Happy New Year…and a rant

9 01 2013

Happy new year guys. or myself.

So far, studying has been slow and work tiring —-been procrastinating my 1 drug a day….

Just a rant…

its a new year !

We had a little boy 6 years of age with 8 days of intermittent nausea/lower abdo cramps/vomiting/diarrea (non billous) whom mum says has lost 4 kg !

He had some right lower quadrant aches , otherwise soft tummy (and looked really well – afebrile, HR 80 and good blood pressure and BSL 5!) Boss assessed him too and agrees —- appendicitis vs gasto vs mesenteric adenitis

Urine dipstick normal

got the line in, bloods sent – – called our nearby Paediatric Surgical colleagues at the Paediatric hospital (we don’t have paediatrics in our hospital)

Paeds Surg Reg was slightly obstructive as adamant about bloods not being ready and not impressed w the story.

He wanted a paediatric USS.

Now at this point :

a. i was slightly thrown off track – – could we organise one ? (well…i think we shouldn’t as : our USS guys mainly do adults and ths kids not be assessed CLINICALLY)

b. my diagnostic thoughts and confidence in my disposition weren’t strong anymore.


I thought : hey this young boy has 8 days of nausea/lower abdo pain/vomiting w RLQ pain and needs to be assessed AT A PAEDIATRIC hospital and we thought hey lets let the surgeon know first up b4 we send the boy in.


At this point, (might be lack of caffeine or the presumed junior position that I thought i was) I wanted to defer the phone call and let my boss speak to the surg reg directly. I asked the surg reg to do you want to speak to my boss “yes, please” and politely asked my boss that the surg reg would like to speak to him.


My boss says ” NO I WON’T TALK TO HIM, that kid is going to that PAEDS ED, and that’s that!”


AM like WTF

At this point in time, I think the paeds surg reg could have hear this from the phone and probably felt sorry for me (his tone did soften, and said he’ll call me back after talking to HIS boss)

He called back saying “ok, send him over”


My rant is :

if you are a boss (i.e. Consultant) and don’t want to step in and STAND Up for your juniors. thats fine.

I’ll learn to harden the f*** up and sort my shit myself.

This is a bad example to set in front of the juniors.

As a consultant/registrar – – – if a specialty you are referring to is obstructive, you NEED to step in and STAND UP for your juniors. This is why as juniors we seek guidance and LEARN from you. If you agree with our assessment and disposition – please have the guts and take the effort to stand up for your juniors.


The genders may or may not be representative of the parties involved.





9 01 2013

Did my first Bier’s block yesterday. unwitnessed fall in a lady (high care nursing home patient) with significant comorbidities : COPD and newly diagnosed malignancy.

I’ve done them twice at least with senior registrars (me being the lever or the counter-traction guy) during the manipulation.

Yesterday was a first adjusting the cuff etc (but the boss still insisted on giving the drug himself)

biers_block —this is a page pdf file produced by the Gold Coast hospital which serves as a good intro and explanation including step by step about the Bier’s block. More goodies from : emergencyweb.net (you need to register – FREE)

Addit as of Dec 2012, the Gold Coast Hospital has limited the access to emergencyweb.net to only their staff.

So….drug of choice we gave was : PRILOCAINE

Let’s talk about local anaesthetics with Prilocaine as our star drug

WHAT is it ?

Local anaesthethic. Amide type


  • Absorption : systemic absorption affected by :
  1. dosage
  2. site of injection – high vascular area e.g. trachel mucosa means rapid absorption ; peak serum level highest esp intercostal block while sciatic and femoral lowest
  3. drug-tissue binding
  4. local tissue blod flow
  5. use of adrenaline (vasoconstrictor)
  • Distribution :
  1. Localised >>>
  2. Systemic …2 compartment model : initial alpha phase – rapid distribution and highly perfused organs. Slower beta phase – less perfused tissue ( muscle/gut) protective effect by uptake in lungs – serves to attenuate arterial concentration.
  • Metabolism
  1. amides converted to water soluble metabolites in liver


  • Mechanism of Action
  1. Membrane potential – blockade of voltage-gated sodium channels
  2. Sodium channel isoforms
  3. Channel blockade
  4. Other effects :
  • Structure activity characteristics of Local Anaesthetics
  1. smaller + more lipophilic LAs, faster rate of interaction w sodium channel R
    —-lignocaine/procaine/mepivacaine more water soluble than tetracaine/bupivacaine/ropivacaine (more potent and have longer duration, also bind more ext to proteins)


  • Neuronal factors affecting block
  1. differential block

Amides vs esters. Usual questions in MCQ for the primary ?which is a amide or ester ?

local anaesthetics that are Esters :have just one ” i ” in their names eg procaine ,cocaine but …
Amides : have more than one ” i ” in their names lidocaine, bupivacaine,prilocaine