Yesterday was the last day of my Orthogeriatric placement. Was a bit bummed out as I've gotten to know the junior doctors quite well and I enjoyed my placement (despite it being only 2 weeks). By being on the Geriatric ward, you realize all the ethical problems and how cost of care can be so high for these patients. For example - hip fractures cost the NHS 1.7 million pounds per year. The problem is that when these patients turn up, they don't just get an operation and then get discharged after a few days. Older people require a bit more care as they tend to suffer from other medical conditions such as vascular disease (MI, stroke, etc), diabetes, etc. Along with needing to continue treating their co-morbidities, these patients are more susceptible to hospital acquired infections (eg. pneumonia) so essentially it becomes a vicious cycle for these patients. Majority of the patients on the ward stay in hospital for a month which is quite a long time. Care 24/7 for 4+ weeks...the costs do add up.
I was probably most involved with ward rounds in this placement than any other placement I've had so far. I was quite keen to actually help out as I know I do get bored quite easily if I just stand around. I got to write in the patient notes and you just feel a slight bit more responsible while on placement. It sounds a bit sad, but it's quite satisfying signing off on something. I mean as a medical student, we never really get to sign off on anything so it's nice being able to sign off the notes you made in the patient notes during ward round. You also feel a sense of contribution as well, which is a nice bonus. Also good practice for the future as well - will be doing lots of paperwork in the near future...
I think the main problem about being on a geriatric ward is that the turnover rate is quite low so the ward round usually consists of a quick check-up and if there are any new concerns/changes. This made me find this week a slight bit more dull than my first week. The only thing is that now I know the patients, but there isn't anything new to see. Their improvement is also quite slow so I must admit this week's ward round was a bit less interesting.
I mean overall it was nice to be back on a proper medical ward and doing "medical things" as I've spent the whole year in very specific specialties. There was a lot of general medicine and it made me realize how much I have already forgotten (quite scary especially when exams are just around the corner too!). All in all these 2 weeks helped me get my sanity back and I managed to grab some motivation back - well enough to take me through to exams. Now I've got 2 weeks off before my next and final placement - Neurology. Neuro will be tough but I'm quite lucky that I've had an attachment in Stroke medicine last year so I shouldn't be too lost on the ward.
2 weeks to dig my head into my books and do some proper revision. Procrastination mode - on. Need to focus!
Showing posts with label hip. Show all posts
Showing posts with label hip. Show all posts
Saturday, October 27, 2012
Friday, July 20, 2012
Old Age.
Had quite a weird week...weird as in a week which really made me change my perspective on things.
I got to go visit a nursing home for people with dementia. I had previously volunteered in a nursing home before medical school but I didn't work with patients with dementia. I went to visit a 75 year old man who has vascular dementia and had just moved to this new home. The nursing staff were worried about him as he had spent the entire night pacing up and down the hallways continuously for 15 hours non-stop. I went into his room and sat down in front of him. His room was fairly small. One single bed. One small wardrobe in the corner. 1 night stand. 1 cabinet. This man just sat in his chair, hunched over. He wore a baseball cap so I couldn't see his face. As he sat there I saw him dribbling on to the floor. It was almost like he wasn't even there and was staring at his shadow. I looked over to his night stand and saw 2 pictures of him and his family. In the pictures, he was middle-aged and appeared to be a very proud man. He stood in the pictures full of confidence. He looked very happy. Then I looked back at the patient, still dribbling and staring at the ground. He looked quite frail. I eventually said hello to him and he didn't reply. I moved his hat a bit so I could see his face. He still stared at the ground. I asked him what is his name and he replied me without looking up. I tried to carry out a very basic conversation with him, which proved difficult as midway through he started mumbling. I couldn't quite understand him and he quickly stood up. He walked to his wardrobe and was very unsteady on his feet. He had a very unbalanced waddling gait. I asked him where is he going and he replied: "Home". I kindly told him this is his home and to sit down again. As he came back to his seat I looked into his eyes and he didn't look happy. He didn't really even look like the man in the picture by his bed. As he sat down, he went back to staring at the ground and stopped talking to me. I just sat there looking at him. I thought to myself: Is this how residents here pass their day? I found it pretty sad as they just sit in a fairly tiny room. This particular man, if he isn't pacing up and down the hallway, he is sat in his chair almost lifeless. Really made me think that people need to live their life to the fullest. Appreciate the things and people around them. I felt bad for this man. His life seemed pointless. He was confused. Ageing is a scary thing. Just comparing this man to the man in the pictures - it is almost like night and day.
Then when I went back to the GP practice, I met another lady who desperately needed a total hip replacement. Her x-rays showed severe osteoarthritis (OA) as in it was bone on bone. The patient had a shortened right leg as well due to the OA. On palpation of the greater trochanter...it felt like you were running your hand over a bag of marbles. You could feel the osteophytes! Range of movement was severely decreased and the patient had pain on extension and flexion. Actually any movement made the patient jump. It was fairly remarkable that she doesn't need to use any aids to walk, but you can tell she is struggling. Unfortunately, the surgeons do not want to operate on her due to her health and as well she does not have anyone at home to look after her. She told me that she has outlived her entire family and there was no one left. She explained to me that she tries her best to get through the day, but usually just stays at home to avoid any hassle and because her hip hurts too much. She has tried all sorts of analgesics and even tried topical treatments (which doesn't work, which is no surprise as her hip was bone on bone). I asked her what does she do every day if she doesn't really go out. She told me she just sits there and read and told me that her life has become very boring and that there isn't much meaning to it any more. She talked about how active she was when she was young and gradually as her hip got worse, she couldn't go out for walks in the park or even do her gardening.
If you think about it, when I start reaching the peak of my career, the majority of my patients will be the elderly. In general the population would be quite old as the current generation of "baby boomers" are starting to reach retirement age. I think it is key for medical students to learn how to deal with the elderly. It is frustrating to hear students go: "I don't like old people. I hate talking to them." I sometimes can't help but say back to them: "Well start liking it as the population ain't getting any younger." I'm sure I have said this before, but I quite enjoy talking to the elderly. They always have a great story to tell or have some pretty wise things to say to you. They are all so strong as they have been through so much. They seriously need a heck load more respect from people of my generation and the younger generations. Ageing is the fact of life and there isn't any way to avoid it (well unless something really tragic happens to you at a young age...). Sometimes it is just hard to see what the future lies for you when you see so many elderly patients.
I got to go visit a nursing home for people with dementia. I had previously volunteered in a nursing home before medical school but I didn't work with patients with dementia. I went to visit a 75 year old man who has vascular dementia and had just moved to this new home. The nursing staff were worried about him as he had spent the entire night pacing up and down the hallways continuously for 15 hours non-stop. I went into his room and sat down in front of him. His room was fairly small. One single bed. One small wardrobe in the corner. 1 night stand. 1 cabinet. This man just sat in his chair, hunched over. He wore a baseball cap so I couldn't see his face. As he sat there I saw him dribbling on to the floor. It was almost like he wasn't even there and was staring at his shadow. I looked over to his night stand and saw 2 pictures of him and his family. In the pictures, he was middle-aged and appeared to be a very proud man. He stood in the pictures full of confidence. He looked very happy. Then I looked back at the patient, still dribbling and staring at the ground. He looked quite frail. I eventually said hello to him and he didn't reply. I moved his hat a bit so I could see his face. He still stared at the ground. I asked him what is his name and he replied me without looking up. I tried to carry out a very basic conversation with him, which proved difficult as midway through he started mumbling. I couldn't quite understand him and he quickly stood up. He walked to his wardrobe and was very unsteady on his feet. He had a very unbalanced waddling gait. I asked him where is he going and he replied: "Home". I kindly told him this is his home and to sit down again. As he came back to his seat I looked into his eyes and he didn't look happy. He didn't really even look like the man in the picture by his bed. As he sat down, he went back to staring at the ground and stopped talking to me. I just sat there looking at him. I thought to myself: Is this how residents here pass their day? I found it pretty sad as they just sit in a fairly tiny room. This particular man, if he isn't pacing up and down the hallway, he is sat in his chair almost lifeless. Really made me think that people need to live their life to the fullest. Appreciate the things and people around them. I felt bad for this man. His life seemed pointless. He was confused. Ageing is a scary thing. Just comparing this man to the man in the pictures - it is almost like night and day.
Then when I went back to the GP practice, I met another lady who desperately needed a total hip replacement. Her x-rays showed severe osteoarthritis (OA) as in it was bone on bone. The patient had a shortened right leg as well due to the OA. On palpation of the greater trochanter...it felt like you were running your hand over a bag of marbles. You could feel the osteophytes! Range of movement was severely decreased and the patient had pain on extension and flexion. Actually any movement made the patient jump. It was fairly remarkable that she doesn't need to use any aids to walk, but you can tell she is struggling. Unfortunately, the surgeons do not want to operate on her due to her health and as well she does not have anyone at home to look after her. She told me that she has outlived her entire family and there was no one left. She explained to me that she tries her best to get through the day, but usually just stays at home to avoid any hassle and because her hip hurts too much. She has tried all sorts of analgesics and even tried topical treatments (which doesn't work, which is no surprise as her hip was bone on bone). I asked her what does she do every day if she doesn't really go out. She told me she just sits there and read and told me that her life has become very boring and that there isn't much meaning to it any more. She talked about how active she was when she was young and gradually as her hip got worse, she couldn't go out for walks in the park or even do her gardening.
If you think about it, when I start reaching the peak of my career, the majority of my patients will be the elderly. In general the population would be quite old as the current generation of "baby boomers" are starting to reach retirement age. I think it is key for medical students to learn how to deal with the elderly. It is frustrating to hear students go: "I don't like old people. I hate talking to them." I sometimes can't help but say back to them: "Well start liking it as the population ain't getting any younger." I'm sure I have said this before, but I quite enjoy talking to the elderly. They always have a great story to tell or have some pretty wise things to say to you. They are all so strong as they have been through so much. They seriously need a heck load more respect from people of my generation and the younger generations. Ageing is the fact of life and there isn't any way to avoid it (well unless something really tragic happens to you at a young age...). Sometimes it is just hard to see what the future lies for you when you see so many elderly patients.
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 layers...it 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 challenging...to 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 operating...it 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 person...no one is watching. Worst bit: I was also shaking like a leaf. No I wasn't nervous/scared...it 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 what...it 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.
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 layers...it 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 challenging...to 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 operating...it 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 person...no one is watching. Worst bit: I was also shaking like a leaf. No I wasn't nervous/scared...it 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 what...it 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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