October 21, 2014
Written by Xiteng Yan (class of 2014-2015)
Dr. Harken’s lecture started at 7AM this Tuesday. Due to the earlier-than-expected start time; I was waiting in the lobby of the surgical department for a good ten minutes before I realized that the day had started. As for the lecture, I had a difficult time following the specifics what he was saying due to the complexity of the subject. However, I gathered that the general topic was about the different types of saline fluids one should give to patients in order to maximize their recovery rate. Dr. Harken ended the lecture by emphasizing how an alternative treatment that supposedly led to an improved response actually did not produce an improvement as dramatic as anticipated. (At that point, I made a mental note to take out my handbook and write notes for my next OREX lecture) After Dr. Harken dismissed the residents, I went up to him to introduce myself. He was friendly and approachable and ready to assign me a resident before realizing that they had all left the room. I quickly told him that I had gone up to the OR as an ED volunteer, and that I didn’t need a guide. Thus, I ventured to the 5th floor on my own, which seemed like a mistake when I realized that, despite having gone up to the OR floor, I have never actually ventured beyond the reception desk. Thankfully, an OR nurse named Wendy noticed my confusion and gave me a brief tour of the area, including the changing rooms, the scrubs-vending machine and the location of the different operating rooms. My luck continued when I bumped into Dr. Harken just as he was about to head into surgery; he invited me to come with him, and I happily did.
The patient in question was a Hispanic man in what appeared to be his mid-thirties. Dr. Harken informed me that his heart rhythm was irregular and that they would be placing an ICD, or implantable cardioverter-defibrillator, into his upper left chest. Assisting Dr. Harken was Dr. Markham, a resident, and J. Weber, the vendor from Boston Scientific, the maker of the ICD. Dr. Harken began by heavily wiping the upper left chest with a dark brown fluid, which I gathered to be an iodine solution. He explained to me that this procedure was necessary to circumvent infection. After a few minutes of setup, Dr. Markham and Dr. Harken began the operation, with Dr. Markham making the first cut. As I stood on the sidelines, watching them cut, Mr. Weber introduced himself to me and explained the basics of the procedure. Basically, the goal is to first slip a sheath into the patient’s subclavian vein from their upper left chest. (The doctor has to be careful to not puncture the lung at this point in the operation) Once the sheath enters this vein, it will be directed down the superior vena cava and into the right atrium and ventricle. Once the sheath is in position, a wire is placed through and effectively replaces it [the sheath]. Finally, the ICD is attached to the wire and secured in the upper left chest, where it is then sealed. I was very glad that Mr. Weber was there to answer my questions and guide me along because, at that point, I was too nervous to ask Dr. Harken and Dr. Markham directly. (Also, the two of them were heavily focused, and I didn’t want to be a burden.)
Once the incision was completed, Dr. Harken took over to insert the wire into the patient’s subclavian vein. Here is where things took an unexpected route. One of the first attempts at inserting the wire resulted in a sudden burst of blood. I was told that this signaled a mistake: the burst is due to the highly pressurized blood of an artery. The target, a vein, is at a much lower pressure and would produce a quiet flow of darkened blood instead. There was, however, some difficulty in finding the vein. X-rays were taken to help determine its location, but the images did not prove helpful in determining its location. Eventually, Dr. Harken asked for a venography. A nurse injected a contrast dye into the patient via IV, and additional X-rays were taken to visualize the dye, and thus, the vein’s location. Even after these procedures, however, it took until the second or third attempt before the subclavian vein was noticeably visualized on the screen. Once the vein was visualized, however, Dr. Markham was able to insert the sheath into the vein and direct it into the heart. From there, the procedure became much quicker. Under the direction of Dr. Harken and Mr. Weber, Dr. Markham was able to direct the sheath through the superior vena cava and right atrium and into the right ventricle. (All of this was visualized and confirmed via X-rays) Once the sheath was in the correct position, the wire was slipped in. The ICD was secured a few minutes later and checked by Mr. Weber to ensure that it was functioning properly. The operation itself ended at around 10:40AM. Dr. Markham told me later on that this procedure is typically very brief – only half hour from start to end; what had prolonged the operation into an hours long process that morning was the difficulty in finding the right vein. After the operation, I shadowed Dr. Markham as she filled out the remaining paperwork and contacted the patient’s family regarding the surgery. Everything was completed by 11AM, and I left the 5th floor shortly afterwards. All in all, the experience was very educational and exciting, although I admit that it took a good deal of effort to pick up the medical terminology and figure out what was happening – even with the help of Mr. Weber, Dr. Harken and Dr. Markham. Hopefully, as I gain more experience with surgeries, I will be able to pick up the material with more ease.