will anaesthetists please make up their minds about 'it'!!

i guess everyone undergoing a specialist's training in anaesthesia has to go through 'it', but i'm about ready to throw a tantrum right now because of 'it'.
and i do mean a real, no-nonsense, fists-and-toes-banging-on-the-floor-and-bawling-away kind of tantrum because 'it' irritates me no end.
'it', my current bugbear, is 'how to do things' in the practise of anaesthesia.
here's how things work. a junior anaesthetist and a senior anaesthetist are posted in a theatre for one whole working day, and provide anaesthesia for all cases coming to that theatre on that day. so the junior has to basically do what the senior wants him or her to. obviously, one allows for the fancies and peculiarities of individuals; i always thought of it as "when in rome...."
but sometimes, it gets to be too much.
here's a few examples:

most people think 100 micrograms of fentanyl should be diluted in a 10 cc syringe for various reasons including being able to titrate the dose, and that giving 100 mcg together can lead to chest wall rigidity. and i guess if everyone does it, it leads to less confusion. but there is a guy who says it's a waste of a 10 cc syringe, and that he's never seen chest wall rigidity, and that most adults can take 100 mcg without any problems. so he uses a 2 cc syringe. that is all very well but for the fact that the same guy insists on using a 10 cc syringe for morphine. when i asked him why not 2 cc, the answer was not very clear-cut. so i guess even people who attempt to sound logical are doing stuff more out of habit than anything else.

i've always been taught here that if one uses a regional anaesthetic technique (like a caudal or epidural or brachial plexus block) in additional to general anaesthesia, one can do without morphine, and thus avoid it's problems. in general, isn't it better to interfere minimally with the body? but there is a person here who absolutely loves morphine and insists on giving it even in patients getting additional regional anaesthesia. the apparent reason is that the patient has pain in the mouth and throat from the endotracheal tube or laryngeal mask which needs to be treated with morphine. fine, the person concerned is an expert on pain management and i'm not about to say he or she is wrong, but surely there is no need to get angry because i did not give morphine till you told me to. i mean, was i supposed to divine that you like to do other than what i had been told to do till then by everyone else?

how does it matter whether i take air or saline or saline-with-a-bubble-of-air in the syringe while finding the epidural space by loss-of-resistance technique? then why insist that it has to be done in any particular way? interestingly, one day, before putting in the needle, i asked one senior what he wanted me to use, and this guy happened to not like that at all! " what do YOU like to use? go ahead and use it!" is what he said! imagine that! on the one day i decided to ask instead of getting rapped on the knuckles (metaphorically) after starting!

truth is, there are more than a few ways of getting from point a to point b in anaesthesia, and i guess i must walk all of them during the training period before i get enough freedom to choose what i'm comfortable with. but i wish they weren't so dogmatic about sizes of syringes and the like. i think i've decided to be a little less picky about the small print when i get the opportunity.

what i learned from i.v. lines and spinals

i think i mentioned some time ago about having a terrible day at i.v. lines
well, that day stretched on to become two and then a few more.
it was absolutely nightmarish, i lost all confidence in the first and most basic thing an anaesthetist has to do.
on the other hand, my spinals were going in jsut fine. i was confident of giving spinals and would invariably "feel the give" and see the CSF flow out.
so i decided to place my i.v. lines in God's capable hands.
seriously, i started to say a silent prayer to God before each routine i.v. line!
am i superstitious? i don't think so. along with the prayer, i forced myself to concentrate harder on the tehnique (even if that sounds like too much of a word to use for something as simple as an i.v. line), and it actually started working.
i've been having less trouble with them now
i understand that sometimes, you just may not get a line, and i'm fine with that.
(i remember an incident form internship when i had to take an ABG at the end of a 24 hour duty in medicine. i poked one radial artery and could not get it, so i tried the other. i still didn't get it. extremely tired and irritated, i went for the femoral artery, and I STILL COULD NOT GET IT!!!!!!! worse, i tried the other femoral and managed to miss that too. to this day, i wonder how i managed to miss two femoral arteries. finally, i got bugged and left it to the next day's duty person.)
the spinals were teaching me something new: i had become too comfortable with them, so along came two or three people in a row in whom i could not get the CSF at all.
so, once again, i have to learn to not be over-confident, to invoke God's help and presence in the smallest of things, and to concentrate on the given work, instead of treating it as hum-drum.

two nervous girls

met two extremely nervous girls today.
will be putting them to sleep for surgery tomorrow.
one is 13, and having a hip surgery. she looked so vulnerable, felt like picking her up, and rocking her to sleep.
was feeling irritated after having to wait for so long to see some patients. but it melted my heart to see her lying so scared on her bed with her mother sitting beside her. so i kidded her some, called her 'your majesty', and that kind of stuff. got her to smile, which was really worth it, i must say. convinced her to suffer one small injection. promised her in would buy the smallest needle in the world for her sake.
the other one was more of a problem. she's 22, and the kind i'm scared will jump three feet in the air if i even show her a needle. and we were planning a spinal on her!
talked to her too. but not sure i did much good in her case. wondering if gas-induction would not be the best for both of them. just hold mask and watch them sleep and then do the rest. hmmmmmm. tempting, isn't it?

forced sabbatical, homosexuality, work stuff

hello, non-existent readers!!!!
was forced to take a break from pouring out my ? innermost thoughts by the temporary closing down of the computer center at the most user-friendly hours.
anyway, got back on the comp today and stumbled on an interesting article:

Facts, not flattery, about same-sex attraction on MercatorNet

wish i could drill some of these facts into my usual bunch of liberal friends
but as is my usual please-everyone-and -go-along-with-everyone-just-don't-openly-disagree policy, i usually don't.

oh, and in case you were wondering, work is going on well, thank you very much
did have a horrific day when i counter-punctured every i.v. line i tried to start. was much more exasperated at myself than my senior was for having to stand behind me and watch, and then having to do it again after i Had just bombed on the best vein on the patient's body
though that day has passes, have still not gotten over the habit of putting in a fervent though brief prayer to the Almighty just before poking the patient. good habit, i think.

anyways, be seeing ya (i'm hilarious!. i mean, who am i kidding? i know not one soul is reading this load of horse manure!)

heartless doctor?

ever since the resus episode, been wondering if i've become too heartless.
funny, because some time ago, i wouldn't even have thought about it.
i guess this reflective mood is coming about because this resus has come after a long gap.
time was, in medicine wards, when we used to be resuscitating day in and day out.
i even started my internship with a resus.
and we all know the success rate for resus is quite low, more so considering most of the patients i crossed by were extremely ill to begin with, when a sudden new problem hits them. as the expression goes around here "cooked and booked cases".
is that crude?
i guess it is.
but tell me, how does one survive in an atmosphere where people die every day?
one does not have the time to sit and reflect and let the emotions out. one has to get to the next patient and do whatever they need, whether it is a blood test, any other investigation, or a first dose of antibiotic, etc. if one stops to reflect on every death, the work will never get done.
i remember days when people used to arrest in rapid succession. what do you do? just try and resuscitate as fast as you can. you can't stop to think.
what else does one do to survive in such a morbid environment?
one of the most important things, i think, was humour.
we managed to find humour even in such surroundings because if you didn't laugh at something, the whole place would soon get to you, you would not be able to function.
we could laugh at the absolute nonsense someone wrote on a chart because they were so sleepy they could not keep their eyelids apart or their head up;
we could laugh at the outrageous diagnosis or treatment suggestions of colleagues;
we could laugh when someone fell asleep on their h.o.d's shoulder while the h.o.d. was operating and they were retracting
we could laugh at the terribly explicit description the patient gave of their stools
we could mimic a patient's accent
we could laugh at all this and so much more
we could and we did
because it was the only way to keep going.

first cardiac arrest bleep

today was my first day carrying the cart (cardiac arrest resuscitation team) pager.
usually, a whole week goes by with nary a bleep, because the mortality in surgical units is much less than in medical units and cart, at least here, is only for the surgical units. the medical wards handle their own arrests.
and what i feared came true. was sleeping when the bleep came, actually was just waking up.
obviously, grossly inadequately dressed to go anywhere.
so i hurried into my clothes, and in the hurry-worry, forget to look carefully at the pager.
they had written the location as usual, but i saw only the phone number. so wasted precious seconds calling them up and finding out where they were.
anyway, the team also includes people from the i.c.u., so they're right below the surgical wards and reach immediately.
they'd already started resuscitation when i reached. thankfully, we performed well i think.
obviously wasn't my first resus. you can't go through a whole year of internship here without seeing more deaths than you can keep track of.
this guy had metastatic high-grade sarcoma and had just been admitted for pain-control. the surgical guys said they didn't expect him to die so soon, so they did not put a dnr (do not resuscitate) order on the chart.
interestingly, we resus'ed for about 15 minutes and throughout, whenever we checked, there was no pulse. but once we decided to stop and checked one last time, we found he had a pulse!
i wanted to ventilate him because he was at least pumping blood now, but the surgery guys were right. they were not going to do anything, and would not be putting him on supports anyway. they would just explain to the relatives and advise that it would be less traumatic for all concerned if the patient was taken home. he never did have a hope anyway, the cancer was too widespread.
once that was decided, we just took off our gloves, and left.
it's strange. having so many deaths happen in your watch in internship kinda kills you off inside too.
well, i don't mean the heartless, soul-less doctor thing that everyone talks about.
but you get so clinical about these things
nothing elicits a flicker of feeling or a second thought anymore.
maybe I'll post later on how this emotion-less thing works
bye

got off early today

today was a good day for me.
as you may not know, i'm doing my post-graduation in anaesthesia.
was in urology theatre today
got to do an lma, a caudal block, 4 spinals, and my first epidural!!!!!!!!!!!
(clap, clap, clap)
plus, got off at 3!!!!!!!!!!!!!
the coming week is gonna be interesting.
will be carrying the cardiac arrest pager (bleep).
was wondering, how does one respond if one is in the loo? does one even take the pager to the loo? (well, i suppose you do if it's a cardiac arrest bleep)

on other areas, got up early today, but slept off again as it was too hot and i was too sleepy.
the top floor is not a good idea at all.
plus, did not go for mass in the morning.
did read the bible though.
it's really tough to maintain spirituality (is that the right word for it?) for any length of time for me. i feel very spiritually lax and give up too easily.
gotta keep it up this time (like i say everytime)

and, i gotta study, don't forget.

my duty day went well

was on duty on wednesday
was doing cases on the trot from 7.30 a.m. to 7.30 a.m. - 24 busy hours, but extremely satisfying. did 7 spinals in one night, and got them all. even put an arterial line and a brachial central line. and had an extremely nice second call
incidentally, we both have the same name (not telling you!)
and to add to the fun, we spent most of the day with a surgeon of the same name! was interesting having three heads turn when someone called out for one of us