Brief orthopaedic stint

Hi,

Sorry for the brief late post this week, but things have been very hectic both in the hospital and socially, with no time to spare. I do realise I start most of my posts apologising for being short/rambly/late but that is just the British way - we love to apologise!

A pretty bitsy week this week, as it was a week of (poorly organised) orthopaedics, added to the fact that my car broke down part way through the rotation, leaving me stranded. That is all fixed now (at some expense) which is a blessing as a car really is a must at the moment! This week of orthopaedic surgery consisted of ward rounds, clinics and theatre time, much like my other rotations, only here they call them 'trauma' ward rounds, which makes them sound a lot more exciting. This, however, is a lie, and all they talk about during them is different eponymous operations, and bones. Lots and lots of bones. I noticed an interesting difference between some of the consultants though. One is very keen and does ward rounds himself twice a day, even when in theatre, while another does one a week, leaving the rest to the more junior members of staff. The former consultant tends to have two or three patients under his care at any time, as his are discharged very quickly, the other seems to have a dozen or so at the moment. This highlights the importance of consultant care when you are in hospital, and shows that they should do a lot fo ward rounds, as well as the fantastic work they do in theatre! 

One of the patients I was talking to on the ward had been sent back from a rehabilitation hospital with a more acute illness, but was begging to be allowed to stay in our (acute) ward rather than being sent back to rehabilitation. She claimed that the rehabilitation hospital was full of 'demented crazies' and she would go mad if sent back there. Currently not too sure what to do with her, as she cannot sit in her expensive acute hospital bed, stopping someone else from using it who has just broken a bone. Perhaps this case needs a consultant who comes around more than once a week.

That's all folks, next week perhaps I will be less busy... As you may have been able to tell, orthopaedics doesn't really interest me too much, and its harder to write about something you find less interesting!

On call

Hi,


This was a pretty exciting week, and not just compared to the pretty humdrum weeks that have passed by recently. This week I spend an evening with the trauma and orthopaedic team on call, followed by a day carrying out the following ward round and surgeries. While other things did happen this week, this was by far the most exciting, which helps confirm that I want to go into some sort of emergency/acute medicine as a career. While I don't enjoy the orthopaedic (or any) surgeries, they seem routine and boring, having to deal with real medical emergencies right there right now is very exciting. I would love to do that later (hoping I have the knowledge), but i get ahead of myself. I will say a little about what the on call was like and why it was so much fun.


The on call, as a medical student, involves going to the hospital mid afternoon and attaching yourself to one of the orthopaedic team until (in my case) about 11PM. Most of the time we have spent in the hospital this year has been in clinics and during the day, so getting back onto the 'hospital floor' as it were, and working at a more unusual time is an exciting thought in itself. After arriving I attach to a registrar, along with my medical student colleague, who works mainly with fractured hips. She is a really friendly, fun, and helpful doctor which makes the evening fly away.


We spend a lot of the time in the A&E department, and as she is the surgical on call, we also go to wards where patients are reported by the nurses as getting sicker, or needing a review, to see how they are. In the emergency department we see 3-4 fractured hips, all of them are in elderly people who have fallen (either through a trip or through a medical condition such as a heart problem) and broken the top part of their femur where the lump makes it into a ball to join into the hip. These are called 'fractured neck of femur', abbreviated to #NOF (as orthopaedic people live abbreviations) and need surgery the next day to replace the head, before it starts dying and you lose the use of your hip. These patients are usually in a lot of pain, and need to have their medical conditions controlled fast in order to operate on them the next day, for example reversing warfarin therapy (for AF) by using vitamin K, so the patient doesn't bleed out during the surgery the next day.

The right of the image (labeled L for patient's left) is a normal hip, whereas the opposite side is a displaced [moved out of position] fractured neck of femur

We soon found out that these patients were the tame side of the on call, as we were called to a polytrauma patient, who had crashed and rolled his truck, and become stuck inside for some time before getting to the hospital. Various specialists are summoned to the emergency department by their bleeps, such as anaesthetists to help stabilise the patient's airway, which goes off when the ambulance lets the hospital know that it is bringing in a trauma patient. The buzz in the air as these people collected, putting on their lead gowns to protect from the portable X-ray machine used to look for breaks and the like, was very exciting. Once the patient arrived, strapped to a stretcher with blood smeared limbs visible in the folds (just like in a TV show) the atmosphere calmed down from that excited buzz to a calm businesslike feel. There are about 10 people or so around the bed, each having jobs to do, with a leader at the foot end commanding people and assessing the overall status of the patient. The anaesthetists work at the head end, while other doctors put in cannulas to give fluids or blood, and others perform a head to toe survey to look for injuries. Scans are taken and it is decided that the patient needs a CT because of a large injury to their head, and they are quickly taken off. All very exciting, and amazingly organised. I would love to be part of that sort of team one day, working together to save someone who is critically ill.


It wasn't just surgical cases that I saw while on call though, as when we were called up to the wards for patients who had problems, these problems were usually medical. For example, one patient who was in a few weeks after a knee replacement (waiting for nursing home) was reported as acting 'weirdly', and after we got there and tried to talk with her for 10 minutes (hard to communicate with) she started having a seizure in front of us. There was just this one doctor and the ward nurse around to try and work out why this was happening, and control the seizure (a very scary thought that that would be me some day. I need to learn so much more first!). The seizure proved difficult to control, and due to some other circumstances a 'medical emergency' call had to be put out which, similar to the trauma call, had a good variety of different medical personnel arrive in minutes to help with the situation. All very exciting, and the patient's seizure was stopped, though they think that she had something like pneumonia or a PE which had lead to this. Both consequences of staying in hospital for too long, a shame that she couldn't just go back to her nursing home.


All in all, a really exciting week, with the on call being full of the reasons that I want to be a doctor. Unfortunately I also talked a little to the doctors about their hours. This came up because I saw that, when I left the hospital at 11PM there were a few doctors who were set to stay on all night, who seemed pretty busy. When I arrived the next morning for the ward round, they were still there, went on the ward round then started their operating lists (being surgeons). This seems crazy - do they have time to sleep? While in a clinic for people with fractured bones, I asked one of the registrars about this, and she told me that she has worked 117 hours this week. That leaves 51 hours of the week left, or about 7 hours a day not in work (assuming she works the same amount each day). That is a hell of a lot of work. While nights give the 'chance' to sleep, realistically very little sleep happens because of all of the admissions and care that people need. A scary prospect for a medical student, where finals seem like the biggest challenge on the horizon. She was less upset about it than I would have thought, though she did admit that it made her grumpy, and she was upset that she only got paid for a fraction of the hours she did, die to the European Working Directive (48 hours max a week)...

Morning stiffness

Hi,


More delays to blog publishing - I would be a terrible journalist! This year is drawing to a close with only a couple of weeks left until summer holidays, the Olympics and the count down for my finals! This week had some interesting fun with joints, including clinics and surgery, where I saw plenty of knee replacements.


Exams all over now, which is a relief. I think they went OK, but you can never tell until you get the results, so I don't want to be premature. Quite exciting to think that those are the last exams that I will have to do before my finals, which are the final hurdle in the way of becoming a doctor. Exciting and scary... I don't feel ready in the slightest yet, and there is still a year left, so perhaps I don't need to worry too much.


Anyway this week I got to sit in on a lot of knee surgeries. Being in orthopaedics, much of what they want to do is bash away on bones to make them right again. While the orthopods (as they like to be known) fine this all exciting, drilling away into the bones with drills, or chiselling away with other metal implements, I think I would find it a bit boring if I had to do it all day every day. It is certainly exciting while you watch the first one, seeing what a joint looks like inside, or even more exciting, a replacement of a joint, where an old joint is replaced with a new one ('revision'), where the skin is cut open to reveal a shiny metal joint! Awesome! (Terminator!) Either way, after I had seen 3 or 4 of these I was becoming quite tired of it. I am sure it is different when you sit in the operating seat (literally) as there is much more to do than watch, but I still don't think its for me. Odd, as I loved playing with Meccano as a kid. 


Other than the rather boring surgeries (each to their own) I also got to sit in on a clinic with a really crazy locum consultant. I had not seen her before, and its unlikely that I will see her again, but she was very strange! Not in a negative way, as her patients clearly loved her, but I had no idea what she was doing. She spent about 5 minutes (no exaggeration) working out her left and right to ask the patient which foot hurt, and refusing help from the patient or me. In between the  patients (on an overcrowded list) she would take 10 minutes or so to talk about something seemingly out of the blue. One time it was how she used to have singing lessons, and how her singing teacher would never talk to her, only sing or mime (so as not to damage her singing voice) and other times it would be about how hard things at home were for her as a locum, and her family problems. Nice to be talked to, but not sure why, or whether it was the best time and place for it. 


The best moment in the clinic came when someone had come in about a problem with her knee. I was running through all the routine questions that would help get a diagnosis, and for one I asked if there was any morning stiffness at all. The patient, quite innocently, answered that "I don't have anything like that, but my husband usually does"... A question or two later quickly confirmed that she wasn't talking about her husband's joint problem. A hilarious, if not slightly embarrassing, lesson in making sure that your questions are phrased to avoid any misinterpretation! 

In case you didn't get the confusion