Written by Arisa Mototake (class of 2015-2016)
I got to OA-2 at 6:50 and there were already 5 residents seated at the table. I politely said good morning but all I got in return was a stare. I sat at the table but felt very out of place. I now understood the urge to sit behind the wall. Dr. Harken walks in and starts his mini-lecture. Today he spoke about acute blood loss in trauma/surgery. He then posed a question, is this blood loss the same as anemia found in cancer, chemotherapy, critical illnesses or other chronic diseases. The residents remained silent. He then poses another question, “Does the number of hemoglobin make a difference or how you got there?” Dr. Harken then answers “We simply do not know”. He then continues to go through different experiments and statistical data and explains that many different patients respond better on the SF-36 when they have higher hemoglobin counts. SF-36 is a group of 36 questions to assess how happy/healthy you are. To wrap things up the goal of this lecture was to press that the goal of a physician was to make the patient feel better.
He quickly wrapped up lecture and I hurried over to him as he was about to leave. I introduced myself to him and he happily introduced me to Dr. Kara Rothenburg, a second year resident.
She looked a bit hesitant at first and told me that she had elsewhere to go afterwards. She quickly explained to me which OR she would be in and told me to meet her there. First time in the OR and now I had to find my way without sticking out like a sore thumb. I asked a cleaning lady where the front office was to get the vendor card for the futuristic scrub dispensing machine. I finally got to the office and asked for the vendor card. “Who are you?” the woman asked coldly. I quickly explained and she told me I had to leave a collateral for the card. Boy, was she intimidating. I quickly changed into my scrubs and headed on over to OR4. (After asking someone of course; I wasn’t going to risk becoming lost on the first day of my OREX)
The first procedure being done was an ICD placement for a 57 year old male suffering from Atrial Fibrillation and CHF (Congestive Heart Failure) with an ejection fraction (EF) less than 20%. EF is the percentage of blood that is pumped out from the heart with one contraction and is one of of the clinical indications of heart failure. A healthy individual will have an EF over 55 percent. This was a great surgery to start my OREX experience as I volunteer in the healthy hearts clinic with CHF patients. Many of our patients have pacemakers so being able to watch one being installed was incredible; I felt my volunteer experiences coming to a whole circle. I walked in and the patient was getting prepped for anesthesia. As fluoroscopy was going to be used I was instructed to wear a lead apron for protection. Dr. Harken walks in and explained the procedure to Kara. They were to insert a catheter through the superior vena cava and insert an electrode into the right ventricle to shock and pace. Kara showed me how to scrub in just in case I ever needed to but I reassured her I was only there to observe. Afterwards we re-entered the OR and the nurse taught me how to assist in gowning. At 8:29AM the patient was completely ready for the procedure and the first incision was made. Kara started cutting away and inserted her fingers to clear the connective tissue. I later saw that this was a pocket for the pacemaker. Kara then continued and inserted a needle below the clavicle for catheter insertion. This was rather a difficult task as she kept hitting the bone and was unable to get into the SVC. It took her many attempts but she was able to get it in successfully after putting in some contrast dye and visualizing it via fluoroscopy. The next couple steps for getting the electrode in was a tad confusing but involved multiple tubings and some pushing and pulling (excuse my crude explanation). But the electrode was placed and a technician was present to check on the signal. The numbers from the signal were stable, and the electrode was fastened and tightened and hooked up to the pacemaker. It was then tucked into the pocket made previously and sutured shut. After the surgery, Kara needed to go to the ICU and so she introduced me to a different resident, Dr. Francisca Maertens.
The next procedure being done was an arteriovenous fistula. This procedure is normally done for patients with end stage renal disease to make an easier access point for dialysis. The procedure first starts with searching for the venous target. It normally is done on the wrist but this time Francisca and Dr. Harken decided to use the area right above the elbow as the vein was easier to find there. As the incision was made and the target was found, the vein was surrounded by large amounts of fat droplets. Francisca isolated the vein and tied it to cut it off. It was then colored with a marking pen to indicate and prevent twisting. She also closed off and removed smaller veins that branched from the larger vein and cauterized them to prevent excessive bleeding.
Once the vein was isolated they flushed it out with a heparin/saline solution (weak heparin). Since the inside of the vein is very thrombogenic, it must be coated with weak heparin to counter these effects to prevent blood clots. There was another incision made medial to the first incision to find the arterial target. After isolating the artery and making a small incision on the artery the vein was looped under the skin to act like a bridge onto the arterial side. Francisca quickly sewed the vein into the artery. There was a discernible pulse within the vein and since veins do not normally hold pulses, this signified that the surgery had been completed successfully.
The turnover time for each surgery seemed to be 20 minutes for the same OR room so I decided to use this time to quickly eat my lunch and went back to OR4 for the next scheduled surgery.
This next procedure was a port-a-cath. It was a 54 year old male with metastatic rectal cancer. Once again this procedure required fluoroscopy and so wearing a lead apron was required. Kara came back to the OR and they (Kara and Dr. Harken) used an ultrasound to search for the carotid artery and jugular vein. This patient was not fully knocked out from the anesthesia, as they used a different form compared to the other cases I saw that day. The anesthesiologist nicely explained that they were using Ketamine and Propofol which induces a dissociative state. Initially it was a little difficult to see but they were successfully able to get the catheter in the vein. The anesthesiologist kindly allowed me to stand in her area where I propped up two stools on top of each other to be able to see more clearly.
Francisca then injected some lidocaine to where she was making an incision, right below the right clavicle. She then continued to insert a rod connected to a white tube. A small device was inserted where the incision was made (below clavicle). They removed the thin, long metallic catheter and inserted a valve like device simultaneously and inserted a tube into the valve. The procedure was a little confusing as I did not understand what was occurring or what it was for. I later asked Dr. Harken and he explained to me that the purple device being put in was a port for chemotherapy patients as the arteries starts to deteriorate when being used for chemo for so long. The white tube connected to the device goes straight into the right atrium and allows the drugs to flow directly into the heart.
I was so grateful for Dr. Harken allowing me to see so much during surgery. I feel like this opportunity was very rare and everyone on the surgery team in OR4 were all so nice, my first day of OREX was truly an incredible one. I finished my day at 5pm totaling to an 8 hour day and boy was I pooped. I thanked everyone for allowing me to observe their work and I happily went home. If you read all of my rambling, thank you! and yay to a great first day in OREX (: I cannot wait for my next day!
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