University of Illinois at Chicago
Unfortunately this program went by too fast and we are approaching our last day. The past few days in Urology we were able to spend it in the OR and presenting to Harp. After our presentation we received good feedback from him and was able to use it to improve our presentation. Throughout our two rotations I was lucky enough to observe many different departments. For example, in Orthopedics we were mostly in clinic and in Urology we were mostly in the OR and SPD. This gave me many opportunities to compare the different environments and departments and learn a lot more about these two specialties. It was also very cool to see the variety of different surgeries especially in Urology and all the different technology they use. I am very happy I had this opportunity and I am sad to see it end.
Our last week in Urology we were able to revisit the Sterile Processing Department to better understand the process of getting the instruments from the OR to SPD back to the OR. The first thing we noticed is the checklist they had attached to each cart displaying which tool and how many are in each tray/cart. We also saw how they have a bright pink sheets on the carts that list all the tools that are missing on that particular cart. Yolanda told us that the operating rooms are informed before the surgery about the missing tools and they can then decide whether or not to use the tray.
We then were paired up with an employee and watched the process of cleaning and organizing the instruments. The instruments first get hand washed and then go through a wash machine to remove all the blood. After, each tray is checked for blood, dirt, cracks, and/or broken instruments. If something is broken it goes into a “needs to be fixed” bin and a company comes once a week to fix them, if something has blood or dirt on it, it will go back through the whole washing process.
Once everything is checked they start to assemble the trays. Every instrument is in their system and they go through the list for that particular tray and check if it is either there or missing. If they have extra instruments they have to go around to see if anyone else is missing them because their system does not have a button for the extras. Juan had each of us go through the process of looking at the number on a tool, finding it in the computer system, checking it, getting the correct quantity, and putting it in the tray. It was interesting to actually be able to do part of the process they do over and over everyday for every instrument.
After everything is in the tray it is locked, tagged, and brought to the sterilization machine. Juan was explaining some things that could potentially go wrong in SPD.
- The lock is white, after it goes through sterilization it turns black
- If the lock is still white when brought to the OR it is not sterilized
- If there is no tag on the tray it is not sterilized
- Single use items come down to SPD but they should have been thrown away after the surgery it was used for
- Instruments are placed in the wrong trays in the OR so SPD has problems finding them because someone else has it in their tray
Overall, being able to spend more time in SPD was very useful and I now understand more about the cleansing process.
The past couple days we were back in the OR and were able to see a variety of surgeries. After our talk with Harp he started to point out when tools were missing so we could realize how frequent and how much of an issue it is. He was explaining to us how the doctors have a preference list for the surgeries they perform so they could assemble the cart with everything they use. One example we saw was a foam mat that was missing from the cart and the surgeon uses that specific mat every time he performs this surgery so a nurse had to go down to the Sterile Processing Department (SPD) to locate one which delayed the patient from moving over to the operating table. I was able to realize more and more throughout the day how this is a huge issue for the OR because it causes so many delays. We were also able to talk to Norman about our observations in SPD and he is going to set up a time where we could go back down to SPD and specifically follow one tray/tool through every process to examine how tools get miss placed.
One interesting thing we learned was how the penile pump works. We were able to talk with the sales representative and she explained how it functions and the main reasons for failure which are infection and/or the silicone ripping exposing the fabric underneath. I am really happy we were finally able to see more of a variety of surgeries this week and I cannot wait to see what our final week has to bring!
Starting week two we finally were able to shadow in the Urology clinic. We saw how they had communication issues, for example, they had three different residents ask the same attendee the same question about the same patient. Harp also explained to us how communication is a huge issue in medicine especially the lack of communication between institutions.
We were then able to show Harp our flow chart we made after the visit with the Sterile Processing Department (SPD) last week explaining all the different needs we found between the OR and SPD. He explained how tiny improvements could dramatically fix some of these needs and he is willing to set us up with a time to present our flow chart to a board that deals with quality improvement. Harp has been amazing and he is doing everything to give us the best experience.
After lunch Nadine (a nurse practitioner) offered to show and explain how the Urodynamic device works. They use this device when every other test is normal and when previous treatment is not working. It checks the bladder to find out why it is acting a certain way. She first explained the Uroflow test, which is done when the patient has a weak stream. To perform this test the patients have to come in with a full bladder which is at least 100 ml so they get accurate results. They have the patient urinate in a portable toilet (which connects to the computer/program via Bluetooth) and that records the flow rate and volume. The next test she explained to us was the Urodynamic test which is when a patient has a function problem or over active bladder. With this test they inject catheters that have sensors into the bladder (measures pressure inside) and rectum (measures pressure outside). Because these catheters have the sensors they do not have a balloon at the end that holds the catheter in place so Nadine has to tape the catheters really good so they do not move. Before the catheter is placed they make sure the bladder is empty. After the catheter is in they sit on the toilet and water is pumped into the bladder through the catheter. The patient then has to inform Nadine when they initially feel the urge, two more times when the urge gets worse, and when the patient cannot hold it any longer. Nadine marks this on the data and then the patient is allowed to urinate. This test measures the pressure in the bladder, pressure in the rectum, the difference between the pressure in the bladder and rectum, and when they leak/urinate. Nadine explained how uncomfortable and tedious this procedure is because the catheters fall out and move easily so she has to stop the test often and untape the catheter, reposition (to make sure the bladder and rectum pressures are the same when the patient coughs to get the correct results), and to tape the catheter back up. Also when the patient urinates it goes around the catheter so it gets on the toilet seat, floor, and catheter. We also noticed how the toilet does not accommodate heavier people because of the handles and Nadine said when they do not fit they have to squat over it.
I am so glad Nadine was able to take time to explain pretty much everything about this device especially since I did not even know it existed. I am excited to learn more from her and the attendees/residents when we go back to clinic.
Day 2 in Urology Harp and Norman had it set up for us to visit the Sterile Processing Department (SPD) where they sterilize all the equipment. We talked to Yolanda who explained some issues they face in this department.
- Their elevator breaks at least once a week so they manually have to push all the used equipment from the OR to SPD which is in the basement
- Not enough room
- They do not have enough shelving so they stack trays on top of one another
- They share space with materials (disposable equipment) when they do not have enough space in the first place
- They are suppose to be on a schedule that coordinates who gets what at certain times but it is never followed
- Only one computer to scan and log all equipment
- Everything is scanned for each process they go through: decontamination –> assembly –> sterilization
- This scanning process allows people in the OR to see where their tools are and how long it will take to finish cleaning
- They had 3 computers for each station but 2 broke a few months ago and they still have not been fixed
- Hours are lost each day because there is only one computer
- It gets so busy in SPD they have to wait in line to scan and some employees do not want to wait so the tray does not get scanned and then no one can find it
We also spoke to Cyndi who is the liaison for SPD and the OR and she said the main problem she sees is that the trays are not correct and if people (in transport) had more education about the tools and surgical departments it would reduce this issue.
The next step after going through SPD is transport and they handle placing the tools in certain trays. We have not been able to visit transport yet but we are hoping to speak to them before our rotation is over so we can see their view and compare their needs with SPD.
The start to the second rotation in Urology was awesome. Harp (one of the 6th year residents) provided us with a lot of information and was willing to coordinate anything to give us the best learning experience.
We started this rotation in the OR and we were able to discuss possible needs with some of the nurses. Here are some issues they frequently run into:
- Communication: switching between computer programs for different tasks
- Communication: physician talking to patient, language, culture, hearing problem
o An anesthesiologist suggested it would be beneficial to have a button device that had simple commands in different languages that they could press to communicate easily with the patient
- Sending wrong tools or missing entire tool sets
Our team also noticed a lot of other inconvenience for the surgeon and/or patient:
- Lifting patient from bed to bed which could potentially injury the doctors especially if the patient is overweight
- They use pillows and towels tapped up to get patient in the right position
- They tapped a patient to the bed so she wouldn’t fall over
- It took them about 30 minutes to position the patient which we thought was a long time but one of the residents said that was normal
- They used a bed with boots to position legs which was similar to the bed I saw in one of the orthopedic surgeries
- One of the residents was telling us how comfy the Da Vinci was to use that he could fall asleep using it
The first day in Urology was very informative and I was really interested seeing the Da Vinci perform a surgery since that was the first time I saw one. I am excited to see how our remaining time will be spent and to learn a lot more about Urology.
Unfortunately, we had our last day in the OR for orthopedics but luckily we were able to see a variety of surgeries that differed from the week before. When we first arrived a sales representative from Stryker had new helmets for the doctors to try. The helmets they use keep air circulating through their suit so the shield does not fog up. The new helmets were designed to weigh less and have added functions like a head light which the doctor seemed to like.
I also observed how patient flow affects the OR similarly to the clinic. Before the first surgery a tech was late which postponed the preparation and delayed the surgery about an hour which pushed everything else back. Factors like this, late patients, contaminated and/or missing tools effects the doctors/patients time schedule.
After the two days we spent in the OR we saw two hip replacements. One was done by an anterior approach and the other posterior. One interesting thing I learned about these cases was the different operating bed they use for the patient. The posterior was done on a normal operating bed but the anterior was done on an operating bed that had two boots to hold the legs in position. These boots allowed them to rotate, push the leg in/out, and change the traction. I thought this was very useful for the surgeons so they could make sure the hip was in place and that it would not dislocate.
Being able to experience the variety of surgeries was an amazing learning experience especially because Dr. Gonzalez would take his time to explain how the tools and prosthesis worked. It was also fascinating to watch doctor interactions during high and low pressure situations. I have learned a lot in this first rotation and I am excited to observe Urology for the remaining three weeks.
As we start our last week for the first rotation I never realized how fast this experience would fly by. I have seen a lot of repetitive diagnoses in clinic but also some really interesting ones. Being able to experience both the UIH clinic and IBJI clinic was an awesome opportunity since we got to compare the difference in patient flow and resources which are a main issue at the UIH clinic. Also, being at IBJI gave us a chance to learn more about certain procedures and anatomy from Dr. Gonzalez since the patient amount was significantly lower. Our last day at IBJI there was an increase in patient volume from the previous week but Dr. Gonzalez was still able to inform us briefly about the different surgeries we would see this week. So far I have enjoyed the IBJI clinic more because of the fact that Dr. Gonzalez is able to sit down with us and discuss the different procedures and teach us about injuries that can happen to a hand.
Today we were back at the UIH clinic. I learned and observed a few new things and also saw problems we initially pointed out. Some new things I learned were that residents rotate the pager every couple days instead of having it the entire rotation, they have not tested to see how weather or other circumstances affect the patient no show rate, and they do not have a system to transfer images to other departments (other than running over there) if the images are from outside of UIH. One of the main problems we have noticed the past couple weeks was a big issue today. People who are scheduled to get an x-ray before the visit but do not, which wastes resident/patient time and room space. Our group discussed how this could easily be fix if they made this order prominent on the patient chart so the check-in desk or nurse could easily see that they should get x-rays before they are given a room.
I am excited to observe one more day in surgery especially after Dr. Gonzalez gave us more information about the procedures. We are lucky enough to get the chance to see a variety of operations that pertain to different parts of the body.
Wednesday we observed Dr. Gonzalez in a completely different atmosphere. We were at the UIC clinic and he was seeing three times the amount of patients than the day before. He was working at a completely different pace and had minimal time to talk to us unlike his clinic at the Illinois Bone and Joint Institute. As I followed Kyle, a 5th year resident, he explained how their lack of resources, for example, tablets and/or more computers, made their job inefficient. This problem presented a scenario where there is the technology to improve the situation but the department does not have the funding for it.
Kyle also explained the ICD 10 (diagnoses) and CPT (procedures) coding system. They recently upgraded to the new version and the amount of codes grew immensely. He told us that they do not have a good system to look up these codes and usually have to google or look in the book for them. They also do not receive adequate training for the level of coding they do so it takes extra time they could be using to see more patients.
As Wednesday came to a conclusion, I was able to see many different patients with different diagnoses. I saw a cast removal and someone who got a cast, I was in the room for an x-ray, and saw a patient who got injections into her knees for arthritis. I look forward to observing more in clinic throughout our last week in the first rotation.
Thursday we finally got to experience our first OR day. We saw a cyst removal from a wrist, plates inserted for a tibia fracture, a knee revision, and two knee replacements. I found it interesting that throughout most of the day he had two surgeries scheduled around the same time and would switch between rooms. Also, it was fascinating to see the different atmosphere in each surgery. The cyst removal was relatively quick and the doctors were pretty relaxed. As we moved onto the tibia fracture and knee replacements the amount of tools used were quadrupled (it looked like a hardware store) and I could tell they were more serious procedures. Most of the time during the knee revision and replacements the residents were there holding up the leg into a bent position and Dr. Gonzalez did the majority of the surgery. Quite a few times during each surgery he would stop and explain to us what he was doing and how the knee replacement worked. It was really cool to see all the different components of a knee replacement and how they all fit together like tinker toys. A lot of time was spent guessing and checking with the trials to see what size knee replacement would fit and then they would insert the actual replacement. One problem we did notice was the wire situation. They had wires hanging from IV stands so the anesthesiologist could easily walk underneath them but on the other side of the room they had some on the floor and I saw Dr. Gonzalez get caught in them a few times.
Watching surgery for the first time was amazing. I have always heard how orthopedic surgeons just saw and drill into bones but seeing it in person was so fascinating and I was amazed by the different techniques and tools that were used. Watching surgery and all the technology that is used has been the highlight to this rotation thus far. I cannot wait to experience it again next week and hopefully see other technology being used.
Starting week two everyone got the chance to inform each other about their rotations. It was very fascinating hearing everyone’s experiences and problems they were observing. In particular, it was interesting to hear about my second rotation, urology, and see what their first impressions were.
After our group meeting we were able to attend Dr. Chmell’s clinic. He was very informative and willing to discuss current issues he observes as an orthopedic surgeon. One problem he discussed was material sensitivity, which is how different patients react to different material. For example, a lot of people are sensitive to nickel when it contacts the skin but they do not have a definite test to see how the body would react when it is in vivo.
Another problem he explained to us was how he cannot tell a patient’s progress after surgery until they come in for a follow up. An option he presented to fix this issue was a designated app where the patient could routinely enter in their progress and the information directly gets sent to the attending/resident. Dr. Chmell provided us with a lot of good information and our group is excited to get input from the various orthopedic surgeons about these issues.
On Tuesday we got to experience the Illinois Bone and Joint Institute (IBJI) with Dr. Gonzalez. The pace and experience was the opposite of the clinic at the hospital. We went from watching the attending/residents handle 87 patients the day before to one attending/resident handling 15 patients. One thing we did notice was the difference in their flag system. They had eight flags instead of only two, the top two were the different colors, the next four said “Room #1”, “Room #2”, etc., and the bottom two said injection and x-ray. Since they did not have as many patients the flags were not as useful as they were at the UIC clinic. With more downtime at IBJI Dr. Gonzalez was able to explain a lot more anatomy and functions of the hand. I look forward to learning more from him throughout the week and seeing his surgeries on Thursday.
Concluding our first week in the orthopedic rotation our group has identified many small problems that greatly effect the flow of the clinic. Problems like trying to track down the attending, not knowing if someone is in the cast room, and/or not being able to see if anyone is in the rooms around the corners effect the speed and wait times for the attending and patient.
When we observed Dr. Mejia’s clinic he presented his method of seeing his patients in a timely matter. He places refrigerator number magnets on the door frame to keep order of what patient is next. He also uses the letter magnets ‘b’ and ‘o’ to indicate brace or operation. This system seems to be effective by meeting with the patients in the correct and most effective order. But, as patients leave Dr Mejia has to run around and switch all the numbers to the corresponding door. This seemed like a lot more work than it should be and somewhat confusing if a number was misplaced.
As the first week came to an end I became intrigued by how the residents and attending worked during busy and stressful periods and how they worked around certain inconveniences differently. I have also observed how different doctors tackle different problems and situations. I look forward to examining how Dr. Gonzalez handles these problems and the issues he has with the current system within the next couple weeks.
The first day in orthopedics we were scheduled to observe a surgery but unfortunately the operating room was closed. Instead, we got a tour of Dr. Siemionow’s lab, who performed the first near total face transplant and she focuses on hand surgery and peripheral nerve surgery. To get straight to the point her lab was amazing! She had her students, Ava and Anna, show us around the cell culture room and the microsurgery room where they perform surgeries on arteries and veins in rats.
The second day in rotation we sat in conference during the morning. A few different doctors talked about shoulder instability, skin grafts, and skin flaps. I never realized how many different techniques and tools were used to perform certain grafts or flaps. I was overwhelmed with all the information that was given within the short four hours but also gained insight of all the information medical students have to learn to perform, what i thought, were simple procedures. During the afternoon we got to observe medical students, residents, and Dr. Marcus in the orthopedic clinic. I learned that residents are assigned to an attending and as patients come in residents will see them first, collect history and problems they are experiencing, conduct a brief examine, look at x-rays and/or MRI’s, and report back to the attending with all the information. Outside of the patient rooms two flags were hung on the wall, one green and one red. When the patient first arrives the green flag is shown to indicate that the patient has not been seen, when the resident/doctor is in the room or already saw the patient the green and red flag is shown, and when the patient is waiting for a brace or surgery papers only the red flag is shown. This system presented a problem with the system flow because sometimes no one would notice the green flag was up and a patient was waiting or it was forgotten to change the flag color if a patient saw the doctor or changed rooms. Another problem that was presented was patients who made an appointment with the call service were given a spot with Dr. Marcus but should have seen a different orthopedic because Dr. Marcus did not specialize in their injury, misusing the doctors and patients time. This is due from a lack of information and history in the call center to correctly place the patient with the proper doctor.
All in all, the first two days have been very enlightening and shadowing the “behind scene” work has given me a new perspective of a doctor visit. I have already learned so much and I am excited to learn more about their system and problems in the coming weeks in different clinics and environments.