CMEs and Surgery

Disclaimer: No time to edit this post... so please bear with my mistakes!

Saturday, December 4, 2011

Last Saturday started off a little slow, but then while doing rounds with the Medical Director in the MICU (medical intensive care unit) when a patient became pulseless and the staff began to run a code on him. This was the first code that we experienced in the hospital and it was run quite different than what we’ve previously been a part of. First of all, there never seemed to be any one person in charge. Second, the medications that were being given were not by ACLS standards for the rhythm occurring. And third, there was no one in charge of notes and charting the events and medications given. The patient was a 65y/o male who had previously had 15 days of chest pain, presents to the hospital on day 16 and an EKG showing significant changes. The heart attack he had 16 days ago back caused a great amount of irreversible damage and there is no cardiologist here. Ultimately they were unable to resuscitate the patient and he passed away. Prior to the start of the code, there little hope for him to survive the damage caused. The staff and family knew that he was at the end of his life.

In India you will only see cardiologists in the cities. There is too much infrastructure and cost (to patients and hospital) required to have a cardiologist in the rural areas. Patients here who survive a heart attack are sent home on at least aspirin, Beta Blockers and a statin. But even still, very few will return for the required follow up or even refill their medications. People tend not to come to the hospital until their condition is severely advanced or treatment is no longer an option. 

It sounds bad to say this, but there were 3 good things that came out of this unfortunate situation. 1) Beth got to do chest compressions. 2) We got to practice intubation after he passed. It’s very different than on the plastic dummies. 3) Forced us to pull out our ACLS pocket references and review rhythms and code protocol when all was said and done.

-

For the later part of the morning Beth and I spent some time with the orthopedic doctor in his outpatient clinic, while Julie and Jeremy did clinic with the internist. The orthopedist was very helpful, giving us pointers specific physical examination tests and findings to look for and a few new ortho tricks we hadn’t learned before. And his English isn’t half bad which makes everything much easier! We really got a lot out of the time spent with him and then were able to follow through by scrubbing in on a few cases in the following days.  

-

Weekends in the OR are usually hopping around since the consultants are here from Mumbai and Pune. Julie got to scrub into a pancreatectomy for a patient with pancreatic pseudocyst and severe abdominal ascites. I was able to scrub in for a fractured radius that required reduction, plating and pinning. We do our best to take turns rotating through different surgeries so we all get a well rounded surgical experience, and so it’s not so crowded in the OR.

Sunday, December 5, 2011
Last Sunday we spent the day in CME course lectures with physicians from around the state. The topic: Nephrology and Urology. Great! I could definitely use a refresher in nephrology. Better yet… it’s in ENGLISH!! I won’t bore you with the details but the lecturers all seems to take one of the following avenues. 1) Try so hard to be entertaining that you were too distracted to get the material. 2) The presenter had a thick accent mixed with monotone. 3) The presenter would be running out of time and completely skip the slides on medications or anatomy and physiology. Instead we learned about surgical procedures that weren’t even in practice any more. So it was a bit of a drawn out day. There were 2 lecturers that were quite good, so it certainly wasn’t all bad!

After sitting lecture all day we felt the need to stretch our legs. So we all decided to go for a run. Jeremy and Julie go running several times a week, Beth and I… not so much. But off we went! I have decided that going for a run while in a tropical country is a bad idea. Too hot for me! And worse than that, people don’t run for exercise around here and I don’t enjoy having my picture taken when I look as I do while exercising. So I may be done with running for the next few weeks. Guess I will just have to cut back on the Chapati instead.

Medical Explanation…

HPI: 31y/o male was filling a large bucket of water, upon lifting the bucket he experiences sudden, sharp, bilateral low lumbar pain, falls to the ground unable to walk, unable to move lower extremities.

PE:  (significant findings)

Neuro: Decreased lower limb sensation, saddle anesthesia, lower limb paralysis, DTR: knees hypo-reflexive b/l, ankle reflex absent b/l.

Did you guess it? You shouldn’t have had to guess! Haha, just kidding… It’s Cauda Equina Syndrome.

Definition: a characteristic pattern of neuromuscular and urogential symptoms resulting from the simultaneous compression of multiple lumbosacral nerve roots below the level of the conus medullaris. Symptoms include low back pain, sciatica, saddle sensory disturbances, bladder and bowel dysfunction, and variable lower extremity motor and sensory loss. Although the lesion technically involves nerve roo and represents a “peripheral” nerve injury, damage may be irreversible and cauda equine syndrome is most often a surgical emergency. Typically several months of therapy are required to regain partial or full motor function.

Back to Surgery

So at 9pm I was scrubbing into a cauda equina repair and didn’t scrub out until nearly 1am, but it was entirely worth it! The surgeon was Dr. Nadkarni, an orthopedic spine specialist that drives the 5 hours to Walawalkar hospital EVERY weekend to volunteer his time doing surgery. When we asked him why he comes every weekend, his reply was “This place inspires me.” Simply put!

It was difficult to see exactly what was always going on through the case since we are working through an incision approximately 2 inches long. In the US many of the spinal surgeons will use magnifiers on the end of their surgical glasses, which many times is hooked up to a monitor so others in the OR can see. Definitely not the case here! This made some of the minor anatomy was difficult to identify (even when pointed out to me!)

I was able to follow this patient up to Post-op day 8, when he was discharged home. In those 8 days he progressed from complete loss of motor and sensory function of both voluntary and involuntary muscle movements of his lower extremities, but deep tendon reflexes present at patellar tendon bilaterally (hammer to the squishy spot just below the knee cap). TO full sensory in all parts of his lower extremities, regained function of both bowel and bladder and was walking with the help of a walker for stability! He will still require therapy to retrain the muscles in his legs (i.e. still hardly able to flex ankles when walking), to strengthen his back and core abdominal muscles. So he has about 6 moths of physical therapy in his future but the Dr. Nadkarni and the hospital’s orthopedist, both expect him to make a full recovery. This is mostly possible because the decompression of the nerves was performed within 8 hours of the injury occurring, the patient did not have complete loss of sensation and reflexes and his young age.

Still catching up on the posts I am missing… So, when the internet is cooperating again, I will get those posted. We have just over a week remaining at the hospital and then we are off for 2 weeks of travel and relaxation! We are busy now getting our homework done and organizing a presentation to be given to the hospital staff before leaving next week. We’ll keep you posted on our adventures. We miss you all.

Becky