Written by Cicily Cooper (class of 2016-2017)
It was so nice to be back in the OR after over a month of not being there.
I made the mistake of forgetting that it was Thursday and showing up at Highland at 6:50 to find the room totally empty. I asked a friendly person and she apologetically informed me that Grand rounds were at Kaiser today at which point I kicked myself for knowing and forgetting. After too much oscillating, I decided that I’d better go to Grand Rounds and be a few minutes late than wait around Highland for 2 hours! And I did, and it was GREAT!!!
The person talking was the head of surgery at SFGH. Her talk was on surgery and disasters and she had a ton of experience and so much to say. I am particularly interested in disaster relief work and found her input on triage and disaster preparedness very intriguing. There was also food and coffee so by the time I headed back to Highland at 8:30 I was in a really good mood in spite of my self-caused morning stress.
When I got to the floor it seemed that most of the surgeries had started already and so I walked into a room that looked like it was just getting going and met Dr Yamaguchi, a urology surgeon, who was very friendly and helpful. She showed me the CT of the patient who had had multiple washouts and debridements of Fournier’s gangrene which had caused necrotizing fasciitis. At the point where he was in front of us, he had a wound from his anus all the way up to near his umbilicus, making a B-line through his scrotum. One of his testicles was completely exposed and enlarged. The wound was about 4-5 inches deep. The plan for this day in the OR was to give it another washout and to partially close it.
The patient had presented with some pain and swelling but it turned out that he had uncontrolled diabetes which was why the gangrene had gotten so completely out of control. He had been completely septic and had he not been operated on would have died very soon, according to Dr. Yamaguchi.
In other surgeries I had been in there had been way more residents and medical students and I felt more worried asking too many questions, but in this OR there was only the patient, the anesthesiologist, her student, the tech, Steve and Tim the OR nurses, Dr Yamaguchi and myself. I had a pretty great view and asked her many questions which she answered.
First she did a saline washout of the wound to get rid of the dead tissue and expose the live pink tissue underneath. Next she very slowly and tediously began to close the huge gaping wound that had remained. She explained that she wanted to avoid creating any pockets where infection could get trapped. We discussed the different types of sutures and when they get used. She explained to me that the braided ones are worse for infection but she had to use some of the braided ones that dissolve inside for the areas that would be impossible to access once healing occurred. The nylon ones for the surface need to be removed.
After about two hours she packed the remainder of his wound with soaked betadyne kerlex. She wrapped his single exposed testicle in saline gauze that did not have betadyne on it to protect the testicle from the betadyne and keep it moist.
After this I watched Dr Yamaguchi’s afternoon procedure which was a cysto-left ureteroscopy, laser lithotripsy and possible ureteral stent placement. In other words, laser blast removal of a kidney stone through the urethra.
For this procedure we all had to wear “leads”, the x-ray proof dresses because x-ray was in the room with live imaging. We also had to wear laser glasses to protect our eyes from the laser that was used. Needless to say, I felt pretty darn cool.
The procedure was super interesting and everything was visible real-time on the screen above her head. I got to watch the camera go into the kidney and search around for the stone and then we saw it on the screen. It looked kind of like icicles or crystals in a cave. It took some time but Dr Yamaguchi blasted the crystals and then had to keep blasting them. She also sent in this tiny tiny wire with an even tinier grabber on the end to grab a hold of the little pieces of stone and pull them out. It reminded me of the game in an arcade where you try grab the stuffed animals with the claw that is really hard to control. Anyway, the stone was blasted and removed. Dr Yamaguchi mentioned to me that one complication of this procedure is that bacteria are stuck in the calcification and then the patient becomes septic after because of the bacteria being blasted all over the kidney. She also told me that these patients usually don’t present with pain because the stones only cause pain if they are restricting the ureter and not just because they exist, which is why people can have massive calcifications before they feel anything.
So, another wonderful day in the OR! I’m going to try to get to Grand Rounds again because that was so great, and I saw Terry there!