Category Archives: AV fistula
Written by Vickie Nguyen (class of 2014-2015)
I had a FANTASTIC OREX day. I mean, it was phenomenal, spectacular, STUPENDOUS, simply amazing. Really though, I don’t think any word in the english dictionary could sum up exactly how I felt about my day. (when is an OREX day not great? I mean come on..)
To start off, during morning lecture, a resident invited me to come and sit next to him. I’m feeling a lot more comfortable with the residents now, and this kind gesture sent warm and fuzzy feelings right to my heart! In the middle of lecture, Dr. Harken asked about Thallium, what it was used for and why. The same resident who invited me over, answered the question with some hesitation. Dr. Harken said he was correct. Almost immediately, I see the resident fist pump under the table and hiss out a “yessssss.” He was clearly pleased with himself. This moment was definitely one for the books, especially as a pre-medical student, I look up to medical students and residents with so much respect and hold them at such high regards. Deep down, I fangirl when I’m in their presence, and sometimes I forget they’re human too. I loved that I could relate to this resident in that answering difficult questions correctly gives us that confidence boost we need to get on with our day, and why not fist pump while we’re at it?!
Today, Dr. Harken took me under his wing, again, and brought me into an OR with Dr. Maggie Brooks. I watched Dr. Brooks perform a portacath insertion surgery as well as an AV fistula, with Dr. Harken as her attending.
I’ve seen these surgeries once before, and a part of me was disappointed. However, I remembered what Lucy said about re-watching surgeries, and how they’re all different and many more new things could be learned. So, I stuck with it and quickly changed my attitude to a more positive and open one.
The patient was a spanish-speaking female. What was different about this surgery was that she was awake upon entering the OR, and everyone in the room made conversation with her and put their best foot forward in trying to make her feel at ease. Language was a slight barrier, but Dr. Brooks as well as the anesthesiologist were able to speak some spanish with her. It was a different change of pace for me, because I’ve never seen a physician-patient interaction inside the OR before.
Once the patient was put under anesthesia, Dr. Harken used an ultrasound to observe her internal jugular vein as well as the carotid artery. Dr. Harken asked me to come take a look at two dark circles on the ultrasound screen. He pointed out the jugular vein as well as the carotid artery, the jugular vein was a black circle resting just above another black circle, the carotid. He explained to me how there is a higher pressure in the carotid artery compared to the jugular vein, which is collapsible.
Dr. Brooks performed the surgery and finished within an hour. After checking to see if the portacath insertion was done correctly, I hear Dr. Harken exclaim “BEAUTIFUL!”
It was the first of many to follow!
The surgical technicians in the OR were also different from the one’s I met before. One was named Tim and the other Joe. They were a lot more talkative and a lot less serious than the last few I met. They asked if I was going to stay and watch the AV fistula, and I said of course I would! It was probably one of the best decisions I made. Ever.
I did watch an AV fistula surgery before, this one was so different from the last. Just a re-cap on what this surgery is, it’s done on patients with end stage renal disease. It is meant to surgically create a stronger vein so the patient can undergo dialysis without the vein collapsing from multiple dialysis treatments. To make a stronger vein, the surgeon will connect a vein in the forearm to the radial artery.
In comparison to the first AV fistula, this patient had significantly smaller veins and arteries compared to the last. It was a lot more difficult to find the radial artery. There was a lot of time spent using a “doppler,” a device to help listen to the pulse coming from the radial artery. Both Dr. Brooks and Dr. Harken were getting a bit frustrated after a while, since they knew where the radial artery was, they could feel the pulse with their hands, but the “doppler” wasn’t picking up the pulse.
Eventually, after delving in a little deeper they found the artery and were finally able to create the fistula. I got the best seat in the house, Tim brought over a stepping stool and placed it directly behind Dr. Brooks. I was literally standing inches away from her, and could see right over her shoulder! It was both a scary and exhilarating feeling to be standing so close to a surgeon while they do their work, but if I were to make one wrong move I’d topple over the entire operation! Luckily nothing of the sort happened, I stood very still keeping my hands crossed over my body and observed. Every time Dr. Brooks pulled a stitch through to connect the vein and artery , Dr. Harken bellowed “BEAUTIFUL!”..TWICE he gave Dr. Brooks a heavy tap on the hand she was operating with and said “BEAUTIFUL!”..Startling to watch, since Dr. Brooks is sewing together the tiniest blood pipes with even tinier needles and threads, very delicate! But of course, everything was beautiful and turned out to be very successful. Truly an operating-room-experience.
Dr. Harken removed his gown and gloves, I said thank you to everyone in the room, and he lead me into another OR. The first thing I saw was a patient with only one foot. Later on, Wendy, another surgical technician I met from a previous OR day, informed me of the patient’s story and why she was getting operated on.
The patient was a 17 year old gunshot victim. She was shot to the side of her shin bone, and her foot could not be saved. There was too much nerve damage and no blood circulated to her foot, it had to be amputated. This surgery was performed by Dr. Green, and the goal was to surgically treat the appendage so it would be a better fit for a prosthetic. I watched as Dr. Green attached staples around the appendage, then the attending surgeon explained how they would be using these yellow stretchy strings called “vessel loops” to tie the leg up as if it were a pair of shoe laces. The operation didn’t take all that long, before finishing up, they placed a piece of silver paper on the wound. The attending explained that silver has antimicrobial properties, and I assume that the paper would stay on the wound for a while to aid in healing.
This was the first real non-traditional surgery I encountered, and I noticed a few differences. First, there were a lot of people in this OR. I counted eight people not including myself or the patient. This surgery was a lot less standardized. Unlike a portacath surgery or an AV fistula, there was a lot more contemplation in how to go about this surgery, meaning they actually discussed how they would go about doing the surgery while in the OR. I heard the attending talk about how they will approach this surgery experimentally. Basically figuring out a way to shape the leg using a new tactic, the “shoe-string.” One last major difference was the patient’s age. Most other operations I observed were for middle-aged patient’s. This was a healthy teenager, and if it weren’t for getting shot in the leg, she probably wouldn’t be any where near this hospital.
It was a pretty awesome OREX day for me (did I mention that already). Now that I’ve been in the OR three times, I feel a lot more comfortable in this environment. I’m learning how to appreciate surgery holistically. As Tim described to me earlier, we treat these surgeries with the utmost respect. Imagine if it was us in the OR, or someone near and dear to us. Though some of these surgeries take place every day, more than once a day, it’s still a very fragile and traumatic experience for any person to go through. It takes the right combination of science and humanistic traits to be a part of this beautiful and literally life-changing art we call surgery.