temperature monitoring

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here is a presentation in ppt format that i compiled from miller 7th ed, smith paeds anesthesia and review articles published in anesthesiology clinics and anesthesia.

Temperature Monit

setting up an ICU

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presentation on setting up of an icu..
shared with permission from the moderator and presenter.


 Planning and Set Up of Icu

shock! anesthetic implications

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revised version!
shared with permission from the moderator and presenter.

Shock Five Point Zero


uncut version!

Shock Uncut Version

new local anesthetics

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presentation on newer local anesthetics and delivery systems.
shared with permission from the moderator and presenter...New Local Anesthetics




 Advances in Local Anesthesia

physical principles in anesthesia monitoring

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presentation by dr pemala on physics in monotoring..
shared with permission from the moderator and presenter.
 Physics in Monitoring

Are we like this only?

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Awaken the neo urban!! erstwhile the realm of the morose stiff lipped upper classes, the arena is now within anyone's enthral. Luxuries of urban life being systematically drilled into virgin newbies through top notch marketing, the laid back native is now a luxury starved beaver!

Money being available enough thanks to development put luxury on a platter and set it up for grabs. The myth of self content being non-existent, the former reclusive ramachandrans rev up late night parties.
Isn't it a good thing to happen? U may ask. Off course it is but with a pinch of salt. The courtesy and mannerisms we expect from civilised people have taken a back seat in the vile search for luxury and recreation by misconstrued neo urbans. Add to it the population that a developing country sadly boasts of (bursting at the seams,rather), we have a peculiar problem arising amongst our midst.

A smile often said a great deal thru the ages.. be it a substitute for a greeting ,innocent apology, gratitude or just courtesy. All of us now have plastic masks on while venturing outside our regions of benefit be it material or otherwise. A very warm hearted executive at the helpdesk on the way home is a vicious “ i want it!” while in the the supermart. The mad rush to reach home during after office hours leads to a symphony of traffic horns that could put mozart into shame! The public transport being ill equipped with the massive proportions often go kaput or are misused. The metro trains being a new addition have packed carriages with the circumstantially polite gentleman quarrelling for want of space.

A recent visit to the cinema gave me a one on one with the neo urban ideology. A puny queue of 4 people at the e ticket kiosk took half an hour courtesy a quarrelling couple right in front testing everyone's hearing capacity to the fullest possible extent. To proceed to the halll meant a longer queue which broke up once the gates opened! A mad rush for seats which are booked by you exclusively for 3 hours looks ironical to the sensible eye. Getting to seats is an achievement but saving your feet from being stepped on by people occupying adjacent ones is quite a feat. The nonchalant zombie look that the purported offenders throw when u wince is a mute reminder that I didn't do my job of saving my vestiges well enough!

Straight cut to the intermission when yet again there is a mad rush for beverages and fast food. A well groomed lady howling out “ one packet of chips for me too” to alert her spouse 4 rows away, had to first pass through a minor impediment called my ear, which for no fault of hers came in the way. The ringing and the singing and the incessant chatter on mobile phones loaded with loud and louder ring tones add to the cacophony. A overwhelmingly endowed (waist-wise) middle aged man loaded with varieties of carb foods pummels into the row so as to settle down early to not miss a single frame of the second half. Side...side..side..he says being annoyed that there are so many feet beneath his that make him lose balance! “Nonsense people i say, cant keep their feet wrapped under them,dirty fellows” he seems to quip.

Podiatric Acupuncture session complete and my feet managing to live through it, the second half of the movie is occassionally interrupted by the heavy munches and crunches and gulps that the fast food industry had balantly interspersed into the movie watching experience. Cut-throat suspense egging you onto the edge of your seats, another gentleman 2 rows behind receives a call.. “hallo, hallo, halla. Who ? Oh wrong number i say!” back to his munching and the movie plays on sans a well deserved rewind and play option.

The movie experience doesn't end without another ceremonious namesake queue that people break to get out of the hall. A feet numbing encounter notwithstanding i still don mind watching a movie with the same lot. Till god intervenes to shower a dense rain of etiquette on all of us, here is me booking tickets for the same rajnikanth movie at the same cinema again! Needless to say... I am like this only!!

obesity and anesthetic management

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presentation by dr sukhyanti on anesthetic implications in obesity and management.
shared with permission from the moderator and presenter.


obesity and anesthetic management -

spinal anesthesia... misconstrued

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Injecting a small quantity of this colourless liquid into someone's back leads to a tingling tryst for the patient and fun for the anaesthetist. Welcome to the realm of sub arachnoid block or the colloquial spinal!

Being trained in patient care both preop and postoperative, we freshers were taught about the different aspects of the spinal world in quite mystique detail. Before being trained to needle a patient's spine, explaining the procedure to the subject in lay man terms proved quite arduous. " You will be made to lie down on your side crouched with your legs tucked in and head flexed. A tiny prick to your spine and u will loose all sensation on the lower half of your body for a short while" is what we intend to profer. This is how a brand new fresher did it..

"Tumhe littake peet me sui chubaayenge. Usse tumhe lakwa padega, operation ho jaayega". In grotesque parlance it meant, " With you lying down,we will prick your spine. you will get paralysed and the surgical procedure shall be completed!."
We last heard that the poor patient with inguinal hernia scooted from the OT complex because he preferred a lump to a limp, anytime!

Preoperative cacophony set aside, the actual procedure involved ceremonious steps being done exactly as told. A brand new way of holding a forceps to dipping guaze rolls in eerie smelling liquids in the name of antiseptics and sterilizing agents to promote asepsis all seemed new to us. The obligatory cleaning and draping done,a spinal needle in hand, i set about finding an elusive spinal canal in the roly poly waist of a plump lady who i must confess took a lot of effort to get on the table. Prick and the needle went it, little by little. Think i hit something... the technician helping me quips cynically.."daactar saab, abhi dilli dhoor hai, aage jaao!" Some more millimeters later,i finally needled the elusive water front and proceded to inject the anesthetic agent. My consultant asks me in a husky voice,"how much will you inject?" Calculating the dose per kg and as per the surgical requirement, i say ,"2.5 ml,sir?". He says, "hmm... no, inject 2.4 ml". A difference of 0.1 ml in a 5 ml syrinje, are u kidding me?!" Guessomatics galore, the prescribed precise volume is injected and the patient placed supine for the drug to take effect.

Religious prods with a blunt needle counted by the dozen and an ounce of patience (which seemed to have gone into oblivion) later, our lady got her lump removed without much ado.

Till the spinal canal conjures up more patient friendly ways to anesthetize itself, here is me needle in hand, wishing that you get the esteemed privilege of being my subject for experimentation!

Have fun!

epidural care... freshers beware!

3^rd year made its debut with promises of more leisure time and academics. Earnest attempts at managing to not hog the limelight when question hour began amidst busy OT schedule were disastrous given the relentless perseverance that the consultants had to somehow drill the volatile gambit of knowledge into our proverbial thick skulls.

A refreshing change amidst dodging the bullets was the entry of the new recruits, the freshers or first years. Eager eyes waiting to rip out from obstinate restraints called eyelids perched on perky noses with an air of accomplishment about them is how the new debutants presented themselves. A deluge of icu postings managing to curb the enthusiasm a wee bit, gas science still meant an entirely unknown world. Having gone through the same drill 2 years back, fresh faces for us meant more fun and more comrades to aid epidural care and follow ups.

Shoving a thin plastic fiber down a patient’s spine in the name of epidural anesthesia meant a painless bump on the back for the patient and a pain in the neck for juniors. Having attended calls of epidural emergencies at weird hours courtesy ridiculously impossible senior residents made first yearship  a roller coaster ride for sure. The subtle training for epidural care usually began with the inevitable quiz on morphine and epidural analgesia. Once the importance of respiratory depression was well advocated (misconstrued fact as I am yet to see one), we were awarded the prestigious role of maintaining epidurals!

Novel yet implausible ideas such as connecting all epidurals to one giant console within reach to automated telepathic bolus injections were contemplated over tea breaks and ration time during our ritual tea club ceremonies.  

Till we imbibe better post op facilities to aid continuous epidural techniques and beyond, here is me wishing all freshmen a safe epidural free passage through the first year!

cheers

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ICU..i see u

13 beds laid out in a row, masonry walls 3 feet high almost but not yet isolating them and a bunch of sleep deprived white coats putting patients into slumber is what the ICU potrays to the eye.

Fresher year was time for us to develop this undying bond of unrelenting rendezvous with tube suction, infusions, ventilators and of course, patients who were critically ill. Liquid debris of vivid origin and content had to be removed from intubated patients on ventilators so that the lungs wouldn’t retire hurt. My overzealous misdemeanor of joining the course a day well in advance culminated in discovery of the art called tube suction 1 on 1. Intricate details ceremoniously imparted by my senior to her newbie fellowman looked like a scene from some epic war movie where the sword gets passed on to the heir from the retired veteran! Quizzing me about the intricacies of the procedure which i had just been told about gave her grin a much regaled squeek. Decked up in proud blue, armed with a stethoscope, the new caretaker of the downtrodden (I mean dudes zonked on morphine with tubes down their throats) set about measuring up the momumental task at hand!

Once the medal for best tube suction was well ordained and pinned onto my blue attire (a figment of my imagination), sifting through patient files became imperative before I set about treating them. The staff nurses, so coveted to their role of occupying chairs and passing on instructions, sporadically vacating them to do errands, vociferously reminded me about the major event in every newbie’s duty… blood sampling! Haven done undergrad in a college with well equipped resources, sample collection came under the purview of the support staff rather than the doctor trainees. Having ventured into a well equipped, yet a government hospital at that, suddenly dawning on me, I set about penning down words in barely legible form for the lab technician to comprehend… lab request forms to accompany the vials of blood samples.

Back breaking rather back bending labor by the patients’ bedside yielded a variety of color labeled vials and syringes for blood processing. The orderly taking the rest of the day off for his movie time meant I had to trudge my weary feet down to the lab after an hour to collect reports. To taste success, we need to either invest brains or brawn. To enjoy success, join a govt hospital as support staff and stay there investing nothing! Ceremonious (laborious) clinical rounds lasting for over 2 hours, the consultant set about discussing each case in detail. The short bouts of vigorous head shakes did make me appreciate the resilience her neck showed to endure all the shakes that her head provided. Left side of the chest not moving much in all patients was a constant finding she picked up. Well, in my defense, all patients still had the left lung in situ! Be it a mirage playing on her eyes or our eyes too tired to notice them, the left lungs in all patients left much to be desired. Having done a 24 hr shift in the ICU straight, I left for the day only to return again. More left lungs needed rescuing, many samples needed to be sent, tubes to be suctioned…

Till I find the energy post duty to give you tips about the suction machine.. me signing off to enjoy a long long nap overdue… I shall see u,ICU…every week!

Cheers! 

Innovation : route to salvation!

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Utilizing resources to the maximum (abusing them at times) is fine talent we imbibe as residents in a government setup . Tedious tenders denying basic equipment seem more of an annoyance than a problem given the way daily supplies excuse themselves promptly venturing into oblivion!

The only 2 entities that never get into the top 10 list of NA (not available) are Doctors and the Diseased. The innovative mind becomes a blessing when faced with shortage of drugs or equipment due to administrative incompetence or the abject poverty that patients seem to be blessed with. Me designing a CVP manometer out of 3 IV lines and a Three way to monitor CVP for a poor critically ill patient is a memorable high in my short stint as a fresher. When we looking around for smart thinking, each cadre in the hospital workforce has something to offer be it trivial or not.

A sweeper having to do without a pickup and dusting pan picking up infected waste with just a broom still comes to mind. Rather than sweeping it all around town, he used gloved hands to use the broom as a modified chopstick to pick it up effortlessly to transfer it to the designated bin. Move into the wards and we see cartons doubling up as elevation for propping head ends of beds up as the complex automated machinery working the beds,procured at mind numbing prices, have gone kaput thanks to overzealous use. Nails drilled into the walls doubling up as IV stands, padded cardboard substituting efficiently for arm rests, freshers working as educated monitors are common yet effective innovations.

Beauty is bought by judgement of the eye..says Shakespeare in Love's Labours Lost.The most uncanny of innovations happened in the operating room where the maintenance folk were short on protective footwear. IV tubing, ryle tube and extension lines post expiry were tested for use as binding twine and there was born a unique slipper with sleek fasteners! My surgeon friend bringing it to everyone’s notice sure made it surface on the blog! (thanks shyam!)

Till we get tired of making ridiculously helpless situations look humorous and interesting, here is me signing off hoping to be a serious nut as the American entrepreneur and the co-founder and CEO of Oracle corporation Larry Ellison puts it.. When you innovate, you've got to be prepared for everyone telling you you're nuts!
Cheers!

Cover duty.. Non clever duty

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Dollops of hierarchy generously added while preparing the ultimate soufflé called work ethic,the everlasting junior senior rant gives it a unique tangy taste that promises so much more than what meets the tongue!

Fresher year was spent getting familiarized with the technical knowhow of gas science and beyond while second year turned out to be a rope trick trying to balance thesis work, free time and whims of the newly enlightened breed called final years. Exam fervor gripping the campus buzz like plague, the formerly fun loving crowd suddenly turned into a book devouring glut of academic proportions. Gone were the days where new flicks, plays and events highlighted everyday banter. All the gossip corners were bursting at the seams with unusual wondrous pondering about the exam syllabus and its antisocial effects on fun and play.

Pacing studies to cover the entire syllabus over 3 years instead of the 3 months seems a simple solution to propose but mighty tough to practise, they say. Tense creases on the foreheads of the exam going batch may make it look like an unenviable position to be in, but throw in the freebies of a nonexistent duty roster, lighter workweek and tons of time to study and you may beg to differ. “You will know what the hype is all about when you reach final year!”, they say. Well, that’s an event for next year, not now, isn’t it?

Weekends of hectic cramming meant more workload on the second string team (us!) and the new recruits (1^st years). Rotation duties were thrust on the ever so non gleeful juniors to drive in the message that hierarchy rules. Finding duty time more fun than ever, given the repetition involved, all the fuss about the load to study seems a dream distant stars away. Throw in a select subset reveling on their own lassitude and the abundance of volunteers, covering for the final years is imperative if not optional.

“if you can’t convince them, confuse them!!” goes a quote. Dilbert said it and I used it! Technical faults of timely proportions doing my mobile phone in, dodging the duty cover bullets was an art which everyone practices to profer. Intricate plans to solve a simple issue being  executed, my brief suggestion to the higher authorities to cut some slack so that the finals years can study is just a figment of a crazy guy’s imagination, it seems.

Till clever ways to conquer our covert tendencies materialize, here is me taking a last yank at them senior years if this write up didn’t … arey sirji, aur kitna padoge?! :D

Videos

Intubation though seems so easy .. yet so difficult at times

Fluranes… Take My Breath Away!

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Eerie aromas simmering through a claustrophobic black hood on my face, a distant voice beckoning me to sleep,I am half awakened by the clutching pain in my forearm where the anesthetist pumps in an additional bolus of propofol . Tense moments that we endure when having to go under the surgeon’s knife , become a tad easier with pleasant induction agents for general anesthesia.

Ever since madman gimmicks with the laughing gas became a part of history,new inhalational agents for anesthesia have become an important cog in the anesthesia wheel of things. Not having a clue about these “liquidy” gases till I got into gas science by choice, my fresher year was filled with inhaling ,inducing and imbibing the essence that the anesthetic gases profer.

The initial days in training were aimed to get the perfect vice like grip on the face mask to make sure, I did not spring a leak,induction gas wise! The C for compression and E for jaw elevation being etched into my budding anesthetist soul, dexterity with either hand was considered pristine. Choice of induction gases became the next puzzle to solve. Being erroneous by default rather than by choice, the chief’s frowns and moans as a response to my impeccably wrong answers made sure the OR was a happening place!

MACs of isoflurane,desflurane,sevoflurane,enflurane,halothane obediently memorized to perfection,my proud prune would get a wash down on being quizzed about the MAC of ether! I mean,gimme a break, here, will you.. the grand dad of general anesthesia, ether, is not the commonly used agent anymore, now, is it!?! Having heard the monotonous phrase “padke aao!” as an answer to my weary questions a million times over, my route to salvation always led me to a calm and quiet place with quiet people doing quiet things.. the college library. Throw in a pillow and the bench on the left aisle in the reference book section would become my haven for repaying my sleep debt! Somnolent misgivings brushed aside, constant searches to find answers were put to rest, courtesy short quips of less known facts that my seniors always seemed to know!

Laborious ,read la”BORE”ious details about the vapour pressures,blood gas coefficients and the kind made these innocent looking strange smelling liquids more complex than they ought to be. Don’t worry,people,no.. I aint giving you total gyan about fluranes here. Lets leave the snooze topics to discuss in snooze moments. Till I master enough of the details about each flooory liquid, let me have some feedback about your thoughts and anecdotes about em elixirs of sleep… FLURANES!

Theme song apt here would be the mystical guitary song by Teri Nunn in the movie “Top Gun”… take my breath away!!!

Cheers!    

sepsis: pathophysiology and management in the ICU

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seminar presentation in ppt format..
i have compiled info from SSC guidelines 2008,Fink (textbook of critical care) and paul marino's the ICU book.
with permission from the moderator..

cheers

Sepsis 31st Jan Modified

Flexing the fiberoptic power!

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Having taken a well deserved break from the eternal strife that marital bliss made him endure , the pompous and glad senior citizen married to this  formerly incessantly chatting middle aged lady, guided her into the doctor’s office. The reason for his absolute bliss, evident from his unusually silent wife, was a traumatic jaw fracture which needed corrective surgery.

Fathoms of gossip yarn ,spindling out from her seasoned mouth into a mobile phone had distracted her while driving their 4 wheeler. The resultant minor blip on the local terrain where she pummeled her car into 4 others ,had led to her jaw moving quite out of place. The power of speech taken away, our lady had to make do with moans and aahs to get the message across. The  constantly ringing mobile phone in her bag made the irony so evident that surgery was planned as soon as fitness for surgery was obtained.

After a brief review and examination with inch tape science, our plan of anesthesia comprised awake nasal fiber optic intubation  for securing airway besides the routine protocol.  Spindles transmitting light have woven quite a niche for themselves in medical science. Our ever evolving branch called anesthesia was benevolent to weave itself a new illuminant device, the fiberscope!

Talking about first impressions that always come to mind, my senior consultant perched on top a small stool ,probing a zonked out dude’s throat with a fiberscope searching for an elusive larynx hidden in a pinkish brownish whitish zone of upper airway did seem quite a feat! If you smudge out the scope in his hands, a lot many years younger, and he would have passed for a poor school kid punished by his stern teacher, by being made to stand on the bench with hands held up. “styand up on dee bench!”, my class teacher would say. Each day with pending homework  would be revved up with the shrill retort that she used to train us with. Having done my ‘up on the bench’ time ,many times over, having to do the same for securing airway seemed like a  crude little joke life played on me if not déjà vu!

Fresher year was spent assisting the scope laden seniors while second year promised a date with this new weaponry to master. Up goes the lever to move the tip back, down goes the lever to move it forward.. white balance? turned on!!.. Magnification? Check!!… suction? Check!!… and there you go prodding some guy’s throat. Glycopyrollate IM before intubation made sure the throat did not have cob webs of mucus lining our batman cave! Oral versus nasal, airway preparation for awake intubation, liberal use of lignocaine were the soft skills we picked up.

Our middle aged lady was wheeled in after preparation to the OR. The entire procedure being explained in quite grotesque detail by my funny resident made sure her heart rate was alive and kicking big time! After a short session 1 on 1 with the patient, the stage was set for the scope to take limelight. ‘Difficult intubation’, meant only seniors could do the procedure. The senior resident climbed up, picked up the scope and the snake charming began. Insistent cajoling by the consultants notwithstanding, the poor guy managed to lever down the tube the right way in a short span of time just clocking a little under 30 mins! Its tough when the limelight is on you, they say.. so true!

Our motormouth lady got her mandible set right and her husband's peaceful existence went wrong all over again. The irony of a normal wife with a mended jaw might give him a lot to hear and a lot less to think about.

Our resident, in the process of needling an anesthetised throat, had committed to a lunch treat soon after to celebrate the achievement. Party vibes simmering through the doctor’s room, the fiberscope set was wheeled out and the food wheeled in. its still a long way to go for me to set my hands on the magic torch but the process of getting there has been pleasant, gastronomically indeed!

Till all of us get versatile with the scope to ‘bend it like beckham’, here is me signing off to savour a treat!

Cheers!! Keep them coming, I say!

IV access:: Login: Access denied

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Denizens of Pandora had customized USB ports attached to their manes for healing; while we humble mortals have to make do with IV access! Cannule of various sizes and gauge, color and type fill up our workstations. Through our training period, judging vein caliber, we answer the eternal question… will this canula fit?!

Each of us would have had our moments with the cannula, be it pleasant or not and no I don’t mean the patient! Well lets face it,not all patients are engineering students from ICE to extend their hands and say.."jahhpanah,tussi great ho!! tohfa kabool karo!! Poking a needle into the limb of a limp guy may look like voodoo science for laymen but throw in asepsis, a cannula of the right caliber and a vein of the right length and we have an important event called IV cannulation!

As a fresher, the first impression of IV cannulation was that it was a back breaking job! No one bothered to tell me that u can do cannulation sitting down beside the patient. Given the abject ignorance to spinal problems that the ward beds were designed with, bending forward and precariously perching my head on a bent back ever so slightly to get that perfect position for the perfect vein cannulation was a talent well practiced. Throw in fancy clothes and I could have passed as a trapeze artist! Back breaking labor with a needle and syringe yielded multitude of blood samples which had to be processed by the lab. Reports of ‘sample clotted’ ,’hemolysed sample’,’ quantity not sufficient’, ’wrong vial,you moron!’ revved up my dull drag of an emergency duty.

Eventual awareness enlightening me, life seemed daft till I got into anaesthesia. Arterial lines, Central lines, Transducers and the kind decked up my list of things to do. The first thing they tell you is that they are all blind techniques. Oh yeah, try doing it with your eyes closed, I say. You could manage to cannulate your own radial artery or a vein while at it, now, couldn’t u? Eyes closed for self cannulation!! We could post a new article in the journals now..New techniques in anesthesia, eyes closed to better cannulation!

Getting a case done with an arterial line or a central venous line insitu , augers well specially in a gynae case where the gynecologist stumbles on a bleed which was long forgotten to send the patient into shock. Persistent requests for repeat samples for cross matching can be heeded to with ease. How they manage to lose samples only to find them later is a mystery given the litres and litres of blood products that the blood bank spews out if it’s a obs gynae patient!

Damping under or over is not just limited to physics, my friend. Thread in an intra arterial and your senior will quiz you on the intricate wave form analysis that your mere act led into. Failure at securing vascular access is a nightmare for an anesthetist. Veins look so tortuous or spiral or designer fresh to the tired eyes. We are blessed with so many challenges of the miniature kind…The stilette goes in, cannula doesn’t; itsy bitsy valve resting just at the tip of your canula; miniscule clot occluding the canula; ripe red tomato appearing at your injection site to tell you…dude.. Counter! When u pat yourself saying, ”aal is well”, manage to thread in a canula ever so perfectly only to find out the drip isn’t running reminds us of a hacker’s job! The jargon “ACCESS DENIED!” flashing in bright brilliant red when you contrive to get past it. And I haven’t mentioned the unenviable job of finding an iv access in a patient in shock, after cancer therapy, after the emergency docs tattoo the patient with failed attempts and the kind, yet.

Till god almighty picks a leaf out of James Cameron’s book to put in a USB port on all of us, here is me signing off.. Well, we all have IV cannulations pending now, don’t we?!

To be or not to be: a gloved dilemma

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Cozy entity of variable sizes shielding our evolved paws; gloves do come handy in asepsis and fun.

My first encounter with this simple yet complicated adage was in undergrad when I had to assist in an open cholecystectomy. After the ceremonial wash, I was asked to get decked up to be an assistant. Gown yanked over me by the OT nurse, I set out to wear this flimsy material the right way! Copying each detail to perfection after 4 failed attempts at the right technique, my short lived elation at conquering the non latex world was interrupted by the head surgeon who handed me the liver retractor. What the surgeons managed to fiddle with, at the depths of a black hole beneath the liver, still beats me. Ok,I knew it was the gall bladder and I knew it had a pebble in it and I knew it had to be taken out…yes… but the metal hands worked in a hole while all I could see was a retractor over a liver making my job a tad boring.

Over the next agonizingly long hour riddled with frequent orders to retract the liver well, I couldn’t help but move into my own realm of my new friendship…sterile gloves. Me judging its stretch ability was interrupted by the surgeon’s irritated look into my eyes as if to say, “will you please focus!”.The surgery ended with fixing the patient’s abdomen sans the dud of a bladder.

Internship provided so many gloved moments in catherization to blood work to wound dressings etc. The second skin we wore on, was actually fun!

Cut back to anesthesia as a fresher… elective OT. Challenges in terms of oral secretions, lignocaine jelly, plaster, dynaplast proved tough to get past. Airway device secured, I was asked to fix it over the mouth with medical grade adhesive tape. Yanking at my gloves and on the plaster, the tough ordeal was somehow completed amidst smiles and comments from my seniors. “Next time”, the head told me, “take your gloves off during fixation.”

Another life changing moment happened after an awareness week about hospital waste management. We were asked to minimize the pairs of gloves used each day. A consultant coming up with this brilliant idea of tucking the still in use pair of gloves onto the waist belt led to unbelievable scenes. Moments of pure horror filled our daily monitoring duties.. Pair of gloves tucked under waist belts of well endowned roly poly horizontally unchallenged waists undulating in synchrony with the blips and beeps! Add to this, the dexterity required in wearing used gloves, obtaining palmar exercises in our daily schedule and we had our hands full for sure.

A mundane thing such as a glove can’t be so interesting to talk about! u say.. Ask an anesthetist and thy shall be amazed. Seniors get a kick out of quizzing juniors now, don’t they? “Should u wear 2 pairs of gloves on to finish with painting and draping before spinals?” they ask. Wearing one pair ceases to be aseptic and wearing 2 holds potential for talc induced meningitis! Think about the glove decked gyrating hips or the praying mantis pose of sterile gloved hands or perennial questions we endure and you will agree with me.

To all those gloved hands, me signing off saying..you two were so meant to be!

Ryle tube.. inserter’s agony, owner’s pride!

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Medical care includes a whole range of gadgets, some simple and many complex. Hollow tubes of different sizes and materials are recruited by us, be it in the form of a slender and puny iv cannula or a stout and rigid pain in the backside, flatus tube! A nasogastric tube is one such wonder for physicians who swear by its “hollowness”! I could never imagine that this wriggly worm like length of modified plastic could test my patience and the patient.
The first time I came across this entity was in undergrad when we went for bedside clinics. Frail patients would have one of these sticking out of their noses. Some would just wear it on their faces after contriving that all efforts to yank them out would be promptly rewarded with a stiffer newer tube assisted by the heavenly ambiance that the nurse threw in with her sharp retort while fidgeting with it.
As an intern, my sacred duty was to see that tubes of all sizes once in,stay in! patency is an emotional and sensitive issue in anesthesia,if you didn’t know.. Each defective cord would have to be replaced before the deadline that the nurse established before her ceremonial drug and tube feeds. Stepping into anesthesia by choice, encounters of the ryle tube kind became more frequent in the name of securing airway and beyond.
My tryst with the whim that a nasogastric tube is capable of became evident on a dull routine day in the ICU. Most of my patients stable (I hoped!), there was me sitting at the counter sifting through patient details before I handed over management details to my reliever hours away. The inevitable scene of a patient zonked on opiods suddenly waking up to find a tube down his mouth and a tube down his nose happened just then. With one swift yank,our dude yanks it out and hands it out to the nurse! The cacophony that followed had to be resolved with a brand new ryle tube being inserted after convincing the patient that it was for his own gastronomical good.
Fast forward into PGship where we received intensive training in the intensive care unit, a fresher had to do the odd jobs as we didn’t have subordinates. The universe would now and then intriguingly conspire to block the ryle tube in patients. And I mean patients who are zonked on sedation and ventilators “taking their breath away” kinds at that. Threading down a new one down his nose and throat would either be like a piece of cake job or end up like threading a needle in the dark! We require umpteen maneuvers and aids such as the light in your throat( laryngoscope) and my metal fingers (Mcgills forceps). Working at the depths of a patient’s tosilled throat can become tricky given the prompt efficiency that the scope boasts of, refusing to light up when I ever so desperately need it to work. A bad works man blames his tools,goes a famous saying.. well the guy wouldn’t have been an anesthetist now,would he ?! fidgeting with jelly and gloves, each contraption is guided into its glorious orifice to rest therein for aiding two way transit to fluids of weird compositions.
All the tubes in,I sign off for the day… until new challenges of the hollow kind beckon.

Fentanyl: Cant smile without u!

let me buzz...

A colorless odorless liquid hidden at the depths of a puny ampule, this miracle looked back at me gleaming with possibilities. Pummeled into dilution duties early morning all through my fresher year,all I could remember about fentanyl was that it was to be made 10 per CC. The mundane yet imperative act of drug preparation was jived up by frequent possibilities of a drug becoming NA! “Not Available” in a govt setup meant one thing and one thing only..that the drug still gets on the tray no matter the hell you pass through hunting for it! Precious stones and pearls light up a dame’s face, as a first year resident,an ampule of fentanyl sure did the trick for me!

 I do not remember the time this word fentanyl doesn’t come up in the OT. Premedication to analgesia to induction to reversal to spinal to epidural to weird skin tattoos for pain relief, we seem to get so obsessed with the drug. Ask an anesthetist dying of pain and his last words would be “fentanyl”.

Scene: surgery OT. Thesis case.. cholecystectomy under GA with specified drug dosage protocol. I break the last ampule of liquid gold (fentanyl),a mammoth 10 ml of it to load it for use. The consultant beside me, looking out for the multitude of errors that I can be capable of, says “ ok, induction!”.The senior resident takes the liquid of joy and pumps it in IV. The Buddha like peace on the patient’s face seems so discerningly uncanny.. I look up and see our stud with a dud of a gall bladder has stopped breathing with dipping vitals. Eyes going into a bizarre twirl, I try to figure out which bizarre crisis protocol the happenings fit into and why!. The resident sheepishly drops the empty syringe into the tray when something grabs my attention. I like my liquid gold fentanyl undiluted while the protocol says 10/cc! our dude had gotten zonked on 500 Mics of the luscious crystal meth of anaesthesia.. fentanyl!

The eternal showdown in little OT notwithstanding, the consultant precisely points out my ever so subtle mistakes with heaps of advice and criticism garnishing it. We get the case done and the dude is wheeled out retaining his smile of absolute bliss.

Win some and lose some they say.. well I lost some gained ground for sure while the gallbladder dude won a trip of a lifetime, free! ‘Dilutionary’ misgivings getting less frequent, I still use the smile maker everyday in discreet amounts. Any guesses for my most FAV song…. Leisurely sung by Barry Mannilow.. I CANT SMILE WITHOUT YOU!!

laws of buzzocaine.. apt yet inept!

let me buzz...
with profound insight and scant relevance to public opinions,i now propose the new laws of buzzocaine.. apt yet inept.

1)the chances of an air column entering the IV line is inversely proportional to the the number of times u check the fluid remaining in the vac.

2)law of blood loss estmation: product of the surgeon's estimate and the anesthetist's estimate is always a constant.

3)relevance of an epidural seems to gain importance exponentially when u have a case under spinal anesthesia.

4)the time taken for an epidural is directly proportional to the duration of surgery.

5)top up dose of relaxant in the drug tray is always one dose short.

6)a stilette is always needed when not checked.

7)malfunction of the pilot balloon on enodtracheal tube only occurs in full stomach patients.

8)gauge of the IV canula in situ is directly proportional to the hypovolemic status of the patient.

9)the vac of fluid you want to push fast IV is always punctured!

10)the probability of late reversal is directly proportional to the amount of opiods that u admit was injected (never the truth!)

11)chances of regional techniques failing rises exponentially with the patient's mallampatti score.

12)uterine perforation during MTP happens at 4 pm on friday evening!

13)light of a laryngoscope fails only in difficult airway!

will keep u guys posted!