To BPT, or not to BPT, that is the junior doctor’s question…

LITFL: Life in the Fast Lane Medical Blog
LITFL: Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

As my graduating peers and I embark on our medical careers, it’s a fitting time to consider which medical careers we actually desire. I’ve always had a strong sense of direction for the specialty path I wish to pursue, but at times, like now, I flirt with the idea of pursuing other avenues. It is an important issue that deserves deliberate consideration as it’s what most of us will dedicate the lion’s share of our lives to.

  • Is being a “specialist in life” as a GP the way to go?
  • Or to heal with steel in surgical training?
  • What about the variety of skills and presentations in ED?
  • How about the doors that open via basic physician training (BPT)?

As I wondered how to systematically manage this internal psychological conflict, I did what any task-oriented and mildly-obsessive junior doctor would do and devised a psychiatric management plan for myself..

32yo male doctor presents with indecision concerning medical career path.

Plan:

  1. Priorities/ Risks
    • There are already a surplus of junior doctors.
    • Over 200 graduates missed out on internships this year in Australia, yet Perth has a new medical school on it’s doorstep.
    • Competition will only get fiercer, the risk of missing a place on that desired specialty program has never been greater.
  2. Status
    • ?inpatient vs ?outpatient.
    • Do you want a hospital or community-based career? Public sector, private sector or both?
  3. Location
    • ?local vs ?rural/remote vs ?interstate vs ?international
    • Where do you desire to live, but also where’s the demand for your specialty?
    • It may be be tough working as an intensivist if you want plan to live in the bush.
  4. Collateral History
    • Gain as much knowledge as possible from multiple sources. Corroborate that information. Consider
    • Advanced trainees (a little satire from Gomerblog, find the trainees during their 1-hour reflection time)
    • Mentors – if you don’t have a mentor, get one. The best experiences I’ve had thus far in medicine have been directly attributable to mentors.
    • Training colleges – e.g. Australia’s approved medical colleges
  5. Investigations
    • Bedside – surf the web, social media groups, research college societies.
    • Bloods – get some skin in the game and attend conferences – e.g. the Australasian conference calendar
    • Imaging – get a first-hand look at the role with placements. Volunteer. Get your face out there. NB: there’s a great volunteering opportunity next year for all manner of Australasian-based doctors at the 2018 Gold Coast Commonwealth Games.
  6. Vitals
    • Supply & Demand – Is it feast or famine for your specialty in the next 5-10 years? e.g. I reviewed the latest workforce statistics and projections in Western Australia.
    • Remuneration – the top 12 most well-paid jobs for men in Australia are all medical specialties, and if you’re a woman, 19 of the top 22 most well-paid are accounted for by medicine.
    • Training Pathway/ Requirements – Compare pathways with this nifty career pathway tool from the AMA.
    • Competitiveness – EVERYTHING is competitive now. Gone are the days off falling into a specialty pathway, so how do you separate yourself from the pack?
    • Have a back-up plan! One of the best pieces of advice I took from a series of orientation lectures recently was to have a back-up plan. Life rarely goes exactly the way we want it, so just keep your options open.
  7. Consults
    • Philosophically speaking, what it is you want to do with your working life? Consider consulting some of history’s greatest minds. Warning: the rabbit-hole goes deep.
    • Alain de Botton (Swiss/British Writer)
      • “work is meaningful…whenever it allows us to generate delight or reduce suffering in others”.
    • Oliver Sacks (Neurologist/ Author)
      • “I have been given much and I have given something in return; I have read and traveled and thought and written…Above all, I have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure.”
    • Epicurus (Greek Philosopher)
      • “…work is satisfying when it’s meaningful, in very small groups or alone and when we sense we’re helping others. It isn’t through money or prestige”
    • Jean Paul Sartre (French Philosopher)
      • “…don’t live in bad faith” –  don’t believe you have to do a particular job, remember you’re a free human being.
  8. Biological
    • How will your specialty affect you physically?
    • Sedentary vs active role? Would you prefer to mostly sit a desk, or run around outside? (NB: yes, you can run around outside as a doctor and get paid for it).
    • Sleeping? Does the routine of a “9-5” or the variability of shift work suit your sleeping patterns?
    • Planning a family? Is that surgical program or part-time GP more likely to be sympathetic to those plans?
  9. Psychological
    • What is your passion? What’s your gut feeling?
    • How is it likely to affect your mental health? We need to be aware that as doctors we’re more likely to experience mental health issues than the general public.
  10. Social
    • How will your specialty affect you socially?
    • Work-life balance? Will you work weekends? Nights? On-call? Shift-work?
    • Team-based vs individual specialty? Do you like being part of a big team/clinic or being more of a lone operator?
    • Social support networks? Do you, or your specialty, have support structures in place?
    • Litigation risk? Doctors get sued. Some more than others
    • Culturally congruent? Does your culture frown upon you working purely in the private sector? Or performing abortions? Or conducting stem-cell research?
    • Is it spiritually fulfilling?
  11. Begin discharge planning on admission
    • Start planning to discharge yourself from your desired training pathway the second you step foot on the ward! Begin with the end in mind.

…or if you’re too under the pump for all of the above, you’re probably already familiar with this much simpler management plan..

Plan:

  1. Continue current management plan

Best of luck!

References

  1. Royal Australian College of General Practitioners. Your Specialist in Life. 2016.
  2. Maria Hawthorne. More than 200 medical graduates miss out on jobs. Australian Medical Association,; 2017.
  3. Gomerblog. Week to Reflect on Their Poor Career Decision. 2017.
  4. AHPRA. Approved Programs of Study. 2017.
  5. MJA. Calendar of Conferences in Australia and New Zealand. 2017.
  6. Gold Coast 2018 Commonwealth Games Corporation. Help Shape Our Games. 2017.
  7. Australia GoW. Specialist Workforce Capacity Program (SWCP) 2015 summary sheets. 2015.
  8. Sarah Kimmorley. Australia’s Top 50 highest paying jobs. watoday.com.au; 2016.
  9. Australian Medical Association. Career Pathways Guide. 2016.
  10. Alain De Botton. Pleasures and Sorrow of Work. Great Britain: Penguin Books; 2009.
  11. Oliver Sacks. Gratitude. Pan Macmillan UK; 2015.
  12. The School of Life. Great Thinkers. Latvia: Livonia Print; 2016.
  13. Tane Eunson. Super Docs 2.0. : 2016.
  14. Mukesh Haikerwal. Doctors’ mental health needs our help MJA InSight; 2016.
  15. Anupam B. Jena, Seth Seabury, Darius Lakdawalla, Amitabh Chandra. Malpractice Risk According to Physician Specialty. New England Journal of Medicine,. 2011;365(7):629-636.

To BPT, or not to BPT, that is the junior doctor’s question…
Tane Eunson

Like a bridge over troubled waters

aka Cardiovascular Curveball 014

A 38yo man presented to ED with a 2 hour history of central crushing chest pain. His past medical history included haemochromatosis and a negative stress echo done one year ago following an episode of chest pain which the patient describes as different to the pain that bought him to the emergency department today.

An ECG is done:

Q1. Describe this ECG.

The ECG demonstrates

  • underlying sinus rhythm with a rate of 75 bpm and normal axis.
  • antero-lateral ST elevation.
  • auto-analysis of the ECG states ‘ACUTE MI’.

The patient looks well. His observations are normal, and despite aspirin and GTN he is still complaining of 7/10 chest pain.

Q2. Is the auto-analysis interpretation correct? Is this an Acute MI?

Thankfully Prof. Steve Smith, an emergency physician and creator of Dr Smith’s ECG Blog thinks he can help…

Dr Smith has created a formula using logistical regression to aid in differentiating between subtle anterior STEMI and benign early repolarisation (BER). This formula is to be used when the diagnosis is in doubt i.e. not an obvious STEMI and no LVH, LBBB, or reciprocal ST depression. [Original Article] [Blog Reference]

The formula:

Subtle Anterior STEMI Calculation = (1.196 × [ST-segment elevation 60 ms after the J point in lead V3, in mm]) + (0.059 × [QTc in ms]) – (0.326 × [R-wave amplitude in lead V4 in mm]).

  • if result is > 23.4 then the sensitivity and specificity for subtle MI is around 90%, the higher the value the more likely the diagnosis is MI.



Q3. How does this apply to our patient?


  • QTc was calculated by the ECG machine at 410ms
  • The result from Dr Smith’s formula = 21.6
  • This makes the ECG findings suggestive of BER rather than subtle anterior STEMI.


Q4. What would you do now?

  • Cardiology were urgently consulted
  • On review they were convinced the ECG changes represented a STEMI
  • The patient was taken to the cardiac cath lab post haste.

Q5. The angiogram report

Interpretation:

  • Left Main coronary artery – Normal
  • Left Anterior Descending coronary artery – Bridging with ?spasm mid-vessel
  • Left Circumflex coronary artery – smooth and angiographically normal
  • Right coronary artery – Dominant, smooth and angiographically normal
  • Left ventriculogram – mild hypokinesis anterior wall, overall normal ejection fraction
  • Impression – Nil occlusive coronary artery disease, Left anterior descending coronary artery bridging with ?spasm

After reading the angiogram report and subsequent findings of no obstructive lesion and with a lesson concerning the finer points of ECG interpretation on my lips I checked the patient’s blood tests which revealed a high sensitivity troponin of 3010 ng/L (<26ng/L).

Despite the Dr Smith’s formula predicting BER over Acute Coronary Syndrome the patient has a significantly raised troponin and a regional wall motion abnormality, however there is no occlusive coronary artery disease.

Q6. Would you have activated the cardiac cath lab?

  • I was fortunate enough to see this patient at 0900 on a Tuesday in a tertiary hospital with a well staffed cardiac cath lab. It would have been difficult to argue against going to the lab given the resources at hand.
  • I also happen to work in a state that is massive and the effort and cost of retrieving a patient from some of the locations in my state can be considerable. Having tools such as Steve Smith’s calculator at hand can be an amazing boon for those who don’t have the ease of access to a cath lab that I do, where they can present objective evidence to the fact that ‘this is not a STEMI’ when people come in with chest pain that you know is not suffering from ACS.
  • In this case the patient did not have a fixed obstruction in his coronaries to account for his regional wall motion abnormality and significantly raised troponin and so the formula was right. Wasn’t it?

Q6a. What is this ‘bridging’ they mention in the coronary cath report report?

  • Myocardial bridging is a congenital anomaly in which a segment of a coronary artery takes a “tunneled” intramuscular course under a “bridge” of overlying myocardium.
  • This causes vessel compression in systole, resulting in hemodynamic changes that may be associated with angina, myocardial ischaemia, acute coronary syndrome, left ventricular dysfunction, arrhythmias, and even sudden cardiac death.



References

  • Smith SW, Khalil A, Henry TD, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. Ann Emerg Med 2012;60(1):45-56. PMID: 22520989
  • MDCalc – Subtle Anterior STEMI Calculator
  • Lee MS, Chen C. Myocardial Bridging: An Up-to-Date Review. J Invasive Cardiol 2015 Nov;27(11): 521-528. PMCID: PMC4818117

Last update: Feb 20, 2017 @ 6:03 pm

The post Like a bridge over troubled waters appeared first on LITFL: Life in the Fast Lane Medical Blog.

LITFL Review 270

LITFL review

Welcome to the 270th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chunk of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

Nick Cummins

Ashley Liebig delivers a powerful, poignant and thought provoking talk on the golden fleece, the golden hour and the golden rule. [AS]

The Best of #FOAMed Emergency Medicine

  • Moises Gallegos introduces a new mnemonic for the management options of EPISTAXIS. [SR]
  • Andy Neill reminds us of the importance of taking a temperature and how those dang tympanic thermometers work (or maybe they dont). [SR]
  • Rory Spiegel explains why evidence on opioid prescription by emergency physicians is only as good as the methodological constructs it is derived from in his post The case of the aimless company. [SR]

The Best of #FOAMcc Critical Care

  • Brilliant and inspiring talk from SMACCDub on the challenges of delivering high quality critical care in resource poor areas from Nikki Blackwell. [AS]
  • Josh Farkas makes an impassioned plea for us to differentiate symptomatic bradycardia based on how sick the patient is and tailor management to the level of sick. Atropine isn’t the answer in the crashing bradycardic patient. [AS]
  • Does light therapy help to reduce the incidence of ICU delirium? The Bottom line review an interesting trial designed to investigate just that. [SO]
  • Critical Care Northampton is becoming an increasingly valuable source of FOAMed. Here’s their February roundup of interesting article, featuring some great ultrasound, resuscitation, and critical care tips. [SO]

The Best of #FOAMed Resuscitation

The Best of #FOAMim Internal Medicine

The Best of Medical Education and Social Media

  • A Ross Fisher twofer: First, Ross Fisher explains why data slides in a presentation cannot simply be the table from the scientific document. [SR]
  • Then, Hysteron Proteron: Putting the cart before the horse. In presentations, as Ross Fisher discusses, this is the act of building your supportive media, before you build your story. [AS]

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

Last update: Feb 20, 2017 @ 2:42 pm

The post LITFL Review 270 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Funtabulously Frivolous Friday Five 177

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 177. This week we have a food based radiology quiz sourced from radiopaedia.org. 

Question 1

Let us start of with an easier question, what bean is seen here?

Case courtesy of Dr Wael Nemattalla, Radiopaedia.org, rID: 10633

  • A coffee bean (a coffee bean is not actually a bean, its a pit inside the fruit, commonly called a cherry – but we digress)
  • This represents a sigmoid volvulus. Sometimes confused with a caecal volvulus
  • In comparison a caecal volvulus has only one air-fluid level as shown below. [Reference]

Case courtesy of Dr Mark Holland , Radiopaedia.org, rID: 2269

Question 2

What favourite cinema snack can be seen here?

Case courtesy of Dr Roberto Schubert, Radiopaedia.org, rID: 14067

  • Popcorn (amorphous calcifications often with rings and arcs)
  • This type of calcification may be seen in many radiological settings including:
    • Chondroid lesions (e.g enchondroma, chondrosarcoma)
    • Fibrous dysplasia
    • Pulmonary harmatomas
    • Degenerating fibroadenomas of the breast
    • Calcified uterine fibroid
    • Metaphyses and epiphyses of the long bones of children with osteogenesis imperfecta [Reference]

Question 3

What particular biscuit represents pericardial fluid on a lateral chest X-ray?

  • An oreo cookie
  • A vertical opaque line (pericardial fluid) separating a vertical lucent line directly behind sternum (pericardial fat) anteriorly from a similar lucent vertical lucent line (epicardial fat) posteriorly. [Reference]

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org. From the case rID: 8694

Question 4

What has been licked here?

Case courtesy of Dr Ian Bickle, Radiopaedia.org. From the case rID: 34600

  • A candy stick
  • It refers to tapering of the tips of the metacarpal bones, metatarsal bones, phalanges or clavicles and is usually associated with:
    • Psoriatic arthropathy
    • Rheumatoid arthritis
    • Leprosy
    • Neuropathic joint [Reference]

Question 5

If your breast implant has an intracapsular rupture what type of pasta will be seen?

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org. From the case rID: 36020

  • Linguine
  • After implantation of a silicone or saline breast implant, a fibrous capsule (scar) forms around the implant shell (right breast above). In an intracapsular rupture, the contents of the implant are contained by the fibrous scar, while the shell appears as a group of wavy lines (left breast above). [Reference]

If this list has inspired you to seek out more foods in black and white while you are at work please see the full compendium on radiopaedia.org by following the link.

Last update: Feb 17, 2017 @ 7:39 pm

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JellyBean 054 Bits and Bumps with Dr Penny Wilson

Bits and Bumps on and off the road. The Nomadic GP has dropped anchor. After a serpentine route around some very beautiful locations Dr Penny Wilson has found a place to put down some roots. At least for a while. In Broome. And why not? It has been quite a journey so far involving fame and femininity, mis-quotes and misogyny, genitalia and generalism.

Twenty years of schooling and they put you on the day shift. And then some one says: “Sorry….. but are you really a doctor?

Penny Wilson burst onto the scene a few years back when an article that she wrote on her NomadicGP blog hit a nerve. The nerve in question is about sexism and misogyny. It was about people not believing that Penny was a doctor because she was a young woman. She wrote about it and a lot of people read it. She had only been writing the blog for 6 months and BANG she is on the Huffington Post. Then comes the backlash.

Only a few months later she is back in the Huffington Post wrestling with another significant prejudice. “Are you a specialist or are you just a GP?

Penny and I have a talk about her life being “just a GP” in which she does almost no work that most folks would recognise as “just a GP” kind of work. She is some sort of Obstetrician/Emergency Physician Hybrid about 8 hours flight from the ivory towers of Perth in Western Australia. It is frightening stuff. I am certainly a bit scared of obstetric emergencies. Maybe you are? Maybe you’re not? Maybe you know everything there is to know about it? Maybe you don’t? Penny has tried to get a #FOAMed resource up and running for O&G, ObGyn, Obs & Gobs, Obstetrics & Gynaecology; the fabulously named https://bitsandbumps.org

I hate the phrase “just a GP”. It underestimates the work of GPs. It undermines the specialty of General Practice. It has undertones of elitism and snobbery. Being a good GP is one of the hardest jobs in Medicine. There is no limit to what you need to know. There is no way you can be an expert in everything. Ask any specialist who has retrained as a GP? (Ask yourself if they are one of the good GP’s I am talking about?)

I have tried it and I can tell you that almost every time you see a patient with a given problem something will have changed from the last time you dealt with it. Either the tests have changed, or the medications have changed, or the guidelines have changed, or the evidence has changed, or the alternative therapies have changed, or the support services have changed, or the referral destinations have changed, or the government forms you have to fill out have changed or the way you and your practice gets paid has changed.

As Heraclitus said; “No woman ever steps in the same river twice…

When you meet Penny you don’t get the impression that she is out to cause trouble. She is just commenting on this stuff from a personal and important perspective. That didn’t mean that she didn’t get attacked though.

Have a listen to Penny and then have a listen to Bob.

//www.youtube.com/watch?v=MGxjIBEZvx0

JellyBean Large

Last update: Feb 15, 2017 @ 3:53 pm

The post JellyBean 054 Bits and Bumps with Dr Penny Wilson appeared first on LITFL: Life in the Fast Lane Medical Blog.