Anaesthetics – what I have learnt so far…

  • your ODP is your best friend and most of the time your saviour – treat them right.
  • there are literally a hundred ways to skin a cat. And more to come up with a plan for anaesthetic for any given patient. All are right and some may be wrong – try to sift though and pick and choose and delete and save – and come up with your own brand of magic
  • always be on time for a theater list – or 30-45 minutes early! Pre-op assessments are part of your learning and an integral part of why we do what we do when we give a patient a particular anaesthetic.
  • make sure you attend most if not all teaching/training days arranged by the deanery – they’re VERY particular about attendance
  • know your doses – sux, roc, propofol, local anaesthetics, etc. You may be called upon at the most surprising of moments to decide a drug amount (for example the surgeon may yell out during the procedure how much local anaesthetic he can infiltrate in his rectus sheath block and you may need to do your maths to give them the answer. Bring your A-game)
  • get ready to be surprised at how chilled and laid-back everyone and everything is. When I first entered the department I expected everyone to be on their toes, pumped full of adrenaline, dancing around critical patients who were losing their airways and fighting fires along the way – while this is essentially what happens, things aren’t quite as dramatic
  • get ready for a VERY steep earning curve. Very steep. Very. With a capital S (for steep)
  • There are 4 times more consultants in anaesthetics than emergency medicine. Even more than that. 6 weeks into my anaesthetics rotation and I still haven’t worked with or met all of them. And only 4 times have I worked with someone I have worked with already.
  • Anaesthetics is not about intubating everyone. In my first month, I had observed 58 surgical procedures – only 7 of which were intubated. The rest were mostly LMAs/iGels.
  • The best talent to have/learn is not how to intubate; How to ventilate, bag-mask is more important.
  • You will really get good at cannulation. All sorts of difficult, easy, wriggly, invisible, stubborn veins – you will put a cannula in to all sorts. And then some.
  • Will continue to update these as the time comes. Feel free to watch this space.

Interesting Observations on a mock OSCE Teaching Day

Hi all – so a few days back I had the unique opportunity to organize (OK who am I kidding? I helped to organise) a 1-day course for the FRCA OSCE exam in our deanery. We as the juniors of the department of anaesthetics/ITU/Theaters were called upon to help with various tasks: timekeeper for the different stations, be a patient for history taking, or be one of the relatives for counselling, be a mannequin for examinations, etc. I had a multitude of nominal tasks on the day, but what I found to be invaluable to me that day were a few observations that I made observing the various candidates as they filed through the different stations, and I list those observations here in no particular order to be taken as advice for all my colleagues who have OSCEs to take, bear these in mind:

– Be cognisant of time. As you walk up to the OSCE station, whether it gives you 30 seconds to read through an initial scenario or there is a piece of paper with questions written on it that you are expect to answer, get into the mental zone where you can mould yourself to give what is required of that particular station in the time provided. If there is one question that needs to be answered, you can be a bit relaxed, if there are 3 questions on the paper, make sure you are aware of the time you have to divide amongst them all to do justice to all. If the station requires an interaction with someone like a viva or a direct encounter, make sure you have a framework in mind, a mental checklist to check things off during the actual station so that you are not rambling on about your second point when there are 7 other things you need to be talking about.

–  When asked a question, don’t feel pressured to answer as soon as you sit down – take a breath, pause, ponder over the question for a few seconds, frame your answer for the next few, and then open your mouth to speak. Do not repeat the question back to the examiner in wonderment, as if puzzling it over, you may think you are buying time while you collect your thoughts, but it looks unprofessional. If you need time to answer, take it, but do not insult the examiners’ intelligence by repeating the question back word for word. It is a waste of time.

– When asked a question, avoid using pronouns like ‘you’ as a general term. “If you are on the floor for a long time, your creatinine kinase levels may rise.” While correct, it looks like you are addressing the examiner, whereas a more professional way to answer would be “Patients lying on the floor for extended periods of time may have elevated levels of creatinine kinase.”

– Following on from the previous point – when describing the anatomical location of anything, or a function, it is OK to use your hands to express yourself, but do not gesture towards your own body as a descriptor for your answer. In answer to the question Where can an IO needle be inserted? you may think it is the right answer to point to your sternum, your humerus or your tibial tuberosity, but it won’t score you any points. Also please practise certain expressions or gestures, gesturing towards your crotch for instance when talking about urinary catheterisation is inappropriate. And for goodness sake, it is even worse to point these things out on the examiners body.

– Use proper terminology, use buzzwords if you know them (we all know them) and specific things carry specific marks so make sure you attend some sort of course at least once in your life for OSCE practise so that you know what the examiner is looking for in a particular station when they ask you a particular question. Also, examiners know when you are beating about the bush and not getting to the point – so don’t waste their time (and yours), admit you do not know, and move on.

– Having done poorly in a previous station has no bearing on how you can or should perform in the next one – so do not let anything bother you. Yes, you may well have failed the previous station, but if you continue to mull over it or let it get to you, you may ruin your chances of passing the next one as well. Once you step out of one station, close that chapter, and open the next one with a clean slate.

–  Do not try to impress with big words and fancy terms – be simple, logical and just answer to the best of your knowledge. They are there to test your knowledge and see how good you are with using that knowledge. They are not there to ask for your hand in marriage.

–  If there is a written station, please write clearly. In our current professional examination climate, where usually there is a tick box or a fill-in-the-correct-circle type answer sheets, we forget how to answer the short answer type questions. Make sure it is legible. Your right answer is useless if no one can decipher it.

–  Read up on the simple things (in case of our anaesthetics colleagues, anatomy and physiology, undoubtedly – aside from the usual physics etc) – understand the concept behind why something is done or not done, and it will make it easier for you in these exams.

–  Study. I don’t know why it is so under-rated, that OSCE exams are interaction based and so I just don’t need to read up on how to take a history or do a pre-op assessment or perform a physical examination or test the cranial nerves – we do it everyday, and we get into a comfortable zone – but the exam might need for us to brush up on those skills and make sure we are not missing out on anything. MOST candidates missed an important part of the history taking station, as well as the counselling station – points were docked, valuable points, and for some that can mean the difference between passing and failing.

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!)

Anesthetics introduction – teaching day

(very rough edit of the knowledge gained from this teaching day – will edit by tonight.)

Introduction given by first speaker – (I missed out the first 10-15 minutes of it, maybe longer, was searching for parking) Gave a few pearls of wisdom, in particular, the Royal College of Anesthetics e-learning website link

2nd speaker – Difficult Airway
objective is to oxygenate – help with ventilation
can be by mask, tube through nose or through mouth, or through trachea
airway assessment — HISTORY -check for pathology – burns etc, identify previous anaesthetic history, charts etc, visualisation of laryngoscope views – grades
clear is grade 1, partial block is grade 2 (take home message was that 1+2 easier) EXAMINATION – multiple airway assessment tests – none accurate enough – 5 things most important to be done – 1)-how likely to face mask ventilate, tight seal etc, facial trauma, elderly, dentures, sunken face, high BMI, snorers/sleep apnea – /2)-mouth opening – 3 cm magic number, estimation usually, LMA/laryngoscope fit, foreign objects, tumors, masses – 3) – neck movement ‘sniffing morning air position ‘ flex neck, extend head trying to align the axes for optimum visualisation, 4)-malampatti score (4 classes – first gen reassuring. upright,mouth maximum open and tongue protrusion max, visualise tongue, posterior, uvula, tonsillar pillars
DAS difficult intubation guidelines – 4 plans need to be aware of
(5)-cricothyroidotomy explained theoretical but not practically ever used – worth knowing in case ever required – explained cartilages etc and neck surface anatomy – I noticed everyone palpated their neck involuntarily, including me!)
priority is ventilation not intubation – whichever way that may be achieved

3rd speaker – PRE-ASSESSMENT
HISTORY (what surgery, elective/emergency, major/minor, PMH, systemic review, medications, allergies, anticoagulants, any prior problems with anetshetics/personal or familial – any surgery to same site, starvation time, risk of reflux, dentition, how they have been in last few weeks, assessment of fitness (climb upstairs) , less than 4 mins exercise tolerance is not good for anaesthesia/ EXAMINATION (gpe, murmurs, chest, vascular access, airway, the back, high BMI, positioning)/INVESTIGATIONS (confirm, assess or alter risk – depends on patient)/MAKE A PLAN (think about conditions cvs -heart failure,aortic, mitral stenosis, ACS/MI within 3 months; fracture NOF)
Preassessment is your own personal way to do things, no perfect way: “there are many ways to skin a cat” (!!!)
patients risk of undergoing surgery/undergoing anaesthesia (?high risk patient, ?high risk surgery, ? high risk anaesthetic) for each problem identified, has it been optimised as much as possible, or how can the risk be reduced/optimized, and do you need to change your plan.
PLANNING
– pre-operative – optimisation any more investigations, treatments, fluids/inhalers etc, ask for help if needed.
intra-operative – technique, induction, maintenance, wakeup
post op

CONSENTING THE PATIENT – Royal college website (anesthetics rcoa pils) details consent information for any medical condition/procedure
complications – sore throat, dental damage, cuts to lips etc, pain, nausea, anaphylaxis, death, loss of airway, awareness and regional complications – low bp, particularly with obstetrics, itching, urinary retention, headache, failure of procedure, infection, bleeding, nerve damage (1/50000 spinal, 1/13000 epidural)

4th speaker(s) – scenario enacted by actual anaesthetic consultants and fellows from the department – to give an idea about how things go in theaters. walking though an actual scenario – from introduction, consent, explanation of steps to patient, end tidal co2, patient under, putting tube in under vision – grade 1 view – inflating cough, good chest rise – end tidal trace, fix tube. looking at the monitor —–smooth induction

5th speaker – anaesthetic drugs
induction agents – 1)propofol -lipophillic, stings a bit, onset 20-30 seconds, 2-3mg/kg generally 300mg given, bradycardia, propofol infusion syndrome 2)thiopental -4-5mg/kg onset 10-20 seconds, tachycardia
muscle relaxants – neuromuscuar blocking agents – depolarising (suxamethonium, succinylcholine) and non depolarising (atracurium, rocuronium, pancuronium, vecuronium)
inhalation – no2 (not very common), sevoflurane, isoflurane, desflurane
reversal – anticholinesterases (neostigmine usually, sugamamadex – newer drug)
other drugs
MAC – minimum alveolar concentration of anaesthetic agent which is required to prevent movement in 50 percent of patients.

6th speaker – anaesthetic equipment

LMA – must have absent airway reflexes, cuff deflated, muscle relaxant not required – but is not a definite airway (vomit, aspirate)
i-gel – preferable
ETT – SIZE – 8 FOR MEN, 7 FOR WOMEN, AGE/4 +4 PAEDS – definitive airway
uncuffed for smaller children; RAE tube – out of the way of head neck surgeries.
bougies – angle tipped rubber tube, aid intubation
laryngoscopes (under direct visualisation)- mac (size 3 adult, size 4 for large adults), mccoy (lever to lift epiglottis), miller (paeds)
indirect laryngoscopy -in cases where visualisation is not optimum. e.g. airtraq, mcgrath (video laryngoscope)

breathing circuits –
APL VALVE
Bain circuit – most commonly used
BMV – AMBU BAG
WATERS CIRCUIT

Anesthetic machines
PENLON NUFFIELD 200
draeger primus – main anaesthetic machine
explained the charts etc – lots f abbreviations lots of number, lost of values and waveforms and colours – confusing but will become second nature to us! reassuring? not really!

7th speaker – chat with an ODP who tells us about his experience and his duties and what is required of them and of us – they check the instruments, the machines prepare trolleys, the tubes, the drugs etc for each interaction – make sure everything is clean or new or usable, batteries etc, lights of the laryngoscopes etc, and going through the checklist, who’s checklist – (something that he asks the whole room if they know about and they all say yes, but I have never heard of. yikes.) they also offer suggestions, ideas, but the final responsibility of what is happening is the anaesthetists. they won’t draw the medication, they won’t give meds (unless emergency situation) here to help you, work with you and make sure your training opportunities are met and are fulfilling – someone asked what pisses you off – lots of laughter – nervous, me thinks?

8th speaker was just the first speaker again – qualified the previous talk with “know your ODP, they will be your best friend”

BREAK FOR LUNCH (not provided *frown*)

Coming back in from lunch to another scenario that started off as a smooth induction but then went on to become a critical incident (penicillin administered to a patient with no known allergies – while undergoing surgery) – some hilariousness ensued as the “surgeon” put her hands up when the patient became critical and watched as the “anesthetist” dealt with it all, even exclaiming “oh is that what is done?” when the anesthetist administered epinephrine as part of the anaphylaxis treatment. *titters of laughter*

9th speaker – vasopressors/pharmacology
background – vasoconstriction, inotropic effect, sympathomimetic – alpha 1 blood vessels, beta 1 in lungs, beta 2 are in lungs, blood vessels
indications – hypotension due to whatever reason – treat if >30mm hg drop from baseline systolic BP or MAP <60, or any evidence of hypo perfusion/end organ damage – always fluid resuscitate before chronotropy.
most commonly used agents – ephedrine (synthetic sympathomimetic), metaraminol (mainly alpha effect, can be given peripherally, reflex bradycardia) and noradrenaline (usually for very sick patients in profound circulatory failure, both alpha/beta actions, needs to be given via central lines)
others – adrenaline (all adrenergic receptors, asystole, anaphylaxis), dobutamine (beta 1 agonist – cardiac effect, should be given through central line), dopamine (central neurotransmitter)
Points to consider -access : peripheral vs central ? arterial line if needed, boluses, side effects, tachyphylaxis (with long term treatment, receptors become desensitised), arrhythmias

another qualification from speaker 1 who I feel might be the head of the department or atleast leading this day. “These drugs are your best friend!”

10th speaker – one of our peers from an ACCS program currently rotating in aesthetics/itu somewhere : hemodynamic monitoring
NIBP, HR, pulses, mental status, etc do the basics
Invasive – ARTERIAL LINES (continuous BP monitoring, trends etc with drug administration, ABGs, posy-major surgery) commonly put in the radial artery (always do the allens test) discussion of types of art lines followed by a discussion of how to put up and put in an art line (OFF TO PATIENT OPEN TO AIR), complications (air emboli), can stay in for a week; CENTRAL LINES (cvp measurements, medications that can’t be given in peripheral lines), goes in a big vessel, should all be usg guided, patient positioning important, aseptic non touch technique, explanation of the technique (excellent explanation and demonstration, including usg) followed by blood gas, transduction image and a car – also discussed complications, how to measure cvp (normal cvp 0-8) – web links provided – frca
session in the middle about us being able to handle the instruments and ask questions

11th speaker – introduced himself as the last speaker of the day (thankfully!) with 9 slides to his presentation and the first slide was his name and he reported the last slide is thank you and any questions.
analgesia – definition – unpleasant sensation associated with emotional connotation related to tissue damage
types/managements/etc etc This part was particularly vague for me as I was just checking the clock by this time, looking forward to the long drive home.

Blogger Recognition Award

I know this post is fairly late in the day – but better late than never, right? Now this isn’t a formal or official award, but it is a mark of recognition bestowed by our peers, recognising our writing/blog work as something that is worth the time and effort that’s been put into it, and for whatever reason was deemed worthy of a more detailed look rather than a cursory glance over the shoulder. I am ever so grateful to the surprisingly humble Kershelle Mike @ The Angry Marketer Blog for deeming the MDB worthy of that second look – so honoured and surprised (read flabbergasted!) at the nomination!

Now the way this works is that:

Step 1: you give an account of how your blog came into being – and;

Step 2: any advice you want to dole out to new and upcoming and ‘thinking-about-it’ bloggers – and mine is this: be yourself, don’t force yourself, don’t try too hard – discover your strength and play to them, be unique and then be regular, don’t worry about how many people are reading your stuff – if you feel you have the right idea then this will take commitment and time invested! Do think about this long and hard, don’t just jump into it – look at other blogs, look up others’ ideas and see how they implemented their ideas – and find out what works for you, and then, finally;

Step 3: you nominate 15 (or upto 15) other blogs/bloggers that you feel deserve to be recognized. It isn’t an official platform, but it sure is nice to be recognised, don’t you think? So without further ado (and in no particular order) my nominations for the Blogger Recognition Award are:

  • My class fellow, friend and colleague, Dr. Haseeb Ashraf’s blog Medical Solutions: The Medic Helpline (link here)  – which aims at creating awareness about various medical conditions, easing definitions for laypersons/non medical personnel and any guidance/medical queries you may have as a doctor or other medical professional, or even indeed any member of the general public
  • Another friend and superstar colleague Anita Mitra – and all round amazing person – she is an encyclopedia on all things ‘women’s health’ – including some topics oft considered taboo – her blog as The Gynae Geek is maybe even more impressive than the legend herself!
  • One of my juniors in medical school is doing something that I am secretly (OK maybe not so secretly!) proud of and who I think has the capacity to touch so many lives for the better – and not just by means of her medical degree! – she does this by reviewing (after reading) the most amazing books as The Doctor Reads – she writes succinct and amazingly relevant reviews that connect you to the books in a way no review or book recommendation has ever done before – atleast not to my knowledge. Absolutely love her style, and the sense of humour just takes it up another notch. She does not have an official blog, but check out her work here, and here – she takes Instagramming to a whole new level!
  • FifisLounge – An amazing cook, who tries and tests recipes herself all the time, and then recommends the successes to anyone looking for yummy morsels and tasty treats – having tried this chef’s cooking firsthand, I can vouch for this blog with confidence! Check out this blog here, and try out the great tastes!
  • A newcomer to the blogging scene – nevertheless ‘Life as Sid Knows it…’ is someone to follow – day to day musings, and personal experiences and an interesting take on the daily routine things that we take for granted – this blog is also a part of my list.

    Unfortunately I don’t have an extensive list of 15 blogs to recommend – but at least the ones I have recommended I honestly believe are worthy of your attention, whether you are a follower of the MDB or just randomly looking for inspiration. Do check them all out!