Global Health Asia-Pacific May 2022 May 2022 - Page 47

I ’ m particularly passionate about . It ’ s flexible enough to allow full knee flexion ( bend ) immediately after surgery without giving way but robust enough not to result in wound dehiscence or breakdown after surgery .
Then there is the ever-important factor of pain management . The pain is greatly reduced firstly by the surgical approach itself . Secondly , I was fortunate enough to spend a year of fellowship training at one of the foremost joint-replacement centres in North America that has published extensively in periarticular injections in the knee to control pain after surgery . This involves not only the what to inject but the where and when to inject it .
Last but not the least is management of bleeding and blood loss . This is important if you intend to send patients home early . It would be disastrous if a patient goes home and has to be rushed back to the hospital at night for bleeding from the wound . In fact , this has also reduced my need for blood transfusion . Now I can consistently say that I would not likely have to transfuse anyone with a starting haemoglobin level of 12g / dL . Even some of those with bilateral knee replacements !
Right-Left : Wan Nur ’ Atiqah binti Wan AB Razab , Staff Nurse , SJMC Home Connect Services ; Lee Seen Ying , Sister , SJMC Home Connect Services ; Dato ’ Dr Siva Kumar Ariaretnam , Consultant Orthopaedic Surgeon ; Dr Gunalan Palari , Consultant Anaesthesiologist ; Milya Shazlin binti Mohd Ghazali , Physiotherapist
Besides the reduction in pain and early return to function that you mentioned , do you anticipate any other benefits from making patients walk early ? Yes ! In fact , one of the biggest benefits of early mobilisation is the reduction of some of the most dreaded complications of surgery which involves getting blood clots in the deep veins of the leg after surgery . These are deep-vein thrombosis ( DVT ) which could also lead to the rare complication of pulmonary embolism ( PE ) which could lead to death . In fact , I was involved in a significant study 15 years ago when I was doing another hip and knee fellowship in Sydney , Australia . We basically showed that if a patient was made to walk within 24 hours of a TKR ( the morning after ), the risk of developing DVT was significantly lower than those who walked more than 24 hours after surgery . Also , those who walked at least 5 metres on the morning after had no DVT in the study population . I have since succeeded in making patients walk more than 5m and climb stairs within hours of surgery !
What made you so passionate about early mobilisation and fastrack TKR ? Initially it had all to do with pain . I was equally pained when I saw my patients in pain . The worst hit I got to my confidence as a young surgeon was when a patient declined having her other knee replaced . She thanked me profusely for the first one but said the pain was worse than childbirth and the thought of going through that again itself could kill her ! I really took this badly and had to reflect and question my role as a surgeon ! Then about a decade later I started treating a fair number of overseas patients . These patients wanted to return home early . So , I had to ensure they didn ’ t have issues with pain and their wounds . Hence my quest to find the perfect wound closure ! I even use dressings that patients could remove themselves without needing to be changed and skin closure
methods that could just be peeled away without having to visit a doctor and have stitches removed !
Do you anticipate that many will opt for daycare knee replacement surgery ? No . Most patients want to stay for a few days after surgery . But I do get requests especially from selfpaying patients coming for their second knees who ask if they can go home the same day because they found the other 1-2 days in the hospital redundant and they could rest at home and save cost . The hospital management back in the day did not allow admission on the morning of surgery and discharge on the same evening , more as a safety concern . So I admitted them in the morning , operated after lunch , walked them myself after dinner and got the physio to get them to climb stairs the next morning and off home by noon ! And I have been doing this for some patients for the last 5-8 years . It is only since they have realised that daycare surgery is being done in some parts of the world , was I allowed to do this . Also , it took some very forward-thinking administrators to get the infrastructure and the licensing for Home Connect ; our in-house home-care nursing team I liase with for my daycare patients for home visits the morning after . They would visit them and examine the patient and organise a video-consult with me to speak to the patient and ensure that the patient is well and totally satisfied with the treatment and progress .
Is this a one-man-show or do you rely on a team to help manage your daycare knee replacements ? Absolutely not . I totally rely on a team without whom I would not be able to do this . Firstly of course as I mentioned was forward-thinking administrators . Hospital managers are often unfairly criticised for being profit-driven , but I must say mine were willing to put a lot of cost losses aside to allow this project
These are deep-vein thrombosis ( DVT ) which could also lead to the rare complication of pulmonary embolism ( PE ) which could lead to death .
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