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.

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