ZNA Middelheim Hospital

I don’t know if you’ve ever been to the ninth floor of the ZNA Middelheim Hospital in Antwerp, I have, thanks to Dr. Spaepen who allowed me to shadow her for a week. By 8:00am I had donned my green scrubs and bad begun to look like a walking stick of celery, well it was worth it.  

Dr. Spaepen is an orthopaedic surgeon who specialised in Podology. The topmost floor of the hospital is normally unseen by us ‘normal folk’ as it is the Operating Quarter. However I was lucky enough glimpse it, as this was where Dr. Spaepen sometimes performed surgery. I had to wear a hairnet in the operating room and a face mask once the operation began. I was warned not to touch any surfaces covered with the blue sheets, such as the table with the medical instruments, as they were sterile. I watched as the patient and room was prepared for the operation, this happened before the surgeon was present.

 The anaesthesiologist briefed the patient on what was going to happen and how they would feel (numbing sensations etc.) He would ask what medication they were on and whether they had taken any pills on the day of the operation. This was because some people for example those who were heavy drinkers or had low blood pressure needed to be catered to differently. The anaesthesiologist then hooked the patient up to the anaesthetic machine. There was an injection and then as patient becomes unconscious their airway is opened using a laryngoscope and pipe with nitrous oxide is put down it. When the patient was sufficiently sedated, the pipe was removed and an oxygen mask was secured fast. The patient was also hooked up to fluid intravenously. Their heart beat was monitored as well as blood pressure and blood oxygen content. The patient’s medical file is brought up on the computer where there is a time log; the time the anaesthetic was administered is recorded. Now that the prepping process is finished the surgeon enters the room.  

I witnessed a toe amputation. The man who needed it was a diabetic, the high levels of glucose in his blood had lead to peripheral neuropathy, he had lost sensation in his feet. This meant that he didn’t know when he had sores or cuts on his feet, he couldn’t feel it and therefore he could not clean and take care of them. The tip of his feet had become infected. Furthermore his diabetes had also lead to poor blood circulation. His blood vessels had hardened and become clogged. His toes lacked oxygen not to mention white blood cells to fight the infections. His wounds would not heal but additionally his toe hoes had become gangrenous and needed amputation. 

Unfortunately, the man had had previous amputations and was already missing toes. The doctor informed me that he was not taking care of himself. His diabetes could be managed if he took his medication, examined his feet regularly and wore appropriate shoes like he was told to. Exercise and diet control would also help. Anyway, Dr Spaepen disinfected his feet using plenty of iodine. With a scalpel she made an incision on his already mangled foot and removed some tissue and then using what looked like a mechanical sander/pizza cutter sheared away some bone as well. She did the same on the other foot, here however she also found a lot of pus which collected a sample off and sent off to the lab for analysis. The cavities that remained were partially closed; the skin was stitched loosely. She told me this was so that the infection bacteria could be aired out.   

In the adjoining operating theatre I saw another surgeon attending to a hip fracture he was assisted by a medical student who was in his last year at university. You always think of surgery as being elegant and dainty but as I walked back into the operation theatre after getting my lead vest, or more accurately dress, and collar, they were getting out the drills. Despite the slightly disturbing noises, the surgery was actually were neat and precise. There was minimal flesh exposed to the air. About a 5cm incision was made near the hip, through this hole a metal rod forced downwards, parallel to the bone, with the help of human strength and the machinery. X–rays were constantly being taken and referred to, hence the lead protective attire, to make sure the positioning of the support was right. It was fastened with a perpendicular screw. It was clean in that the blood lost was caught by the plastic sheet that shielded the patient and covered the machinery, it drained into a bucket. The skin was stapled instead of stitched at the end. During the operation the anaesthesiologist pays frequent visits to the patient and it is he who revives the patient after the operation. The patient is kept in another room in the operation quarter till the after-effects of the anaesthetic wears off.  

Rotator cuff repair and bicep tenodesis was something else I witnessed. The rotator cuff, I learnt, is found in the shoulder and comprises of the muscles and tendons that connect the humerus to the scapula. Inflammation and tear is painful and greatly restricts arm and shoulder movement, however rest or physiotherapy normally solves the problem. The lady undergoing this operation had a Superior Labrum from Anterior to Posterior or SLAP tear. Meaning the tendon of the bicep muscle that enters the labrum was torn. The labrum is the cartilage ‘socket’ of the shoulder joint, the ‘ball’ being the humerus. The two surgeons involved in the operation performed a bicep tenodesis meaning they cut through the tendon entering the labrum and reattached it to the humerus using hooks, anchors and sutures (these are used to stitch tissues together). They also shaved away some bone by using an instrument to burn it. This allowed more room for movement, decreasing pain. This was all done with arthroscopy. Two incisions were made one for the arthroscope (a type of endoscope) which was connected to screen and the other for the instruments handled by the doctors. They used water to clear the area within shoulder where they were working. The benefits of using arthroscopy and minimal invasive surgical techniques are that there is a smaller risk of infection, quicker recovery time and the patient feels less pain. There was one other patient I saw the doctors attend to in the operating theatre, she didn’t require surgery but needed the effects of a general anaesthetic. She wasn’t able to fully extend her leg, her knee was coming up against some resistance, to break through this resistance without any sedation would be extremely painful. The doctor exercised the knee, eventually getting the leg to fully extend.  

The operating theatres were certainly an exciting and interesting place be you're not squeamish, but I didn’t spend all my time there. I was also introduced to another doctor from the orthopaedic department she was in charge of the patients who were staying at the hospital. In the morning, before the morning ward rounds, each patient computerised medical file was consulted; these had the ‘radius of action’ in degrees of the joint in concern of the patient which I found quite fascinating. Handwritten accounts were also browsed through these contained day to day progress reports, types of medication being taken, whether they were any problems before or after surgery and any other relevant notes. This study session gave me a chance to look at the x-rays of the various patients inhabiting the ward. Most of the people in the department were post-op. So I got to see the broken bones and how they were fixed. Common procedures needed included hip replacements. The hip had a ball and socket joint, the prosthesis used is ball attached to a rod of sorts and a socket lined with a thick layer of lubricated plastic. Over the years the plastic is worn away unevenly, ball begins to jolt about and movement is less smooth. The prosthesis then has to be replaced. There was also a few cases of hip fractures. I saw a Dynamic Hip Screw hold the bones in place so that they healed properly. Total Knee Replacements were also popular; the prosthesis here was also made of metal and lined with plastic but was of course for a hinge joint.  There was one knee fracture, one hip prosthesis revision, where the device wasn’t aligned properly and one case of bursitis olecrani (affecting the elbow).  

Bursae (sg. Bursa) are tiny fluid filled sac that are found near bone projections. They reduce friction between muscles and bones as well as tendons and muscles. Without them any movement would be painful. This is also true when the bursa is inflamed and swollen. The cause of bursitis is usually repetitive movement of if excessive or prolonged pressure is exerted on it. If the bursa is also infected, it needs to be surgically drained and sometimes removed which is what had happened to our patient.  

As we made our rounds, I noticed the majority of the people in recuperation were elderly. Older people bones are much more fragile and brittle. If they fall, there is a greater chance of them breaking something. Additionally, people begin to develop arthritis, osteoarthritis (cartilage degeneration) is predominant and a major cause of joint replacements. I recall my time at the Nursing Home when get to an old lady who is suffering from dementia due to Alzheimer’s.  Getting an answer to whether she felt any pain was hard and we had rely on carefully moving the joint to see if we got any response.  On the other end of responsive are the concerned relatives of the patients who are full of inquiries. The doctor broke out her model skeleton and prophesises so as to give above satisfactory answers.  

I saw a Kinectec at work. A man suffering from arthritis had had a TKR and this machine was moving his leg up and down as he sat up on his bed. The machine prevented the build up of fats and blood clots without the additional pressure the man’s body would have put on the new knee if he was to walk instead. Speaking of technology, there was an elderly woman who had fractured her hip and was waiting to be operated. Her led was attached to a traction device, which reduced the pain at he hip.  

But this was a rare sight, like I previously mentioned, most people were at the recovery stage. Patients were able to walk the day after the operation and stayed for on average ten days in the hospital.  

However there was one exception this rule. Another man remained at the hospital a hundred days after his discharge date. He had undergone a bilateral amputation. The surgery was extreme and rehabilitation included psychiatric evaluation. The man had Peripheral Arterial Disease (PAD). His arteries had narrowed and hardened leading to a severely diminished blood supply to the legs. As a consequence the cells received inadequate oxygen and died. The dead cells had to be removed to prevent infections and other disease. If the problem was detected earlier a less extreme action would have been taken for example a toe or even no amputation. Some PAD cases can be helped with lifestyle changes. I was told that the man was an ex-heroin addict. I suspected this was the cause for the disease. The drug is a relaxant and would have lowered heart rate and therefore blood pressure. Lower BP increases the chances of developing PAD. Additionally, smoking heroin would have decreased the body’s oxygen supply. If needles were repeatedly used, collapsed vein become likely. Also heroin when sold can be mixed with other substances which can cause blood vessel clogging. The patient had no support from home. As far as the doctors knew he had no family and no house forget about no visitors. It was quite sad. The doctor told me they can’t just throw him out on the streets in his poor situation. It made think about our healthcare systems and how they took care of people like this. What happens to the man when the department needs his bed? How is he going to pay for his treatment?  

With the rounds done, the doctor I was following was going to talk to doctor is other departments as her patients had other additional ailments; one needed medication for her ear which had previously been operated one and another had bladder problems. But before consulting urology or ENT (Ears, Nose, Throat) we had a call from the emergency room. We made our way to the lowermost floor. Amid the see-through sliding door there was a flurry of activity with highly energetic doctors moving about. They weren’t any serious cases being attended to at the moment. We found our patient in a bed in one of the consulting, lower priority chambers. The woman was elderly, I’d say in her early sixties. She was cycling and had a fall. The fall left her with pain in her side when she moved. The doctor examined her and wagered that the woman had fractured her hip. The x-rays confirmed her diagnosis. She then talked to the lady about past medical problems and whether she was taking any medicine. She also asked the lady how many glasses of wine she had a week and interestingly the Doctor told me she always added two glasses to the amount because a patient nearly always lies! More pertinent was the fact that the patient had had a Cerebrovascular Accident (CVA) more commonly known as a stroke. 

Reading around the subject I found there are many causes of the stroke. You can have an Ischaemic Stroke happen when blood supply to the brain is compromised leading to the death of brain cells. In an Ischaemic Stroke, a blood clot reduces/blocks blood going to the brain. Fatty deposits, high in cholesterol line arteries (Atherosclerosis) narrowing them. If a piece of this plaque breaks away and is lodged in the artery it can greatly reduce blood flow, this also known as an embolism. An embolism is when a 'foreign body' or something that isn't supposed to be where it is, blocks blood flow. Plaque can cause an embolism but so can a thrombosis ('a blood clot within a blood vessel'), fat and gas bubbles. You also find Haemorrhagic strokes where a blood vessel ruptures and bleeds into the surrounding brain tissue. Hypertension or High Blood Pressure can greatly weaken the walls of vessels. The bursting of aneurysms in the brain also lead to Haemorrhagic strokes. An aneurysm is when a part of a vessel swells with blood into a balloon shape due to the pressure. They most commonly found where vessels branch and split off because the walls are weakest here. I didn't find out what type of stroke our lady in the Emergency Room had suffered. However I did know that the stroke had left her with hemiparesis. This mean the woman had problems moving of side of her body. Apparently this affliction is quite common among stroke sufferers. She underwent physiotherapy which helped to a certain extent. You could tell  by the way she talked that her facial muscles weren't what they used to be. She was still taking blood thinning medication as a precaution. We left after the doctor informed the lady that she might have to wait a while before they were ready to operate on her.  

   

Consultations were an another aspect of Dr. Spaepen's life that I was able to look in to. There were two consultation rooms and a 'office' in between them used by the doctors and receptionist for things like paperwork. The troubled man or woman would have to register at the department's reception and after spending a while in the waiting room, was shown into a room. In the room, was not a doctor, but a doctor to be . . . hopefully. A final year medical student would then carry out the following steps: first she asked the person what had brought them to the hospital, secondly she would enquire about past problems and whether the person in question was still on any medication. Following that was a physical examination and lastly a diagnosis and a proposal as to what next. Everything was noted down and the last step wasn't disclosed to the person. Instead a doctor and the Intern discussed the case in question. I saw Dr Spaepen's colleague attend to someone whose knee hurt when she walked, another who had problems moving her arm and somebody who had developed bursitis on her knee. This woman however did not require surgery unlike the last case. Instead the doctor drained the fluid within the bursa using a needle and syringe. The liquid was labelled and sent for analysis to the lab. The woman was then administered a cortisone injection which would reduce inflammation and therefore also pain. 

Dr. Spaepen, having specialised in Podology, had people coming to her with sicknesses of the foot. The most common condition was hallux valgus more frequently known as a bunion. The joint of the big toe had become deformed, forcing the big toe into its neighbours. The obtruding bone can cause a lot of pain. The big toe pushing into the other smaller toes causes them to grow abnormally too. Friction between the touching toes caused blisters. Additionally, for extreme cases finding shoes that fit was a challenge. In such cases where the deformity was quite large and the person was under a lot of pain, surgery was recommended. There were a few people who had already undergone surgery. Their x-rays showed how the jutting out piece of bone was sliced off and their toes made to re-align using metal screws. I saw a woman's stitches being removed and another's dressing changed. They had swelling to various degrees around their foot and ankle. The doctor told me that the swelling continues for one month longer for every ten years of age. They wore a special brace that made them walk on their heels keeping their toes raised, crutches were optional. Recovery takes about three to four months but this can vary. A person's everyday life is greatly affected post-opp. They have to wear flat shoes after the brace goes basically there are a lot of restrictions. In all total recuperation takes a lot of time. Sometimes the joint never works as smoothly as before which can be a problem for athletes especially. It does however take care of the pain. Those who have bunions that aren't overwhelmingly painful and advised against surgery, though it is the patients themselves who inevitably make the decision weighing up the pros and cons. I saw a few people who employed orthotics and had custom made insoles for their feet.

Overall I learnt a lot. I was exposed to a lot of medical procedures. But more importantly I saw that one doctor performed surgery, gave consultations and was on call for the emergency room. The week was busy but never dull. Additionally I had the opportunity to speak to final year medical student who told me that although she had a lot of work it was worth it. She also told me that her internships had inspired her to specialise in Paediatrics.