Salam sejahtera kepada semua yang membaca..
Hari ini hari Ahad..weekend yang free..
sepatutnya ada oncall tapi oncall dah diambil oleh HO baru yang baru lepas off tag..so, last Friday was my last oncall for this month..
Hari ni boleh kata duk saja2 jer kat rumah..sorang
2..
Petang tadi sempat gi belajar kereta..ambik lesen memandu untuk kali kedua..kan dulu dah pernah gagal 3x..hahaha..(memalukan tapi itulah kenangan)
Sejak semalam gak, duk belek buku anatomi lower limbs..naper tiba2 rajin ni??
oohhoooo...hari jumaat lepas aA diberi peluang untuk assist operation Above Knee Amputation..
ni dikira sebagai major operation la jugak..
aA dapat assist as 1st assistant dengan Bos (specialist) yg mana masa tu MO takder coz ada kes emergency kat A&E..
memula takut la jugak nak assisst coz that's was my first time..memang tak pernah tengok operation tu before ni..
nasib baik Bos baik..dia kata takper..sure boleh buat nyer..
so, sepanjang operation tu, nak elakkan rasa takut dan gelabah, aA asyik tanya jer Bos..Bos asyik jawab..tapi bila Bos tanya pasal anatomy, terus aA senyap..
paling memalukan bila tak boleh identified sciatic nerve yang besar giler tu...aiyyyoo...
k..jom kita mula dengan kes patient ni and kenapa proceed dengan AKA..
This patient is only 58 years old..malay gentleman..claimed newly diagnosed Diabetes Mellitus since 1 month ago..
came in with complaint of pain and foul smelling discharge of left lower limb..also for 1 month duration and since then not well ambulating..got fever on
and off..
that's the only history i can get from this patient as he's already became drowsy and lethargic.
on examination, patient's GCS (Glasgow Coma Scale) fluctuate between 14-15..but for me, patient is already 14/15. lethargic and septic looking. also tachypneic..
He was also very dehydrated with very high body temperature : 39.7 degree Celcius.
Blood pressure still normal, but he's tachycardic..
Cardiovascular system still normal... Right lungs got crepitations and reduce air entry at the base.
His left lower limb got wet gangrene a
t the medial and lateral side of the foot...with pus discharge. The skin was bluish and greyish..foul smelly.. (u can even smell it as far as 5 metres away)..Also got crepitus at the level up to just below knee.. (means he's got Necrotising Fasciitis)..
Investigations result... Hb : 9.7 (anaemic), WBC : 36.9 (he's in sepsis) and Platelet 355.
Renal profile deranged markedly.. Urea 38.3 (very high) Natrium 122 (very low) Potassium 4.9 and Serum Creatinine 414..
ECG shows sinus tachycardia.. Chest X-ray shows bilateral upper lobe haziness with elevated right hemidiaphragm and borderline cardiomegaly.
X-ray of left lower limbs shows gas shadows up to knee level with sclerotic vessel.. (later on i will try to get the X-ray image)
we started him with IV Tienam.
Then, after we do some fluid challenge based on CVP reading, we proceed with the operation..after confirming that he got ICU bed available.
Haaaa...itu lah kisahnya..
So, around 1130pm, patient ni ditolak masuk ke dewan bedah..0002 hours, operation started.
Start memula dengan skin incision.. Fish mouth incision..ini supaya bila dah habih semua, stump yang dijahit tu comey jer..mcm mulut ikan.. 15cm from the joint line..tanda dengan marker pen yang sterile punya
Kami potong subcutaneous tissue guna diathermy (ni bos yang pegang)..and aA pegang non-tooth forcep (apa ntah nama dia..bunyik cam MacKindo jer..nanti semula aA check balik ). forceps ni in case kalo ada bleeders (blood vessels yang nampak, aA catch then bos burn kan..so, tak la bleeding..)bila dah nampak muscle...Bos carik sesuatu kat medial side..dangerous area..iaitu big blood vessels..femoral artery and veins semua ada kat situ..penting ntuk settlekan tempat ni dulu..kalo terpotong, means banyaklah bleeding.
Kat sini, aA tolong pegang jer artery tu dgn artery fo
rceps sambil Bos ligated the vessels..
boleh nampak sangat yang vessels pakcik ni dah sclerosis..kuning dan keras..
dah settle part ni..
proceed dengan cutting the muscle..guna diathermy jer..still sama..aA pegang forceps untuk catch bleeders..
bila dah exposed bone..which was Femur (tulang paha)..alat yang diapanggil periosteum elevator digunakan untuk separatekan muscle and periosteum dari tulang..nampak licin jer tulang tu...kikis2 jer..
then, langkah seterusnya untuk potong tulang yang keras tu...
guna bone saw atau namanya Gigli..
alat ni alah wayar yang macam breaded..ada handle kat dua2 belah..
bila nak potong tulang ni..aA tekan pakcik ni punya lutut and scrub nurse tekan bahagian atas paha..sambil bos guna Gigli ni untuk potong tulang tu dengan hebatnya..berhabuk tulang tu jadi nya..
dah potong tulang tu, sambung lagi potong muscle kat bahagian belakang part..time ni, bos bagi aA peluang untuk guna diathermy and the other way round...best best...
bukan setakat muscle, nerve pun dipotong gak...
masa ni la yang Bos tanya nerve apa tu..aA tak ingat and xleh jawab..rupanya itulah Sciatic Nerve..besar nya..mcm satu ibu jari lebarnya..
kami catch nerve tu, then wash stump tu dengan Normal Saline dan povidone..dah cuci semua, proceed untuk settle kan nerve tu..
Bos kata, Nerve tu kena tarik panjang2 dulu then calmp the proximal part..potong the baru ligated..so, nerve stump yang tinggal akan masuk dalam muscle..kalo tak wat camtu, nerve end tu kat hujung stump akan cause pain pada patient tu..
oooo...baru paham..
last sekali, kami jahit layers muscle dengan muscle then fascia dengan fascia..
aA pun dapat peluang jahit skin...hi hi hi..
dah jahit semua..stump tu dibalut dengan stump bandage dengan sangat berseni...
chewahhh...ada skill tu nak balut..
operation tu ambik masa 99 minit..
kul 0141 tamat..
patient tu dihantar ke ICU sebab sepsis and kira tak stable la...
agak penat tapi that was very good experience for me..rasa honoured untuk assist kes tu..dah l takder MO nak guide untuk tulis operation note..aA tulis jer la..ikut apa yang Bos cakap roughly after operation...hahahah...
Moral of this post : jangan takut even untuk kali pertama..kalo takut, cuba carik benda lain untuk distract rasa takut tu such as..cakap banyak2, tanya banyak2...hahaha..
then, if u got diabetes..make sure u have good foot hygiene..if ada luka, jgn nak tangguh2 sampai dah merebak..nanti kena potong..
emmmm lagi...kalo ada kes, tulis blog lagi..so, that senang nak ingat management and procedure. cam recall balik la...k..bateri dah nak habih..adiosss
