I came across this excerpt from Atul Gawande while browsing the TED articles.
What doctors don’t learn about death and dying
It made me realize that only the basic factoids for a foundation in medicine are taught in medical school. The article should open the eyes of my peers; it is ok to accept and understand the fragility of life without thoughts of failure. Compassion, empathy, resourcefulness, etc. aren’t easily teachable concepts or behaviors. One would hope that aside from understanding things on a cellular to anatomical to physiological to pharmacological level, a basic lesson in emotions, communication, and coping would be equally as important as learning the fundamental medical knowledge to clinically treat patients.
What is the adductor canal?
Why all this talk about an adductor canal block (ACB)?
For years, femoral nerve blocks (FNB) have been the gold standard for pain control in more invasive knee/lower leg surgeries (total knees, ACLs, etc.). More recently, adductor canal blocks have been gaining in popularity over femoral nerve blocks because there seems to be less motor blockade from ACB than FNB. This is important because it decreases fall risk and allows earlier patient ambulation while also providing adequate analgesia.
Anesthesiology Mar 2014. Kim et al. Adductor Canal Block versus Femoral Nerve Block for Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial.
How to place an adductor canal block
Overview with quiz
Youtube video of ultrasound-guided ACB – Nov 2014
Youtube video of ultrasound-guided ACB – Apr 2014
Ultrasoundblock.com: Ultrasound-guided ACB with pics and video
Over the years, I’ve been asked to inject various dyes to help light up the urine for visualization of the ureters. Now, we’ve moved to fluorescein because it “lights up” quicker than other previous dyes. Why are we always switching? Drug shortages.
Dosing: 0.25 – 1.0 ml of 10% preparation of sodium fluorescein
Dose: 5 ml. bolus of 10% fluorescein intravenously.
These aren’t my own thought, however, I can easily agree with the list below. One of the things that was left off this list was pediatric hearts. I had the chance to do a one month pediatric cardiac anesthesia rotation at a very busy Children’s hospital and it was definitely an eye opening experience. Teeny tiny babies. Itty bity tubes and IVs. The heart plumbing/circuitry was anything but normal. I have the utmost respect for pediatric cardiac anesthesiologists — and that’s coming from an adult cardiac anesthesiologist.
Taken and shared from The Anesthesia Consultant Blog:
TOP 10 MOST STRESSFUL SITUATIONS IN AN ANESTHESIOLOGIST’S JOB
- Emergency general anesthesia in a morbidly obese patient. Picture a 350-pound man with a bellyful of beer and pizza, who needs an emergency general anesthetic. When a patient with a Body Mass Index (BMI) > 40 needs to be put to sleep urgently, it’s dangerous. Oxygen reserves are low in a morbidly obese patient, and if the anesthesiologist is unable to place an endotracheal tube safely, there’s a genuine risk of hypoxic brain damage or cardiac arrest within minutes.
- Liver transplantation. Picture a patient ill with cirrhosis and end-stage-liver-failure who needs a complex 10 to 20-hour-long abdominal surgery, a surgery whichfrequently demands massive transfusion equal to one blood volume (5 liters) or more. These cases are maximally stressful in both intensity and duration.
- An emergency Cesarean section under general anesthesia in the wee hours of the morning. Picture a 3 a.m. emergency general anesthetic on a pregnant woman whose fetus is having cardiac decelerations (a risky slow heart rate pattern). The anesthesiologist needs to get the woman to sleep within minutes so the baby can be delivered by the obstetrician. Pregnant women have full stomachs and can have difficult airway because of weight changes and body habitus changes of term pregnancy. If the anesthesiologist mismanages the airway during emergency induction of anesthesia, both the mother and the child’s life are in danger from lack of oxygen within minutes.
- Acute epiglottitis in a child. Picture an 11-month-old boy crowing for every strained breath because the infection of acute epiglottis has caused swelling of his upper airway passage. These children arrive at the Emergency Room lethargic, gasping for breath, and turning blue. Safe anesthetic management requires urgently anesthetizing the child with inhaled sevoflurane, inserting an intravenous line, and placing a tracheal breathing tube before the child’s airway shuts down. A head and neck surgeon must be present to perform an emergency tracheostomy should the airway management by the anesthesiologist fails.
- Any emergency surgery on a newborn baby. Picture a one-pound newborn premature infant with a congenital defect that is a threat to his or her life. This defect may be a diaphragmatic hernia (the child’s intestines are herniated into the chest), an omphalocele (the child’s intestines are protruding from the anterior abdominal wall, spina bifida (a sac connected to the child’s spinal cord canal is open the air through a defect in the back), or a severe congenital heart disorder such as a transposition of the great vessels (the major blood vessels: the aorta, the vena cavas and the pulmonary artery, are attached to the heart in the wrong locations). Anesthetizing a patient this small for surgeries this big requires the utmost in skill and nerve.
- Acute anaphylaxis. Picture a patient’s blood pressure suddenly dropping to near zero and their airway passages constricting in a severe acute asthmatic attack. Immediate diagnosis is paramount, because intravenous epinephrine therapy will reverse most anaphylactic insults, and no other treatment is likely to be effective.
- Malignant Hyperthermia. Picture an emergency where an anesthetized patient’s temperature unexpectedly rises to over 104 degrees Fahrenheit due to hypermetabolic acidotic chemical changes in the patient’s skeletal muscles. The disease requires rapid diagnosis and treatment with the antidote dantrolene, as well as acute medical measures to decrease temperature, acidosis, and high blood potassium levels which can otherwise be fatal.
- An intraoperative myocardial infarction (heart attack). Picture an anesthetized 60-year-old patient who develops a sudden drop in their blood pressure due to failed pumping of their heart. This can occur because of an occluded coronary artery or a severe abnormal rhythm of their heart. Otherwise known as cardiogenic shock, this syndrome can lead to cardiac arrest unless the heart is supported with the precise correct amount of medications to increase the pumping function or improve the arrhythmia.
- Any massive trauma patient with injuries both to their airway and to their major vessels. Picture a motorcycle accident victim with a bloodied, smashed-in face and a blood pressure of near zero due to hemorrhage. The placement of an airway tube can be extremely difficult because of the altered anatomy of the head and neck, and the management of the circulation is urgent because of the empty heart and great vessels secondary to acute bleeding.
- The syndrome of “can’t intubate, can’t ventilate.” You’re the anesthesiologist. Picture any patient to whom you’ve just induced anesthesia, and your attempt to insert the tracheal breathing tube is impossible due to the patient’s anatomy. Next you attempt to ventilate oxygen into the patient’s lungs via a mask and bag, and you discover that you are unable to ventilate any adequate amount of oxygen. The beep-beep-beep of the oxygen saturation monitor is registering progressively lower notes, and the oximeter alarms as the patient’s oxygen saturation drops below 90%. If repeated attempts at intubation and ventilation fail and the patient’s oxygen saturation drops below 85-90% and remains low, the patient will incur hypoxic brain damage within 3 – 5 minutes. This situation is the worst-case scenario that every anesthesia professional must avoid if possible. If it does occur, the anesthesia professional or a surgical colleague must be ready and prepared to insert a surgical airway (cricothyroidotomy or tracheostomy) into the neck before enough time passes to cause irreversible brain damage.
A beautifully written piece regarding the amazingly brave and young neurosurgeon who grappled with his own mortality from the perspective of the physician as well as the patient. A truly excellent read.
Posted from Stanford News: Paul Kalanithi
When great souls leave this earth, we mourn.
My condolences go out to his family, friends, patients, and everyone’s lives he touched. When faced with our own mortality, would we change any aspect of our lives?