Tuesday, 3 December 2013

Orthopedic - We Fix You

Bone | Muscle | Spine

"Where Getting Screwed Is Good"

 Remember this song?
Bob the builder, can we fix it?
Bob the builder, yes we can !!

When I first join orthopedic, although I was considered as a senior houseman already (erk..!), I have very little knowledge in this particular field.

During medschool, I spent only 4 weeks in orthopedic department.
So short, yet so many things to learn.

Orthopedic deals with Every Single Bone in our body ??
Of course NOT. Orthopedic only deals with the musculo-skeletal system. In other words, ALL BONES except the skull, don't forget to add the Spine as well. LOL !!

Housemanship To Do List
  • Remember what i always tell you, preparation is vital if you want to survive in any posting. If you think you're slow (at first), i highly recommend you to study some basic stuff BEFORE entering any department. This simple step may hold the key to your successful housemanship life or the ordeal of your lifetime !!
  • As for orthopedic, since you know what you're going to deal with (don't tell me you forgot already, i just told you, musculo-skeletal sounds familiar?), then open your 2 kg Anatomy Book, refresh every single names of the bone. What? You da power already? Sure meh? Carpal bones you remember all in exact order, triquetral or trapezoid or trapezium. Google-lah. Remember how many cervical bones are there? Seven? Eight? You sure its not the cervical nerve you're counting?
  • If you can't remember all, thats totally physiological !! Tips : Remember the long bones first, how to differentiate which one is medial or lateral. Then move on to the bones in hands and foot. Sure can one, Malaysia Bull-eh right !!! Overseas grad, don't be shy if you pronounce it differently, they may laugh at you, but thats how we pronounce it in our University isn't ?? I don't give a damn.
  • Study about Xrays, especially for fracture and dislocation. Always see in 2 views, AP and Lateral / Oblique view. Not all xray require lateral view, eg : pelvic
  • Refresh about open and close fracture. How to differentiate between open fracture and close fracture with laceration wound on top of the fracture site? **tricky question by my specialist**
  • Fracture classification is a must !! You can download the ebook for classification here, its kinda helpful.
  • Learn things like close manipulative reduction (CMR), skin traction, skeletal traction. Don't worry you'll learn alot as time goes by. Tips : ask the ortho MA (medical assistant) if you're not sure. Some of them has been in the department for some time, they have vast knowledge in orthopedic (good thing about specialization). Btw MA does the CMR, not HO.
  • There are so many things i can list down for you, but since i'm not getting paid to write this article (wakaka), i've decided to list only a few which i think are the most important. Its not like you're going to study all of them, lol.
** Quick Facts about Orthopedic ** 

1. This is a surgical based department
- expect to do some surgical intervention in the ward
- eg : suture, incision & drainage, wound debridement
- tips : go YouTube, watch and learn

2. This is a trauma-related department
- learn basic things about urgency & emergency in Ortho
- eg : fluid resuscitation in fracture, estimate blood loss in fracture, pulmonary embolism, compartment syndrome 

“To acquire knowledge, one must study, but to acquire wisdom, one must observe” - Marilyn Vos

 More Tips Coming :
- When you're clerking a patient, say he's involve in a motor vehicle accident. More or less your clerking should start like this, example ;

50 y.o / Korean / Male
premorbid : DM on OHA

PT 8H : alleged MVA (motorbike vs lorry)
hit the back of lorry due to slippery road
GCS on arrival full E4V5M6
no LOC / ENT bleed / retrograde amnesia
ambulating post trauma
c/o pain at left shoulder
(describe the pain then)
** PT = post trauma, PT 8H = post trauma 8 hour, LOC = loss of consciousness, ENT = ear nose throat

 “The secret of getting AHEAD is getting started”  
   - Mark Twain

My experience in Orthopedic

How many of you have given sedation to a real patient in your medschool clinical time? I bet non of you have, as medical student are not allowed to "play" with high alert medication.This happened when i was tagging (day 4 of life in orthopedic), haizz...

My ward mate that day, she entered the department 2 months earlier than me, so basically she should be more familliar with orthopedic procedure, right? She's a 5th poster as well.Happens to be, there was a patient, an ex-IVDU (intravenous drug user), who needed CMR for his dislocation. For your info, CMR is a painful procedure because we manipulate the dislocated bone, so we need to give some sedation and painkiller to the patient prior to the procedure. She help the nurse (newly started working nurse i guess) to prepare the high alert medication. Since the patient's IV-line is closer to me, she gave the high alert medication to me and asked me to inject it.When a senior poster gave me the medication, i somehow did not check the dose (out of trust) and directly inject the medication. The CMR went smoothly. It was late evening that time.
After a while, the patient did not wake up, still in deep sleep (sedated). The vital signs were normal. So i was not worried. Later that night, he was still in deep sleep and i noticed he was not breathing normally (respiratory rate of 10 per minute) !!! When i asked my ward mate, she told me that the sedation (midazolam) is 5mg, which is okay but the analgesic (pethidine) is 100mg, which is way too much !!! My ward mate then left me (as she is working morning shift) and told me not to worry as sedated patient is expected to be like this.

At 11pm, although i'm supposed to go back at 10pm, i was worried so i decided to take an ABG (arterial blood gases) before going back. Turn out the patient was in severe respiratory acidosis !!!
Then, my next step was, i informed my oncall MO. Since i wasn't sure what to do, (even if i know, i still need to call for help). When my MO arrived, i presented the case and told him what happened. Of course he scolded me. He said, "why the hell you inform this in the middle of the night, you should settle this with your ward MO in the evening, blaa.. blaa.. blaa..". He referred the case to Medical team then. My MO ordered IV naloxone (antidote for opioid analgesic). Patient then started gasping and breathing faster, he was restless and unresponsive as well. When medical team arrive, they plan to transfer this patient to ICU for respiratory distress !!! Can you imagine, small mistake i did turned out to be a disaster. But since we gave the antidote, medical team ordered me to repeat the ABG prior to ICU admission. It was already 2am and i have to work at 7am the next morning as i was still tagging, damn tired already. Luck was on my side this time, the repeated ABG came back as NORMAL, just slightly reduced oxygenation. Medical team than cancel their plan for ICU admission, patient started responding to call, breathing regularly and normally again. It seems that he was not breathing enough because of the oversedation, to excrete the carbon dioxide, causing the severe respiratory acidosis. Once he breath faster, more and more carbon dioxide got eliminated thus normalize the pH. After a while, medical team and my MO chow. I went back at 3am, sleep abit and came back 6.30am to work again.

Can u imagine what will happen if i did not repeat the ABG and pretended everything is okay?

" Mistakes will turn into failure if you don't do anything about it " - Anonymous

There's a reason why I'm sharing you my bad experience, we're dealing with people's life in medicine field, sometimes we just CANT afford to make mistakes in the very first place.

" Learn from your mistakes is power,
Learn from other people's mistakes is POWERFUL " - Martin Luther

May Almighty God help and guide us to the right path. No human being is perfect except prophet.


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