Monthly Archives: December 2008

November 2008

By Gabriela Kremer, OREXer ’08-09

Surgeries Observed: AV fistula, and permacath, bi-lateral lower-extremity wash-out, inguinal hernia repair

Morning Discussion:

I arrived in the conference room just before 7am in the midst of a presentation by a young woman from UCSF.She presented a research paper she was developing which focused on Interval breast cancer which apparently has a higher morbidity and mortality than screen-detected breast cancer. The focus of the discussion and the questions was on how best to present her data visually, given that her sample size was only 66 people.

Dr. Shibru and Dr. Gonzalez led a discussion about Rectal cancer. As others have mentioned, the questioning was very thorough and intense. Medical students were required to know innervations and blood supply for any possible muscle or organ being mentioned. It’s pretty intimidating to imagine being in their position but they all took it well and sometimes, though rarely, admitted they didn’t know the answer. Later, one of the medical students talked to me about how difficult he found the first two years of medical school – how challenging it was to his ego and sense of self-esteem. He took some time off after his first two years and traveled and did a PhD in medical anthropology and now, at 33 is finishing his MD. He said the perspective he gained in those few years enabled him to return to medical school and not take the criticism so personally.

After the discussion I followed Dr. Shibru and a medical student Jennifer up to the OR. Over the course of the day I shadowed the medical students (the best people to talk to by far, although Dr. Shibru was also really open, kind and easy-going).

AV fistula and permacath:

A 24 year-old male, Mr. L, with acute kidney failure received an AV fistula and a permacath. Because of his kidney failure, Mr. L will require ongoing dialysis, likely 3 times a week. For people in this situation, the radial artery on the left arm and the radial vein are cut and repositioned for easier access by the dialysis technician. The patient will use this access point for up to 5-7 years. Apparently this method, requiring a new needle to be inserted with each dialysis, is preferable over inserting a permanently accessible port which would present an open site for infection. However, neither method is a perfect solution. Mr.L will be a candidate for kidney transplant, which will ultimately be the only way for him to discontinue dialysis. Dr. Shirbu hypothesized that given Mr. L’s young age and the small size of Mr. L’s kidneys (only 7cm each) his kidney failure was likely due to genetic factors.

The permacath was an access point inserted into Mr.L’s thoracic cavity on the right side. This will be used for his dialysis until the AV fistula “matures” which can take weeks. About a third of all AV fistulas never mature and the operation has to be redone.

I had a chance to look through Mr. L’s chart. I had never done this with another patient and it helped to clarify many of the terms being used by the surgeon and gave me some background and context for the patient’s condition. I saw that the medical students didn’t hesitate to look through the chart so I jumped right in after them and will do this some more in the future!

Bi-lateral Lower Extremity wash-out (aka nasty dog bite), or why NOT to punch a cop! :

Mr. M is a 58 year-old male who, as of 2am on Tuesday morning lost most of the dermis and epidermis on lateral portion of his right lower leg. Apparently Mr. M had a confrontation with the police and at some point either hit or tried to hit one of them, at which point the police dog attacked Mr. M and from the way he looked, my guess is that no one was in a rush to pull the dog off him. From about 2 inches distal to his kneecap all the way to around his heel, Mr.M had no skin whatsoever. The muscle was still intact except for a portion near the right side of his knee. In addition, he had several severe puncture wounds on his feet, between his toes and fractures to his 3rd and 4th metatarsals. He also had several larges chunk missing from his right lateral thigh. These wounds appeared more like a “typical” dog bite as compared with the lower leg wound which looked as if a butcher had flayed him with a knife. On the thigh, the tissue at the edges of the wounds was already black and dying off from lack of circulation.

Despite the shocking appearance of his wounds, Mr. M’s prognosis was fairly good. Dr. Gomez believed that he would recover full use of his leg because there was relatively little damage to the muscle. However, Mr. M will likely require a skin graft to the large lower leg wound at a later date. At this time the purpose of the procedure was simply to clean the wounds, and none of the wounds were stitched close because they were so dirty (not only from the dog but also from the fact that Mr. M had tried to run away – as they were cleaning the surgeons found pieces of grass stuck in among the tissue). The primary challenge for Mr. M will be changing of his dressings, a procedure Dr. Gomez believes will be so painful that Mr. M will be placed in the TCU, as compared with the regular med-surge floor, in order to be sedated while his dressing are changed regularly.

The wash-out was done using a hose attached to a device that looked like a small water-gun with a protective shield around the tip. The end of the hose attached to bags of saline. The surgeons dragged the hose along the wounds flushing them repeatedly with the saline wash. For the thigh wounds they actually pulled the epidermis away from the muscle and put the wash-out gun inside the wound itself. When the washing out was complete the wounds were dressed with a gauze infused with a Vaseline –like substance that will protect the wounds as they heal from the inside out.

Inguinal Hernia Repair

Mr. G is a 30 year-old male who had a small inguinal hernia apparently for the past 4 years, but which only recently began causing him more severe pain. He came to the ED twice in the past week and after the second visit was scheduled for the repair. Once the surgeons made the incision and saw the hernia itself, they were surprised by how small it was given the amount of pain Mr. G complained of experiencing.
As there was only one other operation scheduled for the afternoon, another inguinal hernia repair, I left as they were closing Mr. G.

Another fascinating day in the OR!