Mid-clavicular line is now also known as the mid-nippular line???!!
Mid-clavicular line is now also known as the mid-nippular line???!!
I saw my first ever Ketamine induction yesterday.
It was for a 6 year old boy undergoing bilateral medial rectus botox injections. Apparently, other general anaesthetic agents attenuate the electromyograph signals needed to locate the extraocular muscles too much, and thus render them unsuitable for this procedure.
The boy was shown a little toy snake as a form of distraction whilst I cannulated him.
Then, the ketamine went in.
His eyes remained open. He continued to blink despite looking a little blank. He continued to breathe. He also continued to move his arms about.
Somehow, I don’t know how, my consultant was able to tell that the child was “ready.” She was able to tell that he had been anaesthetised despite him still looking completely awake.
The procedure took all of 5 minutes. We gave him a small dose of midazolam at the end to “dumb down” any emergence phenomena that may subsequently manifest. Then, we transferred him to the recovery area. We shut the doors, turned down the lights, and kept the area as quiet as possible.
The little boy continued to look around whilst in recovery, occasionally picking at his cannula. Then, he started calling out “snake! snake!” He was very obviously having visual hallucinations of the little snake we (erroneously) showed him before his anaesthetic. He started lifting up his covers, and picking up the snake which seemed to have slithered onto his body. The boy did that repeatedly for a good half an hour. Occasionally he would try and get rid of the snake from his body. Other times, he would lean over the bed rails saying “where has the snake gone?” Throughout this entire time, we just watched him deal with his hallucinations. After all, the teaching is not to disturb the child or engage with them as it worsens their nightmares. But what an awful experience it must have been for him!
I wondered how we would know that the child has recovered from his emergence delirium. My boss said that you would just know, because they will start speaking to you properly. True enough, as though someone had flicked a switch, the little boy suddenly came to and asked “When is the botox going to be done? Where is my daddy?” It was then that our recovery nurse finally said her first words to him “it has already been done,” and he cheered.
Seeing as he had finally recovered from the ketamine, the recovery nurse wanted to give him a sticker for his “bravery.” The boy claimed that he did not really like spiderman. “What do you like then?” she asked.
“Snakes” he answered.
I was chatting to one of my juniors whilst at work the other day. We were talking about the horrific situations within which we often find ourselves stuck in in our line of work, and how we have all learnt to cope with the physical and emotional toll these take on us. Yet, no matter how hard we try to forget and move on, there are always certain patients who seem to stick in our minds for a very long time…
I was telling her about the story of a 21 year old boy called Michael whom I looked after as a junior doctor 4 years ago.
Michael was a patient on the haematology ward that I worked on as a F2 doctor. He suffered from acute myeloid leukaemia and had been in the hospital for a number of months receiving chemotherapy. As he was one of our long-stay patients, I had gotten to know him fairly well and had taken it upon myself to take ownership of his care and well-being in the hospital.
I remember seeing him on a Friday ward round (my own, as the consultant did not round on a Friday and the registrar wasn’t about in the morning). Michael was semi-asleep, hiding under the covers when I checked on him. However, he claimed that he felt good and had no physical complaints at all. His vital signs and bloods were all stable too. Michael then let on that he was desperate to be “released” on home leave that weekend. Seeing as there was nothing really to stop me for letting him go home for a couple of days, and on agreement with my registrar later in the day, we said goodbye to Michael that afternoon and “see you back on Monday!”
Monday came around soon enough, and Michael came back onto the ward that morning looking dreadful. He had become really unwell over the weekend. The diagnosis? Pseudomembranous colitis. In fact, Michael had become so poorly that he was promptly admitted to the intensive care unit. Whilst he was in ITU, he was aggressively resuscitated, started on inotropes, and provided with a course of strong antibiotics. He did not respond to the treatment at all. In fact, he responded so poorly that it was felt that there was not much more we could do to “cure” him. “Flogging” his body with further aggressive and invasive treatment was not going to do him any favours… it was only delaying the inevitable, and denying him the option of a good, dignified death. The only choice hereon was withdrawal and palliation.
Now, despite being so terribly ill, Michael remained compos mentis throughout. He decided that he did not want to remain in the ITU, but instead chose to be transferred back to the haematology ward to die. He wanted to be in familiar surroundings, with people whom he knew loved him and had cared for him these past few months. During the time when the ward was arranging a side room for him to return to, Michael even wrote a goodbye and thank you note to the staff on the ward. It was heart-breaking to read.
The atmosphere on our ward was sombre on the day Michael came back to us. There was a dark cloud looming over all of us all day, and a heaviness in our hearts that weighed us all down. He had come back to the ward with a syringe of noradrenaline to keep him alive, and we all spent the day agonising over the count-down to a time when the noradrenaline would run out– the time when death would be pronounced over our dear patient and friend. Throughout the day, the staff on the ward took it in turns to go and say goodbye to Michael (who was still fully awake and aware). No one came out of his side room with dry eyes. Even the counsellor was found sobbing uncontrollably after going in to see Michael.
As for me? I did not go and say goodbye to Michael that day. I was awash with emotions that I knew I would never be able to take control of if I even began to lose it. I had 2 patients in 2 side rooms next to each other dying on the ward. The nurses were disraught. Yet there are still so many other patients who needed looking after. I was sad but had to remain in control. I pressed on with a brave face and a constant need to dab my eyes with my shirt or a tissue all day.
I wondered what it must have been like for Michael to be inside that side room waiting for the Grim Reaper. What could possibly be going on inside his head as he looked at the syringe’s plunger slowly inching its way towards the nozzle, knowing that when the 2 parts kissed, the candle of his life will be snubbed out? I wonder how difficult it must have been to say goodbye forever to his girlfriend and his family? How can anyone be ready to leave at age 21? What about marriage, children, career, dreams, retirement? How can one die in peace when there are still so many regrets in life? How did Michael feel witnessing everyone crying over his soon-to-be passing? How did he control his feelings in the midst of the chaos of emotions that was poured out onto him?
Michael died at approximately 7pm that awful day.
As I was recounting this story to my colleague that day, I found my eyes welling up in tears yet again. The little pearl drops of fluid rolling down my cheeks completely took me by surprise. It has been 4 years since Michael died after all. After such a long period of time, I had expected the rawness of witnessing such suffering to have somewhat healed already.
Nevertheless, like I said, some patients just seem to stick in our memories for a long long time. Their story becomes a part of ours, and I guess their memory lives on.
Michael, you are not forgotten by this stranger.
So, I received my exam score breakdown today.
I scored good marks for my clinical viva.
Then went on to fail the entire exam by one miserable mark.
This is like the primary viva one mark nightmare replayed all over again for me.
But you know what, maybe it is somehow a blessing in disguise.
Maybe God knew that it would not be satisfactory enough for me to have a knowledge base and foundation worth only 31/40.
I am determined to work diligently and consistently in the coming 6 months, not madly and self-neglectingly like I have done for the last 3.
I am determined to go back to Red Lion Square next summer & show them that I am worthy of the FRCA.
Praise the Lord.
Pardon my language. At Stage 2 of my usual coping strategy at present (see Coping Strategies)
I thought I had it in the bag after sailing through a really straightforward clinical anaesthesia viva in the morning.
The afternoon was a lot less pleasant, and I almost certainly fell down on my clinical sciences. I also realised by the end of the afternoon that I had taken a completely wrong route for revising for the science viva. They never wanted me to know stuff down to the detail of the primary exam, but really wanted to focus in on clinical application of the sciences instead.
What a shitty day. After all that nausea, breathlessness, palpitations and queasiness, the FRCA is still not mine to enjoy. The suffering is prolonged yet again, and will no doubt involve more sacrifices of precious time and my mental health.
Been feeling ashamed all evening as I texted all the people who have helped me along hitherto with my bad news. Took the train of shame back home and am now strategising on how to hold my head up high at work tomorrow.
Pissed off as heck at the moment, though I’m sure a moment of thoughtful reflection will strike later on.
Please grant unto me:
– Clarity of thought
– Eloquence in speech
– Confidence in behaviour
– Smiles from the examiners
– Success in my quest
Please help me keep my:
– Concern for the examiners
I have worked hard.
I know I deserve to pass.
I am going to go for it!
Just about surviving.
This pressure is too suffocating.
Dear Lord, please let it be over. Forever.
The mental anguish
The physical exhaustion
The constant worry and anxiety
The niggling guilt whenever I am away from my revision
The dreaded final exam is in 7 days time. I feel like there is still so much more ground that needs to be covered, though I doubt anyone can ever be completely prepared for it. After all, I am “only” expected to learn not just anaesthesia, but also medicine, surgery, paediatrics, obsterics & gynaecology, neurosurgery, cardiothoracics, ITU, A&E, anatomy, physiology, physics, pharmacology, and the art of talking. You would think that “surely they only expect you to know the basic principles,” until you get quizzed on the pKa of cocaine, or the exact angle of the right main bronchus compared to the left.
I do hate being viva-ed. I hate being asked all these difficult questions by my consultants and colleagues. I dread the possibility of coming across as “thick” and ineloquent whenever we go through the long and short cases. Yet, despite how much I really dread asking a consultant to viva me, I force myself to do so. I go asking for trouble. I put myself out there in a vulnerable and very uncomfortable position. All for the sake of practice & perfection.
These last few weeks have gone by in yet another exam-induced blur (It is concerning that there have been so many “missing”/ blank periods in the memory of my life these last 4 years). I have completely sacrificed my evenings, my weekends, my sleep, my social life. Heck, I even sacrificed my birthday and spent it doing 12 hours worth of magic roundabouts at the viva revision weekend. It just sucks so bad when you spend the minutes before going off to sleep thinking about the Budapest criteria for complex regional pain syndrome, then find yourself waking up in the middle of the night with your brain racing away trying to describe the anatomy of the larynx.
Sometimes, I look at the patients smoking at the hospital’s main entrance and wonder if they can or ever will appreciate this torture we are going through just so we can look after them. I don’t think they ever will, especially when so many of them do not even realise that Anaesthetists are doctors too…
Some of my friends have pointed fingers at me accusing me of managing a terrible work-life balance. People shake their heads when they hear how life has now been reduced to the work-study-sleep cycle yet again. I don’t think they understand. This is literally the last hurdle. The Royal College will unshackle my freedom and return it to me the moment I pass this exam. My sanity will be returned to its rightful owner, and perhaps there will finally be time to vacuum the floor, scrub up the bathroom, or change the bedsheets. For now though, I need to work and plan diligently for the day I go to “war” fighting for my freedom.
I do need to manage this stress though, and realise that taking an exam is not a truly stressful situation. As DG always says, true stress is when you knock a kid down in your car on your way to work, when a loved one is diagnosed with a terminal illness, or when you are cold & hungry with no knowledge of when or where your next meal will come from. These are truly stressful situations. An exam? That is nothing in comparison. So what if I fail this test? I get to sit it again, that is all. Yes, it will be a pain in the bottom, but that is not the end of the world.
J, please remember this.
Keep going, keep praying. God will sustain you through it all. He already knows if you are going to nail it or fail it. Note this, and have peace.
It is half past one in the morning now.
I have been wanting to scribble something down on this blog all of this past month but the inertia has been too great. And frankly, I’ve just been too lazy to organise my thoughts.
Truth to be told, I am STILL too lazy to sort out some of these ideas floating about in my head. The effort to translate all the complex magic that happens down at the level of my cortical synapses is just too immense. So pardon this piece of incoherent
27 June. Day shift. Weekend. W’s hospital. Spinal delivered for trial of forceps. Strangely, no detectable effect AT ALL after 20mins. Repeat attempt at spinal x4-5 times to no avail– hitting bone everywhere! Slim lady (which makes this even more frustrating!). Decided to call the boss in. During this time, the Obs reg re-examines the lady and decides that the baby has turned and we can do a non-rotational forceps under a pudendal block. They crack on, and as I stood there feeling like a massive failure for not being able to get my spinal in, I suddenly hear the Obs consultant (who had come in to help) say in a hushed tone “cord prolapse.” Upon hearing the 2 words that spelt out an Obstetric emergency, I had my lady anaesthetised within 2 minutes. It was a difficult delivery– the surgeons really struggled to pull the baby out. They tugged and pulled and yanked and huffed and puffed. I have never heard 2 surgeons panting so hard and sounding so stressed before. Then, they asked for terbutaline to help facilitate the “pull-out.” Danggit, I have never given it before. Thankfully, by then my consultant (who had been called to come and save my failed spinal earlier) had arrived and he sorted out the beta-agonist whilst I gave the rest of the anaesthetic. Eventually, the baby was delivered… but not without the Obs consultant suggesting that the Paediatric registrar organise a neck Xray for the babe– he was THAT convinced that he might have broken something during the delivery (p.s. the baby was absolutely fine by the way and needed no such Xray)
6th July. Night shift. W’s Hospital. I was the Obs anaesthetist on call that night. Called to take a patient to theatre at 3 am in the morning for a category 2 section (planned C/S for next day due to previous 3rd degree tear, but had come in the wee hours of the morning labouring). No valid G+S. Antibodies on booking bloods. Known previous PPH. With her previous PPH history (which increases her risk of bleeding again this time) & the absence of any suitable blood to give her in case she bleeds at section, I felt that the indication for section was not strong enough for me to bite the bullet and take her to theatre. I discussed my concerns with the Obs reg who said that she was happy to wait 1-2 hr for cross-matched blood to come from the regional blood centre. Unfortunately, the lady delivered very quickly during our wait and ended up with yet another tear. Nightmare. I became especially uncomfortable when I then heard the Obs reg go about telling everyone (including her boss) that “The Anaesthetist” was not happy to take the lady to theatre. That annoyed me majorly– 1stly because it was a joint decision, and 2ndly because as a senior Obs reg, she should have been unhappy to take the lady to theatre without me telling her so. Anyway, I was so worried that patient would put a complaint in because she had sustained another perineal injury because of our delays. I had to go back and explain to her why there was a delay– and the fact that she could have died if she bled torrentially with no blood that I can give her…I explained that even if I did give her the O-ve blood we had in the fridge, she still could have died from a massive transfusion reaction given the antibodies in her blood. Thankfully, the lady was actually quite happy to have “done it herself,” and did not mind that she had not been cut open or subjected to the above-mentioned risks.
Same night. Emergency alarm went off in the labour ward for x2 prolonged fetal bradycardias. “Section! Section! Section!” And so I tried to “quickly” pre-op this lady. Badly controlled asthmatic– Salbutamol 8x/day. On oral prednisolone. Bad chest ongoing for the last 2 months. Also had a previous general anaesthetic to which she had a “severe reaction” to– unclear of details. Told never to have a general anaesthetic again. Mm… As she told me more and more of her problems, my heart sank lower and lower. There were no Anaesthetic clinic letters found in her hand-held notes. I was thinking “Damn, I could kill her with a GA. MUST SPINALISE HER.” By the time I completed my pre-op, the obstetricians had given the lady some terbutaline and the fetal bradycardia had recovered. They did not want to take her to theatre anymore and preferred to “watch and wait.” Now, I normally wouldn’t mind that at all, but I was SO KEEN to get this lady sectioned in a controlled fashion. I explained to the surgeon and the patient that given her medical & anaesthetic history, a general anaesthetic for an emergency category 1 section could very well trigger off a severe bronchospastic attack/ allergic reaction that would be detrimental to both mother and baby. I really really did not want to give this lady a GA. Nevertheless, the surgeons were adamant that there was no indication for section anymore & they did not want to do it (the lady was still considering her options). What followed was a chain of phone calls to both our consultants and my consultant finally put her foot down to say that they can choose not to take the lady to theatre now. However, if she did rock up our way with yet another severe fetal bradycardia, we will do it under a spinal at all costs. It was crazy for me to hear that- what a difficult decision it must have been for the boss to say that! But I guess we had no choice… our primary responsibility is to the mother. The silly Obs reg then comes up to me and insists I put an epidural in the lady. I said no– the lady was not requesting one & did not need one for medical reasons. I knew the reg wanted me to site an epidural in case the lady needed to go to theatre– which was NOT the solution to our problem at hand at all. I will not be able to top the epidural up fast enough for a category 1 section. And if she needed to come for a category 2 section- I know I have time to perform a reliable spinal. Obviously, said obstinate obs reg did not (or refused to?) understand what I was saying; she later digs out an Anaesthetic clinic letter & comes up to me smugly to say that the advice on it was for the lady to have an epidural. I was so annoyed! I really do not need you to tell me how to anaesthetise my patients thank you very much. I later confirmed with my consultant that my decision was right (Ha, in your face!). Anyways, despite all that, THANKFULLY, the lady was fine for the remaining 2 hours of my shift, and by the time I left for home she already had a healthy baby in her arms. WHEW.
6th August. Started my new job. Let’s be having you neuroanaesthesia. Please let me love you rather than hate you.
I have had my hand on the panic button since I realised that there are only 3 weeks left before the dreaded exam. Unfortunately, there is no sympathy from the other Anaesthetists. Everyone just says “Well, we all had to do it in the past. It is your turn now.” Revision is horrible. It is worse when you have to try and squeeze it in after your long, exhausting days at work, or when you have to try and snatch snippets of time during your on-call days/ nights to revise. It is awful when you have to sit indoors when the sun is shining & tempting you to go and play in its warmth outside. It is gross when it makes you desire to scrub the kitchen, vacuum the house, or clean the toilet instead. It is irksome when you force yourself to get up at 4am to study simply because you went to bed too early last night and did not manage to learn anything. I have become so exam obsessed now that I am in “revison mode”. You only have to mention a casual topic and I will try and go through in my head what I might have learnt about it. Take induction day on Wednesday for example… I started going through the topic of cell salvage the moment the blood transfusion lady came to talk to us about the Trust’s transfusion service. When the fire safety officer came round to talk about fire safety, all I could focus on was how to treat severe burns. Everything in life just seems to lead back to revision at the moment. My first thoughts when I wake up are “What are the structures surrounding the stellate ganglion?” or “What is the treatment for phantom limb pain?” Days off are spent at the Anaesthetic school office going through past papers. This is making me so miserable. BUT, I just have to grit my teeth through it, hopefully pass it, and then freedom shall be mine!
For now, pain.
The troubled world we live in:
3 freaking plane crashes within a fortnight in the month of July. A Malaysian airlines commercial jet was shot down in Ukraine by pro-Russian seperatists. A TransAsia flight from Taipei to KaoHsiung crashed amid bad weather. And an AirAlgeria flight also crashed in Mali. These air disasters are making me extremely uncomfortable… especially considering the fact that I fly so much.
There is war everywhere. Ukraine is fighting Russia. Israel is fighting Palestine. North Korea is still trying to stir up trouble. Christians are being persecuted in Iraq.
There is an Ebola epidemic in West Africa. There is no cure for the virus. People are starting to worry about Ebola travelling and spreading by plane. The human race could be wiped out by this virus before we self-destruct with all the war & fighting.
God, help us all