Saturday, 26 May 2012


So I may not have been the best blogger and neglected to post last weekend.  Oops.  I find that I just keep running out of time.  I'm so tired during the weeks, I usually just eat, read for the next day's surgeries and then fall asleep and the weekend is the only time I have for sight seeing so I'm trying to cram everything in to what is essentially a very short space of time. But I'm here now. This is my third week in Boston now.  I've settled in, I know most of the team and I think I'd adapted so much I've probably forgotten how we do things at home now.  But I had a minor epiphany this week.  I've been really trying to get my head around how things work here and the main differences compared to home and then I realised.  I suppose it came after a discussion with my attending on how many of the orthopaedic consultants were paid by lots of the companies that produce orthopaedic medical devices such as implants, screws and plates and such in order to use their stuff.  And not just a little bonus.  We're talking about a lot of money here.  For some attendings, it runs into millions.  This is in addition to their normal salary paid by the hospital(s) they work for.  Which is just crazy.  That's not being impartial when you recccommend a particular company's product.  They're PAYING you to do so.  I just don't understand it.  This is not something that could ever happen at home, drug reps aren't even allowed to take GPs out to lunch any more in case this is enough to persuade them to use the brand drug rather than the generic so what happens here takes it to a whole new level. Anyway, the companies were forced to make all this knowledge public as the CEOs of the companies were threatened with being taken to court if they didn't.
So after hearing about all this, I suppose I was taking it all in and I suddenly realised that essentially, healthcare in America is seen as just another consumer business.  It's not about providing a fundamental human right. it's something that money can be made from.  As the Government doesn't provide insurance if you earn over a certain amount, you're forced to obtain health insurance from the private market.  Most people can't afford to just buy it, like you'd buy house insurance so they get it through their employer who provides it at a subsidised cost, as all the employees get their insurance through the same company... lots of people putting money into the same cost lowers the cost to them individually.  But if you lose your job or the insurance offered isn't quite what you want, you're on your own.  The thing that bugs me the most about this system is that the companies sees this as purely a way to make profits.  They don't think of all the lives they ruin by chasing people for each last penny that they owe.  This isn't just a bad loan, this is someone's health.  The criteria they apply for paying out don't always go with the way that rehab or treatment goes.  At my hospital, patients are seen in clinic at dates when their management could change.  So for an ankle fracture, they get seen at 6 weeks as their weight bearing status may change then (from non to partial) they get seen at 3 months to see if the fracture has fully healed and no time in between.  There's no need for it, the doctor doesn't learn anything new and the patient has to traipse to the hospital, sit there for a number of hours, see the doc for 10 mins then go home.  Not worth it when your mobility is limited due to your broken leg.  BUt we had one patient who came in before her scheduled appointment otherwise her insurance were not going to pay for the rest of her treatment.  We also had another patient who was asking for her weight bearing status to be changed otherwise her company was going to stop paying for her rehab.... Sometimes the first questions out of a patient's mouth after they've been admitted is "Will my insurance pay for this?"  I despair at this.  That shouldn't be a worry; the likelihood is that they've, through whatever reason, just had an accident and they need to be taken care of, fixed and set on the road to recovery.  They shouldn't be panicking about the cost of their medical fees and where it's going to come from.  That shouldn't be what healthcare is about.
Coming from England, where all medical schools are public and we get loans from the Government to cover our tution fees, people primarily go into medicine aiming to make people better in some way.  There's definitely an altruistic component.  Here, it seems like that's missing.  Or maybe it gets eroded away over those four years of study.  Maybe, before you've even begun your medical studies you've already got four years of debt hanging over you and you're looking at higher tuition feees, maybe all you can think about is the money and paying all of that off rather than helping all those patients in their time of need.  I know this seems very jaded but there definitely doesn't seem to be as much of a caring culture here.  I miss that.  Patients are described by what's wrong with them, rather than who they are.  A few of the expat doctors on the surface closer to my ends have also echoed this sentiment.  The patients in England are incredibly grateful for what you do.  There's still a few that remember what it was like before the NHS existed and when you needed a doctor but couldn't afford one, so they went without.  And people died.  So to have everything you might ever need, without having to worry about where the money will come from to pay for it is like a miracle to some people.  There's a sense of quiet pride about working in the NHS.  True to form, we complain but when it's under threat, like it is now, we rally round and do what we think is right to protect and save it.  And this stretches nationwide.  I think the fact that doctors in the UK can move around a lot more unlike the doctors here (residency for 5 years in one place vs 2 year of Foundation training, reapplication for Core Training followed by reapplication for Specialty training and then consultant jobs) means that people often work in a number of different hospitals, large teaching ones, smaller DGHs and we get exposed to these different working environnments, their strength and their struggles.  I'm immensely proud to be from a country that back in the Fifties came up with this, it was that forward thinking and I feel incredibly fortunate to be British and entitled to that sort of care.

The patient expectation here is huge.  Bordering on unbelievable.  Unfortunately the internet has made everyone a doctor in disguise and they all think they know better than you do.  So prepare for your next consultation to be an exercise in fending off questions: "I'm on this drug but I read that it causes you cancer so do I really need it?" "I've seen this plate on the tv and I want you to put this one in my leg, not the one that you normally use".  "I've got an important work do in two weeks, now I know I've broken my leg and can't walk but do you think I can leave this until after then or fix me so I'll be like new in time for it?"  "I know I had an absolutely awful break but I thought I'd be running by now (two months later) so what's the hold up?"  Patients want it all and they want it now.  They want to be back to normal or if they have some sort of arthritis, they want to be better than normal and super fast too.  They don't understand the nature of an operation:  erm, we just made a huge hole in your leg, moved all your muscles out of the way, hacked into your bone, for Goodness sake fixed everything and then patched you up.  Yes, it's going to hurt.  A lot.  But don't worry we'll pump you full of super strong narcotics for the first week so you don't feel a thing.  And then they wear off, you'll start to understand what pain really feels like and instead of learning to push through and realising it's not forever, you'll come to the ED, convince everyone there's something seriously wrong and get another refill...  Not all patients are thankful for what you do for them, they expect it as a service, maybe because they pay for it and because the hospital I'm at is ranked very highly unlike at home where care should be universally good (unfortunately not the case) so it's not quite so nice to look after them, not to say they don't deserve it but it's those things that factor into job satisfaction.

I guess this is what happens when you try to turn healthcare into a commodity.  And it should not be treated as such.  Unfortunately, when the insurance companies are making such huge profits from it, I doubt there'll be much call for change.

Monday, 21 May 2012

week 2

so last week went by so fast.  I saw yet even more stuff than last week, so much I can't remember half of it.
So this has been a busy week both in clinic and in the OR.  Wednesday was an 11hr day.  We've had a few cases that have been polytraumas so a lot of work orthopaedic wise but also a lot of work for the colleagues over in general surgery.  We had one guy who came off his motor bike over the weekend, went into a concrete wall at high speed.  Managed to smash up both his tibias pretty badly-he has open fractures which were badly contaminated.  The pictures taken of his legs in the ED are absolutely awful, his ankle is hanging off and he has a really bad degloving injury of his right tibia.  Somehow, somehow he is still neurovascularly intact in both his ankles but he developed fat embolus syndrome which apparently, is quite rare.  My attending reckons that you'll be lucky to see one a year (and my hospital is a high throughput trauma centre too so it would be very unlikely that you'd see one at a DGH)   Anyway the fat embolus totally messed him up, he got super hypoxic and needed loads of oxygen and he became acutely confused and didn't know where he was or what his name was so he was clearly too unwell to be taken to theatre.  The problem was that he has open fractures that haven't been definitely fixed, he's only had an initial washout but he needed the wounds to be irrigated and debrided to reduce the risk of infection.  So essentially it's a balance - fix the fracture and stop it from getting infecte which will delay the healing process overall or take him to theatre too soon and he could potentially die on the table or in the postop period.  So it's a difficult situation.  But here in America, the orthopods defer to the general surgeons, who are primarily responsible for his care.  I'm not sure it's exactly the same as at home but it's not completely different.  So yesterday, we did a very minor irrigation and debridement yesterday and fixed his external fixation as it wasn't really fixating very well.  External fixation is basically where there is a metal frame around the limb holding the fractures pieces where they should be.  I think because our patient was too unstable plus he has open fractures, that's why he was treated with external rather than internal fixation.  I was under the impression that open fractures are more likely to be contaminated and hence there is a high chance of infection of the internal hardware hence there's no point in putting it in but apparently you can so i would imagine he was very unstable.
I do really like poly trauma but this case was super hard.  He is the same age as me and I find it just a bit difficult but then I think, this is what we're here for-we're here to fix his injuries and get him on the road to recovery.  It's just hard when you know he could potentially lose his foot or he could have died and that can be a tough one to deal with.
Proximal humeral fracture: this was fixed with a locking plate.  Not all these fractures need to be fixed but our patient had the head of her arm bone come away from the shaft really and that needed to be resolved.  The locking plate principles are universal essentially what you need to understand is the basic principles and forces acting on the fragments.  The thing I like about this specialty is that things happen in a relatively predictable way.  Ankle fractures- the injury you get can be predicted from the way in which the patient's foot went.  There's a whole classification system based on it.  It's also applied physics and biomechanics,  I find this a hugely interesting concept.  I've always found this to be incredibly interesting.  Nothing fascinates me more than the active individual and how your body copes with the the stresses placed on it during these activities.  Part of the reason why I love orthopaedics.  So my attending explained how a locking plate works and he makes it sooo simple, even for me who struggles epically with physics.   And the principles are the same for anywhere else they may be used in the body.  This is what orthopaedics is about: principles, not the actual methods-they're easy to learn once you know how and will obviously change but the principles are what to come to mind when you're looking at an x-ray with a fracture on and this is what will ultimately determine your management.

Saturday, 19 May 2012

week 2

Massive post covering the whole of this week coming up! I'm just so knackered by the time I get in after having done a 10-11 hr day than I usually eat then fall asleep!!  But it's coming, I promise!

Summer time in the Boston town, however, means sightseeing today!! But by the end of the weekend something will be up :)


Sunday, 13 May 2012

week 1, day 5

today's OR list: percutaneous bilateral iliosacral screw insertion, right distal radius orif with volar locking plate, right tibial non-uniion with iliac crest bone graft, closure of fasciotomy.

Started the day with the meeting.  I keep calling it the trauma meeting, because that's what we call it at home but that really is a trauma meeting.  we discuss all of the previous admissions from A&E to the wards in terms of major trauma, NOFs and other random fractures in this meeting.  well here they do that, but they also go over their lists in general and the post-ops under their care during this meeting.  so it's sort of like the all-purpose general meeting instead of the specific trauma meeting.  After that they round.  I missed the round today as I got chatting to one of the residents, who is from Ireland.  She left after she realised that there wasn't a whiole lot going on at home.  She's done unbelievably well to get onto a residency here and specifically where I am too.  To say I'm impressed is an understatement really.

Then theatre.  Watched a lady who had fallen onto her backside and managed to fracture her sacrum (one of the bones at the bottom of your spine) into a U shape.  It was so painful, she couldn't even walk anymore and she was 1 month post injury, a time where it should be getting better.  She was also starting to develop neurological symptoms so the decision was made to operate on her.  I had seen this patient over the week, first in one of my attending's clinics and then in the other's as she had had a CT scan of her spine in the interim.  The second appointment was where the decision was made to operate on her, the very next day in fact.  I can't quite remember if this is how it happens at home.  At George's there isn't too much difference.  If you're admitted from clinic for whatever reason, depending on the urgency of the situation, you will get operated on very soon.  Maybe not the very next day but within the week, but like I said it depends on the situation.  Plus this lady was medically fit,  not all patients are.  Some need to be "optimised" (anaesthetic term, not a surgical one!) for surgery which basically means getting their hearts and lungs as best as they can be for the surgery as these can result in problems for anaesthesia or during the postop period. So anyway this lady's surgery was very rare.  The sacrum is a bit like a highway for lots of important nerves that control bowels and bladder and muscles in your legs so the ones responsible for walking.  Where the screws go in is very close to where these nerves come out of the spinal cord and you can't see them when you're operating.  We use an x-ray machine intra-operatively so you know where roughly where you are but there's lots of lateral thinking and thinking in 3D to try and predict where the nerves are exiting.  This is tricky surgery in the extreme. 

The right tibial non-union was quite interesting.  The patient had broken their shinbone almost a year ago and it hadn't healed.  People often think that as soon as the metals in there, or they're in a cast that their bones will heal but it's not always like this.  There are certain features that everyone needs to ensure that their wounds heal and bones are very similar.  That's one of the reasons why we don't always let you walk on a broken bone in the leg or foot, because putting the forces through it pushes the pieces apart and this stops the bone from healing.  Well this patient was a smoker and a bit overweight and probably didn't have the best diet.   Not that different from most patients really.  But for some reason, their bones were more susceptible to not healing.  Anyway the metal plate holding the two pieces together in our patient's leg had also broken, so there was not much really holding the bone fragments in the correct position for healing.  So the surgeons had to remove the broken plate, get rid of the tissues that had grown (a fibrous non-union - so like a scar instead of new bone) and then fill in the defect with bone from the patient's pelvis.  I found this a really fascinating case.  One thing I have realised is that I find it really interesting when things don't go as planned.  It's great when things are straight forward but when they're not, it can be a real challenge and I love thinking about what to do about these things, knowing that each case is individual and one approach in one patient may not work for another.  Hopefully, this procedure will work for this patient, it doesn't there aren't very many options left.

I've already seen so much stuff that I haven't managed to see at home, it really is quite amazing.  I'm really looking forward to this week and seeing even more.

Thursday, 10 May 2012

week 1 , days 2-3

so it's been a busy few days.  i spent tuesday and wednesday in the OR as it's called here.  one of the residents reckons the orthopaedic theatres are probably the newest in the world.  they were opened last year.  they are fancy, i'll give them that.  they contain four massive lcd screens which are connected to the pcs and you can see the patient's trend in vitals during the op, what time they got into theatre, what time the op started in addition to displaying i.i. (image intensifier) films on them and the CT or Xray of the initial injury.  They're quite quiet it's rare that anyone plays music, but the atmosphere is jolly and quite relaxed.  The scrub sink is located outside the theatre (which I find odd) and the patients are induced in theatre- there is no such thing as an anaesthetic room here... very bizarre.  Considering that anaesthetists can get super protective over who can and cannot enter their little room whereas here they don't care too much, it's quite a contrast.  And I don't htink I've seen an anaesthesiologist actually put someone under yet.  Seems like the OPD equivalent does it all here!! I can see why PAs at home get put out because all they do is ward work, allied health professions are given much more responsibility and autonomy here compared to at home.
So approaches and techniques are relatively similar, although I did see a patellar fixation that varied substantially from the way it's done in the UK.  Apparently most will hold it together using screws but here they thread through wire via the cannulated screws to hold it together.  My attending said he'd been taught that here.  So clearly that's unique.  When it comes to total hip replacements, the trend here is not to cement the acetabular component which is very unique.  It's just not the done thing.  The residents don't feel comfortable doing it either, (I suppose because they haven't ever done it).  I find these trends fascinating.  Who decides that one day, they're just going to stop cementing in that bit because they don't like it.  And somehow it catches on...  Is that the American culture?  There's not really an evidence base for it, because unlike the UK, they don't have a joint registry so they can't keep track of it over a long period.  I guess they'll look back using retrospective studies.. but that doesn't really help the patient's of today.  One thing I'd like to talk about more is their views on resurfacing.  Considering that it's got such a bad press at home, I'd like to see it that has extended over the Atlantic.  Admittedly, it's not their area of expertise but it's interesting to see what their views are. 
OR cases: Patella fixation, I&D, Right hemi, I&D of right iliopsoas abscess
Both bone (lol, radius and ulnar) fixation with plates, volar locking plate for left distal radius, ex fix for pelvic fracture, ankle ORIF, tibial plateau fracture
Clinic cases: tibial plateau , tibial pilon fracture, pelvic fracture, HO case, subtalar ankle fusion

Back to the OR tomorrow.  Initial observations on the American system vs the UK system come the weekend.

introduction to bones

So this is basically my attempt to record what i do on my final year medical student elective in Boston, as the days are fricking long and I am usually falling asleep within a few hours of getting home, despite seeing so much!!  So sorry, if it doesn't make a whole lot of sense, it's really to make my elective report easier to write later on down the line.
Things i have observed over the last 2 days:
Americans work crazy long hours. Who the hell ever heard of a trauma meeting in the UK starting at 6:30am?! it's just insane, and it's not like they finish early either, we didn't finish the list today until like almost 5:30 and then they had to round on the post op patients. Apparently ortho is the only specialty that does that at my particular hospital (and anywhere in the world...!.  I'm not complaining, it's just completely different to anything I've known medically.
Americans wear scrubs everywhere. And I mean everywhere.  Like the subway, Trader Joes, just out and around.   Now coming from the UK, where scrubs are only ever, ever worn in the hospital (or in bed as pyjamas) I find this incredibly bizarre.  I suppose we inherently see them as dirty as you're supposed to cover them when you go into eating areas of the hospital and you most certainly don't wear them outside the hospital.  It's incredibly odd.  They're almost as common as jeans in some areas. I find this bizarre but will try to get used to it.
So today: OR, ortho trauma all day.  Saw trimalleolar fracture fixation, tibial plateau
polytrauma case.  Very exciting.  Hope there's more in store.  Can't believe the amount I'm seeing and how much I'm learning.  It's slightly insane.  But I fucking love it and it makes me want to do ortho even more. 

Will write more soon...