Tag Archives: reflection

Personal reflection – Cognitive bias

Case of acute and evolving intrinsic cord lesion in pregnancy presenting as unusually bizarre, but evolving neurology, referred as ‘cauda equina?’

When faced with an unusual presentation, particularly if it does not fit with anything ever seen before, and even if on probability it is very unlikely to be pathalogical, need to exclude the relevant and not be biased towards preliminary diagnosis planted by others. Consider Bayesian modelling.

Have an open mind and think broader than the problem presented. Is this something that we have neither yet considered nor ever seen before? How to prove/disprove this? Consider safety nets and worst case scenario. Accept uncertainty in an uncommon, undeclared situation rather than over-confidence. Observe evolution over time with multiple snap shots and opinions.

GAT conference take home messages

Tips:
Give IM atropine with IM sux
In obese O2 consumption is significantly greater during SV rather than IPPV
Epidural blood patch recommend 20ml
Dural puncture: inject 20ml normal saline down intrathecal catheter
NSAIDs may affect  platelets and clot strength of EBP
In difficult airway consider nasendoscopy.
AFOI topicalise. Reduce secretions by suction catheter or Yanker (also tests topicalisation)
Legal position: Prudent doctor  -> prudent patient
Coding – appropriately – gets the organisation appropriate money
Quality measures – e.g. length of stay
How to add value ? Outcome or quality / cost
In a report, if used a guideline say so
Detail discussions with patients, including apologies
References to read/watch/review:
‘Perfect storm NHS funding’
Cardiac arrest in neurosurgery patients

Cliff Reid YouTube videos
DOLS
NICE guidelines on trauma
BATLS, ATACC course
Kirkpatrick model (for simulation)

OLV

Options:

1. DLT

Adv: Best for ventilation/control of each side.
Dis: bulky therefore not in difficult intubation, tracheostomy

2. Single lumen ETT with bronchial blocker

Adv: Use in (pot.) difficult airway, tracheostomy, if ETT already in situ e.g. ICU.
Dis: More specialised kit and technique. Needs fibreoptic scope.

3. Single lumen ETT advanced into main bronchus ( + fibreoptic if left sided)

Adv: Useful in emergency with most simple/available kit.
Dis: no control over non-intubated lung.

Time to muscle relaxation for intubation

I tended to attempt intubation prematurely… 3 minutes feels like a long time.  That’s why, when starting at least, the second person came along and stuck the tube down with ease due to the improved intubating conditions i.e. muscle relaxation!  As for sux, if possible, wait for longer than ‘end of fasciculations’ . JC enforces timing 60 seconds!  Especially important in difficult intubations in elective situations.