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So, I gave my assessment yesterday. It was pretty much expected that it was coming up, as everyone up for assessment were being called based on their shift, and since I was morning at that point of time, it was pretty much inevitable.

The Krishnan luck has proven to have followed me to work as well considering I had pretty much the hardest panel amongst the assessors. No point crying over spilled milk, so lets not harp on that.

First part of assessment is when they look at your various documentations. The first is a green card where several specialists evaluate your ward progress on a bi-weekly basis. Then there’s a 1 month, and 2 month assessment of your progress by specialists. They’ll also want to see a piece of paper that indicates you don’t have any discharge summaries pending, authenticated by the ward sister. Then there’s the log book, a book you fill up with all the procedures that you have done/observed/assisted. Finally, they may want to see your tagging period tagging log.

After they see your documentation and comment on how sad and terribly lacking it is, they proceed to asking you on how to perform any of the myriads of procedures a houseman may observe/do in the ward. So you’ll have to explain the procedure from top to bottom. Ironically, one of my assessors is a neurologist, and surely enough, the procedure he wanted me to explain was Lumbar Puncture.

I’ve come to notice that whilst my previous explanation was partially correct, there were a bit of holes here and there. Considering the nature of his field of interest, we went into many of the intricate specifics. Discussing the spinal needle type, all the way to the bore size. At one point it even got into really specific details like how the needle should be held, to assorted things like what may cause Idiopathic Intracranial Hypertension. Other expected questions were the normal opening pressure, the indications and contraindications. I was also asked two additional indications for LP, which I answered for Spinal Anaesthesia and Delivering drugs, particularly chemotherapy, intrathecally.

Next question was a situational based question where I’ve got a patient who came in with fever, vomiting and lethargy. Gave my differentials, and I decided to go with dengue fever. The full diagnosis turned out to be DSS Decompensated Shock, In Febrile Phase D4, With Warning Signs.

They asked the management at this point, and gave a VBG findings for interpretation. Answered the treatment for Dengue as much as I could, and when the clock struck 5, they said, Okay, we think we’ve heard enough, you can go now. Their faces didn’t show any emotions, I don’t know how well I did. As Parting words, they said, “Karthik, you’re a lalang, you need to be more confident with your answers.” At this point I don’t know how I’ve done as they said nothing.

I walked out confused, curious and depressed (which was cured by beers later). I was supposed to call and find out how I did, but I was in denial and wanted to protect my self, so I did what any self-respecting Indian would do; I denied ever having sat for assessment and made plans for beers later that day.

Now I’ve realized not knowing sucks, every minute not knowing how or what has happened. I asked one of the specialists today on how I fared, she just smiled and said nothing. Y U NO TELL!

No matter, perhaps I may just find an ounce of bravery to try calling and enquiring tomorrow.

P.S. Perhaps my next post will be me bitchin’ about how I’ve been extended.

Cheers.

So my name is up for assessment, and can fall anywhere from 1-20th January. Part of the assessment includes knowing how to perform the myriad of procedures that is part of our day-to-day work life. This will be a way for me to revise the procedures and at the same time find out whatever short comings that I may have. Note that everything here is written based on my memory, without referring to any external sources. Due to that, the accuracy of the information contained within may be questionable and downright incorrect. Should you have different views, please let me know so that I may correct accordingly.

Today we’re going to discuss Lumbar Puncture. Let’s do it systematically.

LP : Divided into Therapeutic and Diagnostic.

Therapeutic would be to reduce ICP.

Diagnostic would be to identify any CNS infections of various nature. Parasitic, Bacterial, Viral, etc. To identify malignancy in CSF. To diagnose any CNS diseases.

Contraindications: Infection at Puncture area. Coagulopathy. Vertebra Deformities (Kyphosis or Scoliosis). *Note, You can do it for Kyphosis and Scoliosis, but the risk of shit going wrong is higher, so it’s generally done by someone experienced, read: Not You.

Procedure:

1) As with all procedures, Explain the procedure to patient, and acquire consent.

2) Respect patients privacy, pull the curtains or take the patient to the procedure room.

3) Prepare all required equipment prior to starting. Sterile Gloves, Dressing Kit, Spinal Needles, Collection Bottles, Local Anaesthesia, Sober Physician.

4) Vital sign monitoring throughout the procedure, and constant reassurement to patient required.

5) Patient assumes the fetal position. Left/Right Lateral with neck flexed and knees as close to the chest as possible.

6) Procedure is done in Aseptic Technique under LA.

7) Clean the area with Povidon X2 in a circular pattern, from inside to out. Clean again with Alcohol. Try your best not to drink the alcohol.

8) Apply Drape.

9) Identify site of insertion. Between L3 and L4. Do not go below L5 as the Cauda Equina lies there. You may use the posterior superior iliac spine as landmarks.

10) Apply LA. As always when you insert the needle, aspirate first to ensure there’s no blood, and then inject the LA as you pull out. Be generous, you may finish an entire ampule.

11) Introduce Spinal Needle on insertion site. Push the needle in till you feel the first “give”. This indicates penetration of the ligamentum Flavum. Proceed till the second “give”, which indicates penetration of the dura mater. You’re now in the subarachnoid space bitches.

12) You may now opt to find the opening pressure by using a manometer. 10-18 cmH20 is usually considered normal. This relates to about 8-15 mmhg.

13) Remove the stylet, and collect drops of each fluid. You’ll need enough to send for the following investigations.

I)Indian Ink II) C+S III) Cytology IV)Biochemistry V) Gram Stain VI) FEME VII) AFB/Microbacterium

14) Once you’ve enough sample, reinsert the stylet into the needle, and withdraw the needle, apply pressure on the site.

15) Apply Gauze with Flavine and complete dressing, and tell patient to get sufficient bed rest.

16) Document procedure into Patient Ticket as retrospective entry.

Complications:

When sufficient CSF is withdrawn, patient may have nausea and headache. Sufficient bed rest can overcome these as more CSF is eventually produced. Other complications include actually damaging spinal nerves, which may cause numbness or paraplegia and epidural bleeding.