Surgery For The System

LOCAL WOMAN BECOMES A PATIENT IN A PROVINCIAL INITIATIVE TO SPEED UP SURGERY WAIT TIMES

Originally published June 14, 2006 in the St. Albert Gazette.

  Dr. Guy Lavoie makes a few final adjustments before sewing up the skin around a knee that was once ravaged by osteoarthritis.   Photo: April Bartlett/St. Albert Gazette


Dr. Guy Lavoie makes a few final adjustments before sewing up the skin around a knee that was once ravaged by osteoarthritis.

Photo: April Bartlett/St. Albert Gazette

This is nothing like on TV. There are no witty exchanges, no Mozart or Metallica blaring from the stereo, no furrowing of brows if an instrument isn't placed in the palm just so. This surgical scene is more comparable to the roaring construction sites clustered outside the Royal Alexandra Hospital.

Tools are grabbed and employed with matter-of-fact movements and discarded with a clang. The grinding and whirring of drills and saws is interspersed with spates of aggressive hammering. Later, when the glue gun comes out, the smell resurrects memories of model building.

The parts being ground and drilled on this job site are thigh and shin bones belonging to Diana LePan, the 56-year-old co-owner of Grandin Agencies in St. Albert.

LePan's face is hidden behind a vertical sheet, which seems to remove her from the right leg that lies wide open from mid-thigh to mid-shin. She's awake, with a spinal anesthetic removing her feeling from the waist down. As the surgical team casually flops LePan's leg at unnatural angles, a nearby anesthetist surveys a bank of machines that beep out her steady heart rhythm. A sedative helps keep her relaxed.

Also in the room are the head surgeon, a surgical assistant, an operating room nurse, a logistics nurse and a sales consultant from Johnson & Johnson, the supplier of the new parts going into LePan's leg.

When it's all over, the ends of LePan's thigh and shin bones will be capped by shiny, stainless steel components, with a white plastic sheath replacing the knee cartilage that's been ravaged by osteoarthritis.

After a little more than an hour, LePan's leg is sewn up, stapled and cleaned of its reddish iodine hue. She's off to recovery. To LePan, the whole episode seemed like 15 minutes.

"You could hear things but it didn't bother you," she said later. "It sounded like they were hammering this spike into your bone but you go, 'Oh well.' "

DIDN'T FEEL A THING

LePan's meandering journey through the frustration of medical uncertainty and wait lists began in a sand trap on a Maui golf course in January, 2000. She found herself on a steep slope with her left foot on the fairway and her right one in the sand, bearing all her weight. The twisting of her leg as she followed through brought husband Al running over. She didn't understand the fuss.

"I didn't feel a thing," LePan said. "I couldn't figure out why he came running."

"That's exactly how you wreck your knee," Al recalled saying.

The next morning LePan's right leg was so sore, she could barely get out of bed.

I lost it. I just started to cry. I told her that I didn’t think very highly of our medical system anymore.
— Diana LePan, knee replacement patient

The following September, LePan had arthroscopic surgery to clean out her knee, but it didn't help. The arthritis brought on by her injury grew worse. In November 2004 her doctor referred her to a surgeon and she was placed on a wait list for a consultation. A year later, LePan still hadn't been called and was getting anxious to have a knee replacement.

Meanwhile, LePan felt sharp pains up to her mid-thigh when walking and she fell three times after her knee gave out. Hills and stairs became her enemies and her family quit going on ski trips.

"As years went on it just got worse and worse. It's actually only in the last year that it's very much interfered in my life," she said.

Last winter LePan heard about Alberta's Hip and Knee Replacement Project, a pilot launched in April, 2005. She got excited, thinking her call would come soon. It didn't.

Her frustration boiled over in April, when her doctor told her she was still on the waiting list and there was nothing that could be done to speed the process.

"I lost it. I just started to cry. I told her that I didn't think very highly of our medical system any more and all those things you say when you're frustrated and mad," LePan said.

LePan's doctor hadn't heard of the hip and knee project so she called the clinic herself then asked her doctor for a referral. Five days later she went for a consultation with a surgeon. Five weeks later, on May 29, she was in surgery. In between, she'd been strengthening her leg with exercises and returned to the clinic two more times to consult with the physiotherapist, nurse and occupational therapist.

A week before her surgery, she was a little nervous, but mostly excited to get it done.

"It's not that I'm lying in bed crying 24 hours a day, it's just that we're not doing the kinds of things that we want to do," she said. "I want to be able to go for walks, look after my grandchildren, enjoy the lake, just normal things -- nothing special but they're special to me."

“We found pieces of practice that we would consider excellent but no one had taken all of the pieces of excellence and put them all together.”
— Tracy Wasylak, project co-chair

Bone and Joint Health Institute

The Alberta Bone and Joint Health Institute started in March 2004 with a $10 million donation from J.R. (Bud) McCaig, a philanthropist and former chair of Trimac Corp. Its mission was to improve bone and joint care in the province.
 
A result was the Alberta Hip and Knee Replacement Project, a year-long pilot aimed at streamlining the joint replacement process. The project involved 13 surgeons in Calgary, Red Deer and Edmonton. In Edmonton's Royal Alexandra Hospital, one of the 13 operating rooms was set aside for the project and its five surgeons.
 
In devising the new treatment model, the working committee looked at methods used across Canada, the United States, Europe and Australia, said co-chair Tracy Wasylak.
 
"We couldn't find any one place that had nailed it down. We found pieces of practice that we would consider excellent but no one had taken all of the pieces of excellence and put them all together."
 
The team mapped out the steps, trying to figure out where bottlenecks would occur. One of the main results was a "common care map," a standard plan for dealing with patients that each surgeon would follow, instead of each having a particular approach. This included everything from the drugs used after surgery to the timing of physiotherapy.
 
Another step was a "central intake" with all participating surgeons working from one office with one waiting list. This clinic, which was located in Sherwood Park, also housed support staff like nurses, occupational and physical therapists so that patients could get comprehensive treatment in one visit.
 
An interim report released in December found that this model drastically reduced wait times, from 35 weeks to six weeks for consultations and from 47 weeks to 4.7 weeks for surgery.
 
While the pilot ended in March, health regions are working to expand the model to include all surgeons who do hip and knee replacements. In the Capital Health region, the project is up to 12 surgeons with all 20 area surgeons expected to be on board in about 18 months, said Dr. Don Dick, an Edmonton doctor heading up the expansion process.
 
The model has shown good results, but it's a challenge getting all the care providers to buy in.
 
"In any group of people you have people who are anxious to change and then people who are less inclined to change," Dick said.
 
The target this year is 3,000 joint replacements, up from the 2,200 done last year. As the project rolls out, more of the procedures will be done under the new model. There are close to 2,000 people on waiting lists in the Capital Health region.

 With the assistance of physical therapist Yvonne Foreman, Diana LePan was practicing walking down stairs only two days after surgery.

With the assistance of physical therapist Yvonne Foreman, Diana LePan was practicing walking down stairs only two days after surgery.

Recovery mode

Back at the hospital, Diana LePan is in the physiotherapy room down the hall from her ward. It's two days after her surgery and she's learning to walk with crutches and navigate stairs. She was able to put her full weight on her knee just hours after surgery and tomorrow she'll go home.

A week later LePan can't wait to have the staples removed from her incision. An infection she picked up seems to be under control and she's glad she had the operation.

She's walking twice a day for about 20 minutes and doing her exercises. The worst part is the daily injection in the belly that she has to give herself to prevent blood clots.

The only pain is in her right leg muscles as they gain strength. She needs pain killers to sleep properly and get the most from her exercises. There is no pain in the knee itself.

LePan won't be able to drive for six weeks and will never be able to ski, push heavy objects or do weightlifting. She's not concerned. For the moment she's anticipating a return to the golf course and picking up her grandchildren.

To get anything done with our medical system you basically have to do it on your own.
— Diana LePan, knee replacement patient

"Overall it was not nearly as bad as I thought it was going to be," she said.

As far as she knows, she's still on the waiting list for the first surgeon she was referred to and is curious to see how long it takes before she gets a call. While she applauds the treatment she got from the hip and knee clinic, her experience with the health system has left her less than impressed. 

"I've learned that to get anything done with our medical system you basically have to do it on your own."

Photos by April Bartlett

© St. Albert Gazette/Great West Newspapers