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!