Vigilance and Happy New Year 2556

As an anaesthetist, the practice of Vigilance should be plenty in blood and all cells. You have to be careful, have an alternative plan when thing goes in an unexpected way or you have to anticipate the worst and be ready to solve it if it does happen.

Enjoy your holidays and Happy New Year.

Anaesthesia and Critical Care with Technology

Fluid management is the centre of shock management, but only in the early phase of shock, your patient will finally not respond to your additive fluid by the end, at that time point, you will have to find more ways to augment your patient's haemodynamics.

Will the application of ultrasonography, the TOE, transoesophageal echocardiograph, will be another helpful equipment to help and guide your making decision. It will help you to differentiate your patient's CVS status. The diameter of great vein either Superior vena cava or Inferior vena cava is an index to demonstrate the dynamic haemodynamics monitoring parameter. If both vessels can be collapsed or compressible, SVC by the breathing from mandate breath by IPPV or IVC from abdominal pressure linked closely to intrathoracic pressure, it would mean that your patient will be improved after you give him/her more fluid. This is shown in the condition 1 and 2 where the SVC is difficult to orientate during inspiration phase, and the diameter is significantly smaller than the expired time. The SVC collapsibility and IVC collapsibility are essential dynamic haemodynamic parameter that will be helpful in the situation that you have to decide whether or not to give more fluid to your patient. If your patient has the condition 3, you give more fluid in, you are endangering your patient, because at this point, your patient does not need fluid loading any more, and he/she would not have fluid responsiveness either.

 

No White Christmas here, Just another Sunny Day

Indeed, we are in the tropical area very close to the Equator, so how we could have white christmas. We just hope that cool wind would stay with us some days longer than a couple of days, so that we can have some cool days approaching the year's end.

Time flies, so you do have to be quick to start something new, question yourself what you have learn as a something new by the end of every single day, so that you would have time to consider and think and reflect to yourself and you will not lose the value of time flow.

Hope you have a good time this coming year's end. 

Anaesthesia & Critical Care get along with Basic Science

In the situation that you have to make a decision to correct your patient's haemodynamics instability, you must gather your patient's details about what went wrong and what you can intervene. Fluid resuscitation is one intervention that is usually performed in the face of severe hypotension. It is the centre of therapy in the early phase of shock management, but in the later phase it may not work in all patients.

You have to assess your patient's cardiac function where your patient's cardiac contractility is by the applying the data you can evaluate on the Frank-Starling cardiac function curve to see where it is. If it lies in the steep portion of this curve, it would mean that your patient can respond to have augmented cardiac output or venous return by just simply fluid loading to increase right atrial pressure or passive leg raising. On the figure below, if you can shift your patient's status from 1 to 2 (right shift), it is safe to proceed your fluid administration, and your patient responds so well with that.

This figure can be accessed from Chest, it is nearly 5 years old, but is an important landmark that you should not miss so that you will not give your patient too much fluid, and keep in mind "less is More" concepts.

Another Video from Chest : severe LV dysfunction

Video : Cardiac function from Chest

Summative evaluation for the 20th Group

Some of these dialogues came from this afternoon session for the summative evaluation by the medical students of the group 20th.

Med Student5: I am nervous and excited all the time especially when I have to do new thing at the very first time.
501: Relax a bit, all new things or the first can happen every single day.

MS5: Learning by simulation is good, have a chance to think, although my ideas can be formed, but I am not sure whether or not my opinion is right.
501: Good, you can think, however, just think and keep it in your head or your mind is not enough, you have to express out and share with others, don't ask can mean either you know it so well or it shows that you are not interested in the topic being discussed. Don't forget the policy "don't ask, don't tell". Everyone who receives your question would be definitely happy, because when you ask, you have to learn something or must know something, and then you have processed your ideas and form a final question out from your brain. It is an essential skill for your generation, the 21st Century skill.

MS5: Would love to have more than one session of the Sim Based Learning, because it is a very good way to learn, is it possible that we can have an examination with this method?
501: You do have to omit three lectures, so that we can have some more vacant space to accommodate another simulation teaching, let us know which lectures  you would like to get rid of. We in this department have waited for a big move forwards from other departments which have more time to teach you especially the department who has more than six weeks working with you, there should be at least three classes of simulation during your study. We have been waiting and still waiting to see major departments start their real high fidelity simulation class like ours which has only 10 days or just 8 days and a half to spend with you.

For the examination or assessment with SBL is a very expensive one and have to invest in the time being with  you, indeed it is a very good way for examination, but you may need a 3-hour period just for a group of 10 for three stations. It has to be done by the faculty policy.

501: What's about preoperative evaluation and preparation? we have been told not to teach you this area, because you have been taught a lot! during your surgical rotation.
MS5: Indeed, we have been lectured about the preoperative evaluation, but it may be theoretical not in the practical way. Co-existing diseases have never been discussed during the rotation especially when the patient has multiple drug therapy such as for management of hypertension, we have no ideas about which one to continue or which should be discontinued. It is also the problem of medical patients, we have never been taught about if our patient need an operation what we should do next on our patient in the continuous care.

It is the Water Sport Day ^.^

The department has been assigned the Orange, and we have done our best to participate this event with smile. It is just one day or once a year for this competition.

Professor Jariya Lertarkayamanee is the department chair person and she was there with us, and she has been assigned to award the medals to the winners too. Thanks for being with us.

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As for the relay team our girl can do it.

Loy Loy Krathong, the 12th Full Moon of the Year

Today Wed 28th Nov, 55 is the full moon day on the 12th lunar month, it is the day we in the Kingdom cerebrate the Loy Krathong ( ลอยกระทง ) day. It is the day to thank and pay respect to the Goddess of Water, and apologise her that we consume water and also pollute it.

Even H.M. the King also participated this important event on the River of Kings (ChaoPraya River). Today in the afternoon, some of us who were free from OR services dressed up and walked in the parade, although some including me had to work in the OR, but we are really happy to have smiles on our faces.

The photo posting here are credited to my friends and colleagues on the Facebook page, and they are all the members of the Department of Anesthesiology @ Faculty of Medicine Siriraj Hospital.

We finally got the New นางนพมาศ (หรือ Miss Loy Krathong), she is now the second year Resident in the Department.

Feedback and Self-reflection

This week the faculty has its internal education audit for the department and school within the faculty. The process usually begins with the presentation by department chair and the education team, then the auditor/ surveyor asks some questions either from the evaluation guide or from the self-assessment report submitted by each department to the organising committee.

Then in the interview process; the auditor may ask some presentative from consultants, learners from undergraduate medical student to nurse student to residents to MSc/PhD candidates, and department educator team. Then the surveyor review the documents prepared by the department member, they can be the schedule of curriculum, document and objectives of learning for each topic, examples of the final test, student evaluation form.

In the learner's view points, they usually would love to have feedback from their supervisor which can be consultant working with them, nurses helping them or other staff member who they are working with. A good feedback or even a destructive one is essential for the learning process, it can make things a complete circle, points some ideas the learners never have thought of or have looked over. The coaching day for the resident organised within our department is another way so that consultant can have time to look after the resident, guide something they did not quite acceptable in the consultant 's eyes, or give them a pride if they have done something really good.

Adequate supervision helps in the learning process, it also helps diminish some avoidable complications, so it directs patient safety.

Self-reflection is also help yourself the learner, know what you really need in particular field so that you can jump or run into some patients to learn more in the area you have not done good or in the less experienced field that you do have to improve it. If you can have both feedback and self-reflection, you should be very happy and have a really good day, although it is Halloween today.

Anatomy in VID

Although in the clinical year education medical students would not have formal education in basic sciences, but you have to realise that it is well cooperated in the various field of disciplines. When you are having your time in surgery, you are totally in the time of anatomy review, you have to recognise where the pathology is and any close associated organs nearby.

In the anaesthetics rotation besides anatomy of the airway, peripheral nerves, cardiovascular tree, you have to understand your patient anatomy so that you will have a clear plan about what you have to do during your care for him/her in the operating theatre, for example, in the video up here, you would need to know the arterial supply of the lower extremities, so that you can plan and have vigilance about what you should do and understand the surgical procedure as well.

Unhappiness from Students

This morning the department was visited by a committee from the faculty, the Internal Education Survey which was kicked off on Monday. The committee was welcomed by our chairperson, and she presented the things done in the previous academic for three learner levels; medical student, anaesthesia resident, and anaesthesia nurse trainee. Then the head of postgraduate anaesthesia training presented all anaesthesia education of all three teams. The history of what happened in the past such as curriculum for medical student, the rotation, the changed learning climate, the changed learners were all discussed and presented to the surveyors.

Then the surveyors interviewed the department board in education, asked our chair about her leadership role and what our department could bring about the social responsibility.

One thing the surveyor team suggested us to perform is the evaluation of Unhappiness from our learners which applied to all three levels, but the nurse education team has led the others, they have already measured the unhappiness from our trainees.

So, action and plan next for undergraduate education team is to learn how we could do to perform this unhappiness in our medical student which has quite a small amount of their time with us.

What is helpful for the judgement of Unhappiness? There has been a research showed that engagement to the team member could help attenuate the unhappiness. By clicking here can lead you to online article about happiness and unhappiness. Team helps because there must be something in common before working as a team member, you have to work with each of everyone belonged to the group, and each has their own roles to perform with a unique identity.

Anaesthesia and Burn

Burn from any cause is definitely harm to your patient, skin is considered not an important vital organ, however, skin is essential to protect your internal organ and prevent heat and fluid loss. When your patient has problems with his/her skin, insensible fluid losses together with visible fluid loss can precipitate your patient's homaeostasis.

When you have to evaluate your burn patient, you have to establish two things, one is degree of tissue injury, the severity of burn from 1st degree to 3rd degree. Then you have to estimate the extent of the injury, the percentage of your patient's skin involved relative to total body surface area. This will have to be examined because it is essential for the treatment plan you patient is in need.

Further anaesthetic considerations for the management of your burn patient will include; what type of injury such as flame, acid, or electrical because the consequences of each cause would be different, and also when the injury happened either acute injury or in the convalescence phase. The scar from chronic wound would definitely affect your decision on how to intubate your patient such as the lower photo here. If your patient is scheduled for skin graft, you have to ask also where the donor skin will come from and which position your patient will be required.

Burn management is very difficult however it is a very challenging discipline. Get it or Lose it.

Communication Skill : Essential part for 21st Century Learnersf

Today in the summative evaluation period for group 16/2555 we discussed about communication skill for medical students. One student mentioned about the current core curriculum does not have enough time slot dedicating for communication practice, and she let us know that in Taiwan there is such a slot for doing the councelling for 2 weeks.

Although we do not have that slot, in my opinion we can do it anytime during their clinical rotation not only the ward rounds, during out patient clinic the student can have a chance to practice that. Even a short 2 week rotation for anaesthetics, if you have time to visit your patient before the operation, you can really learn from that moment, especially if you run into Anaesthesia Residents doing their preoperative evaluation routine near you, you should jump in this chance and chat with them, they would be very happy to answer if you have appropriate questions about why they order that treatment or do that intervention for the patients.

Preoperative evaluation is an essential heart for the practice of anaesthesia, you have a chance to meet your patients which is different from the surgical team which they have known each other for ages. You can have a chance to discuss choice of anaesthesia, plan in mind what you would do, what you will not to participate as a member of the team.

Communication is very important, sometimes you do have to speak out loud!! otherwise others would not understand you, they may think you do not say anything means that you have already accepted, have known it, because consultants may have "don't ask, don't tell" policy. The Culture of Seniority does not mean that you should not speak, it would mean that you have to speak at the right time, ask if you do not understand, speak if you think that something is going out of the way it should be. Speak out before it is too late and ทุเรศ. You do have to.

Access to reach 4000 Today

After being with you for nearly three years now, from the very inactive blog has become a nearly 1000 access hits a month. The rate of reading is better than it was, however, I do not have much ideas what I should put up here, thinking the best I would try to write whatever it suits the aimed audiences, the medical students and their small world of Anaesthesia.

Keep walking and keep posting, thanks for being with us.

Simulation Class of group 15/2555

From last Wednesday, October 3rd 2555, the students of the group 15 were with us to their class of simulation. Staff of the day was so energetic and played an important role.

The introduction period: Time to review the physical examination, abnormal auscultation both cardiac murmurs and adventitious breath sounds.

I do not listen to you now, because you do have to listen to me, you have to do whatever you need to in order to save my mom's life. The scene in the class, the situations ran, the flow of action followed.

Debriefing : Time to appreciate what students had done something good, time to reconsider if there was something went out from the normal way, so that the learners can educate themselves and understand why sometimes it had to learn from failure.

Although they were not the team member during the scenerio, but they had discussed what went wrong with the monitoring and what should have done to pull our patient back.

The action by our Staff in Chief, she had done many things, rearranged the scene, asked technician and secretary to participate with the show.

MCQ the Comprehensive Examination for 6th year Student

A workshop is organised by the faculty to improve and edit the MCQ examination submitted by faculty members. Lots of discussion, edit the text, some questions can be improve, some has to return to the owner because they are inappropriate, does not initiate thinking process, asks only the recall.

From basics to Bedsides: The Critical Care Meeting in December

Annual Meeting Dec2555

This year theme for the conference organised by the Thai Society of Critical Care Medicine in December is to promote the background knowledge for improvement and better patient management. Such as the management of shock runs from basic sciences to fluid management, how to resuscitate the patient in shock, what is happening during shock, how to monitor the patient's responsiveness, how to titrate the response and how you would do to attenuate the complications from shock management.

The second day is about the basic in ventilator management, mechanical assisted device for shock management, ARDS and sepsis. This day also includes the surgical patients who need perioperative critical care therapy.

If you would like to know more, the link to the website is on the uppermost corner.

The Simulation clip

On Wednesday 3rd that we taught med students with this technique, it was quite a pity that the audio system was down so we cannot keep the sound, otherwise the visual view was quite all right. We would like to share with you the event happened a couple of days ago.

The anaesthetic consultant had played an important role in that day, both tricks and treats on the students.

Hope that you would not mind with the sound.

Today Simulation Class

The climate of learning for today simulation learning in our department was so fun, because the anaesthesia consultant in charge had tried her best for the teaching process. She initiated the thinking process and encouraged the learners to think, although it may be both tricks and treats, but overall the session was good, and we would like to thank you our consultant to make such a good teaching and learning day.

One Medical student Response to an Incident

From a 5th year Med Student response in an essay examination about a nurse call asking you to evaluate and manage a patient with BP 84/50, RR 30, and loss of consciousness, she told you that it was the time to record the patient's vital signs after 1 hour interval in the immediate postoperative period. 

He said :
1. Understand the situation: make a short list of the main problems waiting now: unconscious, hypotension, tachypnoea
2. Gathering an essential information
- more patient history : anything important for a diagnosis
- physical examination : especially the consciousness and the CVS 
3. Make a likely diagnosis: because hypovolaemic shock had to be ruled out then surgical site should be assessed
4. Management to the appropriate diagnosis and re-evaluate again whether or not the treatment given is working

Good, isn't it?

Join us in Japan ? An Abstract submission

JCS 2013 in Yokohama

Anyone fancies going to japan? This cardiovascular event is such a big meeting I ever joined, and the registration fee is quite cheap compared to other headline meeting.

We have submitted an abstract about teaching medical student with simulation in the shock management theme a couple of days ago, will update you later on whether we have a nod by the organising committee to let us share our beginning step ( only a year experience in teaching with simulation ).

If you are interested in the meeting web site, have a click on the uppermost section.

Cardiac Rhythm : Electorcardiogram

We do have to maintain the normal sinus rhythm (NSR), if it is possible or there are some correctable causes. The reason for this may come from the NSR would result in better cardiac filling in the diastolic phase when the heart rate is low, however, when your patient become tachycardic from any cause, the systolic time which is normally fixed and cannot be reduced, the diastolic period will definitely be reduced, then your patient will have shorter time for the heart to relax and result in lower cardiac output due primarily to small stoke volume.

This is also applied to the abnormal atrial contraction rhythm which the normal atrial kick would increase the significant amount of cardiac filling volume, Look at the lower part of the figure: you can learn that in this patient although the heart rate is quite low, Premature Atrial Contraction can cause an absent of adequate output in each abnormal beat on the arterial tracing waveform, We cannot the low blood pressure in the screen, but we can see the obvious lower cardiac output.

24th September is Mahidol Day

On this Special Day, we, the healthcare personnel around the Kingdom will pay the tribute to the Prince Mahidol Na Songkhla who was the King's Father. He was named the Father of Modern Medicine for the Kingdom, because he had done so much to improve of the healthcare services for the ordinary people of his Kingdom.

Besides the Surname of the Royal Family, Mahidol is also recognised for a prestigious health award. There are two disciplines medical service and public health service, the awardees will receive the award in the Royal Grand Palace Hall.

In the morning there will be many health clusters with parade to pay respect to the Prince Mahidol.

Fluid Responsiveness! Less is More...

Every mirror has two faces, so the treatment arm has to be balance with the harm or side effects as well. When we administer our patients the fluid therapy, it is true that when we are facing with the low blood pressure, we would start with fluid management or resuscitation at the very first step. However, sometimes or many times that we are endangering our patients loading them too much fluid, because it is simply as they are not the ones who are responsive to the treatment.

I can recall my experience working at the Surgical ICU, there was a granddad with a history of postoperative bilateral nephrectomy, therefore, he was totally dependent on his regular haemodialysis since he did not have his kidneys any more. We treated him, dried him, when he was presented to us because of  the acute heart failure just within 48 hours of his discharge from our unit, there was a call to bounce him back because an episode of hypotension and the first think the uro residents did was fluid loading.

Fluid input requires the way out as well or Fluid output, when your patient has impair cardiovascular tree, the kidney failure will soon follow. Fluid also moves to where it does not belong, for example the lungs, it would cause impair oxygenation and increase work of breathing, when it moves to skin or muscle it would be very easy to detect because you are increasing your patient's body weight and making tissue oedema. When this bad things happen, it would increase the days your patient would need to stay in the ICU or in the hospital, increasing the risks of infection and ventilator support.

You may require more monitoring technique to differentiate whether or not you should load your patient with fluid therapy, if it is the case that your patient does not deserve it, you don't have to do so.

A recent report about the harm of too much fluid for critically ill neurologic/neurosurgical patients on SCCM page can be accessed here. 

Yesteryear Once More!

During working at the department office we discussed a lot about Competency Based Learning, so we wandered around and I can find some photo I took in Last May (2011/2554) during I attended the Asia Pacific Conference about Simulation in Health Care.

From the Speaker of National University of Singapore, he mentioned about the Competency the new 1st year Anaesthesia Residents should be able to perform after a period of one month can be shown here. The baby MO = Medical Officers.

If you are looking for the previous post about the meeting click here.

Compare to Simulation the traditional way of teaching is....

Student Feedback from SBL.

Debriefing period, and the things that our students should get with them out of the class is indeed the new way of thinking.

What's Simulation? This question was the response from my Department Chair, She really did ask me when I submitted her an article about the way of teaching medical students with this means.