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.
