El Hospital General de Zona 2A 'Francisco del Paso y Troncoso' del IMSS es ya una leyenda entre los MIPs de la UP. La rotacion por gineco-obstetricia es una de las mas temidas y odiadas de ese ano en el que los medicos en formacion comienzan realmente a vivir la vida intrahospitalaria.
En un esfuerzo por faciltarle la vida a los MIPs que vendran despues, y siguiendo el ejemplo de la MIP del Bollo les dejo la pequena Hitchhiker's guide to the Tronx.
Actividades Tronqueriles:
El MIP de gineco pasa por tres servicios durante su rotacion: hospitalizacion, consulta externa y la Unidad Tocoquirurgica (UTQ, o Toco). En todas ellas tiene que hacerle de sacachambas (tomar muestras, llenar solicitudes, hacer de mandadero con los laboratorios, etc.), convivir y cuidar a sus pacientes, y entre todo ello estudiar para el examen final de rotacion (OJO, el temario Troncoso y el UP son distintos).
- La Toco: Es el servicio de urgencias ginecologicas, el/la MIP tiene que vestirse con pijama quirurgica, gorro y botas (de preferencia lleven las suyas pq se acaban y luego hay que reciclar las del bote de basura). los internos se distribuyen en las labores A y B para desarrollar el fino arte de panzear (llenar el partograma, tomar foco fetal cada 30 min y hacer tactos vaginales cada hora en promedio) y aprender a atender partos (previo grito 'paciente a expulsion!' porque el camazo paga pastel). Es un servicio con mucho trabajo, aunque todo funciona mecanicamente: hacer ingreso y tomar muestras checar a la paciente, llenar las solicitudes de cirugia o analgesia segun se soliciten, ir al laboratorio por resultados, atender partos o entrar a quiforano para cesareas y salpingoclasias (OTBs). Todo el personal es muy atento y contestan tus dudas, los reganos son raros, y se dan mas que nada cuando no estan a tiempo los labs de una paciente grave (preeclampsia, sufrimiento fetal)
El ingreso: a toda paciente que llegue a la toco se le debe hacer una historia clinica ginecoobstetrica* al ingreso, tomarle BH, cruce (en tubos de tapa morada) y tiempos de coagulacion (tubos de tapa azul). si ingresa con diabetes o hipertension ademas se pide un perfil toxemico, osea una QS, PFHs, DHL y Ac. urico (en un tubo rojo) mas un EGO (en un tubo azul al que se le quito el tubo interno son anticoagulante*). Todas las pacientes deben firmar un consentimiento informado general y habiendo indicado si desean algun metodo de planificacion familiar (OTB o DIU).
- Despues del ingreso: Si la paciente esta embarazada se debera llenar el partograma, anotando cada 30 min la FCF y cada hora la dilatacion y numero de contracciones en 10 min. Esto es muy importante, pues es un documento con el que se ve la evolucion de la paciente y permite tomar decisiones, ademas de las implicaciones legales que le atanen en casos de demanda.
Las no embarazadas suelen llegar por abortos o sangrados anormales, y en su mayoria van a legrado, con ellas hay que estar revisando la intensidad del sangrado, que esten hemodinamicamente estables y procurar tener los laboratorios y el cruce listos lo mas pronto posible para que pasen al legrado.
Si la paciente pasa a quirofano, legrado o se le va a dar analgesia obstetrica debe llenarse una solicitud de cirugia. Las primeras dos deben ser entregadas a la jefa de enfermeras en cuanto el ginecologo solicite que la paciente pase a quirofano, la ultima se da a los residentes de anestesiologia hasta que la paciente ha superado los 6 o 7 cm de dilatacion.
- Consulta externa: Durante una semana (con suerte dos) los internos rotan por este servicio, en las consultas de ginecologia, embarazo de alto riesgo o mama. Es la rotacion mas tranquila, la entrada es a las 8 am y las actividades del MIP son explorar a las pacientes, llenar solicitudes de estudios y en caso de que haya estudiantes hacerles preguntas, explicarles y permitirles explorar pacientes. Los doctores son bastante tranquilos y responden a tus preguntas, aunque no se explayan mucho por el volumen de pacientes que se maneja.
- Piso: La rotacion mas aburrida de todas, los internos se dividen en el segundo piso norte (alojamiento conjunto), tercer piso norte (embarazo de alto riesgo) y tercer piso sur (ginecologia). La chamba varia un poco en cada uno, aunque en tienen cosas en comun.
A todos los ingresos se les debe completar el 'paqueteingreses' (juego de 4 hojas de las que conviene tener varios juegos de copias) y acomodar el expediente de acuerdo al 'estandar' del hospital. Se debe llenar una hoja frontal, una hoja de alta (con copia), la historia clinica y la hoja de alojamiento (solo en 2N). En todos los pisos se pasa visita entre 7 y 8 am, alrededor de las 3 pm y en 3N a las 8 pm.
En 3N solo se hacen ingresos, se pasa visita y se cumple con los pendientes, como labs, USG y PSS.
En 3S hay que tener listos laboratorios, cruces y valoraciones preoperatorios de quien va a quirofano, y hacer una nota SOAP a las pacientes que reingresan.
En 2N se recibe a las pacientes postparto y postcesarea. unicamente se hace el ingreso, se llena la hoja de alojamiento conjunto, se hace tacto vaginal y revision de episiotomia a quien tuvo parto y revision de herida quirurgica a las post-cesaria.
en caso de cualquier eventualidad, emergencia, duda o lapsus brutus siempre se puede recurrir al residente encargado de hospitalizacion, quien suele estar en el 3N y ademas es el guardian de las llaves de la maquina de PSS durante las guardias.
agosto 10, 2010
Paso a paso por Fco. del Paso y Troncoso
agosto 01, 2010
In CPR, Less May Be Better
Fifty years have passed since Kouwenhoven, Jude, and Knickerbocker1 proposed external chest compression to provide circulation of blood to the brain and heart after cardiac arrest. Shortly thereafter, mouth-to-mouth rescue breathing was adopted as an essential addition to this lifesaving procedure. Since that time, there has been very little fundamental change in the method or manner of cardiopulmonary resuscitation (CPR). Decades of observational studies have shown that survival is improved if CPR is performed by bystanders rather than being provided only when emergency medical services (EMS) staff arrives. The use of automated external defibrillators by bystanders and the use of in-hospital hypothermia in comatose patients have also been found to improve outcomes in patients with cardiac arrest.
Only relatively recently, however, have the fundamentals of the initial resuscitation been investigated. Focused, impressive laboratory research has resulted in a surge of interest in these fundamentals. Most of the studies have involved pigs with electrically induced ventricular fibrillation and have resulted in two distinct conclusions. First, the interruption of chest compression results in a lower coronary perfusion pressure and presumably less myocardial blood flow during CPR.2 Second, an increased frequency of positive-pressure ventilation reduces the survival rate. The detrimental effect of this high frequency of ventilation is thought to result from both the interruption of compression2and the obstruction of venous return to the central circulation because of high intrathoracic pressure during ventilation.3
These data, along with observational EMS field studies suggesting that outcomes are better with continuous chest compression and no rescue breathing, led the American Heart Association to advocate “hands-only” CPR4 for bystanders not trained or competent in CPR with rescue breathing.
Two articles in this issue of the Journal — one by Rea and colleagues5 and the other by Svensson and colleagues6 — describe studies that took advantage of emergency medical dispatchers' instructing bystanders to administer CPR. In the studies, patients with out-of-hospital cardiac arrest were randomly assigned to undergo one of two types of CPR performed by a bystander: either continuous chest compression without any attempts at ventilation, or chest compression with interruptions for rescue breathing by bystanders (the current standard).
The straightforward conclusion from the primary analyses of these studies is that continuous chest compression without active ventilation, which is simpler to teach and perform, results in a survival rate similar to that with chest compression with rescue breathing. Equally straightforward is the message that advocating continuous chest compression without ventilation by a bystander should increase the frequency of bystanders' effectively performing CPR and therefore increase the chances of survival after cardiac arrest. Performance of mouth-to-mouth rescue breathing is far more difficult than proper chest compression, and rescue breathing may be viewed with distaste and raise concerns about risks associated with mouth-to-mouth contact. One suggestion made by Rea and associates in their discussion deserves some attention: that mouth-to-mouth ventilation is performed so poorly by bystanders that this periodic interruption for “ventilation” succeeds solely in diminishing coronary flow.2 Nonetheless, CPR courses should teach rescue breathing, since it is important in cases of cardiac arrest due to obvious respiratory failure, which include most cardiac arrests in children and some in adults.
There was a trend toward better survival with continuous chest compression among patients whose arrests were due to cardiac causes5 and among patients whose initial cardiac rhythm was ventricular tachycardia or fibrillation6 rather than asystole or electromechanical dissociation. This trend is consistent with the benefit of continuous compression in animal models, in which arrest is caused by induced ventricular tachycardia or fibrillation.2 In dogs, after the sudden interruption of blood flow by means of ventricular fibrillation, the predicted steep decline in arterial oxygen saturation does not occur until many minutes after the start of resuscitation. The volume of oxygen in the lungs is relatively great when arrest occurs suddenly.7
On the other hand, it might be detrimental not to provide rescue breathing in patients with other causes of cardiac arrest. Oxygenation may be more compromised over longer periods of declining circulation, such as when there is hypotension resulting in electromechanical disassociation or a prolonged period of bradycardia before asystole.
An even more radical suggestion is that in patients with sudden cardiac arrest caused by ventricular tachycardia or fibrillation, it may be beneficial to restore circulation with blood that is moderately unsaturated with oxygen rather than with well-oxygenated blood. Although in animal models of ventricular fibrillation, a prolonged period (i.e., 8 minutes) without ventilation is detrimental,8 recent observational clinical studies support the idea that hyperoxia during recovery from cardiac arrest is detrimental to patients.9 Studies of isolated cardiac-tissue specimens10 have raised the possibility that initial reperfusion with hypoxemic blood may result in fewer injurious oxygen free radicals and less reperfusion injury.
These are intriguing observations and hypotheses, but more research is needed. To my knowledge, definitive studies in animals of hypoxic reperfusion after ventricular fibrillation have not yet been performed. Although clinical observational studies support the relative benefit of compression-only CPR performed by EMS personnel on arrival, there is a need for a randomized study in this setting as well. Particular attention needs to be paid to whether the benefits of compression-only CPR are apparent primarily in cardiac arrest with initial ventricular tachycardia or fibrillation rather than arrest with other rhythms. It will also be important to study the subgroup of patients who undergo bystander-performed compression-only CPR followed by EMS-performed compression-only CPR. There is certainly a need for rescue breathing after a prolonged period of CPR; in such cases, should the rescue breathing be provided while continuous chest compression is performed or should compression be interrupted to provide greater ventilation? A large study might also address whether rescue breathing is of critical importance in patients whose cardiac arrest is not associated with ventricular tachycardia or fibrillation. The answers to these questions may be paradigm-shifting and will almost certainly be lifesaving.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
SOURCE INFORMATION
From the Department of Medicine, Johns Hopkins Medicine, Baltimore.
N Engl J Med 2010; 363:481-483July 29, 2010
Ganas de Chingar
GANAS DE CHINGAREsta expresión puede acompañarse con las siguientes locuciones: ésas son, tengo unas, qué, ah pero qué, etcétera. Ésta es una frase que alude al deporte y gusto por chingar al otro. Uno puede tener ganas de chingar o simplemente nace con esa habilidad. A veces se pretende chingar con dolo y otras, sólo se hace por diversión o por costumbre.<< - Lleva todo el día molestándome. De veras que ésas sí son ganas de chingar. >><< - Ah, qué ganas de chingar... Toma tu chicle y estate quieto de una vez.>><< - Dice que siempre no y que mejor cambies los dos ejemplos y, además, que lo ordenes alfabéticamente.- Ah, pero ¡qué ganas de chingar!>>
