October 30, 2014
Written by Chuck Chan (class of 2014-2015)
My first day in the OR was on a Thursday so I went straight up to the 5th floor. I didn’t have a resident to guide me so I asked a clinical nurse, Patty, if she could help me out with getting scrubs from the vendor. Another nurse named Jose took over to give me a quick tour of the OR. I met the charge nurse, Julie, and she was very acomodating to me. I can’t deny that I was a bit nervous going to the OR without any one person to show me the ropes, but the staff members were incredibly welcoming.
CASE 1 – Skin Graft
I entered the surgery room early and was able to talk to the anesthesiologist Dr. Reddy. He talked to me about the sedation procedure. 2 mg of anxiolytic medication were given to the patient pre-op to relax the patient in anticipation for the surgery. Usually an EKG is done beforehand to note of any heart complications. Dr. Reddy used propofol to sedate the patient intravenously. Next, Dr. Reddy inserted a laryngeal mask airway in the patient to channel oxygen to the patient. Dr. Reddy likes to touch the eyelids of the patient as a technique to see if the patient has been properly sedated.
After sedation, the clinical nurses prepped the patient for surgery. One of the nurses, Tim, talked about using a compression pad for lower extremity procedures to ensure proper blood flow. The patient was getting a skin graft from her left thigh to cover a region in her lower left leg, so the compression pad was placed on her right leg. Dr. Reddy placed an inflatable synthetic sheet called the “bear hugger” to keep the patient warm during the surgery. The left leg was elevated and hung by the toes so that the nurse could soak the leg in iodide solution for sterility. Shortly after, Dr. Shah entered the room.
Dr. Shah is an orthopedic surgeon. He gave me a quick spiel on the orchestration of the OR. His point was that communication and organization were key to great health care. Dr. Shah helped with the final steps of the prep by stapling a glove with iodide in it onto the patient’s foot so that the toes don’t get in the way of the sterility of the procedure. Dr. Shah started by suturing the edges of the wound and cleaning loose matter from the gash. He used a ruler to measure the wound and it was 4.5cm x 2.5cm. He used a tool called the Dermatome to get a skin graft from the flattest side of the left thigh. The physician assistant, Ingrid, used forceps to pull the graft from the Dermatome. The graft was flattened and put through a mesher. The meshing of the skin graft allows for penetration of vascular tissue. Dr. Shah explained it as the process of imbibition in plants which helps the intake of water. The graft was placed over the wound and stapled along the edges. A spongy material was stapled on top and and taped down. Dr. Shah used a vacuum to remove the air from the sponge. Ingrid wrapped the left thigh in gauze followed by ACE wrap for the entire left leg. At this point, I had been in the room for 2 hours but the procedure itself lasted about 1.5 hours.
CASE 2 – Craniotomy
Soon after the first procedure, I got to chat with Glen – the surgical technician for the skin graft I had just observed. He told me that neurosurgeon, Dr. Patel, was half an hour into a craniotomy. Glen brought me through the core doors and asked the circulating nurse if it was alright that I come in to observe the craniotomy. She gave me permission and I was in immediate awe with an exposed cranium 3 feet away from me. I talked to Mike, who worked for an outside vender called BioLabs. He introduced me to Image Guidance, an MRI technology used for a lot of neurosurgeries. Essentially, an MRI of the patient is taken before the procedure and mapped out for the surgeon. This allows for the calibration of the probe used during the surgery. The probe can then be used to scan over the patient’s head and accurately locate the tumor non invasively. Whenever Dr. Patel scanned over the exposed cranium, I could see a small mass embedded in the dura mater on the MRI screen.
Dr. Patel drilled entry holes into the cranium around in a circle. Then he used an L shaped saw that would hook inside the holes and and saw through the holes in a circle. Once a section of the cranium was removed, Dr. Patel used a dural knife to carefully cut through the dura mater and access the tumor. Underneath the dura mater was squid colored mass which Dr. Patel quickly removed using the dural knife and cauterizing forceps. The mass was about half the size of a packet of gum. At this point, the dura mater was lifted and through the clear arachnoid layer I could see the exposed brain. The blood vessels were pulsating and all the superficial blood vessels were intact. Dr. Patel brought four corners of the remaining dura mater together in the center and held them together with sutures. He placed a thin membranous dura substitute on top. Dr. Patel had a physician assistant student drill four flower shaped screw plates into the removed cranium. The piece was placed on top of the dural substitute and twelve screws were put in to hold the removed cranium in place. Dr. Patel proceeded to remove the clips that were holding up the scalp and used a cauterizing tool to clot the blood from the edges of the scalp. The scalp was sutured and stapled and gauze was stapled on top to soak up any other remnant blood. The patient’s hair was washed and the procedure was all done in a matter of 3 hours. I did not get to meet Dr. Patel because I had come in during the middle of the procedure, but I would love to see another procedure of his for my next surgery day.