First OREX Day — October 2011 (Part 2)
By Michelle Davis, OREXer ’11-12
My first surgery observation day started with Dr. Harken’s lecture on Rivers’ findings in his 2001 NEJM article entitled “Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock” (http://www.nejm.org/doi/full/10.1056/NEJMoa010307#t=article). Dr. Harken’s intention for this lecture was to discuss the merits of early goal-directed therapy vs. standard therapy to encourage the surgical residents, interns, and med students to critically evaluate established sepsis management guidelines and apply techniques that improve patient outcomes before sending their severely septic patients to ICU. I was surprised to see how only two of the sleepy the residents, interns, and med students were actively keeping up with Dr. Harken’s eloquent discussion of inserting a central pulmonary catheter when practical and improving cardio-output using various cardiotonic agents when treating severely septic patients.
After the lecture, I asked a nice resident that I recognized from my first Level 1 trauma in the ED (she pumped a gun shot wound victim’s heart with her gloved hand after her team made an intercostal incision and retracted his ribs in an attempt to restart his heart) if I could tag along with her and her team to the OR. She declined since her surgery was cancelled at the last minute- her patient was a minor that did not have a guardian to give consent to the surgery that morning- and suggested that I follow Dr. Hirvela’s team instead.
I followed Dr. Hirvela, Victor, and Aaron to the ICU where they checked up on a patient that came in as a Level 1 trauma during my ED shift prior to my first OREX day. This patient came into the ED with a GCS of 3 or 4 with an exposed compound tib-fib fracture on the right leg with possible facial fractures in addition to facial lacerations. The paramedics explained to the trauma team that the patient had been hit in the chest by a car and then dragged by her leg for a block before she was found stationary and unconscious on the ground. During the trauma team’s evaluation, she was intubated, unfortunately, traumatically due to blood and other fluids blocking her airway caused by her facial injuries. After she was stabilized, the trauma team took her to CT to examine her head and abdomen to see if there were any internal damages or hemorrhages. From that point on I lost track of her case (I had to finish the primary training of a new volunteer) until Dr. Hirvela’s review of her case in ICU.
Even though I was not able to follow everything that Dr. Hirvela’s team was discussing amongst each other and with the ICU nurse, I was able to learn that the patient did indeed have facial fractures and was still sedated and on a respirator. From my observations I was able to gather that she underwent a surgical operation to repair her exposed tib-fib fracture, which was wrapped up in a tight bandage. More importantly, I was very happy to see the progression of this patient’s treatment at Highland since volunteers in the ED do not get to see the conclusion of a Level 1 trauma patient after they are rushed off to the OR or ICU.
After the surgeons finished their rounds in ICU, we then went to the 5th floor and changed into our sterile scrubs in preparation for a re-exploratory surgery in OR 4. One of the surgery support staff was nice enough to point out where OR 4 after noticing me reading the white board. Upon entering the OR, I introduced myself to Rosetta, the circulator for Dr. Hirvela’s team. Rosetta was kind enough to take a bit of time from her busy schedule to bring me up to speed and also help me find a step stool (I’m short and surgeons are tall!).
After Dr. Hirvela scrubbed out, she explained to me that this particular patient was shot in the abdomen last week and his initial exploratory surgery revealed that the bullet nicked his duodenum, pancreas, liver, and superior mesenteric vein as it exited his body. The first team of surgeons repaired the damage but were unable to safely close up his abdomen due to the swelling of his internal organs. If they closed up his abdomen after the initial repairs then the patient’s swollen organs would push up against his lungs and increase the risk of hypoxia during his recovery. Instead, the first team of surgeons added packing and temporary drains, and sutured IV bag over his exposed organs to the skin near the incision to allow his swollen organs to expand without causing more internal damage.
Leaving a patient’s internal organs exposed in this manner for the days or weeks needed for the swelling to subside requires that surgeons must perform a number of re-exploratory surgeries to clean the patient’s organs with saline solution to prevent infection. These extra surgeries also provide surgeons more opportunities to detect and repair subtle injuries and check up on the status of internal stitches made during the first surgery. Because this was the patient’s first re-exploratory surgery, Dr. Hirvela and her team had a difficult time searching out easy to miss subtle injuries because his small intestines were swollen and “messy.” After her team rinsed the organs, checked the internal stitches, and scanned the organs for other injuries, the surgeons inserted a permanent pancreatic drain and then “closed him up” with packing and IV bag.
I then asked Dr. Hirvela how long it would take to close up the patient’s abdomen and allow him to regain consciousness. She explained that it would be a long and hard recovery. It would take numerous weeks before they could close his abdomen since his organs were still very swollen and a skin graft would be needed to replace the necrotic skin near the incision (due to the IV bag). Growing a skin graft for this particular patient would take longer than necessary because his high BMI demands that he would need a larger skin graft than usual. Finally, the patient would need a surgery to repair the hernia caused by exposing his abdominal cavity for so long. We both silently sighed to ourselves about the difficult road to recovery ahead of this patient and then I thanked Dr. Hirvela for her explanation.
After the attending left, I stayed behind to watch Aaron and Victor suture the IV bag to the patient and help the anesthesiologist, circulator, and surgery tech transport the patient out of the OR to ICU. Once they left, I ate a snack in the staff room and walked around the OR to get a sense for the floor. Sadly, I had to end my day there since I needed to study for my midterm the next day, but I felt very satisfied with my experience with Dr. Hirvela’s team in the ICU and OR. Reflecting on my first OREX experience as I walked to my car, I was surprised to notice how relaxed surgeons were in comparison to ED doctors, even though surgeons do not necessarily have a fixed schedule like ED doctors. This observation made me think about Dr. Harken’s speech at UCBX AMSA’s end of the year event where he explained that surgeons can have families and lives outside of the OR. He’s most likely right, which means that a surgeon can have it all- a balance between an exciting career and a fulfilling family life.