Accidents happen to everyone

I should have taken a clue about how my day was going to go from the very first patient of the morning. We were consulted for a tibia fracture in the ER. We went down to check it out before our first surgery of the day, at 7:30. Waiting for us was a middle aged train wreck of a woman. She was on 3 very strong psych meds and had a fifth of jack for breakfast. We learned some other "fun" facts about her while we took her history. She was an alcoholic, had liver failure, kidney failure, Hep C, and was an IV drug user. Perfect...This is just the patient part. The ER was slacking too. This lady had a displaced tibia fracture that clearly needed to be surgically corrected. They hadn't done their side of things and prepared for us to get there. This delayed us and was not in the patients best interest. My attending let the head ER doc have it and the guy never yells at anyone!

The 4 shoulder surgeries we had during the rest of the day had a few problems. One guy had really soft bone and every time we put an anchor in his humeral head it would pull out and leave a giant hole in his bone. Another case was missing pieces of equipment and another the scrub tech dropped like 5 things so we kept having to wait for more tools. It just was not going well. We still had one more case though, the tibia fracture from the ER early that morning.

This was a bigger case requiring lots of hands so there were four of us scrubbed in on this one. Everything was going smoothly and we were making good time. We were at the part when you put one of the supporting cross pins in the tibia. The doctor was drilling a hole through the tibia to place the screw through. He had one hand on the drill and the other on the other side of the leg supporting it as he drilled. Somehow he ended up drilling straight through her leg and directly into the end of his finger!! Let me put this into perspective for you, he drilled a hole straight through her hepatitis C infected bone marrow/blood and straight into his finger! His face went immediately white when he realized what he had done. I watched him do it and even saw both layers of his rubber glove get ripped right off. Anytime you accidentally stick or cut yourself in surgery it's a big deal. You have to go to employee health and go through a battery of tests and sometimes prophylactic medications. If you remember from earlier in this post I said that this woman was an IV drug user, hepatitis C positive, and unknown HIV status. This is the WRONG patient to accidentally cut yourself with. I felt so bad for this guy! He handled it pretty well considering. We paused the surgery and properly cleaned out his finger, then he gloved up again and finished the surgery. The only difference was he was now asking us all of the statistics on blood-borne pathogens. Guess everyone copes with thing differently.

I have been in on a lot of surgeries with high risks like hep C or HIV. The first few times you do them it's a little unnerving but you learn to be a little extra careful and wear a few extra layers and it's not big deal. I had almost lost my fear of these types of cases until today. This accident put that healthy respect back into me. I will remember that case every time I go into a high risk surgery for the rest of my life.

Snap, Crackle, Pop!

Today I was seeing a patient who fell out of her wheelchair and hurt her wrist. The xrays showed a displaced distal radial fracture (a fracture in the thumb side of the wrist that wasn't lined up.) Like usual the doctor came in the room to see the patient after I had seen her. He decided that since she was old (81 years) that she didn't need to have it surgically plated. This meant that we were going to have to manually reduced the fracture in the office. I was standing back watching and he looked at me and said that this was my patient so I needed to fix her. I was kind of shocked and questioned him but quickly jumped at the chance to do this. I have seen closed reductions before but nobody has ever let me do it. I'm going to explain how this is done so be prepared for a little bit of brutalness.

The first thing you have to do is to determine exactly where the fracture is using both the xray and touch. Once you figure that out you have to numb the area with zylocaine using a technique called a hematoma block. That is exactly what it sounds like, you put the needle directly into the hematoma inside the broken bone. It amazes me how little the patient's react to this because it looks excruciating! You then let them sit for a little bit to let the numbing agent set in. Once it is numb you grasp the wrist below the fracture with one hand and grasp above the fracture with your other hand. You then pull the fracture apart and pull the bottom of the wrist in the direction of the fracture. While doing that you push the hand down as hard as you can and it should slide into place. I was surprised at how much force this took. The sound and feeling of her bone moving was disgusting! Generally I love gruesome surgery/injury stuff but this actually turned my stomach and made me a little nauseous. In fact just thinking about it makes me nauseous.

I still cannot believe he let me do that!! While I am grateful for the opportunity to have been allowed to reduce the fracture part of me hopes I don't have to do it very often. Gross...

Last week we were consulted on a 75 year old male with possible multiple myeloma. Before going over to the hospital to see him we pulled up his films to get an idea of what we were dealing with. The man had boney lesions in his humerus, spine, and femur. We were being consulted on the lesion in his femur. The femur is a large weight bearing bone so it's important that it's integrity not be compromised. A lesion will compromise that integrity which can and will most likely lead to a fracture. A femur fracture in a cancer patient would be devastating to their chances of recovery. The oncologist wanted to know if this patient was a candidate for surgery to prevent the bone from breaking. After reviewing his chart and speaking with him and his family it was determined that he would be a good candidate.

We did his surgery 2 days later. This surgery was probably the most manly/barbaric orthopedic surgery that I'd seen thus far. It was also one of the simplest. We placed a rod called a gamma nail down through the femur. Surprisingly it only took 3 incisions, 1 larger and 2 small. The gamma nail itself was as long as the man's femur. That's huge!! The patient is lying flat on their back on the table and the table is up in the air at eye level. During the procedure you basically take this gigantic rod and hammer the crap out of it until it is shoved inside the entire length of the femur. I probably shouldn't have used the word hammer to describe how we get the nail down there. It's actually a metal mallet, more like a mini sledge hammer. It's very heavy which helps with getting the rod down. The doctor was hammering with all he had for 2 straight minutes to get that thing in place. Once it is determined that the nail is at the correct length you take and place another smaller rod and put it through the hip perpendicular to the gamma nail. This holds it in place and provides extra support to the femoral neck hopefully preventing a future fracture there as well. Then you put 2 small screws across the very bottom of the rod to keep it from sliding up. It is the messiest ortho surgery that I've done. I hope I get to do that one again before I'm done!

Sorry there's no pictures. The only pictures I could find were actually surgery pictures and some of you would not appreciate those :)