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.

MUQD Mahidol University Quality Development

Today we are now working on SAR; Self Assessment Report Writing, we are now trying to answer and write down what we have done so far for the last academic year in order to submit the report to the Faculty and be prepared to have an internal educational audit which the auditors are from within the faculty, and the next step would be to prepare ourselves for the MUQD audit as well.

This year we have more knowledge about the Thailand Quality Award criteria which is based on 2011-2012 Education Criteria for Pefrormance Excellence and Baldrige Criteria. If you are interested in what we have been working since this morning, please go to the link below.

Academic Services @ MUQD

The MUQD main page is here.

In the meeting room where we are currently working on. We have just put down the results from our learners both the residents and medical students who just graduated from our department. The bad side in resident comments are mainly the decreasing trend in learner satisfaction, while in our medical student feedback is also the decreasing score by new MD graduates which we have already predicted that we hoped for, and we expected that we would remain in the bottom of the clinical department ranking for the next five years. It is understandable though, we have decreasing time for student rotation, and also the ones who should be entitled to mark the report should be the 6th year medical students who finished our department within one academic year, not 2 more years like the report performed by the faculty which is like we are defending ourselves.

Our FB Page!

Dear Medical Students or other readers who might be interested in anaesthetics, this blog is closely tied with the Facebook Page which is organised by our team.

In that FB page you can get some more photo taken in the past, however, this blog also has photo of the yesteryear! which was nearly 20 years old. You can get some short video clips about some clinical problems requiring your helpful hands, some problems in the preoperative period so that you need to do something in order to avoid mishaps that is Vigilance! You can also get some short status about the lecture we teach our medical students here.

Waiting for you to enjoy and let us know what you think about it, the link for that FB page is just right here by the end of this post.

Our Facebook Page

Another Video Clip from Medical Students

It was a funny happy and educational day we supposed, the learning climate was just right, although the medical students cannot achieve their best performances. However, that was the way of the education process, Learning from Failure, so that some steps would not ever happen again.

This short video clip was taken from the Debriefing video screen which we can enter the log of process the students did and then discussed how to make things better. Apologise for the quality of the video it belongs to my mobile.

Hope it is helpful and do enjoy the show.

Should Reach 3000 Hit Tonight ^___^

It took nearly 2 years to reach the readers of this blog for the first 1000 hits, then it took another two-month period for the second thousand hits.

I expect that by the end of the day here in Bangkok, There must be more than 3000 hits which is approximate a month time from the second thousand hit in August.

Keep on posting, keep on reading, however the thing we can improve this blog is how I can get some feedbacks from the readers, speak out something share your ideas so we can discuss on this blog.

Thank you for visiting this blog and hope you all enjoy the show.

More Photo from Simulation Teaching Room

From the CCTV camera we have two different angles so that we can earn the upper and middle photo which were quite close for the sequences happened at the scene.

In this last photo was in the nearly ended period of the session, we were talking about what went wrong and unnoticed by our students, and of course what they have learned which was the most important part of this learning method.

More photo of the same date of the scenerio or more in the past, turn to our Facebook page, ABC.

Simulation For 5th Year Medical Students

We teach our beloved medical students for a year now, and this is the most recent photo taken from our brand new CCTV inside the room.

Wait and Stay tuned, more photo to come from the recorded video.

Summative Evaluation : from Group 14/ 2555

At the end of two week rotation for the fifth year medical students to our Anesthesiology Department, we always ask them what we can improve to better serve them and any defects we can get rid of. Yesterday, Friday 14th Sept, 2555, we asked this 14th group about what they can get from our department with their two hands and anything they would suggest us.

They were mostly happy with the rotation that we really hope that they should feel that way. We cannot help them much about to become competent because the time would be definitely too short and the experience for each student would not be adequate for them to become an expert, they must keep on practising wherever the chance arrives. We teach them just the very first step, they need to find their own ways to practise more.

We are also happy that they knew more what we actually do each day in the operating theatre, one student mentioned about her understanding about the anaesthesia record, actually it is an essential document because the anaesthesia team would record the important event happened in the theatre, sometimes about the medications given in the OR so that the surgical team would make their appropriate decision about when the next dose would be.

Some students mentioned about their good time learning in the simulation means, we asked them whether or not it was worth trading their important working in the theatre to learning in the simulation lab, they all agreed that it was definitely worth doing so, because they were trading a hand skill learning with real patient to learning with the machine and most students aimed to learn about airway management skills with us. We have a hope that bigger departments would soon start their teaching with the Simulation means, a year has passed, we have not yet seen any move.

They told us that they understand more about preoperative evaluation and preparation, we hope that they can apply this principles to other rotations in their patient care.

Thank you so much for their comments, good luck and good bye.

Complications from Regional Anaesthesia

Indeed regional anaesthesia can harm your patient as well as general anaesthetics, however, it will depend on the technique employed and patients' conditions. Sometimes choosing the best appropriate choice between GA and RA is done because of the patients' conditions and anticipation which one would harm the patient more, and sometimes RA could lead to complications.

First of all we have to learn and know about the agent utilised for the regional or local application, so you can  beware what to look for such as systemic toxicity can present with CNS or seizures or with the cardiac or Ventricular tachycardia/fibrillation or even cardiac arrest.

Then we have review the route of drug administration; epidural, spinal, caudal or just peripheral nerve blockade, because each inject site will lead to its own subsequences.

The Thai Medical Council now just recommends new medical graduates to know just the technique and know just this is RA, do not have to perform this, but it asks everyone to be able to perform lumbar puncture but no need for spinal/ intrathecal anaesthesia.

Sepsis : Anaesthetics Management

There was a patient presenting to us for his source control procedure, he had an infected dry gangrene of his toe. He has diabetes, hypertension, end-staged renal disease and peripheral vascular disease, he receives regular haemodialysis for nearly two months now. His baseline creatinine was somewhere around 2 mg/dl, but after he developed congestive heart failure, respiratory failure requiring an ICU admission, his creatinine rose to 6 mg/dl, and has a double lumen catheter for regular haemodialysis.

When he was scheduled for toe amputation, he may also had the problem of hospital acquired pneumonia, the temperature in the prep area was 38.8C, the heart rate of more than 120/min, his blood pressure was quite all right, but he had oxygen saturation with room air at 93-95%. He appeared to be drowsy however he could respond to verbal command.

When he was at the operating theatre prep area, the nurse at the waiting area told you that he had just been dialysed and was sent from there.

What are your anaesthetic considerations for this man?

His anaesthetic management is just right here;

Sepsis

The meaning of sepsis syndrome has to be learned, one has to remember that sometimes it happens before surgery or as a cause brought our patients to us, or it can occur in the perioperative care pathway as complications.

Sepsis is the combined SIRS with Infection, therefore when you receive a septic patient transferred to you it seems to be a source of infection somewhere in his/her body, it can be that surgical cause such as peritonitis from hollow viscus perforation or as complications such as hospital acquired pneumonia. While SIRS (Systemic Inflammatory Response Syndrome) is comprised of 4 items, there are tachycardia, fever or hypothermia, tachypnea or respiratory alkalosis, and leukopenia or leukocytosis. However, you have to search for more detials of each content about the number for each criteria.

Giving anaesthetics to these challenging patients is also a challenge for anaesthetists, you have many things to do in the intraoperative period, anticipate the problems that may occur on the operating table, and plan wisely for the postoperative course.