What Happens in the OR stays in the OR (Part 3)

Hello again,

I have finally gotten some feed back on my two stories and it has motivated me to write more!  Whoop Whoop, who would have thought.  

For starters I will explain some background about myself, I have been a medical sales rep for years selling primarily orthopedic implants.  I have assisted in numerous cases ranging from simple procedures to cases that have lasted 8+ hours long.  I have covered Trauma, Extremities, Sports Medicine, and Recon so I have experience with surgeries going very well and complete MELTDOWNS!  I will try to keep everything in layman's terms so everyone can understand.  

This next story I want to tell should be a very clear reason why you should seriously contemplate going to your local teaching hospital.  I know it is tempting because the schools tend to have the top of the line equipment and best looking venue but in reality you will NOT have a tenured Dr preforming your surgery.  This piece of advice goes beyond my realm of orthopedics it stretches across all surgical procedures, just do yourself a favor and go to a private practice doctor that specializes in what you need done.

Case 3
"and..... X-ray"

Procedure: Left Distal Fibula Ankle Fracture
Repair: Distal Fib plate with non-locking screws

                           
                                               (Picture courtesy of Google)

Here is a photo of what a typical distal fib fracture repair looks like, a plate, some fixations screws, and possibly a lag screw to hold the fracture together.

Here is a better photo showing fracture reduction (using forceps) and the lag screw technique. This photo also shows the two cortex's of bone.  Cortical (cortex/compact) bone lines the outer layer and Cancellous(spongy bone) is packed in between cortical bone.
                 
Although this might look a bit overwhelming this is probably one of the easier cases to repair.  In short what needs to be done is: reduce the fracture (basically pinch the fracture with reduction forceps so its back aline), lag screw, secure the plate to the bone, then drill, and fill with screws.  Additionally, an X-ray C arm is needed which is used to measure progress throughout the repair.

Okay enough of the dry medical terminology, this case was being preformed at one of the local medical schools in the town.  When I walked into the OR I saw the doctor and one of his residents, "Jill", draping the patient, this is not a good sign.  As a rep I always hate seeing a resident in a surgical gown because they always seem to F*ck something up and its never their fault its always my fault (your drill is too dull, you screws wont thread, your plate is too bulky, etc).  I greeted both of them and immediately started prepping the scrub tech making sure everything is there ready to go!

As the case began I was crossing my fingers that the doctor would have his resident spectate but NOPE she was going to be doing practically the whole case.  After dissecting down it was time to use the reduction forceps and reduce the fracture, after her 75th attempt and 15 minutes later the forceps slipped out of Jill's hands and fell on the floor (ughhhhh, FANTASTIC........).  Fortunately, I always keep an extra reduction forcep for this exact reason, so it wasn't that big of a deal.  By this time the doctor stepped in and closed the fracture in about 1 minute.

With the fracture now reduced it was time to throw in a lag screw to secure the two bone fragments together.  She was able to lag the two pieces together in a timely manner, and with the first screw now in I started keep track of usage.  While I was writing down part and lot numbers the circulating nurse summoned me to steal what I was writing down.

Proceeding the lag screw, it was now time to select an ankle plate.  While I was still talking with the circulating nurse Jill was looking through the plate selection and grabbed one she thought would be appropriate.  Now here comes the complaining.  "George, this plate isn't conforming to the bone!"  "This isn't fitting the way I want, I like "Company X's" plate better than yours".  Due to my knowledge in the industry, I know for a fact that all plates are practically the same.  I said, "Hey do you mind bringing that plate over here so I can look at it?", as she was waving it in front of my face like a small toddler I said, "Jill, why don't we try a LEFT foot distal fib plate".  She immediately went silent and examined the plate in her hand, as she wiped the blood away she spotted the big engraved "R".  Putting the plate down she picked up the correct one and walked back to the patient.  The doctor and I looked at each other and with an impatient expression he rolled his eyes and shook his head at Jill.  

With the plate now clamped to the fibula it should be a cake walk, drill the holes, measure the depth, and fill with screws.  With the drill ready to go, the doctor asked for the X-ray so Jill would be able to see the angle of her approach. She placed the drill, found her angle, then like Tim Allen from Home Improvement she blasted through both cortex's of the fibula and buried the drill half way through the tibia.   The doctor jumped out of his seat, grabbed the drill and said "What the hell are you doing!?!?!?".  With little sympathy for the patient, she just shrugged her shoulders. To my surprise, the doctor continued to let Jill finish the case.  She put a screw in the plate and moved on to the next hole.  Once again, getting the correct angle she slowly started the drill and got though the first cortex.  Now as she is starting to drill the second cortex of the fibula the doctor advises her to drill tap the cortex so she doesn't blow though it again.  With a nod of the head Jill slowly drill taps the cortex then all of a sudden she fires the drill all the way through the bone and lodges it in the tibia.  With the drill still buried, Jill said, "and...x-ray".  The doctor was speechless, he grabbed the drill and told Jill to step aside.  The doctor salvaged the repair and closed the incision.

I still remember to this day the x-ray picture that Jill asked for, the drill was all the way through the fibula and practically all the way through the tibia.  I imagine that image somehow got deleted. 

Moral of the story, if you need any sort of surgical procedure done be sure to research the teaching hospitals.

Please feel free to comment and ask questions, I will be sure to answer all in a timely manner.

Till next time.