November 10, 2015
Written by Andrew Hartman (class 0f 2015-2016)
As I was one of the students who missed the orientation, I was very grateful for all of the excellent write-ups from those who had already gone before to help me know what to expect. That was super helpful, and I had much less anxiety, and it helped me to have a really great first day!
I arrived in the OA-2 conference room at 0645 and took a seat along the back wall. The residents and medical students started arriving just before 0700, and Dr. Harken walked in wearing a suit right at the stroke of 0700. He had some NG tubes in his hand and joked about how, when he was in medical school, students would have to intubate each other while conscious. He then went on to lecture about lung function and how it is particularly relevant to surgeons.
Dr. Harken explained that the Department of Surgery was trying to establish a “surgical hub,” which was a group to handle pre-op logistics that the surgeons didn’t have the time to deal with. He further explained that, three years ago, approximately 44% of procedures were cancelled due to administrative reasons after the patient was already in the operating theatre, and this surgical hub was intended to mitigate that. One of the things the surgical hub would be responsible for would be addressing the four things that an anesthesiologist would want to know about a patient:
- Are the patient’s lungs okay?
- Is the patient’s heart okay?
- Is the patient particularly likely to bleed (for non-surgical reasons)?
- Is the patient particularly susceptible to infection?
Dr. Harken then went on to lecture about lung function. There was lots of interesting physiology and pathophysiology, which I won’t bore you with here, but there were some interesting take-aways for surgery.
- If a patient is taking beta blockers for their heart, it increases their work of breathing.
- Hypoxia leads to an increase in anxiety but not a change in minute ventilation. If a patient is unusually anxious post-op, that patient should always be considered hypoxic until proven otherwise.
- Many physicians and clinical staff think that extubating a patient will reduce their work of breathing (assuming they are off the ventilator and breathing on their own). In fact, this is not so, and the effort of breathing when intubated is about the same as extubated.
We then broke up the lecture. I rushed to introduce myself to Dr. Harken. He was very welcoming and gracious, as others have mentioned, and introduced me to Jessica Williams, a fourth-year resident who is working with him this month. He asked her to show me around and get me settled, which was a huge help. We went upstairs and Jessica showed me where to get the vendor card and where the men’s locker room was. I got my scrubs and got changed and met her outside the board. Her first surgery of the day was to install a porta-cath and suggested that I start with that.
Catheter port installation in 51 y.o. female.
When we arrived in the operating theatre, the patient was already on the table and sedated. I was introduced to the rest of the operating room staff, notably Lindsay who was the circulating RN that day. Lindsay and Jessica taped the patient’s breast out of the way and put a rolled blanket under her so that the neck was curved, making access to the veins easier. Jessica then used a portable ultrasound machine to visualize the vein and marked it with a pen. After that they scrubbed up and prepared the sterile field over the patient. The plan was to use x-ray to confirm placement of the catheter, so we were all wearing lead aprons and neck coverings.
Dr. Harken arrived at 0816 and conducted the time out, where they confirmed the patient’s identification and went over what the surgery was to entail. Jessica then made a small incision, cauterizing the skin with the cauterizing tool, over the vein so that she could pull the skin back and stuck her needle into the vein, sliding a wire all the way down into the patient’s heart. They then took an x-ray to confirm that the wire was in the right place. For my benefit, Dr. Harken asked them to take a continuous x-ray for a few seconds so that we could see the heart beating and the lungs moving with her breaths. That was pretty cool.
Next, Jessica made a larger incision in the patient’s chest, cauterizing the skin as she went, to serve as the pocket for the port itself. She slipped the port under the skin and threaded the catheter under the skin up to where the first incision was. Like others have commented, I was surprised at how rough it seemed. The catheter was threaded along the wire all the way down into the heart, and the wire was removed. The catheter was now entirely under the patient’s skin with nothing showing. Another x-ray was taken to confirm correct placement and that there were no kinks.
Lots of local anesthetic was injected at both incisional sites. Jessica explained that it was novacaine with a little epinephrine in it. The epi is a vasoconstrictor, which minimized the weeping and oozing at the injection site, making it easier for her to close it cleanly and reducing bleeding. Dr. Harken then closed the neck incision while Jessica closed the port incision. Both were beautiful – you could barely see the line. Bandages were placed over both sites and the procedure was over at 0842. The patient was roused and seemed calm but a little groggy. Jessica’s next surgery wasn’t for a while, so she took me over to another operating room where an interesting surgery was about to begin and introduced me to the staff there.
The second surgery was for a 47 yo female who was having a cholecystomy (gall bladder removal) and a partial hepatoectomy (removing part of her liver). Apparently, she had cancer of the gall bladder that had spread to her liver, so some of that needed to be removed as well. Even though that surgery was scheduled for 0800 also, when I got there at 0850 they were still prepping the patient. She was sedated, but as this was very major surgery with lots of bleeding expected, they had established several access points, including an arterial line. They had also tried to give the patient an epidural, but that had not been successful.
The surgery was to be done by Dr. Victorino (attending physician) and Dr. Panmer (chief resident). After they finished prepping the patient, they scrubbed up and established their sterile field. Dr. Panmer then made a HUGE incision (about 30 cm) across her belly above her liver, and used the cauterizing tool to burn through the belly fat (the patient was fairly overweight, so there was a lot of that to get through). They then placed a frame over the incisional site. It looked like a giant erector set with a hoop to which they attached the retractors and pulled the skin, fat, and layers of muscle back to expose the peritoneal cavity. After moving around at the foot of the bed trying to stay out of everyone’s way (and being told by the scrub tech to NEVER turn my back to a sterile field!), the anesthesiologist kindly brought me up to the patient’s head, where she put a stool so I could stand out of the way and watch the procedure over the sterile drape. I was able to see the patient’s liver right in front of me. It was pale pink, not the deep red I normally associate with liver in the supermarket. The surgeons worked for a couple of hours to excise the cancer and remove the gall bladder. They were cauterizing up the blood vessels and bile ducts that they were severing. I couldn’t see very well, but I gathered that not everything was exactly where they thought it should be. At one point, Dr. Victorino asked Dr. Panmer, “What’s your plan?” Dr. Panmer responded, “Well, this doesn’t look anything like the Youtube video I watched.” Everyone got a good chuckle. Unfortunately, I had to leave at that point. My afternoon class had been moved up to a noon start and I wasn’t able to stay as many hours as I had hoped. However, I felt very fortunate that I got to observe two very interesting and exciting procedures being performed and I’m looking forward to coming back in December on a day when I have no conflicts and can stay the entire day!