The Royal National Orthopaedic Hospital is located just outside London, England. When in November 2009 I came across an opportunity to work at its nationally acclaimed Spinal Cord Injury Centre, I immediately applied. Once known as "The Cure of Crippled Children Centre," the hospital is spread across buildings constructed in the 1920s. Americans also erected Nissen huts in the early 1940s. Made from corrugated steel, the prefabricated huts, which are similar to Quonset huts, are used as patient wards. The hospital is due for a much-needed renovation, starting next year.
8:15 AM
I live on site in the accommodation provided by the hospital, so my commute takes about 2 minutes. As always, I start the day with an American-size mug of Earl Grey tea with milk. I report directly to one of the consultants (supervising physicians), each of whom is responsible for half of the 30 patients. I am lucky to work with Hajeena, an excellent junior doctor (resident). Although we share the same duties, I sometimes have additional responsibilities, such as the Outpatient Clinic and writing discharge reports. Patients are mainly spread out over two wards: rehabilitation in the Spinal Injury Unit (SIU) and prevention and care of bed sores in the Angus McKinnon Unit (AMU). Duties center around admitting a newly diagnosed paraplegic or tetraplegic patient; neurologic assessments; and managing a broad range of medical issues, such as pneumonias and UTIs.
8:30 AM
Rebecca, the ward sister (senior nurse), and I discuss Mr. L outside his room. Mr. L is 60 years old and has tetraplegia, ankylosing spondylitis, schizophrenia, and dysphagia. He receives humidified oxygen through a tracheotomy, as he is incapable of swallowing even saliva. Several neurologists, the speech-language therapist, gastroenterologist, and anesthesiologist have evaluated Mr. L without finding the etiology of the dysphagia. CT and video swallowing studies show a lack of coordination and immobile pharyngeal muscles. One possibility is postsurgical complications arising from an anterior approach to spinal fixation. Mr. L needs constant suctioning and has severe hematuria.
9:15 AM
I need to monitor Mr. L's hemoglobin. Nurses do not take blood samples or start IVs on this ward, so after "bleeding" the patient, I fill out the requisition form and put the blood tubes in the attached plastic bag. The bag is then sent to the in-house pathology laboratory. Urine samples and nonroutine laboratory tests, such as thyroid, folate, and B12 determinations, are sent by taxis to a nearby hospital. Because the system is elaborate and samples do go missing, I call to ensure that samples for blood cultures or other urgent requests have arrived. After documenting tests in Mr. L's paper medical record (there is no electronic record), I continue with the daily ward round.
9:45 AM
Ms. T has C5 tetraplegia after a truck hit her in a parking lot. She remembers her accident clearly and felt her neck break. Ms. T is in week 11 of her rehabilitation and has developed neuropathic pain, which arises in 80% of spinal injury patients. Neuropathic pain is debilitating in itself, with only one-third of patients responding to medications. Ms. T and I decide to try her on pregabalin 75 mg at night. I write the medication on the chart and hand it over to the junior doctor or consultant, who cosigns. PAs do not have prescription rights in the United Kingdom. I find this difficult, as the wards are very spread out, and some days I feel as if I am constantly hunting down my colleagues for signatures.
10:30 AM
After completing the documentation for patients at SIU, I'm off to AMU, the ward specializing in tissue viability, or pressure sore management. Unfortunately, pressure sores in spinal injury patients can take up to a year to heal. I take my down coat and brace myself for the cold since only makeshift hallways connect the wards. I go down the steep slope shivering and arrive at a warm AMU. Sunita, an experienced ward sister, requests a new drug chart for Mr. S. Every patient has a paper chart that has to be rewritten about once every month when it is full (which requires cosignatures). I also check on Mr. S, who has no new complaints. He was admitted with a grade 4 pressure sore and osteomyelitis. While in hospital, he spilled hot coffee over his right lower leg and required a skin graft for the burn. Both the donor site on his right thigh and the burn wound are healing quite nicely.
11:30 AM
I check the inpatient lab results. Mr. L's hemoglobin is 7.9%. The consultant, Dr. Gawronski, advises holding off on blood transfusion and repeating blood tests in 48 hours. I reply to internal e-mails and call a surgical specialty registrar. Most of our patients wear a body brace after neurosurgery, and the surgical team determines when the brace can be safely removed. I ask the specialty registrar to see Mr. P, who is anxious to have his cervicothoraciclumbosacral body brace removed.