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!

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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!

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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!