Truth, Tendons, and Time's Paces
On Call for Orthopaedics
A 31-year-old Zimbabwean male presents with an open, transverse fracture of the patella, twenty-four hours after dropping an angle grinder on his knee. How should he be managed?
That was the case that greeted us on call. We removed the dressings, which had been applied at a local clinic, to find an 8cm gaping wound oozing blood without the compression of the dressings. We sedated him with ketamine (0.5-1.0 mg/kg intravenously) to perform wound toilet and administered some antibiotics. The textbooks generally say to rinse the wound with 'copious amounts' of normal saline (0.9% NaCl solution); but this is not usually quantified. We used two litres, which I would consider quite a modest amount, but a more thorough toilet would be performed in theatre together with repair of the extensor mechanism. A quick note on the anatomy for non-medical readers: the patella or kneecap is a triangular, sesamoid bone (a bone formed within the tendon of a muscle) within the tendon of the quadriceps muscle above. The apex points inferiorly (downwards) and is attached to the tibial tuberosity at the top of the shinbone by the patellar ligament. So the 'extensor mechanism' is a pulley: when you contract the quadriceps, the patellar ligament extends the leg i.e. pulls the leg in line with the thigh, straightening the knee. You can imagine if you cut through the patella the force of the quadriceps contraction cannot be transferred - the top half of the patella will just be pulled up.
Veritaserum
With the sedation wearing off, the patient began expressing his deep gratitude for our help as well as some very personal anecdotes. The registrar on duty joked that ketamine is basically a veritaserum, recounting humorous stories of young teenage boys saying very inappropriate things in front of their embarrassed parents. It got me thinking. Is it really correct to say that it's truth serum? One of my friends has a saying: "Drunk words reflect sober thoughts." I'm not sure I agree. When someone is drunk or under the influence of other neuromodulating or disinhibiting chemicals, I suspect much of what people say is just confabulation. Anyway, I managed to gain some rapport with him by mentioning some of the music of the late, great Zimbabwean musician Oliver Mtukudzi. I don't understand Shona, but I brought up my childhood favourite song, Ndakuvara, which I believe translates to I am injured... And, in his case, that much was certainly true.
A triple century and Koshuisverlaters
On a more personal note, I realised this week marks 300 weeks since I started medical school. I started when I was 18, and I'm 24 now. That's a quarter of my life.
I was reminded of a poem dad sent on the family group on my birthday earlier this this year. It's called Time's Paces.
When as a child I laughed and wept, Time crept.
When as a youth I waxed more bold, Time strolled.
When I became a full-grown man, Time ran.
When older still I daily grew, Time flew.
Soon I shall find in passing on, Time gone.
O Christ, wilt Thou have saved me then? Amen.
Without getting into a deep reflection on my six years at medical school, I will say we had a really nice Koshuisverlaters event on Saturday morning. It's an Afrikaans word that roughly translates to "boarding house leavers."
It was an outdoor breakfast in the rolling hills of the Stellenbosch winelands. It was lovely to see friends I've made over the past six years, some of whom I haven't really had much time to interact with over the past few months. I suppose it marks the start of a series of events where we say goodbye to each other. Apparently we are supposed to receive news of our placements for next year in the coming week.
Postscript: Squash
I played a squash match against Jacques, who is in my year. It's the first time I've played in a good few months, and today I'm really feeling the effects—not just in the usual spots like my glutes and hamstrings, but curiously, also in my paraspinal muscles.