spinal anesthesia... misconstrued

injecting a small quantity of this colourless liquid into some one'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 syringe, 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!

3rd 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 passage through the first year!

cheers

Quizzed on an outing.. true story!

“Good Good”,quipped my department head,popping two extra pills of lithium into her afternoon tea to stabilize her roller coaster mood swings, as I stood there nonchalantly wondering what the fuss was all about. “Most of your seniors will not be attending the conference, so you are on the quiz team that takes part in the conference representing our college!”,she said, without any change in expression as the lithium kicked in. “ So cute, So cute, a junior on the team” ,she said as I silently thanked her lithium levels that made her less of a terror than she always looked to be. Being ushered into her chambers on the pretext of getting some paperwork done suddenly put me on a road never trod, less heard. My seniors clearly conniving to get out of the obligation led to a fresher entering inter collegiate prelims on a quiz show at the national level. Having just gotten a whiff of gas science, an entire quiz competition in a subspeciality in an institute wasn’t obviously a piece of cake.

Obstetric anesthesia was the subspeciality I was to master in 8 days flat. The only thing I knew about obstetrics while interning in undergrad was that we had the wicketkeeping job to do, catching the baby on a single take as it wriggled out from its 10 month long prison!  A painless component to obstetrics was less heard evidenced by the dolby surround sound effects that the maternity labour rooms provided, thanks to highly vocal women in labour ,ready to abuse anyone who walked in! earplugs deemed a necessity rather than an option, had slowly been phased out thanks to epidural analgesia being provided on the patient’s demand. Clearly the newer techniques had been elusive to the worm like learning curve that I had just started to wiggle on.

8 never-ending days of cramming put me on a train to Chandigarh to attend the quiz debacle. Optimism being my savior, the D day seemed a little less frightening thanks to the stopover at kasauli hill station to enjoy the scenic views ;) After breathing in the mountain air, drillbit concepts about inhalational gases used in labour analgesia had to be puffed out on command. The 8 days one on one with a fat textbook obviously didn’t bring me a medal to write home about thanks to a certain shady questionable advantage that the home team at the quiz professed not to enjoy. Controversies aside, a paid holiday on a hill resort and an outing to another city was well appreciated ;) bring them on, I say; Lots to discover, places if not concepts!

Here is me signing off with a quote apt for optimists..There is always a light at the end of the tunnel, am so praying that it isn’t the train!

Happy Woman’s day!

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 his 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!

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!

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 days.. Non clever days

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 (1st 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

Plight of the Proseal Plier!

Proseal LMA is an improved supraglottic device with a drain port and a dorsal cuff incorporated for better seal and prevention of aspiration… the multitude of adjectives and traits kept ogling out from the vociferous tone of my well read superior. As a fresher, u just can’t imagine that this floppy thing with 2 tubes and a hood of a spitting cobra is going to be ever so vital in the anesthesia scheme of things!
The first week went with poignant accounts of peruse checks, looking for cuff leaks and insertion techniques. You stand beside your superior watching them shovel the 2 tubed snake into a zonked out patient all in the name of maintenance of airway. Well ,wait the fun doesn’t end there, does it! You pump in some air into the cuff and volla!! Positive pressure ventilation seems a piece of cake! It couldn’t get more easier than this… just hold the reservoir bag and SQUEEZE!
But you couldn’t get away with scant solace when surrounded by airway addicts now, could you? Zipping back rewind mode to shoveling down the snake moment… bespectacled pair of observant eyes glaring through, the consultant says “..Hmm.. Judging by the way the bite block got nudged out with inflation, placement tho theek lag rahi hai. Connect the circuit and check for ventilation”, she says. Taking my role of a 1st year with a sense of pride, I obediently yank at the flinty circuit to connect it to the snake dude in the zonked out dude’s mouth. “Hmm…”,says my consultant, “jelly and ryle’s tube..”. my superior snatches the moment to drill some gyan into my ever fresh from MCQs mode cerebral cortex. “how do you check for correct placement?”, he asks. Now, as a first year, I need not be right with answers given the notion “ ye tho first year hai!’. I rant out calculated guesstimates of plausible methods from my vague memory. The fun thing about anesthesia is that all questions will be repeated. If you ask me,if you learn about 1 entity once, u can survive upto 3 weeks of drillbit questioning going by the number of repetitions of the questionnaire that all seniors tap from.
With the surgery resident onlooking with the praying mantis pose, all decked up in sterile disposable layers of paper, the patient is handed over to them. Brief interruptions of additional queries from the senior resident interrupt my tryst with the beeps, blips and bells that the monitor efficiently rants out. Reversal of anesthesia is the next moment of reckoning. Pump in some drugs IV and the dude starts breathing again. Adamant commands ensue to wake him up to get the snake out. “ Aankhen kholo,saans lo, gehri gehri saans lo”, goes my senior resident. Not to be left behind, I join the chanting for total vocal reversal of anesthesia! “ Suction!!”,commands my resident. The snake has to come out or the patient will chew on it to behead the slithering thing! Sounds like a harry potter tale of the weird kind!
The two tubed snake is out ,the patient wheeled out and the next patient walks in.Routine events with tubes cannot be more intriguing as this for a fresher now, wont u agree?
As a popular saying goes… for a fresher, anesthesia is TDBD..”Tube Daalo,Bag Dabaao!”