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April 2, 2010

Alternative Learning Opportunities

During my mid-term evaluation, I was charged with rating my clinical experience at the Veterans Administration Hospital here in Birmingham, Alabama. One of the questions asked me to list alternative learning opportunities that have been made available to me during this rotation. In past posts, I've discussed the wheel chair clinic and the fall prevention clinic and I checked those off along with in-service training. During this evaluation, my clinical instructor realized that they had other resources to offer me including a health promotion program that VA offers to its veteran and employees. I've devoted four posts (HW1, HW2, HW3, HW4) to the VA's Health and Wellness Promotion called the MOVE program.

One of the other learning opportunities I was granted was to observe a surgical procedure. One was a arthroscopic surgery where a small camera with a light is inserted into a joint and another tool with a debridement instrument is inserted into the other side of the joint. The whole surgery can be observed on a television screen. This particular arthroscopic surgery was on a knee. Lucky for the patient, nothing extraordinary was amiss in there and they sewed him up and packed him off to the recovery room.

The other surgery that I witnessed was a total knee replacement. I was a bit dismayed to discover that the patient was awake in the OR when I arrived, and was being prepped for his surgery. First came sterile prep, then the epidural. That's when I needed to sit down. I squatted against the wall as far away from the action as possible while trying to distract myself by watching the OR nurses check the sterile toolbox wraps for holes. One of them kindly noticed me looking a little piqued and put me in a chair in a corner.

This not only afforded me a place to sit, it kept me away from everything shrouded in blue (meaning it's sterile -- DON'T TOUCH). I was also able to view the front of the patient from here, watching the other anesthesiologist and prep nurse interact with the patient. They helped him lay back on the table, secured his arms to a platform explaining that they tie them down so they won't fall off while he's asleep, and asked him if his legs felt as though they were floating. The epidural had taken effect and they lulled him into the next stage of anesthesia as the prep nurse catheterized the patient. I relaxed once I knew the patient was out and would feel no pain.

They sterile prepped the leg and wrapped it in yellow film. I guess the funny color made the leg "less human" to my mind and the rest of the surgery went by without me becoming queasy. Basically, without all the details of flying bits of bone and general gooeyness, a knee replacement is much like a lesson in carpentry. The surgeons use saws, drills, chisels, and hammers to get the job done. Cuts are made using a template or jig, and measurements are made to fit the prosthetic parts onto the bones.

Fitting a patient for a prosthetic knee is much like buying a two piece bathing suit. Just because you're a size 6 on top doesn't mean you will be a size 6 on the bottom. You could fit a size 6 with a size 8. There is a top portion that is the cap over the femur and bottom portion that is the cap over the tibia. Luckily, despite the size difference, the parts are designed to fit and work together.

Interestingly, if a patient is bow-legged, the surgeon cannot leave them bow-legged. The doctor has to line up the appliance at such and angle that the articulations (the parts that come together) so as not put undue wear on them or they'll wear out, much the way the original knee did. So if a patient's hips and ankles accommodate bow-leggedness, part of their physical therapy will require them getting used to the new way that their knee will interact with their ankle and hip.

The only other part of the surgery that took me aback was watching the anesthesiologist working on the patient. As the doctors were closing the knee, the anesthesiologist began changing the medications in the drip lines. One syringe had a milky liquid, so I asked, "what's the white stuff?" The patient turned his head and looked right at me! This elicited a "whoa!" from the anesthesiologist and a change in the patient's medications. Hopefully the patient was on enough happy meds that he won't remember that.

Posted by linda at April 2, 2010 4:40 PM

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