October 27, 2015
Written by Jennifer Tsai (class of 2015-2016)
What a great first day! I’m so happy to be in this program!
The morning started with Dr. Harkin discussing a theoretical patient coming into the ED, a 55 year old male, complaining of chest pain. The residents were then encouraged to suggest possible diagnoses for this man, and rate the importance of the diagnoses as well as rate “HBIWBIWMI” (How Bad It Would Be If We Missed It”- or a similar acronym). Myocardial infarction, GERD, and other diagnoses were suggested, with different rankings of how bad it would be if they didn’t diagnose the problem. Dr. Harken then passed along various X-Rays, EKGs and results of other tests to narrow down the diagnoses. Ultimately, the lecture was on diagnosing MIs versus Pulmonary Embolisms versus Venous Thromboembolisms and how different studies have shown what treatments reduce the recurrences of PE and VTE in patients. This was a pretty interesting lecture because I had a very vein heavy surgery day.
After the lecture, I introduced myself to Dr. Harkin, who was very welcoming and he paired me up with Dr. Jessica Williams, a fourth year resident. Dr. Williams was a wonderful guide. She took me to the OR,helped me get the scrubs card and showed me how to work the futuristic scrubs machine. I was going to shadow Dr. Williams and Dr. Harkin for their three scheduled surgeries in OR2.
The first surgery was for varicose vein removal. The patient was a 44 year old African American Male, who had multiple varicose veins in his lower left leg that had been causing him pain. Dr. Harken explained that tissue that is stretched causes pain. Distended veins caused pain the same way stretched urethras caused pain. Dr. Williams explained that varicose veins were also removed for cosmetic reasons, but insurance did not cover those surgeries. Dr. Williams and Dr. Harken removed 5 different veins from the patient’s calf. One was very large and wrapped around the back of the leg, this was one was more difficult to remove because of it’s placement. Two small veins that were very close to the surface, near the ankle were also removed. Dr. Williams explained that these shallow varicose veins could eventually cause ulceration as the veins continued to swell and irritate the tissue around them. After all of the veins were removed, the patient’s calf was stitched up with stitches that would dissolve on their own, and the leg was wrapped up with gauze and a stretchy bandage.
The second surgery I was able to observe was also varicose vein removal. This time, Dr. Harken told me I could scrub in! So Dr. Williams showed me how to wash my hands and explained how I could not even rest my arms on my body after my hands were washed, avoid contamination. I was then shown how to dry my hands and suit up in a gown with two sets of gloves, and NOT TOUCH ANYTHING that was not blue! I made a mistake the first time I was gloved and had to be gloved again by the scrub tech. Luckily everyone was very nice and other than some gentle ribbing, I was given a pass.
The second patient was a 59 year old Caucasian Female, who was a former IV drug user, who also had Hepatitis C. I was instructed to watch the CRNA (Certified Registered Nurse Anesthetist) intubate the patient. She administered some anesthesia and a muscle relaxant to help relax the trachea for intubation. She explained that our patient did not have any teeth, and this made it difficult for her to form a seal when administering the oxygen mask. This patient’s problem vein was also on the left leg, but on her thigh. The vein was very long and was marked in ink on her leg. Dr. Williams made an incision in the top of the thigh and after exploring the area, could not find the problem vein, so Dr. Harken suggested she start again from the bottom of the marked vein. She was able to find the problem vein with the second incision, and a long incision was made up the thigh almost to the initial entry point, and the vein was removed successfully. This patient bled a lot more than the first patient, and many blood vessels had to be tied off or “zapped” (cauterized) with an electrified scalpel that Dr. Harken kept calling the Zapper (I just found out it is called a Bovie). The patient was sewn up by both of the doctors and sent to the recovery room.
The final surgery I saw today was an Arteriovenous Fistula (AVF). The patient was a 47 year old African American Male, and the surgery was performed on his left upper arm. The doctors were creating a connection between a vein and an artery (a fistula) for the patient to be able to receive dialysis. He had a previous fistula near his left wrist which apparently no longer worked, so they needed to create a new one. The patient had a funny tattoo on his arm that was kind of rude and it was funny to see Dr. Harken’s reaction to it. This patient was hard to anesthetize and jerked around a lot during his surgery. His hand had to be held down during most of the surgery, and his head kept rolling towards his left arm. At a certain point in the surgery, Dr. Harken exclaimed that he was resting his elbow on the patient’s face! Dr. Williams found a large healthy vein in the inner left arm and tied off one end. It was interesting to see a healthy vein after seeing the twisted and distended varicose veins from my first two surgeries. The vein was stained with ink and flushed with saline solution to stretch it out. There was a hole in the vein and some saline solution started spraying out at Dr. Harken, who quickly clamped the hole and instructed Dr. Williams on how to sew up the tiny hole with three small stitches. A second incision was made in the outer arm, parallel to the first, to locate an artery. Once a healthy artery was found, Dr. Harken traced on the skin where the vein would be brought across to connect with the artery. Dr. Williams used her scissors to cut away connective tissue underneath the skin and was able to pull the loose vein across to the artery. She then made an incision in the artery (which had already been clamped on both sides to prevent bleeding) and very painstakingly grafted the loose end of the vein to the incision in the artery. It was very delicate work with very small stitches. After the graft was complete, they irrigated the vein one more time to find any leaks in the stitches and performed a few final stitches to seal the leaks. At this point Dr. Harken sewed up the venous incision while Dr. Williams sewed up the arterial incision. You could see the fistula pumping arterial blood to the venous side already, it was slightly raised up in the skin.
Below is some information on an AVF that I found from the Davita website on hemodialysis:
Arteriovenous (AV) fistula for hemodialysis
A fistula used for hemodialysis is a direct connection of an artery to a vein. Once the fistula is created it’s a natural part of the body. Once the fistula properly matures, it provides an access with good blood flow that can last for decades. It can take weeks to months before the fistula is ready to be used for hemodialysis.
Fistula—the gold standard access
The National Kidney Foundation (NKF), Centers for Medicare and Medicaid Services (CMS) and Dialysis Patient Citizens (DPC) agree fistulas are the best type of vascular access.
A fistula is the “gold standard” because:
- It has a lower risk of infection
- It has a lower tendency to clot
- It allows for greater blood flow and reduces treatment time
- It stays functional longer than other access types
- It’s usually less expensive to maintain
While the AV fistula is the preferred access, some people are unable to have a fistula. If the vascular system is greatly compromised, a fistula may not be attempted. Some of the drawbacks of fistulas are:
- A bulge at the access site
- Lengthy maturation time or never maturing at all