Learning in Orthopaedics

After the cool confines of the NICU and the dengue filled Paediatric wards, it was time to bid adieu and start afresh in Orthopaedics. 

With no prior experience in suturing/ dressing/ management of Fractures, I had my trepidations regarding this rather male dominated department. Furthermore, I was now setting foot in the new hospital. That is to say, I had so far been a resident of the old hospital which houses the Paediatric Department, Obstetrics and Gynaecology Department and Psychiatry Department while the rest of the Departments, ICU, ICCU are a part of the new massive 4 floor hospital building. (What I'm trying to say is I'm yet to figure out my way through the 4-5 lifts, 4 entrances and ward rooms that all appear the same to my fresh eyes!)

The Orthopaedic department is well organized with two units. Both units function separately and have prefixed OT and OPD days. While unit 1 has specialized interest in spine surgery, unit 2 (under the involvement of the HoD) has a weekly section dedicated to CTEV correction. The Ortho Department has a Male Trauma Centre, Female Trauma Centre and Male and Female Ortho wards. Post OPD, an Ortho intern is expected in the Casualty for all cases that present with Orthopaedic complaints. 

My first day in the OPD gave me a glimpse of the work load and by the looks of it, the number of cases seen by the doctors per day is much more than the earlier department. There is also a CTEV clinic headed by the HoD weekly aiming to correct congenital deformations of the foot. Orthopaedics is about pain management. While in some cases the pain can be eliminated with the right surgery/ slab followed by appropriate exercises, sometimes the original range of movement is not obtained and there is some residual pain. Either way, an Orthopaedic surgeon has his moment when he watches the once bedridden patient taking hesitant steps on his own after the successful completion of a surgery.

It's not just about cutting up and fixing bones. A lot of work goes in before the patient makes it to the OT table. He must be evaluated for his blood counts, tested for seroviruses and often, a physician's opinion is required to rule out any cardiac comorbidities. After this comes the pre anaesthetic evaluation by the Anaesthesia department following which he is said to be 'Fit for Surgery'. In Orthopaedics, there is usage of specific implants for each kind of fracture and this must be procured by the patient prior to the surgery. Sometimes, the patient may also require blood to be transfused prior to surgery to correct anaemia or blood to be arranged in anticipation of blood loss.

My first experience in the OT involved a lot of written procedural work, consent taking and shifting the patients in the order until I was allowed to scrub in. S Sir taught me since it was my first scrub and I was treated more like a precocious kid capable of contaminating the sterile zone. My job was mostly to retract and provide adequate working area for the surgeon. But it was indeed fascinating to watch the theory come alive on the table as Sir observed his work under C arm guidance, fixed the plate, put in a drill to make holes and then put the screws to hold the once broken bones of the trimalleolar fracture in place. Later he closed up and proceeded to operate on the fracture shaft of radius.

My first day in the OT more about figuring out where it exists as the OT complex is pretty much a maze and it had me dejected at one point when I didn't know where I had changed so I thought I'd be stuck in my OT dress until forever. Luckily, I was wrong and I could have a late lunch after meeting the patients post op, giving them the standard instructions regarding NPO, limb elevation and a check XRAY to look at the handiwork of the Orthopaedics. After the rounds with Sir, he dropped us near our hostels (Yaaass) and proceeded to his clinic where a flood of patients awaited him.

Now for the part about the casualty. Having no such prior experience, my first time in the casualty was more of an observation than an action packed experience. Patients being rushed in on stretchers and wheelchairs, limping in, walking in and sometimes stumbling in after an intoxicated night. From the fairly calm atmosphere of the Paediatric wards, it took me some time to adapt to the sights (of wounds), sounds (of pain) and smell (of injuries) in the casualty. Furthermore, I still had to figure out where specific instruments and apparatus were located. What amazed me was how, in spite of all the chaos and rush, there was actually a system in place and perhaps, there was a method in the madness! 

The moment a case was brought in, there was the CMO asking for their history behind the injury (assault/RTA/self fall), a surgery intern looking at injuries in the head thorax and abdomen, a medicine intern assessing if he had any other complaints and the orthopaedic intern looking into his injuries to the back and peripheries. Depending on the severity, each injury is addressed and the patient is admitted if necessary treatment can be provided in the hospital.

As an Ortho intern, it was my duty to assess the limb affected for its movements, neurovascular status, provide wound dressing and suturing in case of lacerated wounds, ask for the XRAY of the specified part and then act accordingly (based on the instructions of our duty doctor). In case of undisplaced fractures, often a slab support is given followed by a review in OPD. Some fractures need to be operated upon such as an open fracture or one that is displaced completely hence the patient is put on a slab support and informed about the need for surgery. Cervical vertebrae fractures are usually not handled here because of its coexisting neurological involvement and they are referred to a higher centre just like cases where the vascularity of the limb is compromised requiring a vascular surgeon intervention.

I usually stay till 12AM and then walk back to the Ladies Hostel and attend to any calls between 5.30 and 8.30am (which are less or none in the early hours tbh). The maximum number of cases are between 8.30 to 11.30PM on weekends, especially post rains. As we clear each case, there are fresh ones being rolled in and so it's a constant state of flux in the casualty. The 'brothers' and sisters in the casualty are extremely helpful, especially when it comes to learning any procedure. After my first day where I made several attempts with the help of my co intern, I was eager learn suturing and sure enough, there were plenty of opportunities to learn in a day. On my next duty day, under the guidance of Basavaraj Brother, I managed to suture a lacerated wound by myself even as curious 3rd years wondered if this new person in the casualty was an Ortho PG. It's indeed a moment of joy when you look at your handiwork after unsteady hands managed to coordinate to close a gaping wound. In the course of the day, I managed to close another badly cut open wound at the shoulder with sutures thanks to the guidance of my senior Co Intern.

The next OT day proved to be interesting with me fainting with postural hypotension and then making it back to the OT to put mattress sutures on the patient posted for implant removal. All in all, each day in the Ortho Department brings forth new things to be learnt, new experiences and a sense of excitement over every tiny new thing accomplished. :)