagnose or rule out a non-haemorrhagic vagal response to trauma”. 

From Elsewhere
“Your extremes are my normality.” 
 
- Nimsdai Purja
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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.