October 29, 2015
Written by Liana Fong (class of 2015-2016)
Today was my first day of OREX. I decided not to go to Grand Rounds this morning so I arrived at Highland Hospital around 11:00am. I was one of the individuals who did not go to the OREX orientation so today was definitely my trial-and-error day. Fortunately, the doctors, nurses, and scrub techs were very nice and helpful when I had questions throughout my day. I walked off the K5 elevators, went to the OR front desk, and got the vender card to get scrubs. Upon entering the women’s locker room, I saw the amazing, massive scrub-dispensing machine. I had never seen one before. The other hospitals I have been in as a nursing student had OR scrubs stacked on shelves. I guess that machine isn’t really supposed to be a highlight but I was intrigued that such a thing existed.
When arriving to the OR board dressed, I’ll admit I had a lost duckling kind of moment. I understood OREX participants are to look at the OR board, pick a surgery to observe, and basically go find it but I didn’t know which one to pick and who to tell, if anyone, which I wanted to see. I knew I wanted a surgery that hadn’t started yet because I didn’t want my first observation to be me entering a surgery midway. However the OR board didn’t have times listed so I had no idea what was happening when. Since I arrived around 11:00 and the OR had be up and running since ~08:30, surgeries were already in session. I asked Julie from the front desk which one I could observe and she then asked me which one I wanted to. I said I’d be okay with any surgery that hadn’t started yet so she told me to go watch OR 7. I walked over to OR 7 to find the staff cleaning the room for the upcoming surgery so I went back to the OR board to wait. There, I asked one of the doctors who wasn’t rushing anywhere how to read the board and get an idea of which surgery is occurring.
A few minutes later, I went into the pre-op area to see the patient of OR 7. I introduced myself and got her, the surgeon’s, and the anesthesiologist’s permissions to observe. The patient was a 46-year-old female here for the excision of a lipoma on her forehead and had no comorbidities. The surgeon performing the procedure was Ben (Dr. Shimel but he introduced himself to me as Ben) and the anesthesiologist was Dr. O. Dr. Allen was another one of the surgeons on this case and his role was to guide Ben through the surgery. Dr. O and Bang, one of the OR nurses, wheeled the patient into OR 7 to prep. The patient was given IV acetaminophen for pain and propofol (general anesthetic) to put her to sleep before intubation. Dr. O prefers administering oxygen through a tube rather than a facemask during surgeries in general because of it being a more closed system. What puzzled me was why another nurse switched out with Bang and a CRNA switched out with Dr. O. Throughout the surgeries I saw today, the nurses and CRNA and anesthesiologist would swap multiple times and I didn’t know why. Note to self to ask the next time I go in for OREX. When the surgery started, I definitely had a hard time seeing since it was being done on a very small area of the patient’s forehead and everyone participating in the surgery was well over a foot taller than me. I carefully navigated to the other side of the room for a hopefully better view. The scrub tech Joe told me it was okay to come closer and use a stool almost next to Dr. Allen. I was worried I was too close but the other doctors told me I was fine. The view from there was exponentially better but I was still too short to see into the incision. What I learned was the initial incision through the skin was done horizontally and then the tissues fibers that ran vertically were carefully separated (rather than being cut through). The cauterizing tool was used with tiny strokes to minimize bleeding and detach the lipoma from the site. When suturing the site closed, I learned that it is intended for the wound edges to slightly bulge with the sutures, as opposed to being exactly approximated and flat, because the skin will contract/shorten as the edges heal. Ben and Dr. Allen were also not worried about the slight concave characteristic of the incision site because fluid will eventually fill in the space where the lipoma used to be. The overall procedure took about 1.5 hours. The patient was wheeled to the PACU and report was handed off to the next nurse.
Since I was not following a particular resident, I hung around Ben until he left to grab lunch before his next case. I then found scrub tech Joe to see when OR 7’s next case was but he told me to go watch Dr. Krosin’s surgery because it was probably among the more awesome ones of the afternoon. I had seen it on the board earlier but didn’t want to enter since it had already started. I was reassured it’d be okay so Joe brought me to OR 5. Dr. Krosin and his team had been working on this case since about 10:00. It was a middle-aged male who was hit by a car while riding his motorcycle and then got his leg run over by another car. He was getting a ORIF of his L calcaneus. When I entered, Dr. Krosin and his physician assistant Megan were in the process of closing up the wounds. It seemed like they were almost finished but closing up took about 1.5-2 hours. There were multiple lacerations on the left leg that required suturing. Dr. Krosin spent a lot of the time closing up the heel; it was cut large and deep enough for him to fit in at least three fingers, and it was actively bleeding. When suturing the heel, Dr. Krosin sutured these cotton ball-looking pads to the heel to apply constant diffused pressure while the wound heals. Because of the heel’s structure and kind of tissue it contains, there would have been a risk of infection in the space inside the wound if only the wound’s edges were closed. Vancomycin powder was added inside the heel before closure as well to reduce the risk of infection. A Jackson-Pratt (JP) drain was added with the tube extending from the drain to deep inside the heel. JP drains look like plastic grenades and are meant to remove fluid building up in the wound. They are compressed to create a vacuum to suck out the fluid. Having fluid in the wound interferes with healing and may result in an infection. A Wound V.A.C. was then added for the lacerations on the leg. A Wound V.A.C. is a negative pressure wound treatment where suction is applied like a vacuum to the wound sites to enhance healing. Black foam is applied to the wounds and sealed completely by transparent tape. A hole is cut in the tape to apply the attachment to the suction machine. You know it’s working when the black foam is flat when the suction is on.
Today started out bumpy but now I know how to make my subsequent OREX days go by smoother.