| Station | FY2 in Ortho department. Emma Johns a 70yo man was admitted yesterday for hemiarthroplasty. She felt at home and sustained a left hip fracture. Surgeon explained the operation and anesthesiologist discussed the anesthesia. Discuss recovery process and post op management with the patient and address her concerns. Don’t talk about pain management |
|---|---|
| Patient info | Scenario1: DrI am glad you are here, l would like to know everything what would happen after the operation. Dr. one of my friends had the same surgery, she developed a clot in the leg. I am worried about that. You live in a house with stairs and the bathroom is downstairs and the bedroom is upstairs. You are worried about stairs. You were walking independently before the fracture. She Is already wearing compression socks. When Dr. offer aids you feel happy. |
| Scenario2: Same + you live with your daughter, but she is going for her postgraduate next month | |
| Intro | I understand that you were admitted yesterday due to a fracture you sustained following a fall and being prepared for surgery. Is that right? |
| History | I’m really sorry about what happened. Can you tell me how did it happen? How are you coping with the pain? Is your pain under control? How is your hospital stay? How is the care by doctors and nurses? |
| I have been asked to speak with you about a few important things you might expect after the surgery. | |
| Concern | Do you have any concern regarding your condition? |
| D.D | Systemic Review (mainly chest pain, SOB) |
| Has someone discussed the operation and anesthesia with you? | |
| P2 | Apart from your previous surgery have you had any other Past surgeries? Explore |
| Past medical conditions? (DM) (HTN) Explore | |
| Р3 | DESA (smoke) (Alcohol) |
| MAFTOSA (Medications) (Family history of clots) (Living home) | |
| Finishing Hx | Thank you for the information you have been giving me |
| Expectations | What do you expect from today visit? |
| Examination | Observation + BMI + abdomen + Legs |
| Ideas | Do you have any ideas regarding your operation that you would like me to address? |
| Provisional diagnosis | Well, from the information you’ve given me, the chance of you getting blood clot in your heart or lung is low. However, we won’t take any risk so, we will take some measures to prevent you from having blood clot |
| Management | 1. We will give you blood thinner injections from before your surgery every day till few days after surgery (usually 28 days). Such as dalteparin SC |
| 2. You will be given some special stocking (TED stocking) that will increase blood supply in your leg and prevent you from having a blood clot. | |
| 3. There’s a device called (intermittent pneumatic compression) which will create some sort of pressure on your legs by charging air pressure → which will improve circulation in your leg. Also, Early mobilization is mandatory. | |
| Explain post-surgery measures: After surgery you will be taken to recovery room where we will monitor you till you wake up from the anesthesia. | |
| We will observe you there for a while, then take you to the ward, if all things go well as we expect. Within an hour you will be allowed to have a drink of water and after a 6h you can eat food. The following day we usually do an x-ray to make sure that everything went well during the operation. If everything went well you will be seen by a physiotherapist within 2-3days post-op, they would teach you some exercises to strengthen the muscles around the hip to hold it in place more. Initially you would need crutches to support yourself before trying to walk on your own for 4-6weeks. | |
| Some important advice, I would like to give you to follow after operation: Avoid bending your hip >90, Avoid twisting your hip, don’t swivel on the balls of your bat, when turning around, take small steps, don’t turn suddenly, don’t cross your legs, avoid sitting on low chair or toilet seats. | |
| Helping with moving around: The physiotherapist would help you to climb up and down the stairs in the hospital. Is there anyone to help at home? | |
| (No) the occupational therapist will visit your home and assess, make changes to make it more convenient for you to live in. | |
| Medical team: They would help to assess for weak bone for osteoporosis. They would perform DEXA scan and may offer medications for it. Also, they would offer treatment like Vit-D, Calcium and bisphosphonates | |
| Complications: Infection (antibiotics), UTI die to catheterization (anti-inflammatory drugs), aspiration pneumonia (fasting before operation), pain (painkillers) | |
| Safety netting After operation: at any time, you have, Swelling in your legs and calf muscles. Or SOB or chest pain. Let us know if you still hospital or ring 999 if you are at home. | |
| Closure | Please at any time if you have questions or concern, let us know |
| Questions | What’s your main concern? (Dr, I am worried in case I have blood clot). May I ask you why are you worried about developing blood clot in your heart and lung? (My friend had an operation well, and she had a blood clot). I’m really sorry about your friend, how is she doing now? |
| Not everyone who has this operation will end up having blood clots; however, we 'll take some precautions to prevent this from happening. | |
| Driving / Sex: 6 weeks when you are able to do emergency stop without pain. If she asks about Skiing (avoid), Ball game (4 months.) When can I come back to work: 12 weeks. |
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Who you are:
You are F2 in Orthopaedics.Who the patient is:
Mrs. Margaret Fletcher, aged 74, presented to the hospital
after a fall with a fracture of neck of femur. She has been planned to have a
hemiarthroplasty.Special note:
Anaesthetist has explained pain management. The consultant has
explained the procedure.What you should do:
Please talk to the patient, discuss about post-operative
management and complications. Discuss about management once discharged
and address her concerns.
D: Hello I am one of the junior doctors here. I can see from my notes that you had a fall. How are you doing so far? (Always try to use your notes)
P: It was a dreadful fall doctor I feel it was really painful around my hip.
Rapport
D: Sounds like an awful experience, I’m really sorry about what happened, how are you feeling now?
P: I am fine.
D: Can you tell me how it happened?
D: How are you coping with the pain? Is your pain under control?
How is your hospital stay?
How is the care by doctors and nurses?
P: Thank you doctor, all is fine.
D: I think you had a chat with a few of my colleagues about what has happened to you and what we are going to do for that, am I correct?
P: Yes they told me that I have a broken bone in my hip and you are going to do an operation to fix it.
D: You are right. And I believe my consultant/colleague has explained to you about the procedure of surgery and the pain management after surgery.
P: Yes doctor.
NO NEED TO TAKE MUCH TIME ON HX JUST FOLLOW THE PATIENT CONCERNS
AND IF YOU HAVE TIME TAKE HX AT THE END.
D: Have you got any concerns that need to be addressed before the surgery?
P: Yes I do.
D: Alright don’t worry my dear I am here to answer all that you have on your mind, please feel free to tell me your worries.
P: Can you tell me what happens after the surgery?
Concern
D: After the surgery you will be shifted to a recovery room, where you will be observed and monitored for a while.
P: When will I be able to walk?
D: We will try to make you mobile as quickly as possible after the operation. We encourage our patients to walk the next day after the surgery, however sometimes you will be made to walk on the same day of the operation. But you will be needing some walking aids like crutches to walk in the beginning. We do this to avoid any complications.
P: What are the complications of this surgery?
D: There can be some complications like:
− Infection or bleeding at the site of the surgery.
− Blood clot in the legs.
− Injuries to the blood vessels or nerves.
− Differences in leg length.
However, if any of these things happen we will manage them accordingly. How do you feel so far?
P: Doctor, I am worried in case I have a blood clot in my heart or lungs.
Concern
D: EXPLORE May I ask you why are you worried about developing a blood clot
in your heart or lungs in particular?
P: (My friend had an operation and she had a blood clot after)
D: I’m really sorry about your friend, how is she doing now? reflect
P: She is fine now but after the surgery when she had the clot she was really
sick.
D: Oh I can understand why you look a bit worried about that then. Not
everyone who has this operation will end up having blood clots; however, we’ll take some precautions to prevent this from happening.
So, is it ok if we have a chat about your health in order to be able to address
your concern in a better way?
Take hx at this point, Hx about symptoms and risk factors of blood clot.
P1
Sx of P.E.
D: Do you have any chest pain ?
Do you have any SOB ?
Have you ever had any weakness in any of your arms or legs?
P: No.
P2
D: Have you been diagnosed with any medical condition in the past like high
blood pressure, DM or any cholesterol problems?
P: No.
D: Any blood disorders or have you ever had any clots in the heart or the lungs
or legs?
P: No.
MAFTOSA
D: Are you currently taking any medications, OTC or supplements?
P: No.
D: Any blood thinners or COCP or any Hormone replacement therapies?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: Any blood disorders or blood clots in the family?
P: No.
DESA
D: How is your diet (Fast or fried food)?
D: Do you smoke?
Take social Qs:
D:
- Where do you live?
- What type of accommodation? 2 floored house with stairs or no stairs and single floor?
- Who do you live with?
- Can they help you manage?
- How was your activity and mobility before ? (E.g. Walks around dependently)
D: Well, from the information you 've given me , the chance of you getting a blood clot in your heart or lungs is low. However, we won’t take any risk so, we usually take some measures to prevent you from having any blood clots after the surgery anyway.
Management:
- Early mobilization is mandatory.
- Exercise program by a physiotherapist
- We will give you blood thinners injections from before your surgery every day until few days after surgery (usually 28 days). Such as dalteparin S.C.
- You will be given some special stockings (TED stocking) that will increase blood supply in your leg and prevent you from having a blood clot.
- There’s a device called (intermittent pneumatic compression) which will create some sort of pressure on your legs by charging air pressure → which will improve circulation in your leg.
Some important advice, I would like to give you to follow after operation:
− Avoid bending your hip >90.
− Avoid twisting your hip.
− Don’t swivel on the balls of your feet.
− When turning around, take small steps, don’t turn suddenly.
− When you enter a car sit first then move your legs inside slowly.
− Don’t cross your legs.
− Avoid sitting on a low chair or toilet seat.
D: Have you got any other concerns?
P: How will I get around in my home?
Take social Qs:
D: That’s a very valid concern can I ask you a few questions about your house to answer you properly?
- Where do you live?
- What type of accommodation? 2 floored house with stairs or a single floor house with no stairs or a flat?
P: I live in a house doctor. - Do you have all facilities on one floor?
P: No doctor my bathroom is upstairs.
D: Don’t worry this is one of the areas we look into before discharging you because climbing stairs can lead to a fall and cause dislocation, one of the complications.
Our Occupational health therapist will assess your home condition and do all the necessary adjustments before you get discharged. They make
sure all the facilities are on one floor as you can’t go up and down stairs until around 3 months. They will also change any low toilet seats to higher seats, they will install rails in the bathroom and shower, they may provide an electric chair for a while as well to help go up and down stairs.
P: What about shower?
D: The bathroom can be slippery and pose risk of a fall, but don’t worry about it, an electrical chair can be fixed in the shower and also hand railings can be arranged. - Who do you live with? Can they help you manage?
P: No doctor, that’s one of the reasons why I am worried.
D: I can understand your concern, but don’t worry about it we can sort that out for you by involving social services and arranging someone to take care of you. - How was your activity and mobility before ? (E.g. Walks around dependently).
Safety netting: After operation , at any time if you have:
- PE sx Let us know if you’re still hospital or ring 999 if you are at home.
-Swelling in your legs and calf muscles. SOB or chest pain.
− Infection Sx: Contact GP if you feel
– Pain.
– Redness.
– Heat.
– Bleeding.
– Discharge.
Questions you will be asked:
- Walking with support (crutches) and with help of physiotherapist next day.
- Will walk without support within 6 weeks, once operation site heals
properly and tissue becomes strong. - Discharge 3 – 5 days after operation. If you are fit and well without complications. Occupational therapist to your home to make some adjustments where everything will be on the same floor as you can’t go up and down stairs until around 3 months. Will install rails in the bathroom and shower, will provide an electric chair for a while as well.
- Driving / Sex → 6 weeks when you are able to do emergency stop without pain.
- If she asks about physical exercise:
Skiing → avoid.
Ball game → 4 months. - When can I come back to work → 12 weeks.
- P: When can I have food and drinks after the operation?
D: You may be allowed to have a drink about an hour after you have been to the ward and depending on your condition, you may be allowed to have something to eat.
FOLLOW UP: You’ll be given an outpatient appointment to check on your
progress, usually six to 12 weeks after your hip replacement.
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