I seem to be in a rut of some sort where I cant get anything productive done. It has to stop at some point. It must stop. Simple strategies: 1. 1 hour of formal project work a day. 2. Train every other day. 3. Less time wasting activities. Lets see...sign...

aortic arch repair

Presentation 2 from shark78

Aortic Arch Work Recently, I was given the chance to do two complex aortic arch reapir work. These patient had aortic tears repaired in an emergency setting. Surgery was life saving. Their entire body circulation was stopped, the clock started ticking, and surgeons had to repair their aorta with a synthetic graft as fast as possible. They made it through the surgery, but a few years down the road, the graft started leaking. My hospital team is extremely experienced in repairing such leaks, while making sure that blood supply to their brain is uninterrupted. The surgery, anaesthesia and perfusion is complex. I was watching and learning about the surgery from the eyes of a novice. And I learnt a lot. I gave a short talk on the topic. I was daunting. I was no expert. If you cant make people understand, it might mean you dont understand. I prepared the talk in a way, that it would take ten minutes, and a beginner would understand so they can be of more help and learn more the next time any of them got a chance. It took about 10-15 mins. The steps were a bit oversimplified-there's a lot more details. The crew needs to be very skilled, experienced and on their toes at all times. I highlighted one major blood flow problem that can arise. Thats about it.

A good upper back workout

The creation of the chair, iPad, table and laptop has screwed our backs. We go to the gym and train the muscles we see in the mirror, mainly the front facing ones. This leads to a race of humans with droopy, weak looking rounded shoulders, cervical spine problems and eventually lower back problems. A good upper back is essential for health, and it gives us that broad shouldered look that and has a lot of functional carryover in daily life. For chicks, its a natural boob lift. It also balances out the tons of pushing work people do in the gym to develop pectoral muscles. The whole upper back musculature is complex, consisting of the trapezius, rhomboids, lattismus dorsi and rear deltoids. A good upper workout will recruit and stranghten all these muscles and should take about 1 and 1/2 hours a week ( two 45 minute sessions). Basicly,all pulling work involves the back. We should start with heavy, basic compound exercises done properly. 1. Pull ups-the grandad of all back exercises. I use a pronated( palms out) shoulder grip style, pull myself till my upper chest touches the bar, then lower myself without dropping like a stone. They are hard to do, and get harder as we get bigger. Often, the limiting factor will be a low repitation capacity. Its very frustating to only knock out 3-4 reps before the range of movements drops. I usually call it quits when my chin can clear the bar. Instead of stopping the set for good, I make it easier-closer grip, palms it grip to knock out a fewmore reps, then when I fail that, I just hang from the bard and retractmy shoulder blades, making them touch in the middle. Thats one ser. Rest a max of two whole minutes,than back to work for another 3 sets. If pull ups can be done, sadly you can substitute with the pulldown machine. Its already pathetic, just make sure the bar touches your sternum. Its an easy, watered down version of the chin up, make it as hard as possible with controlled movements and bringing the bar to the upper chest. Same rep/set scheme as per chin ups. 2. The second exercise will be dumbell shrugs. Just grap a couple of big heavy dumbells, let your arms dangle by your sides, like when we hold suitcases and shrug your shoulders. The range of motion is limited, so make the exercise count by holding the weight at the top for of the movement for a sec.When the weight starts to slip, dont quit, rest the dumbells on something, then keep oing. Target about 10 repitions. Rest only a minute, then, dont feel bad about grabbing lighter dumbells, and keep going-4 sets in total. 3. The last exercise is upright rows-hold an EZ bar-easier on the wrist, do your rotator cuffs a favour by using a mederate weight, and 'row the weight' pull the bar vertically from waist to chin for 10 reps. This hurts my shoulder a lot. A lot. Retracting the shoulder blades, and doing the reps in a slow controlled motion helps. Aim for 4 sets of 10. There, thats it. Do some bicepwork, or ab work or whatever that makes you feel good. Like everything else in weight training, if you are good at doing it, its not going to work so well. Your muscles are no longer traumatised and stresssed. Muscles adapt trauma and stress. Use progressivly heavier weights, slower reps, better form, or shorter rest times so that you look like you are dying of pain to everybody else in the gym. After six weeks or so, you will probably need an entire different workout for that shock factor. These workout should take 45 mins max. I use really heavy weight ( for me )explode on the contracting part of the movement, and go slow on the relaxing part. Then I make rep more interesting by letting the weight passively stretch the. muscle at the bottom of the movement. Thus, each sets builds a lot lactic acid and I take longer to recover between sets. Progress faster, and you would get a modified painful cardio workout. Supplements-water, lots of it is a must. Anti oxidants of any sort are good. Pure coffee is a good pre-workout-after-work pick up. If you are a vegetarian, a spoonful of whey protein isolate might help. Otherwise, a can of tuna or something like that will suffice. Optimal time to repeat-once every three days or so.

art lines

There are lots of ill patients at the Austin, and giving anaesthesia to an ill patient always equals to an art line. Am I right? probably not.

There only several conditions in which an art line is absolutely mandatory, meaning you would put your heart and souls into getting one and will resort to desperate and brutal means of acquiring one and may even cancel the case if there is no art line.

These are in no particular order:

1.Liver transplants
2.Cerebral aneurysm surgery
3.Elective cardiac surgery
4.Carotid endarterectomies under GA
5.Carcinoid tumor resection and Pheochromocytoma resection.
6.Big people where a BP cuff wont fit.
7.Burn victims.

There's a whole list of situations where it will be nice to have one, but it will do jack shit for for patients.
There's an even bigger list where we put one as a safety blanket.

There's also a list of surgeries where we have no business doing an art line until (ironically) the patient is safe:

1.Hypotensive shock
2.In an actively bleeding patient
3.In a hypoxic patient
4. In an obtunded patient with raised ICP.
5. In awake, poor frightened patients going for cardiac surgery.

In bleeding patients, shocked, hyotensive patients we should try to keep them alive. When, a second pair of hands arrive, then second pair should help us keep the patient alive. When a third pair of hands arrive, that third pair should help keep patients alive.

There are thousands of things to check:
-enough crystalloids
-enough colloids
-do we need blood
-do we need products
-acidotic? -do we need a NaHCO3 solution to catch up?-no we dont an art line to dram blood sample!
-are we behind calcium
-does someone need to start an antifibrolytic
-is it time to organize the level one?
-is the patient freezing? can we do more-ask surgeon to apply warm packs? increase bair hugger temp, wrap his whole neck and head up, blah, blah,blah

our first duty is to the patient. when we sort out all this, then we can then make our monitering screen look pretty with an art line waveform. And it DOES look impressive, regardless of the sorry state of the patients BP!


What do we do when (gasp!) we dont have an art line?
use the NIBP cuff, ECG, watch the etCO2 to gauge cardiac output, watch urine output, CVP, pulse oxi waveform, and yes i know its crude and unscientific, but, believe it or not, we can actually PALPATE the brachial an carotid pulse and resusitate accordingly.

I am not against artlines, and would have hundreds. Its just that there's a time and place for everything.

First post 2012

My time at Western Health really flew. I have never known time to fly so fast. There is also talk about my a ten year reunion amongs my medical school friends. A whole decade!
Little Dahathri went for a tumor resection in his tongue. We are still waiting with fingers on the results. But I somehow feel everything will be fine. I obviously didn't do anything very clever, or design them in such a way, but all my kids are extremely durable. They will pull through most things in life.
I am sad to leave so many friends behind at Western, but it was immensely gratifying to work with such a great bunch. They are not the type to shower praise easily and I was extremely pleased with their opinion of me. They also did a lot for my little one!
The Austin is a larger setup then Western with more complex cases, and already the specialist seem to have a certain degree of confidense in me.
Back to hitting the books for now.

just moved into my new house. its nice and comfortable and the kids and wife really love it. mafeitz is having a wonderfull time here.

sometimes, i wonder if i bit off more than I can chew.....different country, new workplace, new home, formal project, exams.....

but then again, i have been struggling for such a long time, that if i get things my way i probably wont know what to do!