Hi,
 
I listened to an emergency medicine consultant deliver a talk about mistakes last week.
 
He recounted a mistake early in his consultant career that had significant negative consequences for a patient, which lead to soul searching and reflection. 
 
The truth is, mistakes are impossible to avoid. But the consequences can vary significantly, from trivial to life-ending.
 
This doctor attributed one major factor to this error - ‘seeing what you want to see’ - fitting information to a preconceived conclusion (or confirmation bias).
 
This occurs due to any number of reasons:
 
The patient might be a repeat attender.
We may have seen a similar presentation before and just pattern-fit the diagnosis.
The triage description may pre-load a diagnosis for us. 
 
It’s happened to me a number of times, and there’s little worse than waking up thinking ‘I should have admitted that patient’.
 
We have to walk the line between resource management and working up the patient, between over- and under-investigation, the risk versus benefit of certain treatments. Sometimes we make a decision, that in hindsight, carries higher risk than initially appreciated. 
 
Usually this won’t lead to significant patient harm, but in certain cases, such as for this doctor, it really can.
 
His take-home point was this; will your decision keep you awake that night?
 
When encountering real clinical equipoise or uncertainty, a good heuristic is to make the decision that will allow you to sleep that night. 

Clinical Things I've Learned
  1. A systematic review looking at outcomes in resuscitative hysterotomy was published Dec 2024. Included a total of 66 women / 68 neonates, with maternal and newborn survival to hospital discharge at 4.5% and 45.0% respectively. Longest survival from collapse to procedure was 29 mins. But certainty of evidence remained low due to bias. Some reminders for resuscitative hysterotomy:

    1. Indicated in cardiac arrest in known or presumed pregnancy >20 weeks (equivalent of palpable uterus above umbilicus). 
    2. The aim is to perform c-section and deliver baby within 5 minutes of cardiac arrest.
    3. Equipment: sterile gloves, apron, chlorhexadine, scalpel, suction, sterile towels/swabs for packing
    4. Give uterotonic after procedure such as Oxytocin 5 iu IV or Oxytocin 10 iu/Ergometrine 500mcg (Syntometrine) IV


  2. The belmont rapid blood transfuser does not like to administer via an IO - the pressures are too high and it will alarm and not infuse. The work around for this is to spike the blood product bag and administer boluses of blood manually using a three-way tap and large syringe. This would ideally be via a blood warming device such as the Mequ.


  3. A refresher on the physiologic benefits of high flow nasal oxygen therapy. This is most useful in pneumonia/respiratory infection, whereas NIV is better suited to COPD and acute pulmonary oedema, where more precise control of IPAP and PEEP are desirable.
    1. Physiological dead space washout displaces excess CO2 with O2, which improves alveolar ventilation and increases pAO2.
    2. PEEP to upper and lower airways, opening up nasopharynx and splinting open alveolar airways. But must keep mouth closed to gain maximum benefits - approx 1 cmH2O for 10 L flow. In practice normally get around 2-5 cmH2O of PEEP.
    3. The high flow rates can match the patient’s tidal volumes much more easily than the maximum of 15 L from standard oxygen therapy
    4. Heat and humidification improve patient tolerance and likely help with secretion clearance

From Elsewhere

“Criticism is always advantageous. I have derived continued benefit from criticism at all periods of my life, and I do not remember any time when I was ever short of it.”

- Churchill
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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.