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letter of apology to the patient's canary for what is to come ...

Dear patient,

My profession is none other than a hospital resident, commonly called MIR, which wants to apologize for the series of events that have happened, are happening and will happen, probably without you, the most affected, know why.

But let me first put a little situation: Currently we are at a professional who represents the midpoint between the specialist and the student fresh out of college. This implies that we studied at least seven years of university education (six plus faculty preparation for the MIR). Later specially chosen as the serial number of the testing and start working as doctors in training. The specialty usually lasts four years and I imagine that you understand how hard it is to get to that point and how much we have to work for our residence. For the avoidance of doubt and you are well informed about what it charges resident in the Canary Islands will summarize our salary in a clear, gross salary: 1103, 54 euros; time on duty (gross and services of 24 or 17 hours): between 8.91 and 14.82 euros by year of residence . In other words, a resident physician canary second year received during his day on duty in a workday (17 hours on normal working day + 7) 10.8 euros per hour, or 1.1 percent less than their normal working hours Navarre, while a the same characteristics obtained with 17.85 euros per hour by 62.3 percent more than their normal hours. As if that was not enough unfairness, is to further reduce the salary, from to charge 7 euros per hour on duty, regardless of year of residence and salary reduction basis. We know we earn more than minimum wage, but we also believe that we deserve. Apart from the great responsibilities they play with their health, we are also talking about long hours (sometimes relentlessly) and all we ask is comparable to the national average, neither more nor less. Recently

as any officer we reduced the salary (about 5%) and assume that in times of crisis we must all do our part. None of us complained.

Well, currently under discussion in Parliament of the Canary Islands budget cuts, including of course those of Health, which will be carried out to address this crisis hits us. Before setting out the measures proposed by the mindless politicians who govern us, we ask a simple question that does not need to be thoughtful. Do you think the solution is to cut investment in health or education?. Neither do we. Did you know that health professionals in Spain are the worst paid in Europe?, Did you know that the community Canaria proposed cuts in health care to more than 11%, the biggest decline in all regions?, Did you know that health services have large waiting lists are being referred for aided schools (private) at a price that would make such evidence in the public health service. For despite the great management of resources, the aim is also that things will get worse:

We were working without public offering, or as we in Spain (of course paid national taxes) so then we have to go abroad to work, is to cut days off (we could get to work over 59 hours per week) reduces the number of days approved for training (ie day to improve our work ) imply that if they enter in a hospital will have to pay to its own water and even their bed linens to be washed every day, will extend the already large waiting lists (are deleted days later), will not replace doctors who need off work (imagine if the consultations are already saturated, much more may become so), and a thousand etcetera.

The purpose of this letter is not to propose solutions to fix the Health, is not we who are responsible for that. Our intention really is to inform you of what the proposed changes and why they consider intolerable.

For all this, we want to ask forgiveness in advance; forgiveness because we will fight for our interests and forgiveness because we are going to fight for theirs. Measures to save the health van by other means so please understand and support our struggle because we, the residents, we will not stop.

Sincerely yours,

Canary MIR Protest Group.

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Abla's manifesto

The health 2.0 tree whose branches reach all parts of Spain, has its roots in Andalucia. Abla, Almería, but with bits of mosaic from the rest of Spain, comes the manifest Abla, intended as a start of construction of a health 2.0. Here it is for the enjoyment of the user:

Abla Manifesto 2010

In the community met for the first time in September 2010 with the first two conferences on Health 2.0 in Sevilla and Granada, and has been reunited at the recent Health 2.0 in Abla (Almería) in late 2010, the initiative # salud20Andalucia arises. But # salud20andalucia

has become much more than a label for a successful application (Twitter ®), # salud20andalucia visionary germ is a group open, collaborative and enthusiastic, where each brings his vision as a citizen and professional and where contributions are not limited to Andalusia but is open to the global community with national and international interests. The

collective ideology comes this manifesto.

Members of this group are convinced of the need to advance towards a new socio more sustainable, participatory and democratic development in the relations between citizens, professionals and organizations are necessary and timely redesigned to achieve a more accessible and nearby health.

think the Health 2.0 concept must be understood as a change in organizational culture supported by a horizontal and collaborative design, compared to the traditional hierarchical pyramid.

health institutions can and should harness the potential of this new change of 2.0 health model for what can count on the professionals who have already taken steps in this regard.

these ideas are written on these lines of work thus become our proposal to start the renewal of health along the lines arising from Web 2.0.

For Citizenship:

citizens under the principle of patient autonomy, as enshrined in the Statute of the patient, are co-responsible for their health, so that their active participation is essential to both health care and in improving Socio systems.

should respect and encourage citizen self-organization in networked communities. There is no better empowerment that arises spontaneously and independently.

talks to citizens about their health and the health system should not be understood as threats by managers or professionals, but as a great opportunity for improving the system.

participatory citizenship does not expect to be asked to review and assess the quality of services. The opinions arising in the network are a flexible and valuable for the continuous improvement of the health system. Organizations can not be limited to traditional assessment systems.

technologies offer opportunities and solutions. All of them must serve the needs of citizens, regardless of institutional agendas. If not, could become an obstacle in improving the health system.

technological solutions must be simple, manageable and affordable. Before you deploy an application must assess whether it meets these premises. Training citizenship is a prerequisite for success.

institutional initiatives with technological support, when not taken into account in public, often fail to move into real practice, so it should be raised from their point of view, allowing you to suit your needs and expectations. Before consolidating

general solutions must build local experiences. The experimental method is not only the most suitable for scientific knowledge, also for design services. The Living Lab experience should serve as a model Abla.

citizens excluded and disconnected from society Current solutions based on Web 2.0 should be integrated, as are most in need of health services.

The first step towards transparency is clarity. And information services should be easy to find, use and understand.

For Professionals:

Establish mechanisms to facilitate collaboration and knowledge sharing through the use of professional networks, as they are they have sufficient information and knowledge to improve their services.

Self-organization geriatric professionals, along with citizenship, should be a fundamental pillar of change. The local community has become a social space for innovation to lead the change.

professionals debate about health system should not be seen as a threat by managers or politicians, but as a great opportunity for improving the system.

Internet is a way to improve the relationship between citizens and professionals. Collaborate on the network target services to citizens and to share experiences, strengthens the common growth.

Unleashing use of Internet and new technologies is essential to organized or sponsored improving the health system.

Technological solutions must be accessible to everyone. Organizations should provide and facilitate access regardless of place of work and qualifications.

Security can not be an excuse for access to the Internet. Should be a right exercised by professionals from the responsibility, not censorship or limitation.

The use of technology must respect the right to privacy, honor and reputation. All users, citizens and professionals must ensure these rights, according to the terms established by law.

training on new technologies is a right and obligation of all professionals. Such training should be encouraged as it promotes the transfer properly knowledge and develop new skills.

should enhance networking strategies through specific initiatives related to professional practice and collaborative technologies that promote two-way relationship with patients.

Authors: # salud20Andalucia, @ cuidadorasnet, @ pacoxxi, @ alorza, @ randrom, @ luisluque, @ marianoh, @ lineros55, @ emilenko, @ moilafille, @ andonicarrion, @ carlosnunezo, # comisiongestora, @ Juany_Olvera, @ goroji, @ rafacano, @ manyez, @ cuidando_es_sfs, @ bbelizon, @ Perielvampi, @ EnferEvidente, @ JuanOdM, @ flupianez, @ CarlosMatabuena, @ Ebevidencia, @ spanamed, @ drajomeini, @ Jbasago, @ alesmismo, @ ntonio_Reina, @ fradiex, @ natho47, @ enfermera2pto0, @ gallegodieguez, @ clarabermudez, @ Bacigalupe, # healthglobal, @ @ DCCU bainab, @ carlosgurpegui, @ lolavellido

This document is a draft collaborative from "Decalogue for ciudadanocéntrica health", in Alberto Ortiz de Zarate, "Health systems closer," the book "Health 2.0: ePaciente and social networks, Vodafone Spain Foundation, 2011.

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perioperative management of glucose 6 phosphate dehydrogenase deficiency

Glucose 6-phosphate dehydrogenase is an enzyme that exists in red blood cells, where it meets protective functions. When a person with deficiency of this enzyme eats or is exposed to oxidizing agents such as aspirin or beans or infection, red blood cells alter their shape, becoming more fragile as it flows through the small blood vessels of the body and breaking more easily , causing a picture of hemolytic anemia. G6PD deficiency is an inherited disease, more common in blacks, autosomal X-linked recessive, which means that predominates in males and that, although cases in women, it is normal that the mother transmit, without autism. The disease occurs usually in the first weeks of life due to low levels of natural antioxidants (like vitamin E) capable of neutralizing any oxidative stimulus. After 48 hours of contact with the trigger or trigger, it causes a hemolytic anemia, malaise, fatigue, generalized pallor, tachycardia and respiratory distress. The urine becomes dark in pigment degradation of hemoglobin and the skin turns yellow. If the patient remains in contact with the stimulus, the deficit can be fatal. '

Therefore, every physician should know what can and can not be administered to a patient with these characteristics. Moreover, if the patient is difficult history, as occurs during general anesthesia. So today I bring you a review on the topic, which you can download here .

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CPR Guidelines: Update 2010 (REMI)

REMI (Electronic Journal of Critical Care Medicine) has sent this week to more than 8000 subscribers with an update of the CPR guidelines, which you can download it here and mismito now hang in the "Resources anestesioblastos." Magazine is an ideal way to keep up to anestesioblastos suffered not even have time to breathe, as you send, email, annotated summaries of the best articles on Intensive Care Medicine published in medical journals around the world. If you are not subscribers, you are taking longer.

I leave you with this delusional RCP Mr Bean. Enjoy!

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Resources

Thoracic

'm rotating. That and I'm back to my service, with its feverish pace of guards, explains my drought update the Chuletario. I wanted to put a review of the physiology of lung ventilation and how to operate in ventilatory support in this type of surgery, but then I found this protocol Service Hospital General Universitario de Valencia, which is much better than I could do. On its website, there are also protocols for video-assisted to mediastinotomy mediastinoscopy and surgery for tracheal stenosis

for completeness, I recommend reading two articles published last year , Current Opinion in Anesthesiology. The first is an update on lung ventilation. The second speaks the postoperative management of acute lung injury thoracotomy.

page in Thoracic Anesthesia , we can keep abreast of what is published in this branch of Anesthesiology. I recommend a visit to the bronchoscopy simulator (You must register and pass a test, but it's free).

Irene Cristina, Argentina anesthesiologist, editor of the blog " anesthesiologist's hands, it's worth that you may know, last year replaced the two posts ( this and this ) on the subject.

I'm waiting to get two revisions: A Journal of Cardiothoracic and Vascular anesthesia on postoperative lung acute injury, and one of Anesthesiology Clinics, on the management of lung ventilation. Both of this year. As soon as get the hang.

And if you have a child at the table of chest surgery, you may serve this link La Paz Hospital in Madrid.

And with that and a biscuit ....

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Thoracic Surgery Treatment of postoperative pain in children in Madrid

We talked about why we painful stimuli. We given an overview of the different scales measuring pain . Come now to the heart of the matter: how to treat postoperative pain in children? The review that I prepared this week tells you here. Enjoy!

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FOB

has begun the registration period of a new edition of the Course of optical devices in Anaesthesia, Critical Care and Emergency. Be held next November in the Hospital La Paz in Madrid. This year has practical content increased to over 65% of the total course in the form of clinical cases in the operating room (in person and via videoconference) and high-quality simulators. This course is extended to all the techniques of airway control that require optical devices for execution: fibroscopy videolaringoscopia flexible and the presence of subject matter experts to establish guidelines for action to resolve the most common situations and more complex as we face in our daily activities.

I did two years ago (with a broken leg) and I recommend it. The link is this .

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Course Measurement of pain in children

The nervous system of the newborn, including prematurity, is fully developed to receive, conduct, process and perceive painful stimuli to the same extent that an older child or adulto.Los basic mechanisms are similar, however, due to the neurophysiological and cognitive immaturity, there are some differences: for example, the pain impulse transmission occurs primarily in infants along unmyelinated C-fibers rather than A-delta fibers. There is less precision in the transmission of pain signal in the spinal cord and descending inhibitory neurotransmitter lacking. Consequently, infants may perceive pain more intensely than older children or adults, because their mechanisms are immature control downstream. In addition, the neonatal nervous system has higher concentrations (and diffuse) of substance P receptor sites, which limits their ability to modulate the pain experience. Therefore, although unable to speak and responses to pain are more nonspecific, we must start from the premise that any painful situation for the adult, also for the child. Moreover, when the latter can not be drawn against an adaptive response to painful stimuli and receives more anxiety as an adult. Pain is a complex psychological experience, which often cognitive and affective mechanisms are as important as tissue injury. The psychological factor is a determining factor in any assessment of pain.

Measuring pain in children is the subject of ongoing studies and comparisons. Apply many methods of evaluation. Some are subjective by scales which are dominated facial images reminiscent moods or colors or numerical scales (from a certain age.) Other times, they appreciate and quantify the external signs active behavior (crying, facial expression, movement, restlessness) or passive (decay, loss of appetite). Alterations of physiological parameters (respiration, heart rate, hormone levels) are more amenable to modification by other independent causes of pain.

been shown to measure pain is not an experience impossible. As a subjective variable, pain should be quantified by the patient, but as we shall see, in childhood this is impractical in many cases, so you need to develop reliable methods of valuation. Pain assessment must be consistent with the child's developmental stage, severity and chronicity of illness, medical or surgical procedure and the environment.

Assessment is the cornerstone of pain management. When it is evaluated with certainty, there is a "point of principle" well defined to determine the nature and degree of pain and evaluating the effectiveness of interventions to alleviate it.

To this end, two types of methods: self-and hetero.

self methods

Because pain is a subjective experience, self-assessment methods are the "gold standard" to measure. From 18 months of age, children incorporate into their vocabulary words to name the painful sensation. After three or four years, the development of the brain is sufficient to communicate the degree of pain (high or low). Therefore, these methods are generally used in children over three years.

Color Scale

consists of a rule, which goes from white to pink to bright red, almost black, up gradation of minimum to maximum pain pain. The patient indicates, according to the intensity of color, where your pain. Obviously, it is used in children over 5 years.

One of the methods used in chronic pain consultations are the color profiles. It gives the child a tracing, front and back and is asked to paint with colors your pain. Although there are exceptions, children often choose red, purple or black in the areas of maximum pain. The use of serial drawings to evaluate the development of pain.

faces Scale

is composed of a series of 5-6 faces expressing a different intensity of pain (from none to much). Asks the child to choose the face corresponding to their pain. Very young children tend to choose the ends, so it is recommended to use after three years. Scale

visual analogue (VAS)

consists of a template, whose numbers from 0 to 10 are representative of the intensity of pain. Can be used for children 6 and older. Has, as variation in the temperature scale (same, but vertical, color and shape of a thermometer).

hetero methods There

scales used to assess the body's response to pain. These scales are obviously reserved for those children who can not express their pain or in addition to the above. In this case, the assessor who, on a number of physiologically objective parameters, gives a numerical value.

behavior measures can be categorized into descriptions of behaviors per minute, conduct social or related to appetite and changes in the status and cognitive function. Facial action and cry acoustic characteristics are examples of very detailed descriptions of behaviors per minute. Although there appears to be a cry of pain absolutely identifiable characteristics that would identify a painful condition is a high-pitched cry, rough and intense.

facial expression has been the most widely studied of the behavioral assessment measures in pain. Is the indicator more reliable and consistent pain in all populations and as such should be considered the "gold standard" of behavioral responses to pain in children. Facial expressions of infants who experience acute pain include the following features: eyes tightly closed, brows, nostrils large and bulky, deep philtrum, square-shaped mouth and tongue tense and concave.

This, coupled with a series of physiological variables, make up the majority of the scales heteroevaluativas. One is the CRIES (Crying Requires O2, vital signs Increassed expression, Sleppless), I put below:

A very interesting article regarding the measurement of pain is " Validity and reliability of the Behavioural Observational Pain Scale for postoperative pain Measurement in Children 1-7 years of age " which appeared in the journal Pediatric Critical Care Medicine, in 2007, which examines the behavioral and physiological variables that can lead to an objective assessment of pain in children 1 to 7 years. You can download it here .

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Bases anatomical and physiological pain Resources

Nobel Laureate Albert Schweitzer called it "the most terrible of the lords of humankind." Joins us from the biblical "give birth in pain" with which God punished Eve, until now, has been a fellow-sufferer of man wherever he goes. Pain, defined by the IASP as "an unpleasant sensory and emotional experience associated with actual tissue damage, potential or described as such" is the third leg of the specialty of Anesthesiology, Reanimation and Pain Therapy. It is we, who are dedicated to the inexact science of anesthesia, experts in the treatment of this terrible master. Always keeping note that, to treat pain, we should not honor the Greek translation of the word anesthesia: numbness. And the pain is, as stated by the IASP, a subjective aspect that can not be downplayed.

In children, the pain is under treated for many years for several reasons. First, training in pain was low (still is, although this is slowly changing) and, secondly, the choice of opioid was afraid of possible side effects. In addition, there was a social tendency to minimize pain considering it a sign of weakness of character and avoided in children if, big mistake, that did not remember painful episode.

For all that, to put my bit in the knowledge of this third leg of the specialty, I dived full (after the lapse of summer, where the dwarves have left me no breathing) in a full review postoperative pain management in children.

But as the house is to start with the foundation, I have broken the topic into a series of revisions: Today is the first. Let's talk about the anatomical and physiological bases of pain. You can download the patch by clicking here .

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pediatric anesthesia and perioperative transfusion

I leave here some links to pages that are worthwhile, related to pediatric anesthesia, which will incorporate later "anestesioblastos Resources." 1 .-
Stanford School of Medicine : In the tab "Education", we have a series of "Teaching materials" that include updated guidelines on CPR and pain management. And clinical cases. The tab "Patient care" delves deeper into the specific techniques of pain management in pediatric anesthesia. 2 .-
Anesthesia Study Group Child : Website Service Pediatric Anesthesiology and Critical Care Hospital of La Paz in Madrid. Includes protocols, articles and recommendations books. 3 .-
Mechanical Ventilation: Also from the Hospital de La Paz. This web influences the use of mechanical ventilation in children and in doing so, contributes resources (protocols, articles, podcasts ...). 4 .-
SSAI : Website of the Scandinavian Society for Pediatric Anesthesia. Very interesting section of "guidelines" which can be downloaded. 5 .- Anesthesia
nursing : At the bottom of this website Anesthesia for anesthesia nurses, there is a box that says "Pediatric worksheet." Is a chart that you estimated the doses of all drugs you have to put each child according to their weight. The only problem is you have to put on pounds (although the translation kilos see below). Very useful. 6 .-
Women & Children Hospital in South Australia : With management protocols and guidelines for regional anesthesia. 7 .-
Pediatric anesthesia: a journal dedicated to pediatric anesthesia.

E

incorporate another book to the library on this subject. It's Smith's: Anesthesia for Infants and Children. To avoid copyright problems and so on, you can email me for a copy to the blog, the forwarding to you a thousand loves.

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Fluid

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caudal block in children Management of hemorrhagic shock

The caudal block is a pediatric regional anesthesia technique which allows the production of analgesia, easily and securely from S5 to T10. Is to produce nerve block by introducing a local anesthetic through the sacral hiatus into the sacral epidural canal in children under 8 years. Surgery is indicated below the diaphragm and contraindicated in sacral deformities, surgery perianal infections and bacteremia puncture site and, of course, in the coagulopathy.

The patient is placed in lateral decubitus or prone position with knees bent over his chest. Palpate the posterior superior iliac spines and visualize a triangle formed by the anterior superior iliac spines and, as a vertex, the sacral hiatus between the two horns sacred, through which it passes in sacral ligament (formed by the supra and interspinous ligaments and ligamentum flavum) above the buttocks, to the pictures.

The most common error is to insert the needle deep down, in the region of the coccyx. We use a 23 G needle (orange) or a 20-22 angiocath G. The inserted perpendicularly at the apex of the triangle in the midline, and then redirect, 45 º cranial direction. You will notice a "pop" of loss of resistance when the needle passes through the ligament between the sacrum and caudal space. Move only 1-2 mm and aim to check that there is no fluid or blood. At that time, inserted in catheter (epidural 20G) if we wish to postoperative analgesia than a few hours or directly inject the anesthetic, after test dose tested.

As a guide, we can say that, to achieve a T10 level of analgesia, use 0.25 cc / kgr of levobupivacaine 0.25% or ropivacaine 0.2%. To reach T6: we must use doses of 1-1.2 cc / kg. (Note: Be aware of the toxic dose).

most common mistakes, besides the aforementioned, are placing a needle under the skin, easily recognizable because it forms a wheal in the skin by injecting a local anesthetic and perform a subperiosteal injection, which is also recognizable, because we can not inject anesthetic.

I leave a video on youtube with the technique.

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When a person begins to bleed so acute, the body develops a series of coping mechanisms. If these mechanisms are overwhelmed, in a ruling entered in a phase known as "shock" bleeding. Time is the enemy of bleeding and, therefore, the doctor who tries to save his life. Leonardo da Vinci said that "the movement is the cause of all life." So do not waste time, let's move on and let's review together what to do to control acute bleeding. This review, which you can download here, I was consisted a major effort (one could say that I have bled alive), so I hope you like it.

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penile block

the most frequent crashes in Pediatric Anesthesia is blockage of dorsal penile nerve for surgery in the area. I have reviewed it in stride and here you can download the result. Below, I add 2 videos. The first is the Society of Anesthesiology, Colombia. Is very well explained the anatomy and, despite performing the technique with a single puncture (which has been shown to have major complications) is used to get an idea.

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preanesthetic management of pheochromocytoma

Pheochromocytoma is a tumor derived from chromaffin tissue of neuroectodermal cells from the neural crest. He is remembered by students as the tumor MIR 10%: 10% occur in children, 10% is malignant, 10% are hereditary, 10% are bilateral and 10% are extra-adrenal. Are tumors of low incidence. The fundamental problem is posed by secreting catecholamines, with consequent effects. The treatment is surgical excision, but a few years ago because there was adequate anesthetic preparation, the surgery of pheochromocytoma had a high mortality, which, at present, has gone to be 0.3%. The preanesthetic management of pheochromocytoma is the issue before us today and you can download here .

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wanted to try to do one more song before the holidays began, but I could not (between Blogocongreso and final year of the dwarfs have been quite busy). The Chuletario return the first week of July with news about Epidrum, a review of the preanesthetic management of pheochromocytoma and other goodies. Until then.