Proseal for neurotization

(This post can be a bit too technical for the non-medical field readers.. i just had to blog this out so that i may refer to this later as a reference.. LEVEL 7 evidence.. hehehe)
I was doing Prof Sara's hand list the other day. It has always been challenging for anaesthetists to provide excellent surgical conditions and at the same time maintaining safe and effective anaesthesia for the patient. ( i dunno whether surgeons do appreciate our efforts for them?) In the particular case of neurotization or brachial plexus injury nerve repair, the surgeons would usually need the minimal usage of muscle relaxation for their nerve stimulation during the repair. The sugery can be very long therefore the issue of balancing between muscle relaxation and tube discomfort that may make the patient gag if the anaesthesia is too light in the middle of the operation.

Traditionally, we would give only one dose of muscle relaxation for intubation and keeping the patient deep under anaesthesia either via increasing the inhalational agent or balancing it with IV Propofol.IN being conservative , we would prefer to keep the patient with a definitive airway which is the ETT. Unfortunately , once the muscle relaxation wear off it would stimulate the airway reflexes making the patient wake up and being uncomfortable. It would be obscene to have patients moving and gagging the tube while the operation is on. However , putting the patient deep with inhalational for many hours may invoke severe post op nausea and vomiting. hehehe a difficult decision ah?Using a laryngeal mask for many hours may not be such a good idea because of the amount of secretion that may build up and precipitate laryngospasm either intra or as one is taking the LMA off.

I tried a slightly non conservative move the other day by putting in LMA proseal and provide IPPV for the patient. NG tube was possible to be passed through thus making me able to channel out the air off the stomach if the IPPV cause the stomach to inflate.I wanted to use LMA SUPREME ( which i find is the most excellent supraglottic airway to use by date) but as usual in UMC- it is not available when you want it!! I did not use a single muscle relaxant for the op therefore there was no way that the surgeons would not stimulate the nerve and making my muscle relaxant as an excuse and pressure !!
Initially i tried to use TCI propofol but unfortunately the infusion kept fissuring my IV access. And guess what? I resorted to the good excellent DEXMEDETOMIDINE which i gave as a small dose infusion to reduce the usage of my inhalational agent which was sevoflurane. I kept the MAC between 0.7-0.8 and my DEX was running at a rate of 0.5-0.7 ic/g/hr. However , i sort of forgot about my BIS until the patient was drapped over which was too late for me to place the sensor! I could have reduced my MAC further if there was BIS on board but i guess ok la tu.. :)
The op took us 6 hours and i kept him on IPPV for the whole period.He was particularly deep and no surgical stimulation as such for the whole duration. The surgeons had a maximal nerve stimulation but of curse the surgery is tedious and micro standard.
Patient was comfortable post op and it was not long too take the Proseal out! with the Dex effect , patient was fairly arousable when stimulated post op! It was excellent anaesthesia on board and i guess should be applied to similar cases in the future!

Block expert wannabees..

Peripheral nerve blocks are certainly the in thing in anaesthesia. The option of having surgery without giving general anaesthesia is an interesting idea. Of course , it is not suitable for all surgeries but definitely for limb and anything away from the mid trunk. It needs a lot of skill and to reach that level of skill one needs a lot of patience. Obviously , male anaesthetists are more inclined towards this technique compared to our females counterpart. This may not be totally true but then agia , its always the man having the upper advantage when you talk about "fine" skills..
I was converted into this "sect" of anaesthesia long ago when i was introduced to it by Dr Salleh ( at that time he just graduated as a specialist) on one of my junior calls in HKL. Later on I met Jeya in Selayang and he further embraced me further bout its benefits. The only way to learn doing blocks were just trying it again and again.
Of course , when i came to UM ; i was introduced to Dr Ling.. the MASTER SIFU of peripheral nerve blocks. He gets so excited everytime there is a block going on and i know , if it was possible he would avoid giving GA altogether !! FYI.. i had the opportunity to perform "extraordinary" blocks with him that our case report was accepted in the coming EuropeanRegional Anaesthesia conference in Austria !! ( but that will be another blog entry in the near future.. :)

And when i thought i was comfortable with the nerve stimulator technique , came the ultrasound guided technique. I was initially a bit reluctant to convert myself ( the usual trend of practices in anaesthesia) . I would have thought that nerve stimulation technique was superior enough but considering the safety that ultrasound visual offer it was difficult to resist.Things u gamble may not be wise after all after seeing how close vital structures are to the neerve bundles under ultrasound guidance! It was so easy to cause a lot of unecessary tissie and possible functional damage if one is not careful. However , it is not for the impatient ones as the whole procedure may take time to perform. Good communication with provisions of time management must be applied to ensure the learning curve is steep.
Ultrasound visuals of muscles and nerves need a lot of imagination and people teeling you which structure is what. It can be really annoying doing the scan an unable to identify which is what !
"There.. Mafeitz see.. you are there already.. "
"Where Ling ?"
" There your needle.. see that. thats the nerve.."
Which one Ling ? I cannot see... "
"Haiiyaaaa.. that one laaah !"
" Ling KU!! Tak nampak pun ??"
" Yeaaah.. give the local..see the spread ?"
" Huh ????"
" Haiiyaaahhh !!"

Uniten Malakoff Duathlon leg 2

Honestly , eventhough i registered for this event early ; I was so sure of ditching it due to logistic reasons. I;ve not cycled on my T bolt for a very long time and this week i was not able to do any runs in the evening. Wifey was on her intensive "learn to swim" classes that I have to take care of the 3 kids in the evening till her return.
Azad called me.. volunteering to carry my bike with his and i never thought it would be possible ! Of course, bila dah kena racun i agreed and yes.. another event done! It was only Azad and me this time around. Uniten location in Serdang can be a bit of turn off i suppose especially when you don't really have the means to bring your bike with you.

We were in Uniten by 8am ; the race was scheduled for 9am which i consider to be a bit late. Uniten is barren and the cloud looked clear and not as hazy as it was few days back. I really haveto improve on my bowel opening ; as eventhough I thought i've "invested" enough at home in the early morning , I still had to go and settle it upon arrival in Uniten! hahaha we sneaked into a nearby college.. andd waahh.. ok settled !! :)
It was cool to have Shebby Singh as our emcee as his voice made the event "sound" good. We just had to take a pic with him so to justify our travels to Uniten.. hahaha The race started at 9am ish and off we went. I did realize the number of participants were markedly less compared to the UM event last year.

How was the race ? Damn blazing hot... TAK HINGAT PUNYA BAHANG !! I was literally roasted because i did not hav any cap or covering as i ran. The first 3km was good ; i actually did a bit of sprint !! well, not that i beat anybody but it was good to know that the body can cope with such stress.
And then came the transition to the bike. Riding a mountain bike is obviously a disadvantage but then..I'm here to compete with myself and see whether i can do it or not! The first lap was a killer for me because i was familiaring myself with the bike and this resulted me exerting too much effort.. Pancit gila-gila punya.. hahaha the 2nd and 3rd lap was better ( at least for me!!) and the most important thing; i rode all the way and did not have to push my bike ! oklah tu.. hahaha I noticed that they did not record our laps and anybody could have just cheated and do only 2 laps! But naaaahhh.. that is not the point of joining races such as this. You would end up cheating to yourself and i guess i will never do that. Eventhough i know
the 3km run back was obviously slower than my initial 3km but the adrenaline was good. It was 10amish and maaannn... i cannot describe the heat. The water bottles given were used to cool myself down from the outside ; but of course , it evaporated fast and its back to the blazing ray of the mighty SUN!!

Yeaaahh.. habis !! I did not time my run but i guess it was satisfactory. My biking was really bad but i am sure it is much better than last year's MUDS.
So what were the highlights of this event today for me?
1. Pic with Shebby..
2.Pic with Samantha Schubert.. hehe
3.I am so dark now that i'm sure everybody in the department will ask what happened to me on Monday !! Hahahaha

Tutorials galore

In the preparation for finals, I must say that my batch is currently getting a lot of teaching . It was obviously absent for my seniors until it was near to judgement day. This time around we started early which was during the first week of us being final years!! It has been going on intensely with at least 2 tutorials per week . We've been having Prof Patrick's class regularly since Year 3 therefore by right the vacuoles in our heads should be filled or if not at least half of it ; to have some sort of idea what anaesthesia is all about.

However, this creates more pressure ( to me at least) to perform well in the coming May 2010 finals. It seems early now but considering the amount of knowledge that we should know in order to qualify ourselves as anaesthetic speacialists ; i reckon all this stuff are essential !!However , the more you think you know is the more things you don't know really... hahaha

I'm not fully geared up for the exams yet ; i guess i am more concerned with my ability to be a good specialist when i pass out. To be confident and having 3 -4 alternative thoughts of management instatenously is a challenge i have yet to master.. hehehehe ( mcm nak jadi jedi laaa...)

One of those rare night..

I'm a Liverpool fan , therefore when MU mentioned that they were coming to Malaysia it did not excite me at all. I was left wndering why Liverpool preferred Thailand and Singapore ; missing Malaysia in between. I guess the fan base in Malaysia is not as strong as the ones sandwiching us.
Fiqar called me up and mentioned how he managed to wrest few tickets for the game.. when opportunities such as this arrive , of course I can't miss it !

No matter what , never will I don a Man U shirt for their game !! Hahaha but i turn up in a scouser's shirt ; sure kena pukul punya! But even if Liverpool were to play Malaysia ; I would still don up in the bright YELLOW of Malaysia ! Mestila sokong Malaysia !! Hahahahaha I reckon , those who turned up in yellow in Bukit Jalil last night were Liverpool fans looking forward to catch a glimpse of Owen !!

There were thousands of POSERS in the stadium area. Why I call them posers is purely because I can gurantee you that almost 70% who turned up yesterday were not the REAL stadium going crowd. Its just Man U is so popular that they had to be in the crowd. The usual scene of thousands of kapcai riders and their pillion passangers were obviously missing. The cheapest ticket price of RM58 is still too expensive except for the real hardcores who knew they can't miss MAn U being on Malaysia soil. One pakcik who were in our stand was fanatical and I respect his spirit and determination to chant for Malaysia all the way in that 90 minutes! True enough it was a bit of an ear sore ; but I have to give it to him.. Thank you Pakcik for your Malaysia BOLEH SPIRIT!!


The game was surprising. I reckon that everybody would have thought Man U would just gobble and wallop the young Malaysian team. I was in fact looking forward to Amri Yahya having a spat and fight with one of the Man U players ( knowing his style and temperament!! ). We managed to play some good football as there was movement and we wer not afraid to go forward and try. MAn U scored 2 goals with ease and you can see their quality glimpse here and there. However , Amri Yahyah broke the Malaysian duck with his cheeky chip voley that made Van Der Sar helpless! The stadium just went bonkers and I was jumping like a small kid ! Oh my god.. we scored and I was glad that i was present in the stadium to witness it! It was pure skill and not a "lucky" goal like the one Amri would score later to blush Ben Foster! Rafa... aren't you interested? HAhahahahaha

Amri Yahyah Malaysia 2.. Owen Liverpool 1.. = 3..
Man U ..2 ..
So who really won last night? hehehe

Back in business

I was on call on Monday after a long lay off. I was excited in a way because after one month of medicine and 2 weeks of "doing the Trunkey" ;I was up to exhilarating work! Hahahaha.. nuts or what? wishing myself to be a jonah!
Well.. as usual with the calls that I have nowadays; I am not Jonah anymore. I guess only in combination with certain colleagues would dwell me into such hyperactivity! Hahahaha
It was the usual stuffs going on and not as hectic as i know the potential it could be.Doing BAD ICU cases is not as exciting as how it used to be.. hahaha.. macam dah tua je rasanya !
At about 8pm , I was informed of a case ; 50odd year old gentleman DM,HPT,CHF,IHD who had an MI 3 months back and complicated by persistent VT requiring ICD insertion. He came for having an infected diabetic foot. It was told to me that the patient needed only "a bit" of wound debridement. On a normal circumstances , it would be absolutely nuts to attempt such high risk case at night. Therefore, i thought a simple ankle block would do it. So i called the patient nearing midnight.
It turned out that the foot was smelly and a likely candidate for BKA. However , the patient was not keen for such an immediate debilitating surgery and opted just for debridement. When i opened up the wound , it was impossible to give a simple ankle blcok and aarggh.. i am stuck to do this patient and there was no turning back.. hahahaha

lateral approach
I was fanciful enough in attempting lateral approach of the sciatic nerve block. He refused the posterior approach as he reckons that he'd become uncomfortable. I thought it should not be a problem.. but there was a keloid scar along the groove where i should poke my needle ; remnants of a 10 year old femur plating !! The attempts were futile as I kept hitting a hard surface ( which is liely to be the plate there !) Failing the stimulate the sciatic nerve , i tried on to visualize it via ultrasound. Again... i could see nothing as the anatomy is totally distorted ! Oohhh.. it was stressful because the only way was to perform peripheral regional block which would not jeopardize his already poor heart !!

In the end , i had to resort to the ever reliable Sciatic nerve block via Labatt's approach!! haahahaha.. Luckily the twitch was not hard to elicit and with a saphenous nerve block cover ; he was ready to be on OT table ! I was initially worried because the block did not work instataneously ; but astime went by. he was sleeping like a dog! Yesss... and of course, the debridement was very EXTENSIVE.. and i pray for his recovery..
P/S And on my post call day, the victims of the RAPIDKL bus crash was rushed to UMMC! Hmmmm... macam FInal Destination la pulak... hahaha

This one is for you Cikgu Azhar SMTTDI !!!

Took this pic for Cikgu during the SMTTDI Golden dinner the other night ! So .. anytime you google his name ; this should come out in your search !! Hahahaha

Acute break

It is Sunday night and tomorrow I'll be back in OT. It is business as usual with putting people unconscious while crossing my fingers that they would come out of it.. hehehehe
These 2 weeks was a good break for me ; away from the busy schedules of OT. I was doing what i like most whilst having quality time with the family. No wonder the westerners encourage time off and going off for holidays ; it recharges the enthusiasm and zest. By right it should gear one up to strive more !! ( hehehe..this is where i reckon the postulation went wrong !
After KK , i took the family to Awana ; and of course up to Genting Highlands for a good fun. We were there 2 years ago and this was the first time for Qystiena. This time around we did not rush and we stayed in Awana which was a wise choice. I felt more relaxed and enjoyed myself very much.


It was so much fun to see the kids having fun. Honestly, i never thought days like this would come. I'm glad I've been on all the rides before therefore making my main objective to see my kids happy! Seeing them grow up and exploring things are priceless. There were few moments i watched them from a far ; seeing how Dzaeff and Qaisya solve their problems which was very interesting ! It tells a lot about their natural personality.

It was a good break and I hope to do this often in my busy schedule. It is fulfilling to see your children grow in front of your eyes..

16th ASEAN CONGRESS OF ANAESTHESIA in Sabah

This was my 3rd Anaesthesia conference and participating in ASEAN level discourse was something not to be missed. It was held in Sutera Harbour Resort, Kota Kinabalu 2nd-5th July which was an excellent place to be at. The resort was beautiful and having it here for an international event is spot on!
I was supposed to go with Hady alone but somehow , our wives were keen themselves to be in Kota Kinabalu! Wifey and kids booked the tickets after mine was settled with UiTM. We didn't stay in Sutera Harbour but in Promenade hotel ; about 2 km away. I guess it was luck when we got upgraded to the club suite on the 11th floor ; room with a picturesque view! Taking 3 kids with us without a maid is a challenge to the max ! We had to try this out in the idea of charting our future travels!

I had an active participation because of my poster and Oral presentation. In a way, it was a justification to be present in this conference as well as having it in my CV. Of course , Suana's poster was a real show of her personality!! hahaha

I was chosen to present my study in the Young Investigator's Award. It was a good experience eventhough I did not bag the prize!I was under attack from the word go by judges on Q&A time and defending my study can be tricky! I thank them for the constructive comments and it certainly widened my horizon to do beter the next time around. Watch out for me ahhh.. hehehehe Well , at the end of the day it was about the scientific value of your study rather than the showmanship and i lost to a better study! Well done Alvin! Cayalah !! Hidup UM !! hehehehehe

Conferences such as this is a wonderful reunion to meet old aquantainces. It was a surprise to know that i knew all escept one of the participants in my award. Well , the other 3 was from the ame uni so dduuuhh... one was my junior in IMU and the other ; a fellow Brestari Muda Public Bank receipient whom i last met 18 years ago !!! And now , he is also a doctor and in his final year of post graduate! Unfortunately , due to the hectic schedule as well as me being too paranoid about the oral presentation ; my camwhoring activities were obviously absent in this post!

The ASEAN night was well organized and it was fun seeing the sportingness of the ASEAN consultants to perform on the stage! It showed how they normal like you and me eventhough they have tonnes of study ( and stil ongoing ! ) under their belts! hehehehe.. Tabik spring tuan !!

Overall it was agood experience and intend to participate actively in future conferences. Whcih means , i have to organize my 2nd , 3rd and 4th etc studies !! Hahahaha ada rajin ka ??
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Wifey and kids did not have a proper holiday. If it was not for the hectic schedule and my involvement in the awards ; i could have shown them more of the SABAH that i love. Wifey knew about this fact and organized herself to go around KK . It was dissapointing that Promenade was under construction thatthey had to close down the pool for use. Wifey initially planned to have the kids enjoy the hotel fascilities which was obviously absent this time.

We managed to have seafood dinner at he waterfront. It was nice to see the stalls which offered variety of fresh seafood. The food was relatively cheap and because of its freshness .. tasted good! The night market was active the whole night but of course , with three kids around ; it was impossible to have a small moment with wifey here..


With good planning job with Hady , wifey went to Manukan island with the kids. I was unable to join them because of my oral presentation on the 4th of July. Intially it was supposed to be Suraya, Suana and HAdy with wifey. We managed to charter a boat which was convenient and cheap. To my surprise , Edmund , Tie , Wong Usha and Susheela tagged along and they all had a good time by the beach. I must thank all of them for voluntarily looking after my kids during the trip! My upmost gratitude !!


I am glad that wifey and kids enjoyed the holiday eventhough it was suboptimal without my presence most ofthe time. This trip was a learning experience so that we can gauge how to handle holidays with the 3 kids!
Next ACA in 2011 in Manila ?? hehehehe.. mesti la pergi !!!

FIshes galore - a retrospective entry

Before going to Riau , I made it a point to spend some time with wifeya nd kids. Wifey is less stressed now with her ongoing thesis saga that hopefully will end next month. She needed the break and that was why the whole entourage will follow me to KK afterwards.We wanted to go to the zoo but as the timing was off , we went to Aquaria instead.
We brought Dzaeff here when he was 6 months old but i don't think he remembered or noticed any of that!


I must say , it was Qaisya's trip because she was very uncharacteristic ( the usual difficult child to handle syndrome @!!!) and she enjoyed herself very much. Her eyes were shining all the way and she even sang as she was walking and i know she truly enjoyed hersef. I suspect she felt in love with the fishes and that was the reason when we bought her the discounted fish from the souvenir shop; she did not let it go at all until she went to sleep that night !! :)

Foreign..

Its not everyday that you get to be in an Indonesian newspaper.. hehehe

The Dabo Singkep experience

I am practically rushing to pack for Sabah but I just have to blog this down. I don't want whatever is still fresh in my mind disappear and me missing the best time to write it all out !

24th June
I boarded flight Firefly to JB in the evening. Mutee was waiting for me in Senai as the plan was to stay at his place overnight. Of course, as transformers hardcore it was irresistable not to go and watch it ! Mutee booked the tickets and we straight away went to Tebrau mall after landing ! The movie was really full of action for that 2.5 hours and to those who say tak puas..i will reply ..biar betul !! JB looks cool at night and i guess having singapore as your rival really push you forward.

25th June
We woke up for Subuh and Mutee sent me to the ferry terminal in Stulang Laut. I met the USM OFMS delegation there. Old faces from Palembang like Dr Lah , Dr Noor Hayati , Kak Zah etc were there with their friendly nature! I met Dr Rowi as well , who is my mentor for anaesthesia in this trip. Prof Zainal and gang from UM joined us this time around . we waited for the Melaka enoturage to arrive before departig to Tanjung Pinang on our charted ferry ! Hehehe..best jugak naik boat. It took us 3 hours and the boat ride was plentiful. Sapa yg kecut perut susah jugak tu.. hehehe

Upon arrival , we were greeted with lunch by the local Belia and we went around for a bit. Tanjung Pinang is the main hub for the Riau islands. Imagine having 531 islands in the province .. wuuhhuuu... The people here speaks less indonesian and sounded a lot like Johoreans ! I guess if i look up my roots , most likely the family originates here!

We were celebrated by the Governor of KEPRI at his official residence for dinner. The garden banquet setting was impressive and I guess , we were here on an official mission and i guess they appreciate it a lot

26 June
We were up early to catch our boat to Pelabuhan Jaguh , Dabo Singkep. It took us 4 hours and my..my.. it ws a long journey! And as we were arriving to our destination ; we saw where one Pantun Melayu originated from. Pulau Pandan..was jauh ke tengah.. and Gunung Daik had 3 cabangs !! hehehehe.. It was true after all and the pantun did originate from this area!

Gunung Daik

Pulau Pandan
After the long sea sickening trip , we had to endure another hour of 4 wheel ride to Dabo Singkep.. i went " mabuk" here and not in the ferry !!! ehehehe luckily i did not vomit as that would be very embarrasing!
We were celebrated in a grand fashion by the Dabo Singkep people! Memang betul2 mcm kampung melayu with their dance and silat before the opening ceremony started. It was past noon by this time and eveyone was hungry.We had to wait for another 2 hours for the official thingy before having lunch !! Hahahaha Semua memang muka kebulur !! MY room mate was Prof Zainal from UM OFMS and he is a cool bloke! I wish my Profs were like him and he really inspired me in this trip to be like him.. tabik spring Sir !!!

THe medical team screened the patients later that night. Most were previous patients from their previous trip in 2007 ; making the operating procedure this time more challenging with the limited backup and resources that we have ! Mak ai... We had a look at the OT and i was glad when they brought in their Drager machine from the main hospital in Tanjung Pinang for our use.. hehehe.. Otherwise , I'd be using Halothane which i don't mind using really !!

27 June

8 cases were listed and we started at 9am after everything is ready. It was a bit chaotic in the morning upon starting the first case but everything went into place as we went along. All our patients were below 12 years old making it paediatric posting for me ! Doing mostly palate surgery was challenging considering the limited backup resources. We can't even have blood ready and if we have to transfuse , it will be purely form thier family in situ !! Giller ape !! We were not familiar with the machine earlier and Prof Rowi ordered hand ventilation! It was a good practice after all training the hands to become sensitive and our minds alert.. hehehe We had few cases which bled immediately post extubation where one of them we had to reintubate.. hmmm.. heart stopping but good experience ! We finished at about 2 am.. and we thought that we will only have 3 patients the next day..


28 June

It would be too good to be true to have only 3 patients to do.. More patients turned up as they only arrive in Dabo Singkep the day before. Having the op free is a temptation not to resist by the poor because they can never afford in their lifetime to have this surgery done. At times, i guess as Malaysians we have to be very thankful that our helathcare system is still free and for us to use it wisely.

The list expanded and we went on till 3am ! We had a 7 year old who is obese , 40kg and we started this elective case after midnight ! Hahahaha.. Unfortunately there was a bit of complication as he bled a lot post op. I was called in to be ready for OT if needed at 5am.. but my boat off the island was at 7am! We were going of early because of our commitments. Otherwise , the plan was to return on the 1st of July! After assessing the patient with Dr Rowi , the boy is not too bad and Dr Rowi said he can handle the case himself.


29 June
AND i was rushing ! PAcked my bag and off to the port !
1 hour - 4 wheel ride to Pelabuhan Jaguh
4 hours - Ferry to Tanjung Pinang
3 hours - ferry to Stulang Laut
3 hours - JB to KL via Prof Zainal's CRV
And with all that... I still enjoyed the trip and hoping that more will come ! An eye opener and of course , more stories for me to tell my grandchildren !!
Perrgggh..and i was so tired with the travelling !! Luckily we went home early ahead of schedule