Thursday, May 31, 2012

What a Day.

So like I said in my last post, my placement is coming to an end and because my supervisor is really good with slowly giving me more responsibilities as the weeks go by, this week has been a lot of fun. My last placement, Obs and Gynae, could easily be the highlight of my medical school in terms of all-round great placement. Yesterday could have EASILY been the highlight day of my degree so far and by the looks of it - this placement will probably become the best placement of my degree.

Anyways yesterday was theatre day and was expecting to have 3 patients on the theatre list but I was actually disappointed in the morning to find out that one of the patients were cancelled so we only had two patients on the list. It was also going to be my last orthopaedic theatre list for this placement so I was a bit bummed out that we were most likely going to finish early. First patient was a simple straight forward one man job so I didn't scrub in and just observed. Afterwards we had a good break prior to the next and final patient for the day. Had some good banter with my supervisor and then I went to go see the patient in the anaesthetic room. It was a bit weird as the anaesthetist had quite a bit of difficulty putting in an epidural and other things just weren't going right/straight forward. The anaesthetist and I had a bit of a chat and we agreed that we have a feeling this surgery is going to be FAR from straightforward. Anyways after the patient was put to sleep my supervisor came in and told me that I will be scrubbing in and will be a first assistant. My eyes lit up. Last few weeks, I was scrubbed in, but I was more of an observer who did a bit of suction here and there, but nothing really special/that helpful.

Brief summary of patient: 1st stage revision of total hip replacement. Reason: Infection

11.10 - first incision made

I am still a bit new to orthopaedic surgery, but I have seen a few now and I knew immediately that something wasn't right. Immediately after the first incision, the patient was bleeding a lot more than usual. As we went deeper, it was obvious that the bleeding is only going to get worse and by the time we got to the muscle was like the flood gates were opened. The patient was bleeding from all sides of the opening and it was difficult to find where the bleeding is coming from. I tried my best to keep up with the suction so we can identify where the bleed is coming from, but we couldn't find a specific source. At least we knew it wasn't an artery as the blood is darker in colour. Anyways it was just a big mess in there and slowly it became obvious that this surgery is going to take a lot longer than predicted. The anaesthetist was struggling to keep the patient's stats normal and eventually had to call in for blood. We took a break during the surgery to try and get the patient to clot by packing the wound with swabs and putting pressure. After a bit, we hoped the swabs did the trick and started removing the swabs (which also gave the anaesthetist time to catch up with the fluids) and 5 seconds after removing the swabs...the blood just came pouring out.

12.30 - removing the femoral stem component

This wasn't too hard and everything came out very easily as the bone was dead and very weak. The cement and the component came out without much difficulty...luckily. Then we had to remove the acetabular cup which proved very the point we had to get creative. Anyways after a lot of creativity and trial and error we did get the cup out. Again the bleeding was still really bad and it was so hard to keep up with the suction and to keep the view clear. There were times where we were sloshing around blindly trying to feel for the anatomy instead of visualizing as it was far too difficult. At this point I was starting to lose track of time as I was completely focused on my job of suctioning and holding tissue out of the way, etc. As time went I could tell we were taking awhile as my feet were starting to hurt. My hands were starting to cramp up due to the gloves. My back was starting to stiffen up. Oh and I had to use the toilet...but guess what: too bad.

14.30 - making antibiotic cement beads

Essentially we leave these beads inside the patient to allow the antibiotics to work and to kill off the infection in the local area. After the patient has healed from this surgery...these beads will be taken out in the 2nd stage revision and a new joint would be put in.

14.50 - patient starting to really deteriorate

While we are is difficult to hear what is going on outside of the operating area as we are in a "tent" area with plastic walls, but you could hear the anaesthetist making a lot of calls for extra help. People were starting to come in and you know something isn't right.

15.00 - closing up the wound

We started closing up the wound and then I heard my supervisor tell the scrub nurse: "vicryl to the student as well please". I was a bit confused as to why my supervisor and I both each had sutures as usually only one person would close up while the other person uses the scissors to cut the stitch (which is usually my job). My supervisor told me to start on the bottom end of the wound and he went off and started closing up the top portion of the wound. Last time I sutured, my supervisor watched me and guided me. This being my 3rd (?) time suturing on a real one is watching. Worst bit: I was also shaking like a leaf. No I wasn't nervous/ was because the last time I ate was at 8.00am and was obviously starving. Anyways managed to close up the bottom of the wound and then proceeded to help my supervisor with cutting and pushing the skin closer together so he can close up properly. Other than the shaking...I didn't struggled with the knots or anything. It actually went fine and my supervisor said my sutures looked fine as well. Proud moment. Thank goodness for masks as I was probably smiling like an idiot.

15.30 - put dressing on the wound (which was leaking out with blood still) and clean up

As we took down the drapes and everything you really notice that the patient isn't doing well as hiding in the back were 4 other people helping the anaesthetist and the floor was covered with empty blood bags. At one point the patient's haemoglobin count dropped to 6 (normal is 12). Apparently the patient had no clotting factors as well and we suspected the patient had DIC (disseminated intravascular coagulation) as the patient was bleeding from the cannula sites and from her nose. By the end of surgery it was calculated that the patient had lost up to 10 litres of blood. Normal human has about 5 litres of blood. It wasn't good and the patient was obviously in a critical state. There was a student nurse watching the surgery so I went over to go talk to her. She initially thought I was also a surgeon and hadn't realized I was a medical student. I was a bit shocked as I thought it would be obvious as I'm the "clumsy" medical student that probably looked lost and clueless during the surgery. The student nurse quickly disagreed and said that she was amazed how it looked like I knew what I was doing and what needed to be done. She thought I was constantly on the same page with the consultant and I didn't need much direction. It was weird hearing that as I always though I looked like a clueless idiot when scrubbed in. Even the other theatre staff gave me a pat on the back and told me I did a good job. Definitely put a huge smile on my face and the surgery felt good. I really enjoyed it and it was exciting. The surgery was also definitely challenging so it was an interesting case for me.

Anyways first time being a first assistant for orthopaedic surgery and a good way to end my last theatre list for this placement. The patient ended up getting transferred to ICU, but she managed to recover so all was good. Definitely a very tiring day. By the time I got home it was around 1800 and I still had not eaten, but guess was fine and I think it is something I have to get used to. My supervisor also hadn't eaten as well and he doesn't complain as I'm sure skipping lunch is a usual thing for him. What a day.

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