University of Illinois at Chicago
The Da Vince machine has many features that need improvement. It is an amazing machine but some of the features do not integrate the best into the OR. Many of these features I have talked about in my previous posts. There is one fault to this machine that came to my attention in one of the transplant surgery. In this surgery the transplant attending already had the Da Vince machine all set up and was ready to being the surgery. However, the anesthesiologist found out that the patients was to close to the ground. Once this problem was identified the transplant surgeons had to remove all the work that was done so the Da Vince could be separated from operating table. This wasted a lot of time because then they had to reinsert the Da Vince machine into the patient. If the Da Vince machine could be rotated with the operating table, then this would prevent the delay.
There is one item in the OR that I thought needs improvement. The first item is referred to as the slush machine. This machine is actually very important. The organ that is being transplanted into the patient is placed into this machine to be kept cool. However, this machine does not have a negative feedback. This machine just gets colder and colder. This forces an employee in the OR to constantly watch the machine and turn it on and off so that the organ being transplanted doesn’t freeze.
Laparoscopic surgery has changed the way transplant is done. Surgeries can be done with more precision and give the patient a quicker recovery. This style of surgery has also opened opportunities for obese patients. Previously open transplant surgery was not possible with obese patients because it increased risk or infection and surgery failure. We were told that UIC is one of only a few hospitals that are rising the BMI limit for transplant surgeries. It is incredible that Laparoscopic surgery has opened up this opportunity for obese patients in the transplant surgery realm.
One of the clinics that we were able to see was the Access clinic for hemodialysis. Hemodialysis cleans the blood since the body can no longer clean the blood itself, which is why they need a transplant. Access is a very important part of hemodialysis because it is where the blood is removed to be cleaned and then pumped back in. However, in order to take out enough and pump enough back in the access has to be large enough. This is done by implanting a larger plastic tube or a enlarged vein in between an artery and vein.
These temporary solutions are insufficient. The artificial implants that are used for access are great because they can be used almost immediately for hemodialysis however they can get infected very quickly. Now if they used the patients own vein to make it enlarged and relocate it for access this works for a while however because of how often the patient has to go in for hemodialysis the vein gains a lot of scar tissue eventually making it impossible to use anymore.
Many times a patient has to get an exploratory surgery before implanting the type of access they are going to get. Then they have to get a surgery to implant the access. Once the access becomes infected or covered with scar tissue they have to remove it in surgery. And then go through the whole process again to gain access for hemodialysis.
During our first week I was in a meeting discussion patients that should no longer be on the waiting list. There are strict guidelines that a patient has to follow in order to stay on the transplant list. If a patient does not follow these guidelines, then they are brought up in this board meeting to discuss whether they should stay on the list. Financial, nutrition, surgery and social services are just a few of the departments involved in the monitory of the patients on the transplant list.
What amazed me was the next meeting. In the next meeting they discussed a way to increase the possibility of patients receiving an organ sooner. This process is being implemented at several other hospitals as well. The thought is if a patient has a willing donor but they are not a match they could switch donors with another patient in the same situation. Because as of now if you do not know someone that is willing to donate an organ to you the only other option is the transplant list. However, if this process could be implemented then you would only need to have a willing donor and it would not matter if you were a match because you could just switch donors with another patient that has a willing donor and is a match with you.
My first week with transplant surgery was very different then my other rotation with Urology. The Urology clinic was always packed with patients and they had multiple Operating Rooms (OR) with patients constantly in them. I remember having to quickly walk with doctors between patient’s rooms and the computers, for note taking, and having that small window to ask questions. This is how I thought the hospital and clinic would operate, very fast pace and constant care delivery.
The first week in the transplant surgery unit was very different. Due to the nature of this unit they have to constantly be prepared for an emergency transplant. This forces at least some of the doctors to be available for such a surgery. Because these patients have a lot of health problems sometimes they cannot make their appointments not only that but these appointments are a little longer then the appointments I am use to. These differences give a unique environment to the transplant unit.
As I reflect on my time in my Urology rotation I think back to how I entered the program. I was afraid that I would not be able to identify needs or that I would not ask intelligent questions. I was unsure in my abilities to accomplish the task we were charged with. It seemed like I did not have the skills to go into a certain department and identify larger problems at hand. But not that I am done with this rotation I know all those thoughts were unsubstantial.
I looked over my notes and blog post and see evidence of my task being complete. I look at the presentation my group prepared for the Urology unit and our final paper for the immersion program and am confident my group was able to identify larger needs at hand not only in the Urology department but the hospital as a whole.
This makes me excited for my next rotation. Excited to go in with more confidence and experience. I think this will increase the quality and meaning of our observations and needs assessment.
This week we gave a presentation to some of the individuals working in our urology rotation. One of the themes we talked was how lots of the technology used is not conclusive in their diagnostics. This means that there are multiple medical devices but individually they provide no clear diagnostic. The down side to this is that the doctors are being crippled in their ability to treat a patient because one device does not give them a clear answer. They have to rely on that device and others or devices and an exploratory surgery to get close to the diagnostics and then can ultimately start treatment.
One example of this is when we were in clinic there were using a urine flow test and bladder scanner. However, the bladder scanner was broken. The clinic still went forward with the urine flow. The results from the urine flow were inconclusive with the bladder scanner. This forced that clinic to have all the patients come in again when the bladder scanner was fixed. This delayed treatment.
Another example of technology not being conclusive in it’s diagnostics is a CT scan and a tumor location. I saw this one surgery and similar ones to follow where the patient had to come into the operating room, be sedated, and operated on for nothing more then being able to identify whether a structure, tumor, was inside or outside of another structure, kidney or bladder. The necessity of surgery to simply identify the location of a tumor seems a bit extreme.
These examples are not scarce. It is not only a problem of streamlining the diagnostics process but is it also a problem of consolidation of technology and diagnostics procedure.
I learned a couple unique things surrounding urological health that I could not believe I did not know. Living in the city and being a college student, trying to save money as many ways as possible, I decided to become an avid bike rider. Unaware to me urologist believe there is a correlation between bike riders and erectile dysfunction (ED). A urologist gave a presentation about the reasoning behind this suspicion, the logic made sense. Now of all the cyclists out there I am curious how many are aware of this and other damage that type of exercise can have on males’ urological health. Base on my small sample size, myself, not many do!
During my time at the clinic urinary track infections (UTI) are incredible common in women. From the doctors that I shadowed I gathered that somewhere around 90 percent of women will get at least one (UTI) in their life time and the reasoning for this is because they have a much smaller urethra then males. The treatment is more or lease easy, however still cumbersome. Although I am not a female, I feel like I should have known this information. Whether it be due to ignorance or a lack of education I think it would be informative to know if females know this about their urological health and if they don’t how can we better educate and prevent this type of infection?
One day we had a large about of ED patients. It is eye opening how many males have this condition and the many types of treatment. The first step they usually take is to provide an oral medication. However once that method no long works they perform a test to identify their future options. If the test goes well then, the patient has the option of do self administered injections. If the test does not go well then, the patients only option is to have a inflatable penile prostatic surgically implanted. I was only aware of the first form of treatment. The other two seems pretty extreme.
The doctors told me that when a patient tells them they smoke a pack a day that they know they have or will soon have ED. Now I don’t know about everyone else but I was not told that in my health class. Now I don’t smoke that much, mostly as a casual social activity. However, that information about smoking and ED gave me enough motivation to not want to smoke anymore. Would smoking be such a problem if people knew about the full extent of its affect. I was told that smoking is bad for me but I was never told that it could contribute to ED. That is a far better motivator then an ambiguous “its bad for me” statement. However, that made me think about what not being health does. Not just smoking but not being health in general. It would make sense that if your body is not health then the “nonessential” parts would go first.
I have not seen many surgeries. Actually Last week was the first surgery I have every seen and I only saw a couple more that week. I am very new to this realm and awestricken by the complexity, talent of the medical staff and resources poured into it. There are is so much attention on the instruments, sanitation, paperwork, personnel training and communication between medical professionals. The goal is one thing, a successful surgery.
The surgery has stolen attention from the patient. From what I have observed, I have seen patients pulled into the Operating Room (OR) obviously nervous and reluctant to have an operation done. This patient is pulled into an OR where individuals are talking on the phone, running around getting things in place, and telling jokes with each other. I once saw a patient not yet under anesthesia and one of the medical staff removing their coverings to sanitize their genitalia. I am curious how this patient receives those activates. I am concerned that the patient’s unease is not accommodated correctly.
I would think that a patient would be more comfortable with a silent and low movement OR at least until they are sedated. Could protocol change so that the genitalia are sanitized after sedation? I think the surgery has stolen a lot of the attention from the patient and that protocol could be changed to be more conscientious to the patients themselves.
This was my first day of going to the Operating Room (OR)
*I am searching for the surgery I am observing by doctor’s name, I walk up to a nurse*
“Do you know where Dr. ____ OR is?”
Nurse, “ He will be in room 8 and 4”
Me, “He will be in both OR 8 and 4 at 8:30?”
My first thought in the OR was how normal of a room it looked. The only special parts of it are the sanitation and the equipment. I expected the room itself to have a more surgical focused design. The surgical bed had a lot of attachments. There were arm extension that could be added on and straps that had to be added on manually. I became curious if it would be easier if all these attachments were not removable.
When the patient was asleep, there was a specific location the surgical team required the patient in for the surgery. They spend some time manually adjusting the patient to get them in the precise location they want them in for the surgery and also removing pressure off of pressure points on the body so that the patient does not wake up and feel sore from that constant pressure on their joints.
When the patient is positioned correctly they make an incision in the abdomen to insert a tube that fills the abdomen with CO2. This allows separation of the epidermis from the internal organs. Then the da Vinci Xi is used.
The da Vinci Xi machine is a robot that assists with laparoscopic surgeries. This device has a total of four extensions that enter the body through small incisions near the surgical area. The extensions can rotate in every angle. Then the instruments at the end of the da Vinci Xi extensions have seven degrees of freedom. These instruments are the part of the machine that will be accomplishing the surgical objectives such as locating the desired region or organ, cauterizing, and suturing. The reason why this machine is so useful is because the incision sites are so small so there is not a large scar. Probably the best part of this is that the instruments that are used on the end of the robot’s extensions are millimeters in size. Much smaller than the space a surgeon’s hands would need to complete the same surgery. Two extensions that are constantly being used are the camera and suction. The camera has great resolution and is displayed on several monitors surrounding the patient in the OR.
This image is also displayed at the da Vinci operating table. This is a table where the surgeon operates the robotic extensions and and instruments at the end of each extension. He has is own three dimensional image that he sees, through a device similar to a microscope. Both of his hands are on two joysticks that control the extensions the surgeon wants to move. The surgeon can move this in every direction that the extension and instrument can move. For the instruments that open and close they are sensitive to the surgeon’s squeezing the joystick. At this separate operating table, the surgeon also controls when to cauterize. This cauterization presents some difficulty during the surgery. Since the abdomen is filled with CO2 the smoke produced by cauterization makes the air inside the abdomen harder to see through, because of the smoke (just like smoke at a fire would).
The suction tool that is inserted into the abdomen just like the robotic extensions provides a partial solution. This suction extension is dependent on someone besides the surgeon at the robotic operating desk. This person must move this extension independent of the robotic operator. If this extension is not close enough to the device that is cauterizing, then the camera become smoke and the surgeon is forced to pause and wait for the smoke to clear. A potential solution is to have the suction extension combined with the cauterizing so that the smoke can be cleared during cauterization and the operator of the robot does not have to wait.
When I first started we, me and my group, went to four locations before we located the resident that we needed to be in contact with for our Clinical immersion urology rotation. I understood quickly that in order to get as much out of this program as possible a more persistent learning style would be needed. Even though this program has just started I am amazed at the equipment and technology that is being uses. Many procedures and technology seemed almost futuristic and serial. The more I saw the prouder and more excited I became about future project I would be working on and as a aspiring bioengineering.
The first patient I saw needed a prostate biopsy. The patient looked very uncomfortable. Already ideas were coming to my mind for how to make this process easier for the patient and doctor through changes in the equipment. During the prostate biopsy there was a large needle that was use to grab specimens for testing. There was a loud clicking sounds that went off when the needle went in to take the specimen. This obviously made the patients tenser. I am sure a design could be made that does not make a sound and could be more silent.
Another complication with the prostate biopsy was locating the suspected cancers region of the prostate. The MRI imaging gives the information about suspected cancer and then the doctor sets an appointment to get the specimen. However, during the biopsy, they cannot location the suspected cancer region found on the MRI. Which forces them to take 12 samples (all different regions) in case the cancer is currently isolated to a certain part of the prostate. What would be helpful is if during the imaging process there was a way to flag the location that the doctor is concerned about, i.e. Leave some sort of indicator for the ultrasounds machine (which is used for taking the prostate specimen) to better isolate the desired location to test.
The ultrasound probe had a unique design. After it was inserted and you located the prostate the probe allows the needle to go through the ultrasound prop so the needle is guided to the exact location the the ultrasound shows.
Another potential concern is the chance of infection since the needle will have to go through the rectum into the bladder. They give him some medication to try and clean out the rectum. But there is still a chance of infection which is concerning.
There is a test that is done called the Prostate-specific antigen (PSA) that has to be done every 6 months and forces the person to come into the clinic. What would be curious to find out is if this test could be done at home similar to a glucose level test that can prick your finger and test the PSA and alter you if there is a need to come in and it send that information to the patient’s doctor and the doctor can review the information independent of the patient’s presence.
This clinic also has a very nice setup where all the nurses, attending, residents and schedules sit together this helps speed up communication and efficiency of the office.