*bleep* holder – First Anaesthetic on-Call

So I have just come back from my first call as an anaesthetic doctor (or more specifically, an emergency medicine trainee rotating in anaesthetics who is holding the dreaded anaesthetic bleep very much reminiscent of a hand held grenade with the pin taken out. It may go off any second, heralding news which may be good or bad, usually bad).

So, I started the day taking a handover from my colleague who was the previous bleep holder. Or, I should rephrase that and tell you what actually happened. I waited for them to turn up to the operating theater for emergencies, and when they didn’t turn up after 20 minutes, I bleeped them. I found out they were in the middle of trying to help out a consultant with a dodgy arterial line for an elderly patient (who apparently at 92 had everything under the sun going wrong with her, and having managed to break her femur, was getting it surgically corrected), they rushed to meet me, handed me the bleep and a quick handover of the patients on the list (none!) and 2 patients that might require some analgesia maintenance sorting out later, and headed out the door. My first port of call was the consultant currently in the trauma theater dealing with the dodgy 92 year old. Old lady with CCF, AF on warfarin, small bilateral pleural effusions, past history of CVA (just last year) and a CABG 9 years back. She currently was using a frame to walk, and had tripped over an overturned edge of her carpet and ended up (long story short) on the operating table that evening. Anyway, the procedure went swimmingly, and she landed in recovery wihout any significant problems. My presence, though not directly helpful to the case, was atleast helpful in the sense that my consultant was able to grab a quick meal and some semblance of a hot beverage, and she mentioned she appreciated the chance to talk to someone. So far, so good, the call was going.

I was then bleeped about a potential appendix that was rumoured to have surfaced in A&E and the surgeons were contemplating taking it out. Young male, fit and well I was told. I took the opportunity to go round and see the patient myself, but as I was walking out of the recovery room, Cardiac arrest bleep goes off. In the heart centre (yes, ironic, isn’t it? I couldn’t make this up if I tried!) Apparently just a vasovagal syncopal episode though, as I ran down to the heart centre I saw the ITU registrar motioning me to relax as he seemed to have it under control.

Phew! On to the appendix…but first…ANOTHER CARDIAC ARREST BLEEP! Where is it? Second floor you say, oh the ward FURTHEST FROM WHERE I AM CURRENTLY STANDING? THANKS! I run to said ward, find CPR in full action on a what I understand is a 70 something year old gentleman found unresponsive on the ward (it is an orthopedic ward) and the rest of the history is a little late in coming, so CPR is in full progress, the ITU Reg enters almost at the same time as I do, he asks me if I have control of the airway, I reply in the negative as I am finding it difficult to bag mask ventilate. He chucks an I-gel towards me, which I insert successfully and ventilation is now adequate, as evidenced by the now rising saturations. CPR still ongoing, and there is now return of spontaneous circulation. He is intubated in the interim and post-resuscitative conversations/management are taking place (all this happens within the first 90 seconds of our arrival!) and someone then pipes up with the history (finally) that this patient is a known epileptic, admitted with multiple c-spine and other fractures, s/p corrective surgery for the spinal fractures 5 days back, was last seen alright 3-4 hours prior to being discovered unresponsive/in cardiopulmonary arrest. Based on the absence of pupillary reflexes, absence of any respiratory effort on the patient’s part, and cardiac function likely in response to the drugs given by us during the CPR, as well as the pre-morbid situation of the patient, it was the collective decision of the whole team involved to withdraw treatment. This was also agreed upon by the ITU consultant who we telephoned to ask for advice. The ITU reg offered to write up the notes as I took the tube out, and I went to see the appendix.

Very straightforward appendix – never had any anaesthetic, no family history of anaesthetic complications, last eaten/drunk something 11 hours back and that too vomitted up. Allergic to penicillin, otherwise fit and well young male with a slight language barrier, through which I discerned straightaway that he wasn’t happy about the surgery. He did not wish to proceed with the surgery for now. I stepped out of the room and let the surgical resident handle the situation. They would let me know if he still wanted the surgery. For now I would keep him on our list with an almost question mark. The staff in theaters would know what that code meant!

Bleeped again, this time from A&E RE an elderly female, Hmeatemesis with massive hemorrhage protocol in place, could we rush them into theaters for an urgent endoscopy +/- surgery? Her HB had dropped from a last known reading of 125 a few months prior to 49 on today’s blood gas. She already had a couple of IV lines secure, and the ED team had been excellent in pushing fluids, arranging blood and 2 units PRBC had already been given to her as well as 4 units of FFPs. I quickly pre-op assessed her, gave my consultant a quick phone call: he was happy to drive in (20 mins away) and assured me he would be ready and waiting by the time we got to the theaters. We did, and he was there, and it was an RSI, 4 more units of blood went into her, her last Hb was 98 and they found the bleeding point and treated it endoscopically, there was no need to open. Out into recovery where the ITU consultant also eyeballed her quickly, deemed to have no need for ITU support at that time and then moved to the ward after stable. He did ask me to give her the rest of the blood/FFPs booked for her, and afterwards send off clotting and FBC profile whenever transfusions over. Crisis averted (this took 2.5 minutes to write and around 2.5 hours to manage from start to finish, in which time I was bleeped 4 more times!)

One of those bleeps was from the surgical reg – appendix guy was agreeable and we would proceed for the surgery next. The consultant offered to do the RSI for this next one as well, I drew up the drugs for the case, and left to deal with the 2 pain patients from the handover (which seemed such a long time ago now!) and also deal with the 4 other bleeps that I had while we were dealing with PR bleed lady. 2 were urology cases apparently cystoscopies needed to be done for 2 elderly males, both with long term urinary catheters in place but unable to be taken out as the ballons werent deflating – eerily similar weird cases that were as much of an embarassment for the urology registrar as they were a hassle for the rest of the theater staff. Also while dealing with the bleeding lady, another consultant who was running the trauma list and who is now going home after his procedure has ended hands over 2 of his patients who are in recovery “shouldn’t be a problem but if there is just so you know about them” and walked out. I quickly scribble down their details so they don’t fall out of the back of my mind.

During my assessments of those 2 cystoscopies I got bleeped to remind me to do the bloods for the previous lady. I added it to my growing list of things to do.

I get called back to the theater because one of the other post-op patients in recovery (that the trauma consultant handed over) was being a bit…ummm…difficult. I quickly go see them. One of the other consultants prescribes some haloperidol. He is an elderly gentleman who has had a hip DHS, no prior known comorbids but slight cognitive impairment previously. But nothing as dramatic as how aggressive he was being right now. he was trying to get out of bed, he accused me of stealing his clothes and he accused the blushing nurse of having an affair with his wife, and he had quite a few choice words for how we were treating him. The halloperidol seemed to not do anything at all. It took all of our combined efforts (and a little bit of his analgesia) to calm him down and he went off into a deeply snoring snooze. Sigh. Phew.

9th bleep (or is it the 11th?) Urology registrar (sounding to be at the end of her thether, bless her) calling to tell me the first urology case cancelled as they were able to remove the catheter successfully, but the second case (similar) added to list, yet the consultant urologist was coming in to try to deal with it – should he fail, this was to be done cystoscopically so could we please keep the patient on our emergency list.

Another bleep – another story. A new bleeding patient, this time an esophagael variceal rupture potentially? Has not been booked on to the list but this is the theater staff calling to tell me there is a potential case – and to await further instructions. I swear I stared at the reciever of the phone to register my incredulity. At the end of the conversation I still wasn’t sure if there was or wasn’t a patient with a bleeding/hematemesis situation that needed to be urgently anaesthetized for their procedure. *DEEP BREATHS*

Another lap. appendix. Another x2 bleeps from pain relief point of view: something about a rectus sheath catheter that had dislodged, and another about someone who’s pain wasn’t being controlled despite adequate analgesia (problem was solved by a simple look at the drug chart which informed me that they WEREN’T in fact adequately analgesed!). 3 bleeps from various wards about cannulation difficulties. And finally, the last bleep of the day:

“Oh Hi there, it’s XYZ, coming to take handover – whereabouts are you?” I could have screamed in relief, but I managed to restrain myself till she got to the office where I handed over my bits and pieces. She was more senior than me, and asked how my first on call went, and then looked a more thorough look at me and said, “you know what? I know exactly how it must have gone – go home and get some rest. See you tomorrow!” Uncanny how she could discern from my expression and my hair and the overall dishevelled look and the stains on my OR shoes exactly how my first on call shift as an anaesthetic SHO went.

Just as I was stepping out of the office, I heard the bleep go off. And I was reminded of my own favourite pearl of wisdom: There is nothing worse than the sound of a bleep going off. And there is nothing better than realizing that it is someone else’s bleep that has gone off. I was smiling as I exited the office, and the hospital.

The perks of PERC

The really worrying question sometimes arises (or depending on your luck, most times arises) while you are in an ED, and you see a patient who comes in with ‘some chest pain’ that’s maybe a little pleuritic in nature, but pleuritic chest pain could result from a punch to the chest, or if you cough too hard or too long (I unfortunately speak from experience!) and you don’t know what to do and someone’s already done a D-Dimer on the patient’s initial bloods as they were triaged, before you saw them, if you are lucky enough to work in a department as great as ours (or unlucky, depending on how you view the over-testing of D-Dimers!) – I have been handed the most amazing tool: the PERC score, or the Pulmonary Embolism Rule-out Criteria. For those of you already aware of the existence of such a magic wand – bravissimo and kudos to you, and no need to read on any further. For the ones like me who until very recently hadn’t even heard of it, please proceed further.

Patients who present with clinically low risk for development of a PE can be subjected to the PERC. This is a pre-test probability type situation, whereby you assess a patient based on clinical parameters (which you obviously already do!) but you mentally check them off a list of specific parameters, and if they meet all 8 (yes EIGHT!) criteria, then you can safely say they do not need further assessment RE:pulmonary embolism, D-dimers, CTPA route etc. This creates a warm and fuzzy feeling in me, because almost every patient in the past 3 years of practising emergency medicine in the UK that presents even remotely with pleuritic sounding chest pain, regardless of whether they have a clinical indication or not, automatically had a D-dimer, and, God forbid, should they have an ever-so-slightly-raised D-dimer level, they were referred to the acute medical team faster than you could say enoxaparin. These were then possibly unnecesarily given doses of enoxaparin, until the gold standard rule-out test could be performed, which is the CT PA (CT pulmonary angiography). That’s just the way things worked, because a positive D-dimer can indicated possible pulmonary embolism, but it needs to be taken with the complete clinical picture, and a (very large) grain of salt. D-dimers can, unfortunately or fortunately, be raised in a number of different situations, e.g an underlying active malignancy (which gives the double whammy of raising your chances of getting a PE in the first place), an infection anywhere in the body, certain medications and inflammatory medical conditions.  This lead to over treatment of many patients with anticoagulants till the CTPA was performed to finally confirm the existence or absence of the offending clot. Things may have changed for the better with the PERC, though.

The parameters you base your PERC score on are Age (< 50 years), O2 sats (greater than or equal to 95%), Heart Rate (less than 100 BPM), Absence of Hemoptysis, Absence of Oestrogen usage (Contraceptive pills), Absence of history of surgery/trauma requiring hospitalisation/immobilisation within past 4 weeks, Absence of lower limb swelling (unilateral), and absence of prior personal history of clots/emboli/thrombi.

These parameters and this score are widely used now and available as calculator/apps on most phones.

So the way I understand is, low-risk patients meeting the PERC score criteria need not be further assessed (even if they have had a D-dimer done that’s slightly raised, you can ignore it because the pre-test probability was extremely low). Low-risk patients not meeting the PERC criteria may then go on to be assessed on the D-dimer route, and the high risk patients go directly to CTPA without faffing around with PERCs and WELLS and GENEVAs.

Good luck, and happy PERC-ing!

My PLAB experience (a VERY long time coming!)

Very recently, I was asked by one of my friends if I could share my experience about the PLAB exams, as guidance for prospective candidates. Having taken the exams quite a while back (2014!) I found it hard to address the issue, so they sent me a questionnaire to make things easier to explain to someone not very familiar with the way forward when contemplating taking the PLAB exams. I am sharing the whole Q&A session here (with a few minor adjustments/deletions with the author’s permission). Thank you @Sadaf Taymor (http://sidtay.blogspot.co.uk) for the opportunity to express myself and to share an important experience with everyone!

The curious case of PLAB (09/10/2017)

What is the PLAB exam and how does it help in initiating a medical career in UK?
There are many routes of entry into the UK for doctors who wish to train here. The easiest and most common one is to take the PLAB  (or Professional and Linguistics Assessment Board) exam and become GMC certified. Let me tell you a bit about this – basically any country that you work in has their own authority that confirms that you are good to practice in that country. For Pakistan, that authority is the Pakistan Medical and Dental Council, for the UK it is the General Medical council. Passing BOTH PLAB 1&2 gets you the license for the GMC to practice. After you get those out of the way and are certified then you are basically allowed to practice in the UK. That’s what people usually do.
The PLAB exams are the basic, entrance-level exams. You could potentially also get GMC certified by taking any of the more advanced membership exams for any of the Royal Colleges (but more about that at a later juncture – let’s keep this simple!)
The bottom line is you can not practice medicine in the UK without being GMC certified, and the easiest and most common route of entry to get that is to take the PLAB exams.
What kind of a format does this exam follow and what time limit does the candidate have for the exam
The PLAB has 2 parts – both are compulsory to pass individually. The first part is theoretical, and is based on the multiple choice questions format (or should I say, the single best answer format). You are given three hours to answer 200 questions. I have often heard people lament that the time is not enough, but I think it is doable. It may be difficult if you are not used to such a format, but in this field, better get used to this format, because later exams are also going to be in the same manner, same time frame (possibly even worse!)
The second part is interactive and consists of multiple stations. It is OSCE-based format, where each candidate rotates in 14 stations, each station assessing a different skill. Examples of such interactive sessions include taking a proper history, examining certain system, counselling a patient about something, and so on.
You can attempt the PLAB 1 as many times as you wish. Once you pass it, you have three years to pass the second part, failing which you will have to take the PLAB 1 again. You have 4 maximum attempts to take the PLAB 2.
Does the test have a certain validity?
Once you pass both parts of the exam and are GMC certified, you do not have to retake it again. You just have to keep up to date your assessments and your competence and you get re-validated automatically every 5 years.
 Any specific tips on cracking the test?
For the first part, I would advise go back to your roots, back to the basics. The whole syllabus is available on the GMC/PLAB websites. Try to practice as many questions as you can, get your tempo going, get used to this format before you take the exam. 2-3 months of prep should be enough.
For the second part, it can only be taken in the UK so make sure you have everything sorted before you travel for the exam. There are course available which guide and prepare and help practice the various stations that may come in the exam. These preparatory courses are much recommended before you take the PLAB 2 (if you have never worked in the UK or similar circumstances before).

The Day of the Beating Heart Donor

24/08/17

I observed an eye-opening and mind-boggling event today – something I had heard of a thousand times before, and I knew was commonplace and such a great, great gift to give to someone – yet you never think things through and the details and the minutiae and the step-wise journey that gets you to a certain result sometimes just doesn’t register till you are actually on the other side of the coin. Today I observed an anaesthetist keep a clinically braindead patient comfortable on his journey to giving the greatest gift to a multitude of individuals – through his organs that he donated, the gift of life. I am still reeling, and literally have no words to express how chaotic and inexplicably sad I felt on the inside, and what the whole process entailed and how I came to realise and came to terms with what I bore witness to today – I will surely like to revisit this topic at a later point for a much-needed debrief. But not today. I just felt like I had to share something about this day, and I will. But not today.

RIP.

26/08/17

OK – so here I am, it is the following weekend – and I finally have enough time to do justice to this post
the day began with a pain clinic round – for those of you just joining us, I am now in a anaesthetics placement currently, and aside from all the wonderful cases we are meant to preside over anaesthetics-wise in theatres during various surgeries, we are also required to oversee patients in acute painful crises of any sort, and make a pertinent plan for adequate analgesia, whether it be a PCA pump or varying doses of different drug regimens. It was a cheerful day – not because we saw patients in pain, but because we saw the aftermath of what adequate analgesia does – happy, comfortable, asleep patients – patients with broken vertebrae from falling off horses and post surgery patients and patients with chronic pain issues who had become acutely unwell – all were magically comfortable with the various cocktails measured out to them in various dispensers (epidurals, blocks, PCAs, oral/iv/subcut/intramusc meds) – and to top it off, my consultant was a particularly cheerful, fun person; the ward round was informative and collaborative, and we struck up a dynamic where we bounced ideas off of one another, and she made sure I felt included and did not feel as alienated with the whole deal of being new to the idea of a pain clinic as I thought I would be.
Fast forward to 3 hours later and my consultant gets bleeped about being roped in to performing the anaesthetic for a donor extraction surgery – a team from the nearby major transplant centre were coming in to perform the surgery, and to harvest the organ(s) from a patient currently admitted in our hospital. My consultant asked me if I wanted to continue with the day’s pain rounds or would I like to join her in the theater to see this procedure? I excitedly said yes, thinking I would get to see the miracle of someone donating their kidney to their loved one and both donor and recipient ending up side by side on adjacent beds in the ITU. The reality was far from this very romantic notion.
As I changed into theater-appropriate attire – I realised what was going on as the team from the other hospital introduced themselves and told us the story – this was a 50-something male patient, who had suddenly had a massive stroke, and had been declared clinically brain dead the evening before. He was being kept artificially alive on a ventilator, and the family had said their goodbyes and understood the terminal nature of his condition. All of this however did not prepare me for what this procedure actually entailed: We would be providing anaesthetic to a brain dead patient, in order for him to be as comfortable as possible during the procedure which would entail the team of surgeons harvesting whatever organs had been consented for donation (in this case both kidneys, liver and pancreas) and for us to keep his organs as adequately perfused and optimum physiology as possible till the last possible minute, and at the point of removal of the organs, the blood exsanguinated from his body, at which point we were told ‘your services would no longer be required’ meaning to say the patient would then have been declared officially dead. So we wheeled this patient into the operating theater for what were to be his last few hours of life (albeit artificial due to the ventilator). It doesn’t get any sadder than this does it? It does, in fact. Not with anything else that happened during the procedure – but with the multitude of realisations I had over the next few hours.

I have seen asystole many hundreds of times (I am not proud of it, just the nature of my job) but I have never seen a beating heart become…just a heart. It literally was beating enthusiastically one second right in front of me and then it…wasn’t.

I have attended many surgical procedures which involve trying to get the patient to improve – never to mark the end of their life.

I have seen a heart being jump-started by electric paddles to kickstart it to life – never have I experienced the opposite, cardiac activity ceasing as a result of the drainage of blood from the major vessels entering the heart, and therefore from the rest of the body.

I have heard of so many organs that are transplanted into deserving human beings whose very life depends on the organ(s) being amazingly gifted by someone else who no longer requires their use – but I have never quite registered what it means to actually remove tissue of any sort from a ‘alive-till-the-organs-are-removed’ body so that once these viable tissue are removed, the body will essentially very quickly shutdown.

But I also had one other, very major overwhelming realisation: there is no precedence and no other example I feel of such an amazing, voluntary gift, either on the part of the donor, or on the part of the family who consent to the donation – a gift that may well mean (quite literally) the difference between life and assuredly painful death for so many individuals. While I may have initially felt that the procedure meant the end of a life, I was wrong. The procedure that I witnessed did not just mean the start of a new lease of life for the individual(s) who got those organs, but also their families and friends and loved ones and all the lives in turn they will interact with and influence and touch just by being alive – they may go on to teach, to lend, to help, to protect, to heal, to donate; they may go on to hold someone’s hand, walk someone down the aisle, attend a graduation, a christening or a birthday. They all owe every moment from here onwards to this, the procedure that started it all – thanks to the beating heart donor.

Last shift as an ST1 – bittersweet to say the least

So for ACCS we have 6 monthly rotations for the first 2 years, and tomorrow I go for my last shift as part of my A&E rotation (yay, yes I made it to the end!) AND  it will be my last ever shift as a year 1 trainee (or ST1) – even more yay!

This year has been wonderful – I got to know the slightly different other side of the coin as an acute medicine doctor the first 6 months of this year, and got to see firsthand what happens when you refer a patient to the medical specialty: what they look for, how they assess them, what investigations do they do and what is there mindset – and I learnt there were things I could do while the patient was in ED as my patient, and I could tweak certain things and maybe request something that would help the acute medicine department deal with the patient and make an informed and safe decision about their medical care – and maybe stop them from being admitted in the first place! This last bit was especially a unique experience, trying to sort out a patient with the 4 hour time pressure, but sometimes you picked up a patient that usually would be referred to the medical specialty, but if you had the time in ED you could potentially start a treatment that may actually make them better before their 4 hours were up and you could end up sending them home rather than in-hospital – like for a second troponin or someone who is slightly tachycardia with a fever, treat them and re-evaluate, obviously if they still warrant it, get them admitted but if they improve and can continue treatment at home, then let them go into their own familiar surroundings (sometimes the best option for patients with dementia and other cognitive impairment) – and the it doesn’t go unappreciated by the medical team!

The next 6 months were truly wonderful – learning experience from the get go – and since emergency medicine is my chose poison, my specialty of interest, I really was looking forward to it – and it did not disappoint. I learnt so many new things, and not just about the medical bit of it, but about myself as well. I gained confidence. I passed an exam (again, yay!). I realised I was interested in paediatrics, with a possible PEM (paediatric emergency medicine) fellowship consideration seriously for the future). I realised it wasn’t JUST about the resus patients, the cardiac events and the rest pains and the low-GCS and the stabbed-in-the-groin and the 3 passenger trauma call  – those were the interesting and the adrenaline pumping stuff you think of when you think emergency medicine. But I also realised that on a day to day basis you may not even see any of those heart-pumping sort of cases, and may have to deal with accidental overdoses and dental pains (!!!) and minor injuries (oh how I loved the minor injuries – really loved learning there!) and the beautifully vague C?C or ‘Collapse query cause’ and an amazing amount of geriatric and elderly care cases. And I realised I had chosen the right field. Because you don’t just treat the stuff of legend – crack open a chest or put a tube into the chest or restore alignment of a broken or dislocated bone, but you also end up (mostly) sorting out the more mundane cases and they teach you patience and empathy and make you also realise that these cases are also equally important: passing a catheter may be considered a legendary feat by the patient who comes in with 15 hours of urinary retention, or the wrist brace you put on an elderly patient with a sprain may make a world of difference to an elderly patient who has been unable to sleep due to the pain. It is the sorting of these cases which some may consider to be ‘boring’ or ‘brander’ or ‘not exciting’ that is truly the bread and butter of the ED physician.

And now I stand at the cusp of transitioning from year 1 to year 2 – going onwards to a 6 month rotation in aesthetics followed by ITU for 6 months. Am I excited? Yes. Am I nervous? You bet! Why excited, you ask? because: new things to learn and do that I have never known/done before. Why nervous? Because…exactly the same reason! But I am certainly looking forward to airway skills and critical care assessment, and gaining more confidence by adding to my skills – I hope its not too steep of a learning curve! Onwards and upwards, eh?

(Also – no weekends or nights for the first three months in aesthetics, and Friday half day –  somebody pinch me! I might just die of excitement at the prospect of that routine after the A&E rota! So yeah, joy!)