Simulation Class Atmosphere on Christmas day :(

Learning atmosphere on simulation class in cardiovascular and respiratory crisis in perioperative patients for 5th year medical students.

We began with short introduction about the way we would proceed, how the learners should perform, and we told them we can let go the patient death because it was a simulated event, it would not the real world. So, we ended up just one patient survived, one with complications from the medical treatment, and unfortunately all the remaining four were discharged with mortality.

Finally, the learners' feedback about what they have to acquire for more knowledge and more reading, that is the most important ideas for the day.

Medical schoold director addressed his closing remark

Professor Prasit Watanapa, the Medical School Director, made a closing remark to the consultants of the Faculty of Medicine Siriraj Hospital on the workshop of Curriculum Change.

Unfortunately, the language of the video is not English, however, if you would like to get the atmosphere, please click the link below.

New curriculum

Excuse me, does he....?

A kind good looking surgeon was surprised, and reluctantly quietly asked his anaesthetist counterpart whether or not the patient needs any kind of airway intervention.

Then he was questioned by his anaesthetist what went wrong, everything was fine and business is usual.

So, have you found whether or not there is something Right!!!

A short vid Clip

For an airway control, we have many choices/ airway alternatives, we can just use a mask and bag as a non-invasive airway control, or we can intubate him/her with many airway adjuncts, or a classical way of endotracheal tube placement.

Have a look at our homemade video, the consultant who performed it was so smart.

Enjoy your time here,

Homemade Video

Feedback from MD graduates 1

What did new MD graduates, Class 2007 tell us? 1. The thing that we won't change...

1. The size of MS5 per group, 3-4 MS5 a group is too big, better to have MS5 : Consultant at 1:1
2. Handouts of lecture, no standard, not harmonised across the academic year
3. Practice more in Paediatrics and Emergency patients
4. Would love to experience the Surgical ICU and Pain Clinic

Response: 

Dear our Med Students, Imagine or Ideas sometimes is not practical in real life, working 1:1 with consultant doesn't mean education, it usually means training (depends on what you 'd like to have Brain's or Hands' skills). You can apply for elective period for extern, we now have SICU, Pain management and the newest "Clinical Anaesthesia" elective. Please don't even think of practising anaesthesia in children or emergent patients, if there is anything bad happening, you will never ever forget that event, dear.

Your chain link, don't miss any link

Basic Sciences are All Around U

Working with medical student again, however, this time it is for elective one. Telling her that "if you don't have your background knowledge in basic sciences, you are wasting time working with us in the operating theatre."

Anatomy : Pointing a C-arm intraoperative fluoroscope for the procedure, you can plan or anticipate what bad situation may happen from the operative field, patient position, important nearby structures, ...

Physiology : That continuous vital sign monitoring machine is always an ingredient of the OR, can you explain why your patient had hypoxaemia throughout the procedure,...

Pharmacology : from oxygen to a muscle relaxant reversal, have you ever counted how many drugs you have administered to your patient?? drug interaction, allergy, CYP450, ...

Wrong Number??

Cardiac Care Unit or Intensive Care Unit

In the middle of the night, a call from recovery room nurse asking you for help was made, you told them that you will go to have a look of the previously healthy young guy who was anaesthetised by another consultant. You reviewed the history and learned that his HR was 150+, BP 100/60, RR 28-32 with dyspnoea, urine for 3 hours in RR was only 70 ml and you were thinking of severe sepsis from his necrotising fasciitis, so you asked the RR nurse to measure the temperature, and it was 37.8 via axillary route. Although you had given 2 units of blood (OR EBL was 800 ml), and crystalloids, but it seemed that he was fluid non-responsive. Finally you decided to call the ICU nurse to get the ICU bed access.

On the phone, you told ICU nurse that your patient was tachycardic, and the HR was now at 155/min.
On the Reply "Why don't you call for the CCU admission?? he is tachycardic, isn't he?".

How would you explain the ICU nurse to get the booking??

AMEE2013 Associations of Medical Education in Europe, Praha

From the just ended AMEE2013, we would like to share some photo with you all. It mentioned about nearly every aspect for the education, including what the new future MD graduates should learn for this century. In that points we will share with you later on, but for today post just for the reasons why everyone has to learn, even CR.

The second and the third photo taken are all about you as medical students, you have to think whether or not they are true. They were presented by a Londoner doctor who just transformed to a new MD graduate in July.

We need a great and brave step forwards

In order to become somebody an anaesthetist need to move forwards to be a part of care team, we are perioperative physician so we must stand up and move ahead, telling our surgeon and physician colleagues that we can do many things in our area and expertise. We are capable to perform many treatment interventions because we have done it performed it for years. we really are perioperative critical care physicians.

We are not Noboby or Let 's call it "Intraoperative Faceless Physician".

From an open session of 78th Annual Meeting for the Royal College of Anesthesiologists of Thailand.

Premedication at before bed time

A good night sleeping pill

During an intra-articular procedure or right knee for a young & healthy foreigner, everything was smooth as silk until...
Big Surgeon : Prepare for dressing, and Slap, and please release the touniquet
OR Nurse : There is a second dose for Cefazolin for him
Unkind Consultant got the antibiotics ready and administered, and screamed out loud to Anaesthesia Resident " What's the hell is going on?? The end tidal carbon dioxide is at 48, what level did you record last time?"
1st year Resident  was stunned and told "33 mmHg."
Unkind C : is it from the exhausted sodalime? looking at that colour
R1 disagreed, so UC spoke out "That should be long time ago, not immediate rise."
UC : Does it come from your inadequate IPPV setting?
R1 raised the RR from 16 to 18/min, and told 'No".
UC : So, what intervention has been recently applied to him?
R1 : Touniquet ?? UC : Tell me the textbook you have at home.
R1 : Baby Miller. UC : Good, there should be at least one table on this issue, read it tonight before going to bed, OK??

R2 entered the room later on, and was told that her junior was ordered to get a sleeping Table(t) tonight.

External Audit

The faculty has been under audit process since this morning, there has been a four-people committee working on this challenge. The vice dean for undergraduate education has been questioned a lot, however, as a team member, there is always a help available to answer some difficult questions from all preclinical and clinical department representatives.

In the afternoon session, the clinical departments including department of anesthesiology were interviewed in a big room. When I entered the room, the topic was about grade designment, how often, which method to judge the learners' score, how to announce the grade, etc.

We were also interviewed about log book, competencies in laboratory skills, hand skills, and they also asked about the 21st century skills how to improve it both in the students and also more important the teachers.

Critical Care Conference in Thailand 4th, Just ended

The 4th CCCiT was organised in Dusit Thani Pattaya on Thursday 27th to Saturday 29th June, it was quite a success for the organising committe because the number of participants rose to double from 200 in the first year to more than 400 this year.

The new concept of Shock management was discussed and presented, some are
1. Early organ support such as CRRT not wait for Creatinine to more than 10 before initiation
2. "Less is More" concept not too much fluid volume because mortality can be higher in the loading patient group
3. Choice of catecholamines can determine the outcome Noradrenaline is better than dopamine
4. The vasopressin analogue should be given early but not a replacement to catecholamine
5.  New concept of massive blood transfusion in trauma

Simulation based Education

The first vid clip was for the fresh up the consultants so that they were up to date with cardiopulmonary resuscitation. While the second clip was a rehearsal for the scientific meeting.

An essential skill for Every MD graduate

Insertion of an intravenous catheter is a must skill for an MD graduate, however, it need repeated training. Time after time you can do much better, first of all, you need a good old experience hand, so that the vessel you chose would not move when you puncture it.

Our Family Ceremony; We love our teachers

Today in our department has organised a family party, just to say "thank you to our beloved teachers".

Here are some samples of the event, in the lunchtime we had lunch together to say good bye to the new graduates and welcome newcomers.

Report discussion : The Oral Presentation

Report Discussion by MedStudent about what they think and translate anaesthesia service into their presentation.............

Each student will have 15 minutes to discuss about preoperative medical problems their patients have, and what to do or prepare for their patients so that we can avoid perioperative complications. They also have to discuss the choice of anaesthesia which way they should proceed, and also postoperative management, any problems and pain control.

Some questions may be asked according to time available such as......

MS : oxygen was administer 3 lpm....
ABC : what does it mean? at what levels of inspired concentration you gave to your patient? you did not give a clue on which apparatus you utilised, you may harm your patient if you used a simple facemask...
MS : oxygen 3 lpm via a nasal cannula...
ABC : that sounds better and we can imagine that

MS : anaesthetic was maintained by.... oxygen and air are given at the rate of 1 lpm each......
ABC : just would love to know the FiO2 level you mentioned, can you tell us please...
MS : .........(silence is definitely not golden '')
ABC : that's all right, it is quite unexpected by you being asked this question ไม่ได้เก็งข้อสอบข้อนี้มากระมัง!!!

A half an hour clip, that is it.

We have just done the handmade pick of our photo for the european trip. Hope you enjoy this in the mean time before my academic things start to run as usual.

Follow the link below.

European Trip 2556 Slideshow: Toomtong’s trip to 9 cities including ปราก was created with TripAdvisor TripWow!

A European trip

Mobile Uploads Slideshow: Pti’s trip to 7 cities including ปราก was created with TripAdvisor TripWow!

Foto from our FB

Three photos shown here are recently posted on our facebook page, so you can find more details of each event there.

The upper most one was about we just began to keep our students away during the examination. The middle photo was about the cannot intubate crisis, the one who finally put the tube in place was our ex-chairman for our department, there were two professors there within the room. While the last photo we discussed about rapid sequence induction with cricoid pressure, and manual in line cervical stabilisation in an unfortunate guy with previous treacheal resection

. 

Crisis management in Anaesthetics

When you have put your patients under anaesthetics adventure, you have to realise what priority after anaesthetics induction you have to do further more. You may need to monitor the blood pressure after the induction dose is given which may reduce the systolic blood pressure, therefore, you must have vigilance to anticipate what may come up next, let the more important things be on your watch lists so that you would not lose your patient contact and delay in your patient management.

In an anaesthetics for a grandpa for robotic surgery, you knew that he was a big guy, so you have to prepare for adequate ventilation support after a successful endotracheal intubation, you can definitely preset your ventilator setting, so that you can switch it on when the time comes. Instead of looking at your patient response to ventilator setting, one was busy in an IV cannulation while the other one was concentrated on more monitoring probes, so it took seven minutes to detect that your patient was hypoventilated and the first response was just after that time point.

What you think??

You have successfully given spinal anaesthetics for a mom-to-be, everything went well and smooth, after a delivery you gave some med to promote uterine contraction, and then antibiotics prophylaxis for her.
You still observed the paedritician taking care for the newborn, it was quite longer than expected, then he came towards your patient telling her that her NB was in need of closed neonatal care because of respiratory difficulty.

So, can you explain what has happened in this scene for a poor newborn?

NPO time

You picked up a call, it told you that at the MRI suite there was an uncooperative lady waiting for you. She had something in her head, and the MRI technician mentioned about the follow up scan to evaluate the patient's prognosis. You hurried, you ran, you walked very fast to be there as soon as possible. When you arrived there, the technician told you that the patient had dinner approximately two hours ago.

So, what you are going to tell her daughter who is actually anxious about her mom's condition? and would you proceed the procedure as plan or just run away?

After had a provisional diagnosis of Septic shock, a med student would manage something with higher priority first,,,,
1. hypovolaemia with rapid fluid loading with balanced salt solution then re-evaluate the response together with data gathering from patients' relatives
2. full PE : conscious, pulse, pulse pressure, RR, airway, ventilator adjustment, JVP for volume status, then re-evaluate again, if the patient is still unstable, give another fluid loading with vasopressor
3. closed observe, continuous ECG monitoring, control fever

how many stars you would give to this student???

an Essay response from a med student about patient care after GA with a tube: he says,,,,,,,,,,,
1. evaluate conscious, verbal command, stable vital signs, regular RR, tidal volume, airway reflexes, muscle power, oxygenation
2. if all above are good then extubate, and transfer to PACU area to observe for conscious, oxygenation, ventilation, haemodynamics, complications (nausea, vomit, pruritus) and pain control
3. use aldrete score for discharge criteria, and advise about self care for OPD or send patient back to ward with good pain control

good, isn't it?

A survived mode not Fighting mode

In the morning we discussed about the curriculum of Anaesthetics for medical students in another university in Bangkok, we had been informed that those students in that particular school would have a 4 week time slot, three weeks for the skills practice in the operating theatres, and one more week for the surgical critical care service teaching. Compared to our school which is focusing on preoperative evaluation and preparation with only an hour for SICU topic.

That has brought us a flashback when we were informed by the department chairperson that from now on we would have only two weeks for med students, not as three weeks, she just told us after she had promised the dean that we would be able to teach our students in a two-week slot, so we just a good follower, when our boss just gave a nod, we did have to do so. The curriculum has been five years old now with only two weeks, with a minor change nearly 2 years when a simulation was introduced to this course, we did not fight back after we have found out that it is a worldwide trend at the time from Ottawa to Melbourne just a two week slot. Although we have time with them only two weeks, but we are not the least, many schools in the kingdom do not have their anesthesiology grade on their student transcripts any more.

In the school with have a week longer into four weeks, we supposed that their faculties have united and fought back and realised what would be beneficial to their students. We will update this when we have more details, but for sure the mode between us and them is indeed totally different.

Bangkok Judgement Day

An election for the mayor of Bangkok happened here today with the unexpected rain shower in the hot winter time.

Independent candidates need to do more to get a nod from a bangkokian.

Students' Self-reflection on their Anaesthesia Rotation

So, we have just put all the response from 5th year medical students who were with us for their working with us. Hopefully, their skills which can be beneficial elsewhere in the hospital will be better and better with they grow up and gain more experience in patient care.

There is also some competencies about the situation they have to make up their mind what to do or not to do, and their interests in choosing anaesthesia as their future career.

Thanks for your kind co-operation to respond to the survey, so that we can improve ourselves to suit you all much better.

Preoperative evaluation and Preparation

It is the heart of anaesthesia for medical students, if you do not have an anaesthetic mind during your surgical rotation, you would definitely not understand why your patient is in need for such investigations, and medication concerned. You have to have holistic mind so that you would not only focus on how the surgical diagnosis would be made and the steps of surgical procedure in your patient would be, if you throughoutly look after your patient, you will not lack the core of medicine in your patient and it would definitely bring you another world when surgery and medicine are met and walk along with each other.

Preoperative evaluation skills are just comparable to the skills you have already had when you perform ward round in every discipline of medicine, for a quick look from head to toe, then you can focus the leading cause of your patient hospitalisation for this admission and focus of what else he/she has in the topic of concurrent diseases. It should be a skill every MD graduate can perform by self with no need for consultation, such as hypertension, asthma, diabetes, etc.

Outcome first then Process

Yesterday we joined the faculty meeting for the curriculum improvement for medical student. Actually we were still by the process we were informed in the morning. Everyone expected to discuss how the curriculum would be changed, how to rearrange the slot for teaching, unfortunately we were nowhere, repeated the same process which happened last April.

We were grouped together to discuss how we expect a medical graduate would be, or discussion on the outcome we would love to see at the time they would graduate, the committee had given us 27 items of how we expected to see them which was too much and exaggerated, therefore, each group did the grouping of 27 items to less than 5 or 6 headers, according to the university motto as well as the faculty motto.

Then in the afternoon we discussed the main outcomes in six domains which has been announced by the Thai Medical Council. Our team from the department was quite disappointed with yesterday meeting, as we are anaesthetists, so we have to act fast and sharp and of course safe. Will update this topic again because it would be ended in a year time or longer than that because it will be used for the Academic year 2558 when they arrive our faculty as 2nd year medical students.

Responsible or Sensible???

Finally the process of grade decision has come to a close, we have just finished a report back to the faculty. The problem we have found is an episode of a student misconduct, no! she/he is not cheated, but she/he should be more self-love according to Today Valentine's Day.

Self-love can be interpreted as more responsible to the work assigned to each of everyone, if your work or assignment is done, there should be a sign to your mentor/ consultant/ attending whatever it is for you. In order to get a feedback to you, you must be professional enough to accept other opinions especially if it means to help improve you in the future. It can be the meaning of sensible things you should proceed as well, it appears to be a normal way it should be and no-one would not have to shout it out. If one has chosen not to follow that path, one should be prepared to be ready for what would happen after that.

What is the reason why??

We are in the process of searching what the reason for medical students to earn the A grade from our department would be, because we are just short period subject so the effect from score in both MCQ or essay would not be so much impact. We see quite comparable scores from the whole class in both exam. So, the other causes can be a report which used to be a written patient case study, but we have changed to oral presentation format, the next reason can be participation of each single student during their problem based learning activities, and the final reason can be bed side teaching during working in the operating theatres.

We will update this later on when we can find it.

Decision making or a Judgement Day

We are in the final process of Academic year 2555, we are doing the grade making for each medical student. Indeed the grade earning and giving can be manipulated not too rigid and strict to the rule or scale. It can be adjusted to give the learner higher benefit.

Sometimes it is quite difficult to choose to give or not to give the learner higher score in order to shift their grade up a level, so hard to perform that.

It is going to finalise soon, so there will be some with smile on their faces, and some would receive just an OK, hopefully.

A call 4 Help

You have just extubated your patient after an operation he required was done, have you performed the right thing or you are going to harm him?

First of all you have to re-evaluate his condition, diagnose the main problem then you can correct the pathology or the cause of the problem he is really in need and waiting for your hands to manage it.

So, what you are going to do for him?

Absolutely not Minor!!

For medical students and new medical graduates or young doctors, if you are in the process of decision making to become an anaesthetist in the near future, you have to understand and know what we are routinely doing for each single day. When you are doing your anaesthetics rotation, you may get some happy time because you have participated in the patient care, you can perform some skills by your hands which is totally different from other specialties which you become an observer and distant yourself from the care process.

You have to realise that you will not receive an ASA 1 every single day, when you are working with your supervisor, we can manipulate the surgical list to match the competency of medical students, so it is also not the real world. Working in an operating theatre should be paired to an ICU bed, imagine you are performing shock resuscitation, close monitoring, airway and ventilator support, and more for your patient, it is like that the anaesthesia world.

We are just worried that you have chosen us, the specialty, because you have thought that it is not hardworking, it is fun and thought that even the nurse can perform why can't I? You are misunderstanding something dear. If you think you can work in an ICU environment for every single day for the rest of your life, this challenging world is calling for you, dear.

Time Flies so fast!!

Tomorrow friday Feb 8th  will be the last day of the academic year 2555-2556 in the Faculty, they will have an intensive course so that they will be ready to work and learn as their final senior year.

The Simulation teaching will be one and a half years old, and will continue to utilise this technique for the learning process, we have heard that some departments have already started to teach our med students with this method too, and it should be because the learners should have more practices and this technique they can learn from nothing, from mistakes, from misunderstanding, because we can repeat the scenario as many times as they'd love to.

Next Friday 15th, the faculty will organise a very first meeting about what we should move for the new medical student curriculum towards the 21st century and also the ASEAN community integration.

So, it will be time period to repeat again because newcomers will due to arrive to the department on Mon 18th, we will meet and greet and prepare the MCQ papers, essays, revise the simulation and arrange the rotation for them.

It is on our ABC

It is quite inactive blog for a while, but we are frequently posting on the facebook page. On that page, we have asked for comments from our readers. So, if you are interested in anaesthetics, we are still there, however, we are still here too.

ABC

Shared Airway

We have posted about shared airway between surgical team and anaesthetic team before, but today it was about a share between our team and the dentist!

In order to promote grow in children with difficulty eating/ swallowing, they must pass through this.

enjoy

Teachers' Day

Today Jan 16th, here in the Kingdom we cerebrate the Teachers' day, some schools are closed, some are business as usual. Even the Google web page still runs a special event for this occasion.

As a medical teacher, I would say that I never ever need a smart with high score ranked students or residents, but I would be proud when they are good guys or gals, do everything right not cheated, not selfish, with their best quality heart.

The link below is a music video on youtube about this special day. Enjoy...
A Reward for Teacher

Fibreoptic Assisted Endotracheal Intubation II

The previous post that I mentioned that I cannot upload the video, so i tried a new means of doing it, upload vial the Google+.

So, it you are interested in the real event happened at the operating theatre, please move to the G+ link to the clip below.

enjoy

The Original Clip

Scoring an ESSAY

A MedStudent Response to an ESSAY about an aged man with anemia and colonic mass

1. Hypochromic microcytic anemia is likely iron deficiency from lower GI bleeding. The consequences of anemia is reduced oxygen content leading to hypoxaemia which will stimulate the peripheral chemoreceptor and sympathetic system to increase the work of breathing, and stimulate the CVS to increase cardiac output to increase tissue oxygenation and myocardial oxygen demand.
Therefore, we have to concern hypoxia and myocardial ischaemia during his anaesthetics

2. An ageing man: look for his hidden underlying diseases; DM, hypertension, with lower metabolic rate and reduced renal function would affect the motabolism and drug excretion, and prone to drug toxicity

3. Colonic mass : the mass could affect peristalsis, bowel function, increase the risk of delayed gastric emptying then prone to pulmonary aspiration, delayed feeding in postoperative period and malnutrition

Great, isn't it?

Fibreoptic Assisted Endotracheal Intubation

What I tried to add the original video clip for the anaesthetic management for this patient, but I cannot do it, may be the size of the original one is so large that it will never happen in the blogger, so i did try to repost it with the utilisation of my not smart phone.

You have to differentiate the plan in airway management especially the expected difficult airway, when the plan is organised for a known difficult airway, the scene will be smooth as silk if the essential airway devices are in position and ready to be used. In the other way round, the unexpected difficult airway is usually problematic and can induce a chaos if you cannot help ventilate your patient 's lungs. In this video, the patient was an employee of the Electricity Generating authority, when he was injured, it caused him scar contracture which can reduce the airway motion and create a difficult airway to challenge anaethetist in charge of him.

Can't help with the quality of the clip, but it is better than nothing...

A review of Anatomy: Vid clip w/o Sounds

It is a post to remind you about preoperative evaluation in your patient, with modern technology you do have to review the film by yourself so that you can learn something about it. You may read the report of any imaging studies by the radiologists, but after that reading you should get back to the plain film or slide to identify where the pathology is hidden.

For this video clip, what you can learn from it? After you have evaluated the patient, then you can make your plan how to manage the patient's airway, what you can do and cannot do to help him/her.

enjoy....

Teachable Moment : Seize it or Lose it!!

Working with medical students can initiate some ideas what to teach them or educate them, because some time we do not know what should be the first lesson of the day. Getting some good questions from what they have observed during their friend was practicing can be a good start of the day, yeah indeed, some questions are good to talk about and pay more time on it, it really depends on the consultant whether they can catch this teachable moment or not.

For example: the Lesson of pre-emptive analgesia
Med Student : Why the surgeon has to infiltrate the local anaesthetics before her incision? we have put our patient in to general anaesthetics, haven't we?
501: Indeed, we induced our patient to deep GA. What do you think about the benefits of LA in this patient?
MS : It helps prevent blood loss.
501 : Really, it creates vasodilatation, doesn't it?
MS : But, it was mixed with adrenaline.
501: Oh, I see. Any more benefits and how it works?, you can use and search via your smart-phone.
MS : It inhibits the Na channels.
501 : So, this is physiology and pharmacology, remember that I told you before that nothing new has been discussed here. Although you have administered GA to your patient, but you have to realise that the nerve ending and nerve conduction pathways are still intact, so that the pain induced from the surgical procedure can be transmitted to the brain. Have you recalled anything about nerve conduction pathway, the spino-thalamic tract?
MS : yes.
501 : This will be emphasised again in pain lecture. If you inject the LA in pre-incisional time, the result is much better than post-incisional period. Prevent is better than Cure!

.... Some discussion were on and on, Stay Tuned

From Google+

Have time to find out during your private time, think, consider and then reflect out whether or not you are satisfied with it.

Have a Look Here

A new way of learning by a new Mind

Working with med students today was fun, and pointed them about the way of anaesthesia education by looking things in an integration way, instead of thinking of anaesthesia rotation as a hand skill learning to do those and these. Explained them, why don't they look that what we are doing in every single day in the operating theatres, in Surgical ICU, in Pain clinic, acute pain services and Pre-anaesthetic clinic is really the things they have been learnt, taught, and practiced for years.

Nothing new has been taught, I am afraid, is what we have discussed in the OR.

It is just Anatomy : when the laryngoscopic view was asked after they just put an endotracheal tube in place, when you just inserted the iv cannula wasn't that Anatomy?, told me where the brachial plexus is? and explain how the spinal cord ends?

It is Physiology : it displays on your monitoring screen, it is really the clinical application of monitoring, from an ECG, oxygen saturation, end-tidal CO2 tension, arterial blood pressure, airway pressure. You have to know what goes on from the surgical side or the other side of the OR border, such as you see an episode of hypoxaemia in a lady who underwent Sentinel Lymph node dissection, can you explain how this happens? Thinking of oxygen-haemoglobin dissociation curve, then apply it in real life, if all your patient have 100 % oxygen saturation, does it really mean that everyone has a really good or perfect lung function?

It is Pharmacology : it is just in our magic box, induction agent, pain killers, or a nail to pin your patient not to move during surgical procedure. In a vascular suite, there was a patient scheduled for vascular access, he does not have any urine for ages, what the first thing reaches your mind right now besides the diagnosis of a plain ESRD. A guy on the table has 4 kinds of antihypertensive agents, so can you explain why he developed hypotensive after an induction dose of propofol and even the endotracheal was placed in his trachea which should have been a painful stimulus.

It is also Pathology : a very closed friend to anaesthetists, we share many similar things, we know everything from head to toe. In the hypertensive guy, can you explain what really happens in hypertensive patient, the SVR, any change in circulating blood volume from normotensive changed to hypertensive patient.

Happy Holiday would be fading away, Welcome your new life with a New Mind-Set.