University of Illinois at Chicago
Rounding is a common routine for any department that has patients staying in the hospital. For transplant surgery, there are daily morning rounds that bring together surgeons and nephrologists along with a team of residents, pharmacists, and nurse practitioners. A consultation with a physician from infectious diseases is also common given that the majority of patients are under immunosuppression for their transplant. Rounding begins with “Table Rounds”. It’s a whirlwind of information during these meetings as each member says their piece about the patient currently assessed. Overall, the individual pieces of information with the meeting headed by the attending surgeon and nephrologist come together nicely to quickly, but smoothly, run over the list of current patients. After about an hour, the group moves on to walking rounds as they visit the individual patient beds. Rounding typically occurs without major bumps or hurdles, but there are still areas of improvement.
Timing is an interesting issue when it comes to the morning rounds. Rounding cannot officially start until one of the attendings has arrived. There is no official start to the morning rounds, but generally is scheduled for some time between 8 and 9 o’clock. The transplant unit members know when rounds are scheduled for the day, but the actual arrival of the attending physician and his or her readiness for the meeting is not easily predicted. Although the wait isn’t usually long – no more than 15 minutes perhaps – and the members can often find something to do in the downtime, it is still interesting the see a half dozen medical personnel more or less on standby till the head physician arrives.
The other notable observation is the attendance for these rounds. As mentioned previously, the number of members in these meetings is sizable for the transplant unit. Yet, there is definitely a need for each of these people. Transplant care is inherently multidisciplinary due to the high level of care needed to keep these patients and their new organs happy. As it’s an academic hospital, each of these components to the transplant unit will also have their own students and residents. In general, it’s a sizable group of people which makes the meetings highly informative but can be quite daunting during the actual walking rounds. In the eyes of the patient, it can be quite uncomfortable having more than a half dozen people present during the daily interview any subsequent physical examinations. On more than one occasion I’ve seen the patient noticeably tense or stunned by the flock of white coats entering their room. However, this is one of the small sacrifices expected in admission at an academic hospital. But I have to wonder if a protocol should be implemented to limit the number of people that actually enter the patient room at any given time. White Coat Syndrome is a common concern and the added stress by the sheer number of observers can make some parts of the examination more difficult and the overall patient satisfaction lowered.
For transplant patients, the transplant surgery itself is obviously incredibly important, but it takes up a very small portion of their time in the hospital. The transplantation team has its own area of the hospital known as the Transplant ICU where patients associated with organ transplant are kept for extended periods of time. These patients could be waiting on the transplant list, be recovering from a recent surgery, or be returning patients that require constant care and surveillance because of their transplant. All transplant patients are under immunosuppression, which means that certain lesser complications become much more dangerous. If one of those patients are admitted into the hospital because of any infection, they are almost certainly taken directly to the Intensive Care Unit. It’s simply too big of a risk otherwise.
There are multiple ICUs within the hospital, but they all have similar routines. Unlike other areas of the hospital, the nurses in the ICU never have more than two or three, patients to monitor. This allows them to give a much better level of patient surveillance. And this surveillance is needed. One of the physicians I talked with noted that instructions for ICU patients will almost never last a full 24 hours. Changes are constantly made based on how the patient is fairing at any given time. The overarching patient instructions are mainly directed by the daily morning rounds, which brings together transplant surgery, nephrology, pharmacy, and other consultants to go over the patients currently kept under the transplant unit.
With this system in place as is, there are some components of the ICU workflow which can cause difficulties. Because of the large number of hospital staff that follow the ICU at any time of the day, there is a lot of hand-offs from one staff member to another or because of a shift change. On a few occasions, this has led to certain patient instructions for one patient to be forgotten by the new staff members taking over for the next shift. Blood work and urine analyses are needed often multiple times a day and can be crucial for monitoring the patient’s health. Specific measurements could get lost in the fray, and it’s up to the morning rounds to make sure everything stays on track. Easier methods of communication for patient hand-offs could be useful.
How the ICU manages its patient numbers can also be tricky at times. Hospital beds are categorized based on the amount of care needed, with the ICU holding the most care. Due to the limited number of beds in the ICU, newer patients can sometimes bump older patients that may no longer needed the full care of the ICU to a lower level of supervision in the hospital. Although these patients are typically already on track to be moved over, the added pressure to admit a patient in a more critical condition can sometimes be non-ideal for the care of other patients. Overall, the ICU is a very dynamic operation in the hospital with a lot of moving beds and staff members to keep everything on track.
Transplant patients are composed mainly of those with kidney failure. Although there is a high demand for all organs currently used for transplant, the availability of living donors and usually 2 kidneys from a cadaver means access to a kidney is somewhat easier than say a heart or liver. But there is still a major shortage. To get by without a kidney transplant, the many patients with chronic kidney disease have to rely on dialysis to filter the blood in place of a functioning kidney. Hemodialysis isn’t easy. To stay in good health, patients usually come into a clinic multiple times a week for hemodialysis. They are hooked up to a large machine for up to 4 hours at a time and their blood is circulated out and back in one cleaned. To minimize the time needed for hemodialysis, the machine requires access to larger vessels. Veins are easier to find, being close to the skin, but they lack blood flow. Arteries have that blood flow, but are found deeper in the body. To remedy this issue, the transplant surgery department created an AV Access, which is an artificial connection between are larger artery and vein, which will increase the blood flow to the vein needed for hemodialysis. AV Access can be created in two ways, by a direct connection of artery and vein called a fistula or by engrafting a, usually teflon, tube between the two vessels.
There are several benefits and problems associated with the fistula method, but this blood will be discussing the troubles of an artificial graft. A fistula is usually the ideal method of access, but can often be unsuitable for the patient. These polymer grafts make an arterial-venous connection more possible, but are artificial. The major difficulty of these grafts is it’s guaranteed expiration. The commonly used polymers like PTFE, i.e. teflon, are not suitable with the constraints of hemodialysis. Each hemodialysis requires needles entering the vessels to circulate and clean the blood, and teflon can’t properly handle these pictures. It’s an artificial avascular material that cannot self-repair. Those pictures, occurring multiple times a week for years and years, eventually wears down the integrity of the graft.
It’s is almost guaranteed that a long term hemodialysis patient with an AV graft will have to undergo surgery again after a few years to replace the graft. A replacement will usually also be at a different connection point, but potential areas of an AV access are limited. Overall it’s a losing battle for hemodialysis patients.
After some time in the clinic, the team was able to watch a few kidney transplantations. Because the body normally begins with two kidneys, it is possible two having a living donor along with kidneys from a cadaver donor. Regardless of its source, organ transplant surgeries definitely have import in the OR. A living donor is scheduled at the beginning of the day 6:30 sharp and the recipients are prepared well ahead of the organ being available. There is definitely the coordination to expedite the procedure and maximize the organ’s viability.
For these procedures, the da Vinci systems are used most often. Unlike previous surgeries seen, these transplant surgeries usually have two attending surgeons. Like the usual robotic assisted laparoscopic surgeries, one surgeon is on the console, controlling the robot. The other surgeon however does something I wasn’t able to see in the urology department. The second surgeon’s main hand is wrapped in a surgical drape and pushed into the patient’s abdomen to help assist the robot. The main purpose of this is to easily remove the kidney once it is cut away from the body, but there was definitely a lot of added benefits throughout the procedure. The hand is much nimbler in pushing away tissues and orienting the kidney for the robot.
However, the benefits for the surgeon on the robot come at the expense of the surgeon at the bedside. In order to get the hand invested in the patient’s abdomen, the surgeon must lean over the bedside for multiple hours during the procedure. Even with a chair, the surgeon was clearly not comfortable for the main duration of the procedure. On top of this, the bedside surgeon has to always be aware of the moving robotic arms, which can be right beside his arm or face. Of even more concern from at observer’s perspective is the close proximity of the surgeon’s hand, covered only in surgical gloves, to the robotic instruments. Although I know the surgeons on these transplant procedures are experts at the da Vinci system, it still can be worrying seeing the bedside surgeon’s hand so close to needles, sharps, and cauterizing instruments throughout the procedure.
Overall the robotic system definitely helps streamline the entire procedure, but supplemental instrumentation might be needed to help the assisting surgeons work around the added difficulties of the robot.
This Friday I had a chance to observe a weekly meeting in the department of transplant surgery. Starting at 7:30 in the morning, a group of thirty or so members associated with kidney and pancreas transplantation come together to monitor and screen potential transplant recipients. What I quickly learned was that transplantation screening is no easy process. To begin with, the meeting was composed of multiple professions including the transplant surgeon, a cardiologist, multiple nurses and administrative workers, pharmacists, pathologists, social workers, and psychiatrists. Each of these members played a part in the screening process.
During the meeting, the talk would consider one patient at a time and determine their transplant status: Active (waiting for transplant/donor), inactive (on hold till concerns are addressed), or closed. For this review, the staff discuss the patient’s physical wellbeing, any contraindications from other health issues, psychological wellbeing, and likelihood of finding a donor organ among other aspects. Just one problem in the patient’s profile can completely halt any progress for transplantation. Most of the candidates reviewed were placed on the inactive or closed categories, often for similar reasons such as comorbidities in obesity or heart failure, the usage of certain illicit drugs that puts the patient at risk during surgery, or complications in mental health.
Ultimately, the main constraint for most of these transplant patients is the absence of a suitable organ donor. Living donors are common in kidney transplants, but the majority of kidney transplants are still from cadavers. Finding a suitable donor then is matter of chance. However, after the meeting was over, the head surgeon at the meeting discussed the idea of starting a Donor Swap Program at the university. The proposed program would offer a one-to-one swap between two hospitals. If two living donors are found suitable for the other donor’s potential recipient, then the two pairs of donors and recipients would be incentivized to “swap” the donated organs to everyone’s benefit. By expanding this program to multiple hospitals, the likelihood of a suitable donor swap would be greatly increased. This seems like a very interesting method to help resolve the shortage in suitable organs.
But it seems strange to me that this sort of program isn’t already in place. Kidney transplantation has been possible for over half a century now and the suitability of organs has always been a concern. That said, programs like this are already implemented. However, the occurrence of these programs seems to be specific to only a few hospital systems around the country. Again, it seems strange that such a program isn’t more pervasive in healthcare, but perhaps this goes back to the common issue brought up since the beginning of this immersion program: That of poor communication between healthcare systems. In many ways, it feels like hospitals are fairly exclusive, acting fully independent of any other healthcare systems nearby or otherwise. But I have to wonder if programs such as this Donor Swap initiative, which focus on the community aspect of healthcare, are strongly crippled without the necessary cross-talk between the healthcare communities. It might be time to address this issue. We are well into the 21st century, but it amazes me how reliant hospitals still are on the fax machine for obtaining medical documents from outside the healthcare system.
This week begins the second rotation in the Clinical Immersion Program, which brings a new group of student observers together and a new medical department. To begin our exploration into the department of Transplant Surgery, Dr. Hoonbae Jeon introduced us to the origin and current use of some tools used in transplant surgery. The presentation explored hemostats, current electrical cauterizing tools, and methods of organ preservation and transport. His consensus of all these tools is that everything could still be improved. The discussion impressed upon us the constraints from a surgeon’s perspective: costs, ease-of-use, capabilities, precision, reliability. Although medical equipment is rapidly evolving, it’s hard to check off all the boxes, especially when each physician has his own preferences and ideas.
One example that comes to mind are the current electrical cauterizing tools that are commonly used in surgery. These tools are various forms of electrodes used to run an electrical current through tissue, essentially acting like a cauterizing scalpel “slicing” through the tissue it burns. It can otherwise be used for spot cauterization to stop any bleeding from the cuts made. In general, these tools are much bulkier compared to the classic surgical tools that people know: metal scalpels, hemostats, forceps, etc. But it is the ergonomics of those classic tools that Dr. Jeon would like to repurpose. Those tools, he argues, almost become extensions of the surgeon’s hands over years of practice since the earliest dissections in medical school. That familiarization, that finesse, is hard to reproduce with these electrical cauterizing tools, the smallest of which is similar in size to a soldering iron. For most surgeries this doesn’t seem to be a major issue, but transplantation requires tissue preservation, which can be a delicate process when working with the smaller vessels attached to or within these organs. Finer work can be done with robotics, but that isn’t always available. These surgeries are executed as fast as possible as every minute counts from the moment the organ donor is called. Robotics may not always be available or plausible given the window of opportunity for organ transplantation. So what can be improved? Smaller, portable instruments tailored to the surgeon’s preferences could shave off more than a few minutes to surgery completion. When some of these organs have a transplantation window of only a few hours, those minutes can make the difference.
Over the next three weeks I’m hoping to have the chance to see the transplantation process from beginning to end. My previous three weeks’ experience tells me that delays in the OR are bound to happen. But it will be good to see just what are the true limiting factors in play during transplant surgery.
We are at the end of the first three weeks of the clinical immersion program, which leads to the end of our first department rotations. The last three weeks of urology has been an interesting look into a field I didn’t know very much about prior. From only these few weeks I’ve been able to see a broad range of the activities related to the practice. At the clinic these ranged from the simpler follow-up visits to more serious meetings involving the risks of cancer to more voluntary appointments looking into patient fertility. Many of the procedures are done via outpatient appointments that are over in five minutes. Other surgical procedures relied on more advanced equipment and techniques including the usage of the da Vinci robotics, laser lithotripsy, and different imaging strategies. I was even able to witness a more specialized procedure at the UIH, a male-to-female gender reassignment surgery partnering urology with plastic surgery that lasted all day and went into the night before completion.
However, regardless of the different activities associated with urology, communication with patients is a potential struggle. The University of Illinois health system is one of the top billers of Medicaid in the country and its patient population is reflected through this with a very large percentage of patients incapable of speaking English. Fortunately, there are staff members within the urology department, nurses or doctors, that are able to speak Spanish or a few other languages, which can help streamline patient care for these non-English speakers. Yet, most of the time the doctors must rely on telephone interpreting. This phone translation system usually works very well, and its use is well established. Sometimes, though, there are unique circumstances in which a typical phone translator cannot be used. This week I observed a follow up appointment with a Spanish-speaking patient who was also deaf. This was an already established patient in the UIH health system, but the urology staff were stumped on how to communicate with the patient. How does one find a translator to sign Spanish? Ultimately the nurse practitioner heading this appointment had to rely on writing down the questions and instructions to the patient during his appointment. Luckily the follow-up appointment brought up no major concerns or other questions from the patient, allowing for a somewhat smooth interview. With that said, there was still a lot of mouthing of basic English and Spanish words and rudimentary gestures to give the patient instructions.
So what exactly is available for the health practitioners when there are such major restrictions to providing care to a patient? All of the clinics I visited over these past weeks had fairly new VoIP phone systems in every room. The phone console has a small monitor and webcam that in theory could be used for video calling. Yet, none of the hospital staff working at the clinic or that I have talked to knew how to set up a video call with the console. Even if they did, they weren’t sure if the phone translating services used by the health system were capable of video calls or had a translator who could sign Spanish. In theory, there is possibly a way to properly translate a conversation with this deaf Spanish speaker. But this experience showed me that, although technology and resources might be made available to health providers, if the staff aren’t aware of the full uses of equipment or services, then those resources could be wasted, much to everyone’s disappointment.
Over the last few weeks I’ve been able to see a wide variety of activities that the urologist takes part of. One thing I’ve noticed is the common need to move across the medical campus throughout the day. The doctors could have multiple patient populations to see on any given day. The morning begins in the hospital with residents and medical students doing the rounds for the In-Patients. The group of 4 or more float from one floor to the next within the main hospital to check up on their patients, most of whom come from a recent urology surgery. Soon afterwards it’s time for the main assignment for the day either in the clinic or in the OR, and sometimes those roles last only a half day with another clinic duty at a different location in the afternoon. After those duties are over, it’s not unusual for the doctors to head back to the main hospital to do consultations from other departments as were requested throughout the day or for the residents to do the second set of rounds with the In-Patients.
By the time the day is over, many of the doctors would have come to and from several different locations on campus to meet their patients. Overall this movement from one place to the next is generally accepted by the doctors, but the time can add up. One time in particular that created a large hassle for one of the physicians I was following was during a patient consult. In the hospital, a patient was scheduled for a CT scan that required a urologist on site to overview a cystogram. For this procedure, the urologist injects a radiopaque dye into the bladder that can be used in a CT scan to discover any leaks or fistulas from the bladder. Unfortunately, when the urologist arrived at the CT room on time for the procedure, the patient was nowhere to be found. It wasn’t until after talking with the patient’s nurse that a miscommunication was discovered. The nurse originally expected for the urologist to confirm his or her ability to make it to the procedure prior to calling for patient transport. As no confirmation was made, she presumed the cystogram was called off.
At this point the urologist was in a dilemma. Either he would have to wait on site until patient transport can finally bring the patient, which could take up to an hour, or he would have to find a way to transport the patient himself. He chose option B to cut down time. But even then, the urologist had to find where the patient was located, talk to the nurse in person, and then travel around the hospital until he could find a free transport bed for his patient. By the time he could bring the patient down for his CT scan and have the CT room prepared again, the procedure was already delayed by almost an hour. From talking with the CT technicians, it seems these sorts of delays are constantly occurring.
It’s hard to say where the major setback occurred. Was it a miscommunication between the nurse and urology? Is the patient transport service too busy for a quick response? Are other transportation capabilities and equipment properly available if needed? There are many points of potential improvement, but I keep reminding myself that the hospital is composed of a bunch of moving parts, all with their own agendas and directions, and that helping out one small area of healthcare might have unexpected benefits to the system as a whole.
Image from Wikimedia.org
Over the past couple of weeks, I’ve seen a good number of different surgeries and medical procedures for urology. The trade is fine-tuned to increasing the efficacy of a procedure while being as minimally invasive as possible. By location, the surgeons can often take advantage of the laparoscopic tools to tinker with the patient’s abdominal organs. The major advantage of smaller incisions is countered, however, by limited usability. This week I had a chance for the first time to observe a couple of surgeries with robotic assistance. Both were laparoscopic procedures, but the capabilities compared to a physician’s hands were so much greater.
The da Vinci robot systems are interesting sets of equipment. They require a fairly significant investment from the hospital. The bulky size can take up most of the OR and the price tags begin in the millions. It’s a bit surprising that these systems are ever purchased, but that’s without consideration of their potential. The system I observed was the da Vinci Si, which allowed up to 4 arms to be controlled during laparoscopy. At the same time, a second surgeon would stay at the patient’s side to manually hold other laparoscopic tools. When walking into the room mid-surgery, all you can see is a circle of equipment stands and tables around the center. Above the patient is a mass of metal and plastic elaborately set up to control an assortment of tools within the patient’s abdomen. Above even that is a halo of monitors to give everyone scrubbed in a view of the surgery. It has a different feel compared to a regular surgery, and that’s probably due to the head surgeon sitting off in a corner while using this awesome control terminal and giving commands over the speaker system.
Once set up, the robot can fly, quickly and accurately moving by the surgeon’s control. Tedious work with manual tools can be done efficiently, allowing the robotics to take on much more sensitive tasks instead. One of the surgeries I witnessed was a radical prostatectomy. The prostate and bladder are practically glued together with only thin fibrous tissue layers found between. But the robotic arms were able to precisely and meticulously separate the two organs.
However, the robotic system isn’t without its own constraints during surgery. One of the obvious issues is that the robot is big. It really is a tangle of large metal arms that crowd over the patient during surgery. This might cause some limitations in its movement due to hindrance of the neighboring arms. But more importantly it can make the work of the hands-on second surgeon much more difficult as he works around this bulk of the arms. Luckily this isn’t usually an issue as the surgeons are constantly talking back and forth. The laparoscopic tools themselves carry similar constraints as their hands-on counterparts. There is extra mobility near the end of the tool, but the tools are still limited by its port of entry. The camera as well tends to fog up and requires removal for cleaning. More complicated actions such as suturing are slowly and carefully executed in the confined space of the abdomen, but the arms have a lot of strength. The suture can sometimes snap under the stress. Only later would I learn that the da Vinci (at least the Si model) doesn’t have some form of haptic feedback, which could relate back to the surgeon if the arms are using significant force.
With all that said the da Vinci robots are worth the added costs and effort. After the initial setup and a good exchange of directions from the two surgeons, the operation advances like a well-oiled machine, able to do some of the most elaborate procedures I’ve been able to observe.
This week I had a chance to observe a weekly meeting known as “Tumor Board” where urologists and other associated physicians meet at the pathology department in order to analyze current patient cases. As the meeting name suggests, the cases presented are patients that have or are expected to have benign or malignant tumors within the tissues associated with urology. Through these case studies, the physicians pull together any prior imaging records (MRI, CT, PET, or otherwise) to identify the suspected tumors or tissue abnormalities. From this reference, the pathologist can move to the findings from biopsies of the abnormal tissue. These biopsies are stained and presented on microscope slides via a multi-headed teaching microscope that allows up to 13 pairs of eyes to look at the slide around a discussion table. This interesting setup promotes a close discussion between the physicians in the room.
Dr. Abern headed this Tumor Board, presenting a few of his patient cases from the past week. Two of the cases looked at patients with different stages of prostate cancer and another case presented kidneys with multiple cysts with a concern for potential malignancy. Within the first case of prostate cancer, limitations in the examination were quickly brought up. The Tumor Board brings together various departments including urology, pathology, radiology, and radiation oncology who all have different preferences in the examination. As mentioned in a previous post, the prostate biopsy is not a comfortable procedure for the patient. Therefore, the urologist prefers a biopsy probe that only takes a small tissue sample from the patient which would is less painful and more convenient for the patient. This small strand of tissue, however, makes the pathological assessment difficult. A biopsy from the prostate can perhaps only be a handful of cells in width and prone to fragmenting during processing. Therefore, the pathologists would prefer a larger biopsy which would be too painful for the patient using the current outpatient procedure with local anaesthetization. So where is the middle ground in this dilemma? Perhaps there is a limitation in the current procedure or biopsy technology that needs to be addressed. A few of these points of difficulty were brought up throughout the meeting.
In the afternoon I also had the chance to visit and observe the University Center for Urology outpatient facility at 900 N Michigan Ave. Unlike the other facilities I have observed, this is a half day clinic open only once a week because of its narrower patient population focusing strictly on male reproductive health. The typical patients that seek help at this clinic are males with infertility difficulties. Many of the patients are initially referred by reproductive endocrinologists after gaining interest in in vitro fertilization. There were some other noticeable differences to the patient population. As these examinations are largely voluntary, the most obvious difference I found was that these patients were much more compliant than in other healthcare settings. There is also an obvious nervousness as the men are waiting for the doctor’s findings. This nervousness seems difficult in relieving, even with good news from the doctor. But it’s easy to understand their stress. Most of these patients have already spent months if not years trying to conceive a child without success. Regardless of how well their hormone levels are recovering or their increase in sperm motility, the only way to truly ease their stress would perhaps be that one viable pregnancy that could still be months away.
After spending a couple of days with urology in the clinic, I finally had the chance to see some of the more sophisticated procedures in the OR. On Thursday I followed Dr. Abern and Dr. Wadhwa along some of the longer surgical procedures, taking up half a workday a piece. At the beginning of the day, we headed to the Surgery Center where they keep all of the patients prior to operation. It’s a long room with patient beds circling three of its walls. From an outside perspective the place seems like control chaos with beds being rolled in and out along with doctors, technicians, and patient visitors constantly moving here and there. A half-hour later our patient’s bed is the next to move out and we headed to the OR.
My first impressions of the OR felt only a little less chaotic compared to the Surgery Center. The anesthesiologists were already preparing the equipment and the patient for surgery. At the same time, the surgeons were walking in and out, reviewing the patient information and prepping for sterile surgical technique. Finally, the pre-operation “time out” was called to review the surgery information and Drs. Abern and Wadhwa made the first incision. For the first procedure, I was able to see a laparoscopic adrenalectomy. A laparoscopic procedure utilizes three small incisions that act as ports into the abdominal cavity in which a camera probe and two other tools can be used at any given time for surgery. The abdomen is then inflated with carbon dioxide for greater visibility and mobility of tools. Surgical procedures involved with removing all or part of the kidney or adrenal glands can be difficult. Both organs are secondarily retroperitoneal, which in essence means the surgeon has to go through multiple layers of membranes, fat, and other tissue in order to reach the organ. This difficulty was noticeable early on as the surgeons had to gently probe the abdominal cavity, pushing between other organs in order to find the adrenal gland to be removed.
To actually cut into the tissues to reach the adrenal gland, the surgeon uses an interesting tool. On the end of one of the probes is a blunted pincer. On the inner edge of the pincer is a metal wire that rapidly heats up upon running an electrical current through the tool. When triggered, the tissue grabbed by the pincer is burned through while at the same time any vessels within the tissue are cauterized to avoid bleeding. The outside surface of the pincers is insulated from this heat in order to avoid burning the surrounding tissue. This very convenient tool, however, still seems to have its own constraints. For one, some of the larger vessels may require a second burning to fully cauterize. The tool also has some restriction in mobility. It’s a straight rod that is limited in movement based on the location of the port it used to access of the abdomen. Once inside, the surgeon can alter the angle of the probe from the port, but otherwise can only rotate the pincer. To reach any tissue that is covered by an organ, the organ has to somehow be moved aside in order to reach the desired tissue. This was a major difficulty for the adrenal gland, which is so deep within the posterior abdominal wall. As well, the cauterization of the tissue can result in smoke and steam which can sometimes fog/cover the outer lens of the camera probe. It then needs to be removed from the abdomen to be cleaned. This cauterization can also leave burned remains on the pincer, which will also eventually need cleaning to avoid impairing its cauterization function.
Overall, even with the constraints of their tools, the surgeons worked efficiently at cutting the assortment of vessels and tissue surrounding the adrenal gland. After a couple hours, the gland was finally removed and extracted through one of the incisions previously made. The team very efficiently closed the incisions on the patient and followed a routine of post-operative checks. Not an hour later and the patient was being wheeled out of the OR for recovery. The surgeons and left soon after while the remaining technicians stayed behind to finish cleaning the room and preparing for the next patient of the day.
With an extended holiday weekend, the Clinical Immersion teams started their first rotation on Tuesday. At the beginning of the day, the participants of the programs met at the UIC Innovation Center for a brief overview of the next six weeks in the clinic along with a discussion of the expectations of both students and the program’s faculty. By mid-day we split up into our groups and made our ways to our medical departments. My first rotation would be the Department of Urology, involved with health of the urinary tract system from kidneys to urethra along with most male sex organs, which share the same piping.
Soon after finding this day’s Urology clinic at the Miles Square Health Center, the group met with Dr. Wadhwa to briefly discuss the interests of the program and immediately we were off to follow various doctors as they met with patients. From talking with the doctors I followed, I made a couple realizations fairly quickly. First was that the UIC Urology residency program was unusually long at six total years. For asking why this is, the immediate response was for practicing the surgical procedures. Before starting this program, I assumed the urologist routine was more in line with the specialties associated with internal medicine having a larger focus on lab-work. But instead one of the attending urologists I followed estimates that 80% of his time is involved with surgical procedures. Even in the clinic, the urologist is expected to do multiple digital rectal exams, prostate exams, and cystoscopies on any given day. On this first day I was able to witness by first prostate biopsy, which involves using an ultrasound probe through the rectum to visualize and obtain tissue samples from the prostate. Looking back at this procedure, my initial thought goes to “discomfort”. Aside from a local numbing anesthetic, there is little that can be done to help relieve the patient besides finishing the biopsy as soon as possible. What was really striking was the sample-taking. The biopsy probe uses a spring mechanism to quickly punch a hole into the prostate and obtain a string of tissue. Although this is supposed to be quick and relatively painless, the pressure of the action is still felt and the rather loud snap of the mechanism had an obvious depreciation to the patient’s mood. Overall, the procedure can only be described as unpleasant while multiple tissue samples needed to be taken.
The second day on rotation found myself in the clinic again with Savan as we followed Dr. Abern and Dr. Halgrimson. Similar to yesterday, many of the appointments are for follow-up visits for patients currently with, at risk of acquiring, or recovering from prostate cancer, a form of cancer that typically goes unnoticed without any symptoms until the patient is first screened for blood PSA (Prostate Specific Antigen) sometime during middle age. Along with these patients were more prostate biopsies. Interestingly, although a tumor cannot be distinguished from the prostate on an ultrasound, with clever manipulation of an MRI image taken previously, the doctor can orient the MRI image (with greater contrast of the tumor mass to prostate) in-line with the current image generated from the ultrasound probe to help determine where to properly take biopsies of the tumor. Once the two images are aligned, tracking software follows the movement of the ultrasound image and automatically adjusts the MRI image to match the new placement of the ultrasound. This nifty technique could perhaps be used in a multitude of surgical procedures to help align information from two separate images to the physician’s benefit.
Overall, the first couple of days have been an interesting first glance at the field of Urology. But the momentum is just starting to grow with the next couple of days to be in the OR watching much more elaborate procedures.