Week 5

I've spent a lot more time this week working on my research project.  Now that we have a complete list of patients and have found some additional information about them from their charts, we have begun determining if any patients no longer fit our inclusion criteria.  For example, some patients were included in the list because they were coded for having "Total hip replacement vs hip resurfacing".  But we only want to include TKR and THR, so these patients that actually ended up getting a hip resurfacing had to be removed.  This took a lot of digging through charts to determine if they eventually came in for surgery, when that surgery was, and what kind of surgery it was.  We have also decided to keep track of how many times a patient has scheduled and cancelled a surgery appointment before they get the surgery (if they ever get it at all).  So that means more digging through charts next week.
Other than that, this week has been pretty standard.  I have followed Dr. Goodman as she sees patients.  Nothing too out of the ordinary with the patients this week.  I also went to CAP conference where a couple of particularly high risk patients were discussed.  One of these patients had a left TKR in 2013 which was intended to be the first surgery in a staged bilateral knee replacement.  However, the patient suffered from a stroke (due to a blockage in her carotid artery) after the first surgery so the second procedure was postponed.  She has recovered somewhat from the stroke but still has difficulty speaking and her muscle strength is fairly low.  The surgeons feel that after she gets clearance from the vascular doctors (to make sure that her carotid is clear) that she will be ready for the right TKR.  Though it was interesting that the surgeon who did her left TKR openly admitted to being scared to operate on this patient again.  The second patient that was discussed was hoping to get a left THR.  She has Lupus, she's a smoker, she had a stroke in 2007, an aneurysm in 2002, and a history of avascular necrosis. Again the surgeons felt that as long as she was cleared by the vascular doctors and the neurology doctors that she was ready for surgery. 
At Grand Rounds this week I heard a lecture on the Chikungunya virus (CHIKV).  The reason this virus was discussed at Rheum Grand Rounds was because it causes both acute and chronic rheumatologic symptoms and may cause the onset of RA in certain high risk individuals. There are two major strains of this virus: one localized in Eastern, Central, and South Africa (ECSA) and the other localized in Southeast Asia.  Each of these strains is carried by a different species of mosquitoes.  Within the last decade or so, this disease has migrated outside of its normal regions. The ECSA strain was found in India and Europe by the end of 2005 and by 2013 was found in North and South America.  It has been determined that the virus was able to spread because of two reasons: it was being carried by the SE Asian mosquito species and the virus had mutated slightly.  The SE Asian mosquito species had already migrated to the Western hemisphere in the 1980s.  The U.S. had been importing a lot of tires from Japan at that time and the water trapped in the tire wells on the cargo ships were a great breeding ground for the insects. The mutation of the virus allowed for it to be passed more easily in urban environments, bypassing its normal enzootic cycle.  These changes allowed for the virus to spread more rapidly and as of 2015 there have been several cases within the U.S. (mostly in Florida and along the Gulf coast).  During this lecture we were shown a video of how a mosquito "bites".  The mosquito's proboscis can bend and move to find a blood vessel after its been inserted under the skin.  The proboscis also has two separate tubes: one for blood intake and a separate one for spitting (the virus replicates throughout the mosquito's entire body, but is transmitted by saliva).  Basically, this whole talk reminded me to never let myself be bitten by a mosquito.
On Thursday this week, I was able to go into the OR with Mandy and Dr. Bostrom.  I watched two THR, a total hip revision, and two total knee revisions.  I was even able to scrub in on one of the THR and one of the knee revisions.  The surgeries were so cool to finally see.  It has always blown my mind just how violent orthopedic surgeries can be.  It's amazing how little orthopedic surgeries have changed in the last few decades.  The techniques have improved, the equipment has improved, the replacements have improved.   But they're still using saws and mallets and brute force and there are bits of bone and flesh flying around all over the operating table.  But despite the roughness and trauma of the surgery, the human body can take it.  A little old lady will sleep through this whole violent ordeal and could be fully recovered within 6 weeks.