Written by Katherine Lam (class of 2017-2018)
I arrived a bit early in the morning, nervous and confused, trying to find to the lecture room. There was a door to which I could not badge in, but luckily one of the doctors had found me wandering around and made the correct assumption that I was apart of OREX. She badged me into the hallway and lead me to the room. I was the second to arrive, but med students and residents quickly arrived and took their seats at the table.
The case study for that day was about research regarding the “step up approach” for necrotizing pancreatitis, or pancreatitis where pancreatic tissue starts dying. They discussed why it was worth studying (because the traditional treatment for necrotizing pancreatitis had high mortality/morbidity), and how the results of the intervention. They also discussed some background of the disease: its etiology was alcohol or gallstones; the gold standard to diagnosis was FNA culture; initial orders for this diagnosis were fluids, IV, foley, and NPO; CT scans of the body showed enlarged pancreas. It was all very interesting as I had never heard of necrotizing pancreatitis.
I moved to the OR floor, again feeling a little lost. One of the residents was very nice to show me where I could find the vender card and how to use it to retrieve scrubs. I also met nurse Julie who sensed my obvious inexperience and showed me where to find the necessary gear and rooms.
The first procedure I had the chance to observe was a Port-A-Cath placement. I took my place at the side of the room, but I ended up moving to the other side as large machines for X-ray and imaging monitors were maneuvered into the room. The nurses gave me a lead vest to wear during the procedure. The patient came in, as well as anesthesiology who explained that he was giving her some medication to help her relax. She quickly fell asleep from the sedative. The nurses proceeded to tie down her body and tuck both arms into her sides to prevent falling. She was given oxygen through a mask, but ended up being intubated. An ultrasound machine was used to view the neck vessels for any signs of clots or intrusions. They read out patient info, and the procedure she was here for, and finally started the procedure at around 9:00 AM. The nurses and the surgeons were very fluid in working as a team, to my surprise. They began with a small incision in the chest area and made a “pocket” under the skin for the port. They used a long spear-like metal instrument to guide the catheter under skin and clavicle to enter the vein. X-ray imaging was used to check positioning of the catheter in the left ventricle of the heart. They used heparin to “lock” the catheter. After port placement, they closed and stitched the incision. The whole procedure took around an hour to complete. The patient was decannulated and woke up in a panic. As the anesthesiologist was trying to calm her, they moved her out of the room so they could begin cleaning.
I was again confused where I should go next, but the nurse told me I should stay for the next procedure, which was after lunch. It turns out the next procedure was an ORIF, or Open Reduction & Internal Fixation, of the left zygomatic and tooth extraction. After preparing the room, the patient was moved in and given sedative and oxygen. He was also given some nasal spray (I was not able to catch what it was or what it was for). His eyes were taped shut with a sheet of plastic dressing (tegaderm) and his face was cleansed with iodine multiple times. His mouth was stuffed with gauze and cleansed with mouthwash and toothbrush. They marked the artery at the temple and injected numbing medication. A small incision was cut at the mark while blood was suctioned away with a tube. When a large enough hole was made in the skin, they stuck a long flat tool into the hole, under what I presume to be the zygomatic bone, and pushed it outwards from the head (which is when I started cringing). Clear liquid started dribbling out of the hole and suctioned with the tube. When finished draining, they stitched the incision. They continued to the next operation to extract teeth. They injected numbing medication into the gums and started yanking out teeth. It was noted that his blood pressure was rising very quickly which is a sign of the patient being in pain. They quickly finished up and stitched the gums. The entire procedure lasted around 1.5 hours.
The last procedure I unfortunately did not get to see from the beginning. The procedure was for a diverticulitis laparoscopic sigmoidectomy.The lights were off in the room with two monitors and multiple people surrounding the patient. On the monitors I could see what appeared to be the guts (intestines and surrounding organs) of the patient. The nurse explained that the patient’s abdomen area was currently inflated with CO2, and had a couple “ports” or holes to ensure that the abdomen was “air tight”: one large “gel port” for hand access, one port for the camera, and one for the cutting(?) instruments. It was a bit hard to tell exactly what was going on on the screen, but I could see an organ getting cut/separated from another. After the procedure the nurse and surgeon had explained that the patient had diverticulitis, or inflamed small pouches, in the sigmoid of the colon, and it was stuck to the bladder where a fistula was formed so he had bits of stool and blood coming out with his urine. The procedure was to take out the sigmoid segment and attach remaining ends of the colon together with a stapling tool. After the procedure was completed, they removed the tools and stitched up the holes in the abdomen. I was able to see the sigmoid that was just removed, and the surgeon cut it open to point out the characteristic diverticula. This procedure was definitely the most interesting and educational experience for that day. I was very grateful that the doctors, nurses and staff were all very friendly and open to OREX students, and I can easily see that they encourage an environment of learning and education!
Thanks for the opportunity!