Difficult Airway

The Anatomy

You must prepare the kit to be utilised when you find your patient with some anatomical problems, such as the chin; evaluated by the Thyromental distance. If you ask your patient to open their mouths widely, the relative size of the patient's tongue to intraoral structures such as Uvula, Tonsillar pillars, and posterior pharyngeal wall can help you predict the difficulty of your patient's airway.

This Method is called Mallampati's Classification. The easier airway means that lower grade on Mallampati's which means that you can have a glimpse on your patient's uvula and tonsils, while the more difficult airway means that you cannot see your patient's uvula and the tongue is relatively big in the oral cavity.

Endotracheal Intubation any Contraindications??

Once upon a time, there was a question raised by a Medical Student asking his consultant whether or not there are contraindications not to intubate the patient's trachea.

That Consultant told her experience regarding the incident.

One consultant immediately replied her, yes if that unfortunate patient does not have a trachea, so we do not have to perform an intubation.

More situations can be contraindications to intubate the trachea as well, what your answer would be??

Direct Laryngoscope

The force to open the airway by DL Direct Laryngoscope is to elevate not the fulcrum on upper incisors.

Another thing besides the position of the laryngoscopic blade is the position of the performer elbow. It should not be in Flex position.  Some put their elbows on the operating table which is comparable to the ENT Surgeons. 

Move Forwards with a Look Backwards

ก้าวไปข้างหน้าอย่างมั่นคง หันมามองหลังสักหนึ่งที

ภาควิชาฯ กำลังจะมีอายุครบสี่สิบเก้าปีในเดือนพฤศจิกายน สิ่งหนึ่งที่กรรมการจัดงานกำลังดำเนินการอยู่คือหนังสือหนึ่งเล่มเพื่อวาระดังกล่าว ทีมการศึกษาก่อนปริญญาได้คุยกัน เกี่ยวกับโควตาหนังสือจำนวนห้าหน้าว่า เราควรจะใส่อะไรลงไปบ้าง
๑. เราเปลี่ยน เราปรับปรุง เราสอนสองสัปดาห์ตั้งแต่รุ่น ๑๑๖ ตอนนี้เด็กรุ่น ๑๒๑ กำลังอยู่กับเราเป็นกลุ่มที่สองแล้ว
๒. เรานำ simulation มาใช้สอนซึ่งจะครบสามขวบประมาณสิงหาคมนี้ เราทุ่มหมดหน้าตักแล้ว เพราะต้องแลกกับวันที่ทำงานในห้องผ่าตัดและบรรยายภาวะแทรกซ้อน กับ การเรียนด้วยสถานการณ์จำลองหนึ่งครั้ง นักศึกษาบอกว่าน้อยไป..ได้ครับ เราจะลดวันในห้องผ่าตัดลงอีกหนึ่งวันครับ
๓. เราสอนโดยให้นักศึกษาหมุนไปเจออาจารย์สามท่าน ตอนนี้เราจับให้ทั้งสองไปด้วยกันตลอดสองวีก เกือบปีแล้วสินะ
๔. เราเน้นการประเมินผู้ป่วย การเตรียมผู้ป่วย ดังนั้นเราเลยทอนวันจากห้องผ่าตัดอีกวัน เพื่อการนี้โดยเฉพาะ เราพานักศึกษาไปที่ศูนย์ส่องกล้องทางเดินอาหาร
๕. ไหน ๆ ก็ปรับ ก็เปลี่ยนแล้ว แทนที่จะต้องเขียนรายงาน ก็นำเสนอรายงานเลยแล้วกัน จะได้ประหยัดพลังงานทั้งคนเขียน กะ คนอ่าน ปีนี้เราเลยเปิดห้อง ให้ทุกคนได้เข้าไปพร้อมกัน ครั้งแรกนะ นี่
๖. จำนวนผู้เรียน ทำไมมากขึ้นนะ ไหนว่าคุมกำเนิดได้ดี แต่นักศึกษาแพทย์ต่อปีเพิ่มขึ้นจริง ๆ ตอนปีหกสิบเอ็ดเลือดสี่สิบสองวีก ยังนึกไม่ออกเลยว่ากลุ่มจะใหญ่ขนาดไหน
๗. ความประทับใจเริ่ด ๆ มีหรือเปล่าไม่แน่ใจ...่จำได้ว่ามีคนบอกว่า เคยคุยกับน้องปีสองแล้วว่าไม่รู้ว่าเรียนเบสิกไซเสด ไปทำไรบอกน้องไปว่าได้ใช้นะ เปิดภาพในอดีตดู..บอกว่าหุ่นยนต์สามารถทำผ่าตัดได้ แต่หุ่นระงับความรู้สึกยังไม่มี
๘. ตำรา...อุ๊ย ต้องมีด้วยเหรอ แล้วจะขายได้เหรอ?? แผนกลยุทธ์...นะ เล่มล่าสุดของฟาหรั่งเค้าปี ๑๙๗๖ นะเธอ สิบอกให้
๙. ทำงานได้ทุกวันนี้ คนที่เหนื่อยกว่าใครนะหรือ...คุณพี่แก้มแดง ของนักศึกษาอะสิ กำชับตลอดเลย ถ้าคุณเธอลาออก...ทุกคนในทีมลาออกตามเธอหมดแน่นอน กระซิบพี่หัวหน้าแล้ว กรุณาหาผู้ช่วยเธอด้วย
๑๐. เฟกบุ๊ก หน้านี้..สองปีฝ่า ๆ แล้ว ที่เขียนที่ทำอยู่ คิดว่าเป็นเพราะกลัวแพ้ภาควิชาฯ อื่น ครั้งแรกที่เห็นจากการนำเสนอที่คณะฯ เป็นภาควิชากายวิภาคศาสตร์นำเสนอ เราเลยเดินตามภาคนั้น
๑๑. อนาคต..อะไรจะเกิดขึ้นกับรายวิชานี้ คิดว่าเราคงจะหายไปหนะ ใครจะคิดว่าอย่างไรเราไม่รู้ แต่โรงเรียนแพทย์หลายแห่งเค้าไม่มีรายวิชานี้บนใบทานซาคริบมานานแล้ว เราสอนรายวิชาที่ผู้เรียนไม่ได้นำไปใช้ในชีวิตประจำวัน แต่อย่างไรก็ตาม เรายังสามารถไปร่วมสอนกับภาควิชาต่าง ๆ ได้ทั้งปรีคลินิก และคลินิก

สรุปว่า โควตาห้าหน้า นี่มันจะพอไหมเนี่ยะ

For Basic Clinical Skill Class on April 10

For the class of this academic year, it is the yesteryear once more.

Old clip Venepuncture

AMEE 2014 in Milano

The annual conference of AMEE for this year is going to be in Milano, and today is the last final day to submit an abstract for presentation at the meeting. Our team has sent two abstracts in undergraduate anaesthesia education, one is about the happiness of the medical students during their time with us, we analysed at the mid term that the overall time for happiness is approximately 60+ per cent of their time, and the whole year data is sent for considered at the conference.

The other abstract we sent was about the response from 5th year medical students in their decision making process in crisis management, the problems we found are two things, one is the students did not ask for help, they should learn the team working process, they are not alone, there are help available all around them, but they do have to ask for, and the latter problem is re-evaluation of the interventions given whether or not they are working well in the patients.

Will update this again in April when the results are due to release.

Cardiac Centre

Working in the cardiac centre is like working outside the normal operating room routine, however, it depends on the conditions and what procedures are scheduled to perform there. Some trainees are frightened when they are assigned to work there, because it is the place and environment that is not familiar to them.

Today we had two ageing men requiring interventions to control their cardiac rhythm, one had ventricular tachycardia while the other one had 2:1 AV block, not counting an early morning patient with an AICD implant. The former had cardiac resynchronisation therapy, while the latter had a dual chamber pacemaker implanted.

In the paediatric room, we had two cardiac catheterisation in two cyanotic congenital heart disease patients, and the last patient also the youngest of the day had her central venous catheter placed.

That was a normal busy day in the cardiac centre, too tired to have exercise, better go to bed instead.

You must be time conscious, Dear

It is unacceptable for the professional who cannot keep the time, if you have an appointment with somebody, it is your responsibility or your commitment to be there before the very last minute. It can be applied to every single student to be right at the examination place before the time the teacher lets them in, in the last academic year the department got approximately half of the final examination dates which there were somebody entered the room late that their peers.

It is totally stupid to be that, you do not have to let your friends take any advantages over you, you have take enough time to finish the paper, but you should take the start point together with your friends.

The committee for the examinations had made their minds to give the students, who report themselves later the time limit which they know well before, a failed examination result.

Time conscious is so important for professional, isn't it?

Anaesthesia for the ageing patients

Time is flying and never stops, therefore we are now facing the bigger patient group, the ageing population. The better healthcare technology together with better care management make our people live longer, and they are presenting themselves to us later in their lives. The anaesthetics for this group of patient requires some concerns such as:

1. Underlying diseases: the aged are more likely to have more problems than the younger counterparts, it is the thing that cannot be avoidable since the organ functions are declining since the age is more than 30. We should evaluate every organ system, so that we can make a further plan what we should proceed later. The more problems they have, the more prescriptions for them are increasing, and increase the risk of drug interactions.

2. Declining organ function : the metabolism and excretion of the drug given are more likely to have more effects, since the GFR is lower when the age is going up and up. Postoperative cognitive dysfunction should be evaluated in the perioperative period.

3. The skin is more likely to lose its temperature control, the longer operative time means that they would have a lower core temperature, therefore, temperature monitoring and interventions needed to control the worse outcome should be implemented.

It seems that we are doing the same things to the ageing patients like what we would do to the neonates and paediatric patients.

Simulated patient and learner for consultant workshop

Today the department organised a meeting for consultants, they joined together for a review for teaching methods, from an inspiration from another colleague, how to give a good feedback to the trainees, how to supervise your trainees during a procedure and finally what a good reflection from our learners should be.

The sample of what happened during the day is available in the following link, it started with a volunteer to supervise a simulated doctor trainee to perform a simple procedure, but it went out a nightmare because of a simulated patient. Enjoy the show.

Supervision

What would you do if the ventilator you are applying to your patient shouts "TV cannot be delivered"?

After the ventilator alarm "Desired TV cannot be delivered"....

1. back to patient clinical conditions, does he/she have hypoxia
2. recheck the tube position either end-tidal COtwo or auscultation
3. recheck the previous IPPV setting whether or not, it is appropriate
4. look at Paw whether there is any air leakage
5. change a new ventilator machine
6. if it cannot be solved, postpone the surgical procedure, support patient ventilation
7. ask for help/advice about IPPV setting or checking
8. if the ventilator is truely malfunctioned, turn down the alarm volume, so that it would not disturb others

What should you look for?

In a situation that makes you confused, do not know what to perform next, calm down a bit and concentrate on your patient again. Some occasion you cannot perform a useful investigation, because it is not possible to palpate your patient's arms or legs because of an obstructed C-arm fluoroscope, because the CVP is not the up-to-date monitoring in this world and it just tells you whether or not your patient has a right heart failure, because PPV cannot be interpreted since your patient's cardiac rhythm is not sinus.

So, what you could possibly do are listed in the attached foto....

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.