*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!

Transfer Training

Attended a Transfer Training course today. I know what you’re thinking, who needs training to learn how to transfer a patient? What rocket science is involved in the few seconds or minutes to transfer someone from one bed to another? Or how much of preparation and thought needs to go into transferring a patient from one hospital to another? It has to be fairly simple right? Atleast thats what I was thinking when I was applying for the course, I thought it’s going to be like a 30 minute session, Bam Bam, thanK you, Ma’am type situation. Boy was I wrong – this was an 8 hour long proceedings, and I actually learnt quite a bit. Some gems from today’s talks:

Movement effects
Movement of any sort brings with it it’s own demerits. So only move the patient if absolutely necessary. Deceleration causes gastric contents to come up; it also may cause fluid to ‘back up into the lungs’.
Acceleration causes the opposite: hypotension, decreased preload. Both may lead to heart failure

Limit affects of any sort by making sure patient is well hydrated; lift the legs up to counter hypotension(during acceleration)

Head end up (15-30 degrees), NG (during deceleration)

Consider if you need Blue light? Is it time critical? Make sure to limit sudden movements, blue light ambulances are notorious for getting into accidents (large vehicles, moving at high speeds, sometimes against traffic and/or against traffic rules)

Specially important is the need to be careful in head and spinal injury patients
Contrary to popular belief and your gut feeling, the more critical the patient, the slower the transfer needs to be. Not faster. Fast, hasty movements make for bad decisions, wrong or sharp turns (as well as deleterious effects of movements already discussed)

Static effects
Hypothermia is the most common problem
What is the first thing that happens when patients are brought in to ED? Their clothes get taken off. Coupled with cold environment, not a good combo
Children/eldery most vulnerable
Monitor patient during the transfer as well for temperature changes; aim for normothermia
HME filter is one way to counter drop in temperatures – ventilator usually gives cold, not-too-moist air going directly into the lungs, bypassing the moistening and humidifying warmth of the sinus cavities; connecting an HME filter to the ventilator circuit effectively prevents the dry cold air going in, and thereby prevents hypothermia.
Blankets and foil may be used, especially in ambulances
Pre warmed fluids may be considered
Cover open wounds/burns (cling film is best as wound is still visible for any changes, is sterile essentially and can be airtight)

Avoid vibration injury/movememt in ambulance/helicopters
Pad and protect soft tissues to avoid pressure sores, and reduce fractures where possible. Ulnar nerve is most commonly injured during transfer – bean bag padding is ideal for such transfers.
Interference can be caused with electronic monitoring by the unnecessary vibration.movement aberrations from helicopters and ambulances; dislodged/trapped leads may also be a concern.

Motion sickness may develop – stop feeding the potential transfer patient. A couple of hours of NBM won’t kill the patient, but aspirating their own vomit, or vomiting when their neck is immobilised can be quite a significant clinical concern. Consider NG (with free drainage) and sitting upright. Avoid rear-facing seats for transferring teams. Do not read/documentation, as can make things worse. Be prepared. Take antiemetics.

Communication
Sirens/alarms make communication difficult. Make sure you can always hear alarms. And, we all are guilty of doing this, but NEVER ignore alarms.

Immobilisation
Need to ensure patient can undergo immobilisation. Make sure patient can actually physically lie flat for CT scans, etc (e.g. may get short of breath if massively obese or really bad CHF)
Consider sedation (and airway protective measures) if absolutely necessary to scan and lie flat.
Make sure you have everything you need before you leave. And before you need it. Always be prepared for every eventuality, every foreseeable complication.

Lying supine can also have other deletrious effects on even patient who can lie flat – secretions can accumulate, reflux might be an issue, V/Q mismatch occurs, inability to cough when lying flat, strapping someone down for a scan may itself cause restriction of lung movements in an otherwise comfortable-in-lying-flat patient.

NOBODY GETS BETTER DURING A TRANSFER! They may get worse, so only transfer if absolutely imperative.

Special considerations?
Trauma
general information about the Trauma network
ED pitstops – their pitfalls

Head/spinal injuries – RTC, falls, sports, assaults, self harm (gunshots), and non-traumatic
Motor aspect of GCS is more important than anything else in the GCS
Immobilise with correctly fitted collars
Aim for Normal pO2
Normal pCO2 is now the new teaching, as low PCO2 (which was previously the guidelines) causes cerebral vasoconstriction, reducing blood flow, and ischemia is a far worse complication than brain swelling, atleast in the initial phase of the post-injury timeframe.
aim for a MAP of 90 (this is ideal for cerebral perfusion pressures to be optimum)
Normoglycemia
Normothermia
Head up, minimize movements
Urgent Neurosurgical care
Maintain parameters at all times, even if the transfer is for short periods
Monitor pupil size, GCS, Heart rate/rhythm strip, blood pressure, pCO2, resp rate during transfer
Immobilisation and transfer methods were also touched upon, various methods to transfer patients, scoops, trolleys, mattresses, sliding sheets, boards etc
Consider Spinal shock if triad of hypotension+poikilothermia+bradycardia
Avoid fluiding with large volumes if unresponsive to fluids, consider escalating to vasopressors.
Will improve on own if spinal shock
Autonomic dysreflexia – injury above T6 (headache, flushing/sweating above level of injury, urinary retention)

Paeds

Rarely transferred. Only ever in cases of trauma/head injury
CATS
WETFLAG
Broselow tape bag
Vecuronium/pancuronium, fentanyl, ketamine (children) combo in children safe.effective cocktail

Balloon pumps- weigh 70 kg, slows movement, runs off battery

 

Another day, another training…

Attended another training/teaching day sponsored/arranged by the deanery – was a very, VERY useful and informative day – and though it dragged on for hours, it was very interesting and explained quite a few things that I had not known previously – gist of the major salient points of each of the talks are listed below – may expand on 1 or more of these topics in the near future – so inspiring!

There were 4 speakers

PUBLIC HEALTH PROMOTION – how to explore facets of public health while in ED, because most people interact with someone in the ED, and that may be the only point of medical contact they have had up until that point.
smoking cessation, weight loss, exercise, pre-diabetes identification –
screening programs are fixed, inflexible , protocoled care, applied across a particular age group- safeguarding, frailty, VTE, dementia screening, hypertension, alcohol issues, obesity, domestic violence, smoking

case scenario of overweight person presents with orthopaedic problems, upon discharge do you speak to them about their weight? as an ED physician

case scenario of unwell child who has never been vaccinated – what will you do? How do you approach the subject with the parent, or do you even approach it at all?

case scenario of alcoholic patient with head injury – would you address the alcohol issue? (unit is 8 gm or 10 ml) 25 in whiskey, 10 in wine and 40 in spirigel
alcohol problems discussion
(having withdrawal symptoms when not drinking is being dependant on alcohol)
who should you be screening for problem drinking – selected presentations
how do you ask for alcohol intake?- use PAT scale – CAGE questions are useful in establish alcohol related problems.
important because intervention is helpful

PUBLIC HEALTH AND EMERGENCY MEDICINE
as doctors/physicians it is our ethical duty to reduce injury and illness, wherever we interact with patients.
we tend to have more interaction with the general public
you are more likely to see violence/injuries than the police – some studies show more than 3 times!
how can you help as doctors? injury survielance, mandatory reporting, better design, improve treatment, collate data and improve conditions – location of assault, date/time of assault, weapon, age
is anonymous,
crime rates went down because of data collected due to targeted policing
what are barriers to implementation? – police expectations, IT issues, governance, receptionist, leads
pitfalls – mission creep, fatigue, silos
conclusion? violent injury surveillance and control is effective in reducing violence. implementation can be challenging

QI (Quality Improvement)
audits are important but rarely work
why do they fail? – tick box exercise, temporary staff, lack of feedback, career advancement a priority rather than care advancement, lack of collective responsibility (if your rotation ends, the audit ends with you, no continuity)
has now become quality assurance rather than improvement. “maintaining/meeting set standards” rather than “improving the standards”
RCEM guide to QI is the QI bible.
do less, do it better
choose a standard to improve:is it important?, is it fundamental?, is it fixable?
talk to the stakeholders (nursing staff, frontline staff, triage, juniors, etc), ask them why this is not happening – how to improve conditions?
measure the standard
intervene to implement a change, and then re-measure after a suitable timeframe.
establish or convey a sense of crisis – reiterate how important/imperative this measurement is.
rapid cycle

CARDIOLOGY – ACS
definition of ACS
reiteration of importance of history – onset and character
repeat ecg, compare with previous
do not delay treatment waiting for biomarkers in “cardiac-sounding” chest pain.
consider bedside imaging if hemodynamic instability
escalate appropriately, consider involvement of tertiary care
dissection a differential? CT aorta stat (discussion about d dimer as useful in this scenario – some people say a negative d dimer rules out a dissection – research shows that is not the case)
management – analgesia+dual antiplatelet therapy, GP2B3AI, antihypertensives (b blockers) ACEI. statin, REGARDLESS OFWHETHER AN INTERVENTION TAKES PLACE LATER ON OR NOT, GIVE THE MEDICAL TREATMENT. if already on aspirin, 300 or 225 of aspirin either way doesn’t matter, 600 of clopidogrel and 80 of tigacrelor (not to use if warfarinized – MAKE SURE INR IS THERAPEUTIC)
immediate management – angio +/- PCI (for STEMI within window, ongoing symptoms, cariogenic shock, for NSTEMI – hemodynamic instability, ongoing schema or shock, IF REFRACTORY TO INITIAL MEDICAL THERAPY)
high risk/labile/recurrent schema – urgent angio
all others get routine angio
12 hours stemi – def PPCI, greater than 12 hours – if symptoms, PPCI, greater than 48 hours – no PPCI.
<30 mins door in door out in non pic centers. <60 mins door to wire crossing in PCI centre. and LBBB/RBBB considered equally. no o2 if >90 sats on RA.
consider CPAP, IF DISTRESS. iv amiodarone for AF, Look for hyperglycaemic states, MRA if CF.

if unable to decide if LBBB is new or old, compare to previous but if none available to compare, look at the patient. vast majority are not acute, unless they’re in cariogenic shock.

 

DIARRHOEA
definition
types
causes
symptoms
may be a symptom of sepsis – does not mean primary focus is gastrointestinal- particularly in the elderly
rotavirus most common in children – vaccine now available, rotarix at 8 and 12 weeks, seasonal
COD – dehydration/acidosis
use dioralyte instead of pure water for replacement. diluted juice.
norovirus and c.difficile has to be reported.
electrolyte disturbances – hypo/hypernatremia, acidosis, acidosis, hypoklemia (3-3.5: oral replacement or 20/1000 ml saline over 2-3 hours; 2.5-3: 40/litre over 4-6 hours; <2.5 or with ecg changes at any low level such as prolonged QTC, flat t waves at risk of arrhythmia; <1.5 will be paralysed, muscular weakness, apneoic. ECG-CARDIAC MONITOR-CONSIDER RESUS
discussion about hyponatremia and its management

 

PALPITATIONS
multiple cases discussed and shown, along with rhythm strips, interactive 1 hour session with responses from the audience tailoring the talk. VERY interesting.

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.