Cast & Curious

Tag: Orthopedics Practice

  • Wrong side of surgery: Which site?

    Although rare, wrong site surgery happens even to the most able and busy OR team such as in this hospital. Imagine the horror of both the OR team and the patient discovering the closure stitches in the normal side after the procedure. But thats another story.

    What I’m a bit surprised is how the hospital administration managed to “rectify” the error and came out with better policies to prevent future incidents like this to happen. Their CEO even blogged about it, so the whole community would know about the lapses, the steps taken to correct it, and prevent further “errors” to happen in the same way.

    I can help but wonder if most of our health institutions here in our country have the same attitude towards wrong site surgery and medical errors. A universal protocol for wrong site surgery has been existing and updated regularly for quite sometime already. The American Academy of Orthopedic Surgeons (AAOS) also had its recommendations to reduce surgical sites error in orthopedics. Most of the stories I hear in our country from the gossip tree end up in long, expensive court duels. And even with the pay off, none of the parties learned anything (but money and pride) from the mistakes which should have been preventable in the first place!

    Not to be over simplistic about this but parallelisms can be drawn between mistakes like this one and that of mistakes done on people you care of. Admission is a braved act. Facing the consequences is an even braver act. But taking actions to prevent such errors from happening is a mark of a true caring physician. That is how we deal with people we care. To us physicians, that would be our patients.

  • First Cut, a baptism of fire for an orthopod

    I was expecting fireworks and a band playing for a great summer homecoming last year. Indeed, I was greeted by a different kind of “fireworks” but no band of course, one that ripped souls and six other lives. I was just starting a provincial, orthopedic practice then. This was my christening…

    It was one rainy afternoon.I just arrived from an orthopedic conference in another place.  My butt just landed on our sofa. Barely 5 minutes have passed since I heared a loud thundering blast that rocked the wits out of my ears. It was gone in a moment and I was too tired to even think about it. Besides, such loud noises frequently disrupts the still atmosphere of our neighborhood. Firecrackers are being manufactured on god knows where near our place so I didn’t bother.

    “Kuya phone!!!!” came the second reminder from our helper. I lazily picked the land line first.

    “Doc, we need you here in the hospital. A bomb just exploded in the market and patients are being wheeled in to the OR!” an ER nurse of hospital (A) told me. ” Bomb?!!!” the loud thundering blast flashed back and I froze in horror.

    “How many injured victims there?” I asked. ” Lost count doc, ER is filled!” Came the obviously panic stricken nurse.

    “OkayI’d be there in a minute. Please triage patients based on injury severity” Then I hang up the phone and hurriedly grabbed my scrubs. I almost didn’t noticed my  cellphone is still ringing.

    “Doc, please come immediately to  hospital (B) , we have bombing victims with mangled extremity here.” Said a resident on duty from another hospital. “We have an emergency intra op referral for you a mangled extremity!”.” Said another ROD in another hospital.

    “Oh God! This bad?!” and I’m the only ortho in town right now. Then the land line rang again. I suspect it was the other hospital nearby asking for the ortho to see the blast victims. Indeed it was.“This is nuts!” My first year and my first summer here.

    An improvised bomb planted by unknown persons exploded inside a jam packed billiard hall (that was just in front of a pedicab terminal) in Tacurong City. The bomb is an Improvised Explosive Device (IED) where the shrapnels consist of 1 inch long concrete nails, ball bearings and god knows what other dreadful things. Planted in a strategic and crowded location, it was planned with an evil thing in mind- maime people. Not to kill, but sow terror.

    The site where the bomb exploded is chaos and terror glorified. Blood stains littered everywhere. Stalls ripped apart. Glass windows blown into pieces. People where shouting, crying in pain and helplessness. A father was holding his bloodied dying son. A passerby was holding to his mangled left leg. Several injured people lay in agonizing pain just beside the sidewalk. It was hell on earth. A gory, horrific site.

    Those who recovered from the trauma and passing pedestrians began loading injured people into pedicabs and tricycles. The parish priest brought his pick up and hurled all injured persons he can and brought them into the nearest hospital.

    Most people on site were in shock to even move.

    I was taken aghast by the sight of patients still waiting to be seen by MDs in the hospitals. “Oh god!” Patients were coming in to no end. The ER is full, patients lay on hospital floor and benches. The nurses and hospital staff where all up,  rushing IV fluids, blood samples and splints. All MDs I know are in the hospital seeing patients already. Most hospital here are secondary hospitals so beds easily filled up.

    I grabbed my scrubs and then went on assessing patients and triaging them based on injury severity and treatment priorities.

    A 32 year old passerby driving his motorcycle was hit by shrapnel. He works as a par time driver to sustain his family of four. He had an Open 3C fx (fracture with open wound and blood vessel injury) of both his R leg and ankle. His right foot is barely recognizable. He also have an open femur, elbow and hand fractures. I have to cut his leg and put an external fixation to all his other open fractures.

    Another 40 year old driver was hit by a shrapnel in his right arm and chest. Lucky for him it did not went deeper into the lungs. I debrided the wound and put external fixation on his open fracture. He had no relatives to attend to him.

    “I have to go to the other hospital!” I said to the ROD. I have to relegate the other more stable extremity injured patients to surgeons and MDs available in that hospital. All the patients I assessed for OR where prepared so that the we waste no waiting time. “Have to go to the other hospitals muna and see the other patients there! Please ring me when it is my turn to go to OR!” I instructed the nurse.

    Then I ran to the other hospital and saw the same gory sight again.

    Patients were already filling up the hospital corridor. Media men and hordes of bystanders are inside the hospital. I was passing through a maze of make shift beds and bloodied hospital floor. I saw all the extremity injured patients and prioritized who should be treated first.

    A 22 ear old store helper was hit by shrapnel near the blast site. He sustained second degree burns in his lower extremity and both his feet are beyond recognition. “He is in respiratory distress already! I have to bring him first to the OR or this patients die!” I shouted at the NOD, signaling him to prioritize this one for OR. But there is an ongoing OR of another blast victim. “I hope this guy makes it to the OR.” I stabilized the patient first. Then I looked at the other patients and prioritizing treatments.

    I lost count of the patients I saw. it was the longest patient triaging and stabilizing I experienced. More than what I experienced from where I trained. It was a nightmare of all sorts. Blood, pain, hysteria, crying and grief. “This is too much..”

    After juggling between patients and hospitals,I started OR immediately when my turn came in. I started around 8 PM then operated on successive blast patients until 6 am. “Do we have sufficient OR needs?” Do we have blood on standby?” What about our meds?” I queried the nurses. I slept for a total of one hour 30 minutes and then started doing ORs until 2 pm. I slept for another four hours and went back for OR from 6 Pm to 2 AM. I made rounds the whole afternoon. Then for the next whole week, I was doing OR every night till 2 am next day.

    It was a baptism of fire for me.

    A bombing cruelty. Six dead, 32 injured, 12 ortho patients needing OR and re ors. One whole week of nightly OR till wee hours of the morning. I was taking naps in between ORs, slept in the hospital benches, OR beds and make shift tables. I rarely slept in my bed, nor eat in my home. It was like I’m some far away war front like Afghanistan or Iraq.

    But no, this is not Iraq nor Afghanistan. This is my place. And when you see dead or injured people because of so called altruistic principles, I can’t help but curse at their bullshit war. People get killed, some maimed and families lost love ones. And these are civilians with no business whatsoever in their so called war to freedom.“You call this fight for freedom?” I have a better adjective for this type of people who sow terror in the guise of “freedom”- cowards!

    One year now, that summer, I still vividly recall the gory that baptized me into my practice. I can still remember the crying people losing their loved ones, of dying people under my care. Lost limbs, lost souls, all because of that “bomb” for freedom. I still have bombing patients under my care now, recovering from the trauma they sustained one year ago. Most of them became my friends. Some, lost on follow up.

    I hope this summer would not be the same summer as last year. Not again. Please?!!!

    (This is my supposed to be entry to TBR5 but just didn’t make it to the deadline. I had a last minute change of heart from the usual posts of outdoor adventures that summer. )

  • Training Perspectives Part I: Dummies guide to surviving an Orthopedic pre-operative case conference

    It’s never a pleasant experience for me, as an attending, to see a resident tremble in front of the consultant staff, his pre- op case vanishing in room air and his morale at the level of the floor mat. I was in the same undesirable instances before, as any resident would be, not a long time ago. Often, the deja vu, nauseates my academic appetite. Ironically some of the best lessons I learned in my training came from such spectacular display of “enlightenment”.

    I am in the opposite sitting arrangement now, as an attending, throwing the same bullish questions I lovingly evade before. But then again, if you are a resident and you accept your status as it is, this might be the best way of freeing yourself from such lowly self esteem!

    A word of caution though. This is not Us, The attending vs You The Residents sort of set up. As Someonetc said, were all in these together. Nethier you or us nor the patients should lose. We all learn from it.

    The common question from the frustrated resident is “How will I ever satisfy this ever critical attending? I’m always wrong to him!”So our residents will ask me, “how can I ever avoid such hell questions during pre-op?” In the short time I’ve been an attending (and the long time hibernation as a resident) these are the “attributes” I look for and emphasize during rounds and pre-op. In this particular order.

    1. Present the case for your patient. Know your patient, examine him well, take care of him, and decide according to his realities and situation. Put him in the top of your indication list. Err on his side. Overdo things for his welfare. I cannot emphasize more. Nothing irritates us more when the patient is not on your number one list or if you forgo the patient’s welfare just because you were busy with something else.It is always wrong to reason out that way!
    2. Never lie or bluff your way out. We will be sending you to vacationland for good or force you to jump-off training. Believe me.
    3. It’s the decision making process that I look in more. The logic behind why you do the labs, why did you decide to do the the surgery or not. This separates you from as a scientist and surgeon to a technician. Treatment protocols may vary, gold standard of treatment will change in the future, but logic and decision making attributes remain the same.
    4. Read for your case. Read voraciously what is relevant to your patient and case at hand. Hit your ortho books but new relevant studies will always grab our interest. Never come unprepared to the pre -op. No patient (not even you as a resident) would want a surgeon who doesn’t know what hes doing, to operate on him
    5. Accept mistakes and make good at your promise to do well next time. The attending will always remember the next time.
    6. Talk to your attending or consultant after the conference (and the patient) to make sure you got what they advised you.Its always a mark of a dignified resident to clarify his lessons and make sure he understands them well.

    Again, we’re all in these together, you residents, us the consultant staff and the patients. I still believe no consultant is in there to personally destroy a residents career. Most of us are there to help you learn, learn the right way for you“-free of charge. Perhaps, thats the best assurance you can get from us.

  • Trauma care facilities for bombing victims

    One bombing attempt foiled, another one killed many people and injured hundreds. Seems like a normal day for me. But I am not in Iraq or Afghanistan. I live in the Philippines.

    The news of another foiled bombing attempt in the busy marketplace of Tacurong City just went on the news because of a hero’s brave attempt at saving lives. Without such bravery and gore, I bet it would just be another addition to the so many attempts on the bomb scarred Tacurong City.

    I wonder whats with Tacurong City that terrorists seem to use it as a bomb exercise target more often! Money?Power?Politics? The place is bleeding! It had barely recovered yet from the previous bombing injuries it incurred! And here we go again…

    Manila has been rocked lately by a bomb that killed and injured hundreds of innocent victims. It is a nightmare to everyone.

    But unlike Metro Manila, Tacurong City don’t have the Level I Trauma Care center and the facilities to support medical staff tending to bombing victims. In the last powerful blast that wrecked havoc in Tacurong City, the medical support personnel were practically scampering for help and logistics and the city bled with its finances just to help the injured victims.

    Needless to say, prevention is still the best way to prevent this acts of terrorism. But when such disaster occur despite efforts to prevent it, it may be wise to just coordinate such medical interventions with the alert medical trauma response team and a Trauma Center.

  • A known research bias.

    Here’s an interesting finding on the influence of royalties, stocks or fundings for researchers with conflict of interests on their tendency to report more of their “positive findings“.

    I think, that is why there is such a thing as conflict of interest.