Thursday, September 21, 2006

And winner for the longest anaesthetic...

A very old woman is to undergo a laparotomy for investigation of small bowel obstruction.

She has no significant cardiovascular or respiratory problems excellent.

She has been admitted to ITU/HDU after a surgery last year due to difficulties ventilating – bollocks!

Time = 0hrs 0mins

The lady comes to anaesthetic room, very cheerful and smiling as all the “sick” old women are. The anaesthetist tries for 20 minutes to find a peripheral vein to cannulate. After around seven attempts he abandons this and moves onto an arterial line.

Time = 0hr 50mins

The arterial line is still not sited despite attempts in both radial arteries and brachial arteries (one under ultrasound guidance). It is decided to move on to a femoral arterial line. At this point a vein on the rear of the lady’s forearm stands to attention and lets us cannulate it.

Time = 1hr 10mins

A rapid sequence induction with cricoid pressure is carried out. This happens with relative ease. Despite popular belief across the pond cricoid pressure is required as (in this case) the patient risked aspirating 700mls of fluid from the stomach.

Time = 1hr 25mins

After a number of trips for ODAs and students to ICU a femoral line is finally sited under ultrasound guidance.

Time = 1hr 40mins

The epidural is finally sited despite this patient seeming to be made entirely of calcium.

Lessons learnt:

Little old ladies are made of clotted cream, atheroma and calcium...

Always use cricoid pressure in rapid sequence induction...

If at first you don’t succeed… use ultrasound guidance...

Even the best can sometimes struggle !

Thursday, September 14, 2006

Hard decisions

Over the past few weeks I have been learning about pre-operative assessment with regards to risks specific to surgery and anaesthetics. This has involved identifying key conditions (e.g. severe aortic stenosis) which may impact upon how anaesthesia is performed. I have then been putting this into practice and clerking patients before their surgery, making note of key conditions and considerations and specific assessment for anaesthesia – airway assessment, etc.

Until today this wasn’t too complicated as the most difficult issues I have dealt with were severe arthritis of the neck resulting in an inability to perform a standard intubation and allergies to some of the commonly used agents.

Today was somewhat more challenging however. I attended the preoperative assessment clinic where potentially complicated patients have already been identified through routine nurse-led clerking. One patient was particularly difficult (clinically) and quite upsetting as an observer.

The patient was an elderly woman who was to undergo major abdominal surgery. As well as this she had a significant history of respiratory and cardiac disease with coronary artery bypass surgery and pacing unable to control a longstanding history of unstable angina.

This lady was then told that she had to make a decision as to whether she had the surgery with a significant risk of peri-operative death or did nothing. A tough decision and certainly not one I would lightly make for myself or my patients…

Friday, September 01, 2006

48 weeks and counting…

In a few days I return to university to start my fifth and final year of my medical degree. I have been looking forward to it as it means that I am only a few months away from finishing what seems to have taken me forever. Having said that, panic has also started to kick in as we are constantly sent emails on how long it will be until we have to apply for our first jobs, when we will be told where we will be working, and (most worryingly) how to appeal a decision!

This has been a great summer for preparing me for my fifth year as I have been writing formative assessment questions for students in lower year groups. I have been able to write questions based around the areas in which I am lacking medical knowledge and I am sure that this will prove to be of value in our assessments and certainly on the ward. I have also been working with two doctors who are undertaking posts in medical education, interestingly one as a senior house officer and the other an F2 doctor – essentially the same role but each training under a different career structure. It has been interesting to listen to their experiences and how best to cope with work on the wards and I will take their advice forward into this coming academic year and beyond.

This year I have five training blocks and my medical elective to carry out, alongside all the assessments which run throughout our medical degree.

My five training blocks are anaesthetics, haematology, respiratory medicine, colorectal surgery and general practice. I consider myself very lucky as I had put all these in my shortlist for placements I would like to undertake. Anaesthetics and respiratory medicine are careers I have given a great deal of consideration to, whilst haematology and colorectal surgery were placements I thoroughly enjoyed during my third and four year placements.

My medical elective is starting to take shape and this summer I have spent a great deal of time getting ‘jabbed’ and searching the internet for cheap flights and insurance, all of which are now sorted. It doesn’t seem at all long until I’ll be off to South Africa and I really can’t wait now.

I will be making more of an effort to keep this blog updated now as I have found out that a considerable number of people from all over the world seem to be logging in to see what I have been up to!