University of Illinois at Chicago
Portal hypertension is a common problem seen the in the IR. Portal hypertension is associated with liver disease. We have seen two stages of the disease. Portal hypertension leads to increased pressure in portal veins that is then transmitted back and increases pressure in other vessels. This backup of blood means that blood is not filtered by the liver but instead finds alternative routes back to the heart. This causes swelling (varices) in certain veins (esophageal) which are then at risk for rupture or it creates patent veins that should be closed (umbilical). A patient like this is at risk of hepatic encephalopathy, aka confusion/disorientation. This is caused by unfiltered toxic portal blood entering the CVS. How is this treated in IR? The varices and patent veins are blocked up, forcing blood to be filtered by the liver. Only problem is that the liver is still diseased, but its the best that can be done at the moment.
However, Portal hypertension can also exist without varices or unwanted patent veins. In this case the blood has nowhere to go. This is almost the opposite problem. The treatment? To place a shunt (tube) in the liver between the portal vein and hepatic vein, bypassing the liver, effectively mimicking the function of varices and patent veins. Patients that are treated like this are at higher risk for hepatic encephalopathy, but at least they have blood flow from the portal system and a decrease in portal hypertension. Besides the fact that neither treatment addresses liver disfunction, the problem is that this porto-hepatic shunt is static. Meaning once its in place, flow cannot be adjusted. This means that there is no way to balance the shunts flow for either too much or too little shunting, both of which would be problematic. It seems that this could be a valuable problem to address.
Image credit: https://quizlet.com/9551975/portal-hypertension-flash-cards/
Our mentor mentioned a problem he thinks we can/should solve.
IVC filters are placed for various reason but in general, to catch freed blood clots from making their way up from the leg into the heart and then lungs. IVC filters look like the skeleton arms of an umbrella that is half open, without the handle and without the fabric. The ends of the arms bounce out and into the IVC, holding it in place. IVC filters are placed on a regular basis and can stay inside a patient for life if no complications arise. If complications do arise, such as further clotting around the filter, the filter has to be removed. Because of its umbrella shape, it should be removed from the top, meaning pulled up and out through a jugular vein for example. The tip of the umbrella has a tiny hook which aids in the removal. However, there are cases where the filter cannot be removed from the neck, for example if there is worry about passing the heart. In this case, the half-open umbrella has the be inverted and pulled back down and out. We saw x-rays of this process and it seemed crazy. All the arms have to be bent in half and back. There is risk of perforating the IVC. It looked messy. And one big risk is arms fracturing and flowing up into the hart. This can be prevented with a balloon, but our mentor believes that it would be useful to have “specifications” of a filters material properties. For example, there are ~20 filters on the market. When inverting each filter, it would be useful to know which one has arms that will bend and which has arms that will break? How much can they bend? I’m still not sure how much of a problem this is. It does sound like it may be good to design the filters in a way that they can be pulled out in either direction. Interesting topic that may be worth looking into.
A problem encountered with IR is vasospasm. Vasospasm is a natural reflex of the arteries (and veins?) to constrict following physical irritation. For example, if a catheter pokes a thin vessel, the vessel can constrict and prevent access by the catheter. It is not a problem I have seen yet, but I have heard it mentioned several times and it seems that its something the doctors have to worry about regularly. I wonder how frequently it occurs and if “softer” catheters produce less irritation that harder ones. Another case of uncontrolled response to physical irritation is the heart and it contracting uncontrollably when touched. This circumstance is mentioned every single time any device gets close to the heart. This circumstance seems more dangerous than vasospasm because it can mess with the heartbeat.
Something I’m seeing in about 50% of cases is the doctor has to ask the nurse/tech for help with the imaging technology. The controls for the x-ray, the monitor and the bed are on one side of the bed but can actually be attached to the other side as well. However, when working by the neck, which happens very frequently, the Dr is far from the controls and asks someone else to maneuver the surgical layout. This seems silly.
Balloons and stents, devices that are used regularly, are stiff and therefore harder to maneuver around tight bends in the vascular/arterial system. Either making the devices more compliant so they can take sharp turns or make them more maneuverable is a need many of the doctors express. I’m still surprised by how little control the doctors have of the distal end of any of their devices. There are techniques to learn to maneuver the devices well but there is still some bumping around the vessels, especially at turns/branches.
Hemodialysis is crazy. Hemodialysis is the filtering of blood which has to be done for patients with renal failure. Renal failure is frequently due to uncontrolled hypertension and diabetes. Patients have to get hemodialysis 2-3 times a week. They have to filter all of the bodies blood so we’re talking high flow rates which means big needles. Access to a good artery/vein for high volume blood draws 2/3 times a week in not natural, so an artificial access is created. This access can be anywhere on the body but are most frequently on the arm since that is the most convenient. There are two primary access types. Fistula where a vein is directly hooked up to an artery. And graft, where an artificial graft connects an artery and vein. There are major problems with both including clotting and aneurysm. A significant portion of procedures in the IR suites were related to hemodialysis. I want to learn more about the procedure and if anything can be done better.
All the procedures we have seen so far have not used any fixed guiding system. For example, a pt was getting the fracture vertebra filled with cement. The Dr. had to position the needle by hand using the 2-D single sided view in order to position and drive the needle into the vertebra in all 3 coordinate planes. I see the need and benefit to being adjustable in driving the needle, proceed a little, check the position, proceed a little more. But since the doctors had an existing scan of the vertebrae, I found that the procedure might have been augmented with the use of a guide which held the needle in place, especially during the initial positioning and hammering. Another place I though some “guide” might be useful is in deploying a stent. Stents are placed in very specific areas, trying to cover certain landmarks (clots) and making sure to avoid others (brach vessels). However, deploying the stents seems to be a little haphazard, especially for the residents. The un-deployed stent has radiopaque markers for the start and end of the stent which can be seen using x-ray imaging. However, when deploying the stent there can be movement of the patient, of the catheter, of the physician….so its not super stable. I thought that the stent designs might benefit from a stabilization component, either internal or external, which would allow physicians to more precisely deploy the stent, knowing exactly where the tip and end of the stent will be. The image is that of a venous filter, which is meant to catch large emboli in the venous system and prevent them from reaching the heart and also aids in the breakdown of the embolism. We have not seen the placement of one yet, but I was told it can also be an unstable deployment procedure.
First impressions: IR is cool. The use of various imaging modalities to improve patient care and complete minimally invasive procedures is both efficient and effective. I have not seen them place central lines “blindly” but with ultrasound guidance. It seems much cleaner than doing it blindly which was standard practice in the OR. IR has a diverse scope of procedures so I am learning a lot and asking lots of questions about what is going on.
One of the primary tools IR uses are catheters or various kinds. The thin catheters allow the doctors to perform tasks “at a distance” in small areas that might be impossible to access otherwise. There is certainly skill involved in using the catheters, pushing, pulling and turning them to guide them in the correct direction. However, even the most experienced doctors require several passes at most junctions, simply by nature of the anatomy and fluid flow. It seems that a big improvement would be catheters that can be more precisely directed in the patient around tough obstacles. Balloons are also a common tool and they tend to be stiff, making them difficult to maneuver around obstacles as well, sometimes limiting their access to areas they are needed. I will certainly keep an eye out for this.
Another area that required some guesswork was blowing up balloon catheters in vessels. This is done for various reasons. The pressure of the balloon is seen and controlled. However, there is no feedback on the magnitude of force the vessel puts on the balloon. In one case, fibrous bands surrounding an artery had to be broken by use of such a balloon. Even with the burst fibrous band, the artery could return to the original shape. Therefore, telling weather the band broke or not was difficult. The risk of the procedure is pumping the balloon too much and bursting or dissecting a vessel. I want to continue to observe this practice and see if there is a need for more feedback from the balloon.
Doctors almost always have to kick the foot pedal around to get it into a desired location. Drs also trip on the pedal occasionally.
Patient is on the verge of coding after procedure. Patient had a history of trouble ventilating. Rapid Response Team was called- RRT. Dr. thought it was Respiratory Response Team. The patient needed to be intubated but nobody on RRT was qualified so only then was anesthesia called and they intubated. Classic inter-disciplinary miscommunication. With the code, at one point there was 40 providers in the room from 5 different departments. For each new provider of importance all the pts stats and info were shared over and over. Very interesting to observe.
Red bag waste is supposed to be for biohazard material including blood and tissue. Regular trash and red bag seem to be interchangeable in the IR suites. Something I hope to keep an eye on.
Photo: Doors tend to stay open in the OR even with signs that specify that doors stay closed at all times (open even with patients and radiation occurring inside). Perhaps because the doors have knobs to turn rather than levers. This means it would be impossible for doctors in sterile dress to open the door and leave. Doctors have to leave the rooms frequently when certain radiation modalities are used. Perhaps new door mechanism are in order to increase compliance of keeping doors shut.
Anesthesia has been a fantastic specialty to shadow for the last three weeks. By its very nature, anesthesia is involved in a lot of surgical and a few non surgical specialties from neurosurgery, to interventional cardiology to pain clinic. I have greatly enjoyed the diversity of cases that I got to see. It also an invaluable position to hold in the hospital. By necessity the anesthesiologist is well connected with hospital staff in various departments. This means that anesthesiologists are able to observe and identify cross-specialty themes and are also in a place to communicate about them with physicians in various specialties. In a way anesthesiologists are observers of the OR, maintaining the patient but also being an catch-all of the goings on. It is a prime position for identifying needs in anesthesia and the OR in general.
During our final talk with our mentor, he tried to sell on us why we should do anesthesia as as a specialty. His points include:
- diversity of patients from children to adults from every specialty
- you can take breaks during operations
- the strong ties to physiology in anesthesia
- he gets to wear pajamas all day
Anesthesia seems like a great place to innovate in with many new aspects to the field such increasing use of imaging during treatment, AI, better electronic records and increased evidence based practices.
We spent a day in pain clinic. It was very different from OR anesthesia. We mostly watched procedures but supposedly its much more clinic based. The procedures we watched were mostly related to back pain. The patients were getting longer lasting epidural shots in order to deal with the pain. There was a lot of fear from the side of the patients. The procedures are only done with local anesthetic and even getting the local anesthetic is not very comfortable. There was a lot of wincing and grimacing from the patients. After all, they are getting a long needle stuck into their back. Its hard to make any great observations after only one day in the pain clinic.
p.s. the painting is from the hallway in front of the pain clinic. I thought it was cool
Image: The image shows a resident who hooked up a new bag of solution to an IV tube for the patient and now has to let the solution drain through the line so that air isn’t introduced into the patient. The IV tube is very long which means the resident has to deal with making sure each consecutive segment gets below the bag so that gravity can feed the liquid through the tube. So far I have seen physicians deal with this problem by dropping the IV on the floor or into a trash can and then pulling the tube up, thereby displacing the air. All the systems are effective but at what cost? is the sterility of the IV something to consider? Is it a foolproof method that removes all the air? As an outsider it seems like a silly yet simple maneuver.
To further a previous post, I saw another arterial line being placed again. It required many passes and two sites of insertion.
There is an issue I have been seeing over and over and it is medical waste produced in the OR. All waste in the OR is split into only a few categories: sharps, red bag waste (biohazard=blood/tissue), and trash. There is no recycling, not of unsoiled packaging or tubing. There is no collecting of of cloth/material that was not soiled. There is no collection of gloves. There appears to be a huge opportunity for collecting certain materials for reprocessing of some sort. Currently trash cans are somewhat randomly placed around the OR, but with come planning and placement, materials worth collecting can be identified and collection containers can become a presence in the OR.
The thing is, just like other big issues that come up (sterility, communication), they are a cultural phenomena and need cultural change. No matter how good a design is, culture has to change first. But I believe it has to be a top-down approach. If I work in the OR and want to recycle, its impossible. Even if I get recycling bins into the OR, others won’t recycling unless they are prompted by their superior. I think that is also true for creating a strict culture of sterility or a open and effective culture of communication. The “boss” has to dictate that “this” is a big deal and we want to see “these” improvements. Just a thought.
We observed an epidural injection today (L4 level), performed for the purpose of a complete knee replacement. The procedure caused the patient noticeable discomfort even with local anesthetic given before the epidural injections. It took the doctor several “passes” meaning he had to pull the needle in and out about a dozen times. Its not all too surprising considering the procedure is done “blind” aka without imaging.
From my experince the last two weeks, multiple passes or other complications (dropping a wire or catheter or infiltration into the surrounding tissue) are not an uncommon problem when sticking a patient either with an IV, an arterial line, a jugular catheter, local anesthetic or in this case an epidural. Here I want to explore the problem. This is solely based off my recent observations so is by no means fully informed so these are all extrapolations rather than conclusions.
Is it a problem? To establish it as such, lets identify the negative consequences and frequency.
I estimate that frequency is high. From what I have seen ~%95 of patients undergoing anesthesia get an IV line; half get an arterial line. Of those I would guess that half of the arterial lines and half the IV lines need multiple passes and/or multiple attempts (sites). Local anesthetic/epidural/regional nerve blocks are also common. Therefore I operate under the assumption that multiple passes, multiple attempts or “incidents” of dropping something or something going wrong are significant when a needle is used in a procedure.
What are the negative consequences? If the patient is awake, (certainly the case for an epidural and nerve block) multiple passes/attempts causes significant pain and discomfort. This in turn can lead to spikes in HR, BP (which anesthesia is trying to control) and even movement/reflex which can complicate the procedure or presumably even harm the patient especially when working around nerves/spinal cord. In all patients, sterility is always considered a priority. Something to be researched is whether multiple passes/attempts is correlated with higher risk of infection? Blood loss is not usually large in these procedures, but any amount of blood loss is not beneficial to a patient going into surgery. Time is also an important factor. Multiple passes/attempts/incidents means more time spent doing these procedures. More prep time means higher cost especially if prep is done in the OR. More prep time can also mean longer time spent under anesthesia which is correlated with worse outcomes. Infiltration (needle is depositing its content not in the vein but surrounding tissue) was especially time consuming since anesthetic was not being received therefore delaying induction. Point being, there are complications that can occur when working with needles with varying degrees of consequences.
With this in mind, lets assume that placing lines/using needles of some sort has a failure rate high enough that we can consider it a problem due to the negative consequences. Failure is loosely defined as the necessity for multiple passes, multiple attempts/sites and infiltration. Negative consequences include: discomfort to the patient (short term pain and long term pain/bruising if tissue is damaged), increased prep time leading to increased cost and risk associated with longer anesthesia time, some blood loss, higher risk of infection.
So lets try to find the root of the problem. These procedures are done for what purpose? They are numerous including: drawing blood for analysis, giving drugs/fluids, injecting drugs for local action and measuring systems parameters (eg. arterial pressure). But what is the goal of these procedures?
The purpose of drawing blood is to analyze it, and the results tell us something about the condition of the patient. Drugs and fluid are administered by IV to maintain a desired condition in the patient. Regional blocks are given to allow for surgery to occur in a localized region.
But can the results of the analysis be measured using a different method without actually taking blood? Can the patients condition be controlled by other means? Can any of these goals be accomplished without using an invasive/needle procedure? I believe the end goal will be to find ways of achieving our goals without breaking the skin barrier which is our primary defense system.
However, for now we are stuck with needles, so are there any “quick fixes” that we can use to decrease the “failure” rate. So what is the cause of failure? Is it lack of experience? To an degree I think so. Residents are not as skilled at placing lines as physicians. In that case, perhaps more training on simulators is required, or perhaps better simulators. However, physicians also “fail” with placing lines. Experience is not the problem in that case. Are physicians more careless if the patient is anesthetized? Perhaps, but not conclusive. Is placing a line inherently going to fail? It is after all called a blind procedure. Surface landmarks are used to then plunge a needle flesh hoping you hit the right spot. When that is the case, it is not surprising failure will occur. But that is only the case for a percentage of procedures. Many of these procedures can be done under ultrasound guidance. The problem is that doing it blind, two hand are needed to place the line well but with ultrasound a third hand is required at this time. This adds a level of complexity that can make the ultrasound option less appealing. The procedure might not be blind but you might not be able to confidently hold and insert the needle with one hand.
I won’t discuss solutions at this time but this could be a problem worth discussing further.
Image: We stopped by the MRI rooms. It was pediatric day, meaning they scan the kids. Kids are tough to put in an MRI machine because they are not good staying still and calm, both of which are required for an MRI. Therefore they undergo anesthesia before entering the MRI machine. One child was lying on his bed, about to undergo anesthesia and he started covering his face. Everyone assumed he was being shy since he was surrounded by ~8 people. However, when I looked up, I saw that a bright ceiling light was directly above the patient (see image), so the patient was most likely shielding their eyes rather than hiding from the crowd. The intubation was going on in a hallway, so hardly a designated intubation site, but its a feature that is probably worth considering when designing a hospital.
I was able to observe my first robotic (DaVinci) surgery today. It was during a bilateral inguinal hernia repair. The surgery was greatly complicated by the fact that the patient had COPD and congestive heart failure. Another complication was that the patient had to be in trendelenburg position, where the pelvis is elevated above the head. From what I understand this position is in order for the abdominal content to “fall” away from the sight of surgery (pelvis). The problem is that the abdominal content “falls” onto the diaphragm making it more difficult to ventilate the patient and with COPD the difficulty was only exacerbated.
The DaVinci was fascinating. I was impressed with how precise the movements of the surgeon were. I guess I was expecting frequent overshoot or undershoot of the robotic arms but it looked like almost all the movements were spot on.
In the last 1/4 of the surgery, the patient began to show elevated ST segments. After closing, the EKG got more erratic and eventually the patient went into VTAC. The defibrillator was used, the rhythm restored but VTAC occurred again. Within several seconds the patient restored his own rhythm, but preparations were immediately made for transfer of the patient to the Cath-Lab (interventional cardiology). There, using a femoral catheter, a block in the LAD was found and stented. It seems that the surgeries have been improved to great extents and are very efficient. The inefficiencies occur during set-up, take down and transfer.
During the hernia repair and in the interventional cardiology OR, I was reminded to speak very quietly because the surgeon had to communicate with staff from a distance in both cases. In both situations mic-speaker systems were in place but everyone had to be conscious of interfering with the mic-speaker system. It obviously necessary and possible to speak quietly, but it did make communicating and therefore learning more difficult.
I’ve continued to keep an eye out for repetitive problems/inefficiencies. I saw several medical staff trip, stumble or kick aside either tubes, wires or power lines in this one surgery alone.
I’ve also noticed consistent problems with the beds:
- no specific place for power cord (they are dragged along or put on top of the patient
- no specific place for machines (monitors, defibrillator, O2 tank; they are put on the bed next to the patient and while moving patient from bed to bed the machines have to be moved out of the way)
- IV pole has to be pulled along by a person so that lines don’t get disconnected
- no place for patient’s chart (it was misplaced by the time it got to the ICU)
- no place for patient’s belonging (inhaler was just put on the patient when moving)
- about a dozen cables have to be unplugged for the bed to be mobile (this took at least 5 min, preparing the bed for moving is quite the process)
- system problem: while moving bed with a patient experiencing an MI, they still have to wait their turn for the elevator while on their way to the Cath-Lab (interventional cardiology)
Some reoccurring problems I’ve noticed:
- medical workers try peripheral nerve stimulator on self
- drug trays/boxes are kept on the floor (see attached image)
- trouble ventilating patients in trendelenburg
- Anesthesiologists only saw the back of the screen in the Cath-Lab, the room is not designed to include the anesthesiologists, they kept walking around the entire table to come see what is happening (this was also true in the other radiology suite)
I was not expecting as much imaging in anesthesia as I have experienced so far. Imaging is used in what seems like two main categories: monitoring/diagnosing of patient’s condition and as an aid during procedures. Here are the types of imaging I have seen so far:
- Trans-esophageal echocardiogram (monitor the state of the heart during bypass surgery)
- Ultrasound of jugular (aids in placing jugular catheter)
- Ultrasound of brachial plexus (aids in regional sedation of arm)
- Ultrasound of wrist/forarm (aids in placing arterial line)
- Visualizing the airway (aids in intubation)
- Xray of chest for pneumothorax (check for possible pneumothorax/collapsed lung)
For the imaging that is used as an aid during procedures I was interested to learn about the efficacy of these “aids”. Does using ultrasound actually help in placing a jugular line? After a quick Pubmed search, Brass et al. found that “Based on available data, we conclude that two-dimensional ultrasound offers gains in safety and quality when compared with an anatomical landmark technique. ” . This seems to be true of the other procedures as well meaning imaging has a significant potential for improving patient care and making these procedures faster. However, even with the help of ultrasound (US) there still seems to be difficulties and complications that arise frequently. Sometimes it took several attempts to place an radial artery line, placing the IJV catheter was quite messy and took a long time and one arterial or venous line “perforate” (I think thats what they called it; probably venous bc arteries are usually not used for drug delivery) which meant that instead of supplying drugs to the circulation, the drugs deposited locally into the patients forearm. This created confusion because the patient stayed “awake” even after receiving large amounts of drug and the perforation was only noticed after several minutes of trying to figure out why the patient was not yet asleep. Point being, imaging is already proving to be a useful took in aiding of procedures but there is certainly room for continued improvement either in imaging and its application or in the procedures themselves.
Something that I found true for all the imaging was that it is not obvious and sometimes difficult to orient oneself in the image. The echocardiogram revealed a lot about the heart, its valves, its chambers, the vessels flowing in and out but only when the physician pointed out the landmarks. The probe was adjustable in three planes so the perspective changed continually. With training all these images can make sense, but to a novice the can be very confusing.
Certain imaging machines were not well labeled. As an example, the echo machine and dozens of sliding knobs, but non of them said what they do so I never actually figure out what they were for. I’ll have to ask next time.
The image I am attaching goes back to my last post. I observed a resident who was meticulous about his IV line organization and his strategy was to roll up the tube and then tape it up with tape that says what line it is (specific drug or saline).
My first rotation is through Anesthesia. People in the medical field express that anesthesia contains a lot of physics and physiology, two thing I enjoy so I am particularly excited to learn more about the field. Also, from what I understand, anesthesia is unique because it allows for observation and monitoring of the entire OR in many different situations, creating the potential for a more wholistic view of the OR than say a specialized surgeon.
So far I am really captivated by the whole experince. I am learning a lot about the medicine of anesthesia. I can’t highlight enough how very important it is to be observing/interacting with someone who is willing to share their expertise in the field, especially at this stage of observation. Even though the primary purpose of the rotation is “needs assessment” a certain baseline of knowledge is crucial for making informed observations and deductions.
Quick note on morning lecture – predicting difficult airways; The day started with a very informative lecture on airway management intended for the new residents. In undergrad my senior design project was to improve upon existing airway management manikins so it was fun to hear about the subject again. At the end of the lecture the doctor and fellow did presentations for different airway management techniques using an airway management simulator. Having worked with the manikins in the past, it was no surprise to me when the doctors exclaimed about how the manikin texture was too sticky for intubation, the tongue unrealistic and the jaw and neck too stiff. These were all parameters that my design team and I found to be the problems with the manikins, all of which prevent realistic learning or practice to occur on the manikins. This may be a subject I might want to engage again.
Day 1 case- moyamoya bypass
Day 2 case – triple coronary bypass + esophageal echocardiogram + ultrasound guided IJV line placement
I watched two major procedures and one observation that really stood out to me was the fact that both cases required significant prep time once the patient was already in the OR. From some of the assigned reading, there seems to be a push for more efficient use of OR time. Boiling the idea down, efficient use of OR time would allow for more surgeries which allows for helping more patients and more $$. Therefore cutting down on inefficiencies would be beneficial. I can’t make generalizations after only observing two procedures but here are a few tasks that stuck out as opportunities for improvement and that I definitely want to keep an eye out for in days to come:
- sterile bagging of equipment (ultrasound, microscope)
- sterile field needed for IJV line
- lack of defined space for certain objects (“christmas tree” airway tube attachment for bed)
- pinning mechanism cranial cases: cumbersome, required three people, hair gets tangled
- interference of electrical equipment (IV tube heater) with electrical signal recording (EEG, SSEP)
- fiber optic headlamps require power cord, stand, re-plugging of fibers when surgeons move/switch spots
- placing arterial lines, placing IJV catheter
- tangled cables (IV)
- tangled cables (EKG)
- tangled cables
- IV tubes hang down on floor and are stepped on
- Power lines are tripping hazard and prevent easy mobility of mobile equipment
- Power lines on mobile equipment have no designated holster when equipment (bed) is wheeled around/out
These are some of my initial thoughts. Stay tuned for more.
P.S. Apparently we have to attach a picture with each post. I didn’t know that so for now I’m attaching a photo of the crazy mess of IV tubes on top of the IV pumps.