Friday, July 5, 2019

EPISODE 04 - INTERNSHIP DIARIES (What will I do with your blood? -Vials and sampling)


- By Upasana and Jay

It has been a tired day at the hospital. You are almost at the end of your day of duty when your senior resident asks you,

“Dr Kesh, can you please prepare the Laboratory forms, sign them for me and then, submit these blood samples to the Main laboratory?

“Yes sir!” You pressure a smile and look at the blood samples and the empty Laboratory request forms needing your signature and your gleaming new stamp with your licence number.

You sit down to prepare the blood samples.

******************************************************

(Lesson 2)

There are 3 types of blood we use for different purpose:-
  1. Capillary blood
  2. Arterial blood
  3. Venous blood


WHEN DO WE NEED CAPILLARY BLOOD?

Often drawn as a small amount of blood in a microtubule. Often used a sterile needle to puncture the skin of the fingers, toes or sole(esp for an infant)

  • Strip for blood sugar meter also called Glucometer.
  • Bleeding time tests
  • For infants and young children 


WHEN DO WE NEED ARTERIAL BLOOD?

  • Specially required for estimation of the blood gases ABG(Arterial Blood Gas) ,PH,PCO2 and PO2.
  • Collects quickly,and fills completely due to the arterial pressure.
  • Always mention Spo2 of the patient measured by pulse oximeter.

  
WHEN DO WE NEED VENOUS BLOOD?

  • MOST COMMONLY USED METHOD
  • Majority of routine tests are performed on venous blood.
  • The best site -deep veins of antecubital fossa. 

IMPORTANT - DO NOT TAKE BLOOD FROM HAND WITH VENOUS INFUSION,THIS LEADS TO FALSE RESULT DUE TO DILUTION OR ADDITION . TAKE THE SAMPLE FROM THE OPPOSITE HAND OR A FOOT.

SUPPOSE WE ARE GIVING GLUCOSE DRIP AND YOU TAKE SAMPLE FROM THAT HAND. THE BLOOD GLUCOSE COULD COME OUT AS 600mg/dL DESPITE HE BEING NOT DIABETIC WHICH WOULD LEAD YOU FOR A MISDIAGNOSIS AND YOU MIGHT END UP GIVINIG HIM INSULIN.

Note that in Pediatric Patients, the vial sizes could be smaller and the blood needed will be a smaller amount as well, often amounting to 1ml for infants and toddlers.

SERUM:-

Liquid remaining after blood has clotted naturally in a plain tube.
It is the most common specimen required for chemical and serological test.

PLASMA:-

A fluid obtained from anticoagulated and centrifuged blood.
it is required for coagulation profile and fibrinogen assay.

FOLLOWING THINGS WE ALL SHOULD KNOW ABOUT THE CAPS OF THE VIALS:-

LAVENDER CAP - Most commonly used. Contains EDTA. Used for Routine blood tests like Hb,TLC,PS,ESR determination by Wintrobes method.
GREY CAP- Contains sodium fluoride. Used for blood sugar estimation.
BLUE CAP- Contains citrate as an anticoagulant so we used for coagulation tests and ESR by wetergreens method
DARK GREEN CAP - contains heparin so used for ABG analysis,Osmotic fragility tests and immunophenotyping.
LIGHT GREEN CAP - for plasma determinations.
PINK CAP-is similar to purple but used for blood banking.
RED AND YELLOW CAPS -CONTAINS NO ADDITIVES and are used for serum studies.

Cap Colours of Vials




The ratio of anticoagulant and blood. :
  1. Sodium citrate 
  • in blue tube :- 1:9 
  • in black tube :-1:4
2. Heparin Dark green tube:- 0.5 to 1 mg per 5 ml of blood.


  • HOW MANY TIMES YOU HAVE TO INVERT TUBE TO MIX THE BLOOD WELL?

-          8-10 TIMES.

THINGS YOU SHOULD THINK BEFORE TAKING OUT ANY SAMPLE :

  1.  Identify the patient (Name, age and sex). Certain parameters are different according to age and sex of the patient.
  2. See the provisional/working/admitting diagnosis
  3. Site of collection
  4. Time of collection of sample
  5. Your expectations with this sample in leading you to diagnosis hence helping to select the vial.

At the end of collection make sure you always write the 
  • Name of the patient 
  • The sample and test 
  • The date and time
  • Optionally the name of the Doctor who ordered.

********************************************************

You finally finish your lab requests, sign them, stamp them and send to the laboratory, and stand up to go home!

It had been a tiring day saving lives! You deserve a nice meal and a good night’s sleep! You walk out of the halls of the San Jose General Hospital, with a sigh of relief!

********************************************************

Main Author : Upasana Yadav
Co- Author : Jay 

EPISODE 03 - INTERNSHIP DIARIES (Let me gain access into your veins)

(Lesson 1.2)

Inserting an IV line or an Intravenous line is a very much of an expected skill from a Medical professional. Although often performed by Nurses, the skill can come handy at any time because in a case of a hard insertion the nurse or the ancillary staff may refer the patient to you to perform.

Before inserting an IV line you need to know what is an IV Cannula or an IV Catheter.

A cannula or a catheter is a small tube made out of medical grade materials that would allow a medical professional introduce or extract a substrate to or from the body. In a case of an INTRA-VENOUS cannula the access is taken in to the VEINS.

Usually an IV cannula can be used to introduce IV fluids, IV medications as well as sometimes to draw blood(often at the insertion moment).

1. The catheter itself is composed of (a) a tip for insertion into the vein, (b) wings for manual handling and securing the catheter with adhesives, (c) a valve to allow injection of drugs with a syringe also called a LUER lock-valve, (d) an end which allows connection to an intravenous infusion line, and capping in between uses.
2. The needle (partially retracted) which serves only as a guidewire for inserting the cannula.
3. The protection cap which is removed before use.

(By courtesy of Wikipedia (
https://en.wikipedia.org/wiki/Peripheral_venous_catheter) retrieved 7/5/2019)

These cannulas come in different shapes and sizes, and the sizes are measured in BIRMINGHAM GAUGE SYSTEM often abbreviated as G. In this system the lower number is having a higher diameter and a higher number is having a lower diameter of the catheter tube. (This is different from French Gauge System where it is opposite from this numbering system and is often used in NGT tube sizes)

So, an 18G IV cannula is larger than a 20G IV cannula.

The recognizing of these cannulas are done by the colour of its Luer lock-valve or the tip of the needle in some varieties.

The colours are pretty constant throughout the world but sometimes it differs. So always refer to your senior before checking out a cannula for the first time or better yet, READ WELL of its packaging.

(Note that in some countries 26G could be of Purple colour)
- Table by courtesy of Wikipedia (Retrieved 7/5/2019) -


Check for your needed equipment and material.
  • Alcohol or Hand Sanitizer/Soap and water
  • An alcohol wipe. - To sanitize the skin
  • A tourniquet. - To block the venous flow and engorge the vein as well as fix it.
  • An IV cannula - As mentioned above.
  • A suitable plaster or a Tegaderm® - To fixate the IV cannula/catheter on to the skin
  • A syringe with normal saline - To flush the Catheter
  • A clinical waste bin with a sharp disposal section - To dispose the waste including the needle.

STEPS

  1. Identify a visible and/or tangible vein. Try to feel it. A rule of thumb is, the better you feel the vein the more successful your insertion will be.
  2. Once you identify the vein, apply the tourniquet and recheck on the vein if its engorged and tangible.
  3. Apply alcohol on your hands and clean it. Wear your gloves properly as explained before; in case you were already wearing gloves, check if you can request for a change of your gloves. Touching a patient without gloves is discouraged.
  4. Clean the patient's skin with Alcohol wipe, a cotton ball soaked in Isopropyl Alcohol 70% or Ethyl Alcohol 70% is alright.
  5. Before inserting the catheter and check if the catheter tip is clear without any manufacturer's defects such as a defect end. Check the needle for its bevel up. 
  6. Stretch the skin distally, and look for your insertion point. If your vein-in-concern is not much engorged you can try slightly tap on it.
  7. Tell your patient to expect a sharp pinch on their point of insertion.
  8. Insert your needle beveled up, usually around 30-45 degrees to the skin and advance your needle to see if there is a flashback of blood at the hub of the syringe.
  9. If you see the flashback, then advance the whole needle about 2-3mm and then retrieve the needle slowly and check if a streak of blood is following the returning needle. If it does...Congratulations! IF NOT, try withdrawing the needle a bit and change the position until you see the flashback.
  10. If you cannot do it while the needle is inside, then retrieve the whole catheter and re insert at a different point of a different vein.
  11. If you still cannot, then ask for help from a senior.
  12. In the fortunate incident of you are already inside the vein, remove the tourniquet and while removing the needle, give pressure to the top of the cannula tip already inside the body so the blood will not reek out making your field a mess!
  13. Insert your prepared flush into the catheter and try to inject. If it proceeds with no resistance, then you are good to go!
  14. Get your Primed IV line or HEPLOCK (which is used to administer IV medications in a later  time via the catheter and it will stop the blood from reeking out) or close the end with the white cap of the needle(Often used with those catheter types with Luer lock-valve where a heplock is not needed)
  15. Take your previously prepared Plasters or already opened Tegaderm® and secure the IV catheter on to the skin. There are several methods of securing the IV catheter on to skin using plasters. We will discuss 
  16. Dispose your needle to the sharps disposal.
  17. Clean and wash your hands.

Congratulations, you are done with your IV catheter/cannula insertion.

*******

You look at the face of the patient after finishing your work, and you are proud that you got access in one hit and did not spill the blood.

"Thank you doctor!" Your patient thanks you.

"You are welcome!" You smile and leave the patient with your tray.


*************

Thanks guys for the support! Thanks for the messages you have been sending to my Whatsapp requesting for more articles. We will try to provide more topics soon. 

With love,

Jay

Wednesday, July 3, 2019

Fregoli and Capgras.

So this post is regarding Delusional misidentifiaction syndromes.
There are two of them i. e. Capgras and Fregoli syndrome.

Now both of them are super confusing and are often asked in entrances. I made a mnemonic to remember them. If you can remember any one of them, you can figure out other.

So I hope all of you are aware of GOT-Game of thrones! Remember Arya stark had face swaping ability? She killed entire Frey family by it. So did how she kill them? She disguised herself as head of the family - Walder Frey and killed them.

So take A from Capgras. Here A stands for Arya stark. Arya killed family of Frey by disguising as Walder Frey (Family member). So in Capgras, patient thinks that murderer is going to disguise as a  family member and kill him. Eg Nurse disguised as a wife to kill him.
Capgras is also know as The Delusion of doubles! 

OR (To non GOT fans)

FreGoli:
F= Family
G=Gun (In hindi you can simply remember Goli)
"Family members trying to kill patient with Gun but disguised as someone else"
Eg: Wife disguised as Nurse to kill patient (Husband)

"Valar Morghulis"

That's it

-Demotional bloke.

EPISODE 02 - INTERNSHIP DIARIES (Protecting you and myself)

NOTICE!

Awesomites, I'm super sorry for being super late, I was so busy with my MD graduation hence I couldn't update the promised topics on Internship Diaries. I will update as soon as possible all the topics we need to discuss.

With love,
Jay


(LESSON 1.1)
WEARING SURGICAL GLOVES

       There are three forms of wearing gloves. 
  1. OPEN, 
  2. CLOSED 
  3. ASSISTED. 


Closed is the most sterile method and used mainly in operating rooms where you wear gowns and glove yourself and asepsis is highly expected. 

You utilize the Open method in situations in wards, and other Non-OR situations. 

Assisted method is when someone else such as, a nurse or a fellow colleague will serve you the gloves and you simply slip your hands in.


OPEN method,

  1. Remove whatever you are wearing in your hands, including rings, bracelets and watches. Try to keep it free elbow-down.
  2. Wash your hands with soap, and use Sterilium(R) or Isopropyl or Ethyl alcohol 70%. (Using them will eliminate the remaining bubbles of the soap.) 
  3. Then wipe your hands with a sterile towel.
  4. You will take your surgical gloves, open the outer cover and bring the inner cover outside without touching inside the gloves. 
    Surgical Gloves Inner cover
  5. Leave it on a flat clean surface and open the flaps, and you will see two gloves one for the right hand and the other for left hand.
  6. You will also notice the sleeves of the gloves are rolled upwards. The inside out part is considered unsterile and the inside the roll part is considered sterile. 
    S = Sterile part   |    US = Unsterile part
  7. So you use your non sterile dominant hand, hold the glove from the non sterile outside part and slip over your non dominant hand. Do NOT flap back the sleeve because will get contaminated because you are not yet wearing gloves on that hand.
  8. Now use your non dominant hand with the glove on, and slip the four long fingers of your hand into the rolled sleeve of the other glove. Because it is sterile. Bring it up and slip the glove over your non gloved hand. And flip back your sleeve.
  9. Then use your newly gloved hand to roll down the sleeve of your other glove from the inside the roll.
You are successfully gloved!!!



In closed method someone will open the outer cover for you and you take the inner cover out, and wear it in such a way where you do not touch the glove at all skin-to-skin directly, but it will be discussed later. Too much info in one post will cause brain freeze. 

In Assisted method after gowning yourself, someone else will open gloves and serve you. Check if the thumb side is correct accordingly and slip in. If not you will be stuck and will need a new pair of gloves. Waste of time, waste of gloves and waste of effort!!

*******
You put on your gloves and see the nurse has prepared alcoholized cotton balls, 5 plaster strips of around 4 inches long and partially opened the IV catheter pack.

You take one alcoholized cotton ball and start looking for a vein.
[ To be continued... ]
*******
The answers to our previous questions regarding gloving are,
1. There are 3 methods
       1. Open
       2. Closed
       3. Assisted
2. There are 2 types of gloves
       1. Examination gloves - Often clean but not essentially sterile although some sterile varieties exist.
       2. Surgical gloves - Often sterile and comes in a tightly sealed pack. Do not use if the pack is already open.