University of Illinois at Chicago
This week we got to witness and experience a few things that were different than what we have seen so far in this rotation and the last. What really stood out to me was the fact that we got to meet a hospital biomedical engineer who maintains and fixes the devices and equipment in the hospital. We shadowed him for the whole day so we better understood the behind the scenes of device management. First, he showed us an anesthesiology machine with a monitor that stopped working in the middle of a big surgery. he explained to us the importance of quickly responding, identifying the problem and replacing the device or component that is causing the problem. It turns out some solution from an IV bag leaked onto the transducer in the anesthesiology machine. The biomedical engineer described how replacing parts of a device are so expensive simply because the company knows you’d rather buy it from them to avoid liability when the components are simple and inexpensive. We also saw the company field engineer look at the anesthesiology machine and decide the problem. It was interesting how first he needed to come look at the problem and then order the parts and then come back later to fix it. This delay can me very problematic especially if the type of device is sparse in the hospital and the spare would need to be used for some time. The biomedical engineer also showed us how he has access to all the monitors in the hospital for if a health care provider calls filing a problem, he can see what the problem is from his end before heading over to that location. It seems that most of his calls are user misuse of the device and not having the proper training on the device. I am sure there is a simple fix for this where time isn’t wasted on the health care provider waiting for the engineer. The biomedical engineer also does diagnostic tests on the devices to make sure they work properly. Some devices do it automatically every morning and sends a report to him. Other devices require a monthly “check up” from the biomedical engineer. The engineer preached the importance of us understanding the voltmeter and ampmeter, because that’s “all you need” to be an engineer. It was interesting to see the back end of medical devices in the hospital and how the processes run there.
A patient is in the waiting room, called in for registration, then seen in triage, sent to wait again, and finally placed in a bed. Every patient whether they have a large wound or just need their medications are placed in a bed. These beds are in shared rooms, private rooms, or the hallway. Of course running tests and labs might take some time due to lapses in another department running the tests/labs or receiving the results in a delayed manner. So in the ED patients that are not going to get admitted but are in a bed while waiting. At the same time, the larger issue appears to be the wait for open beds upstairs for ED patients to get admitted to. Some patients end up taking up a bed or room and stay for as long as 24 hours waiting to transferred to the department admitting them. It also appears that communication with those other departments are difficult and unclear. When an ED patient is ready for admittance, the doctor will literally call that department and just ask if there is a bed. Maybe knowing if the hospital is full before some patients are seen, ED could have provided a more efficient flow. Sometimes they do know and then they communicate with patients accordingly or even go on bypass. What really shocked me however was that when an admitted patient is unstable on the floors, they are brought down by the nurse to the ED where they need to wait to register and be seen by the ED and again take up a bed when they have a bed on the floor. I really thought the departments would have people who can react in emergency situations without having the patient come down to the ED. It seemed entirely inefficient to me, and it really crowded the ER when 4 floor patients were brought down at almost the same time. Now I better understand why people wait a long time in the ER, the doctors and nurses all work very had to see patients as soon as they can, but waiting for beds seems to be what slows them down.
The first day (or rather, night) of emergency medicine has been one that comes with mixed feelings. As much as the emergency room seemed busy or crazy, there didn’t seem to be much going on. We started the evening by discussing with an attending physician what she feels is the biggest obstacle in the ER, we got on a tangent and instead discussed the possibility of having a monitoring system that was wireless using Doppler or ultrasound technology and sent the data to a cell phone. Although this was solution based thinking, it helped us realize the overall frustration of not having a more mobile modality to accessing patient information, especially as an ER staff member that is always on the move. The first thing we noticed walking into the ER was the lack of space, there are patient beds in the hallways, and there were not enough computers for ER staff to use. When it comes to space, an especially important aspect we noticed was the lack of space for family members that come with the patient. Another major factor is the beds flow. Beds flow includes the time it takes to get a patient in the waiting room on an ER bed and the time it takes to get a patient admitted and moved from the ER and to their respective place in the hospital. As one resident explained it, the ER looks for like “organized chaos,” and what was interesting is that despite the minor complaints, staff seem satisfied with how the ER is.
Since it is the first day observing the ER, there are a few things we saw, but we weren’t sure what to make of it. There was a pop up on the patient monitor screen that covered a room’s monitor readings; it stayed there for a bulk of the night without anyone getting concerned. The picture above shows the pop-up warning I am talking about. There were so many sheets of papers hung up on walls, on the main white board, and on desks giving instructions. I felt as though they could easily be ignored because there were so many of them around. It was the same way with the sounds: there are monitors beeping, phones ringing, pagers going off, cell phone notifications, and more that I can’t identify. With all the false alarms, there came alarm fatigue. We observed an emergency ophthalmology examination, it was interesting that the doctor used an app on his phone to check the patient for color blindness. But what really surprised me as it surprised me in anesthesiology was sterility. We saw an examination for an open wound on an extremity. The wound was exposed down to the fascia, yet the physician just used regular gloves to examine and touch the wound; I imagined the use of sterile gloves at that point. Another major thing I witnessed and thought would have been more streamlined was the fact that in order to take patient history and information, the doctor writes down everything they ask the patient on a scrap sheet of paper and go back to a computer and try to type it all out as fast as possible before they forget. Every examination had the same questions that follow OPQRST, an acronym that asks the important questions to understand why the patient is in the ER. Yet, for every exam the resident would have to rewrite their checklist and write the answers. I felt like the least that can happen is to have a template checklist typed out for them, if not a tablet device to take down patient info directly.
The next three weeks will be useful in better understanding what is an actual problem and what is just “organized chaos”.
The anesthesiology rotation has come to an end and it was very bittersweet. In one way, I was very excited to share our findings with the rest of the Clinical Immersion team, but on the other end, I felt like I really was going to miss the rustle and bustle if the OR. I will miss everyone’s willingness to teach, explain and help. Dr. Edelman is an amazing mentor and his passion for his job is the positive energy I know I’ll miss. Today we gave our presentation to the Clinical Immersion team and I really thought about what the past three weeks consisted of.
We saw some branches of anesthesiology I didn’t know existed. Aside from pediatrics and cardiology, we also saw pain management anesthesiology. Spending the day in clinic, we saw a major problem with EMR, where the physician was forced to spend another 15 minutes after each patient typing, rather than the templates we saw being used in the OR. We also discussed with a pain management attending the multi modal structure that should make up a pain clinic: a team that consists of the anesthesiologist, a psychiatrist, a physical therapist, a social worker, and whoever else might help provide a more wholistic form of care.
We also got to do a later shift in the OR. The OR was backed up due to scheduling with surgeries that were scheduled for earlier in the day. Although that day had 12 ORs operating at 6 pm compared to the usual 4 ORs they have, it was still considered a slow day. What was interesting was that there was a “Gift of Hope” surgery scheduled; this is a removal of donor organs from what is considered a deceased patient. The surgery ended up being canceled right before its scheduled time. Dr. Edelman explained to us however, that because the heart would have been still beating, the anesthesiologist would need to maintain the heart rate and blood pressure to ensure the viability of the heart and organs. They would also need to provide a sedative for paralysis because there could muscle stimulation which is “outright creepy” as Dr. Edelman stated it. Besides that interesting conversation with Dr. Edelman, not much happened that night. But what we did notice was how crazy scheduling is and how some people end up working longer than 12 hour shifts with only a few hours break before coming back again. I thought the system for scheduling would be more defined with protocols for each scenario, but it was very much going with who was available and who was okay with working a few extra hours.
From what we have seen the past three weeks, we have seen three major themes: culture/communication, technology/layout, and sterility. They all go hand in hand in describing the overall needs in anesthesiology and the OR. We got to see some really cool technology in this rotation, but there is always room for improvement.
My first shift for my next rotation, Emergency Medicine, starts tomorrow and I’m very excited to see what it holds. It will be an overnight shift, go big or go home, right?!
By the way, the photo above is really cool because those are my brain waves on a bispectral index (BIS). Anesthesiologists use it when they want to know how “conscious” the person is. The higher the number the more awake and aware they are. Everytime I blinked or smiled, my BIS would change immediately, it was very cool to see.
The past week of anesthesiology has been a concoction of different experiences. We saw anesthesiology in pediatrics, in MRIs and in examinations. Being in the anesthesiology rotation is very interesting to me because spending everyday in the OR, I get to see things from the perspective of the surgeon, nurses and techs in there too. I can’t help but notice how resilient the human body is. We saw a surgery where the surgeon took bone muscle and skin from one part of the body and reconstructed it for another part of the body. Also the fact that the heart can stop completely during surgery and be started up again according to when the surgeon wants is amazing. In the case of stopping the heart, a perfusionist would take control over blood circulation and the drug control from the Anesthesiologist. The heart lung machine is this very large contraption with lots of tubing coming out of it, that when connect to the patient, the blood is circulated into this machine, oxygenating the blood and returning it to the body. What’s interesting is that our heart uses pulsatile flow according to the closing of its valves. However, this machine uses laminar flow with some turbulence; this isn’t the most ideal environment for the organs. The perfusionist needs to make sure the patient is producing urine to ensure the organs are still properly working. There came a time when pulsatile flow was used with the machine, but results showed that there wasn’t a very different trend than that of laminar flow machines and that it was just much harder to maintain. I think that the unnatural flow of blood regardless of the type of flow is what causes organ damage, and I would imagine that with better technology that would become more natural.
It is very interesting to see the dynamic of all the team members in an operating room. I would have imagined that with a big procedure happening there would be a better procedure or way of doing things. So many things are done perfectly, while other things seem like simple miscommunication that could have been avoided in the first place. In one surgery, a cardiology team came to insert an Echo scope down the esophagus to monitor the heart. It intrigued me that no one knew whether they needed an Echo at that point in time and were just like “Oh yeah sure we can do one, I guess, since you’re here.” I thought it would be known in the OR if the echo was needed and during which part of the procedure. Then the Echo team didn’t have the right sized scope, so they just tried to make it work, and when it didn’t, they called it a day, left and didn’t come back. If this was a necessary procedure, shouldn’t the proper size have been provided and an Echo completed. If it was an unnecessary procedure, why did they even try and irritate the patient’s esophagus.
These common themes keep popping up at us: communication, technology, and sterility. And it is very interesting to see how these things keep coming up over and over.
The image above was taken from: http://www.aviva.co.uk/health-insurance/home-of-health/medical-centre/medical-encyclopedia/entry/technique-surgery-using-a-heartlung-machine/
The start to week two has been different and interesting. On Monday, we arrived at the hospital in time to tag along with some Anesthesiology residents to the Simulation lab. The Simulation lab is a facility dedicated to medical education using scenarios and mannequins. I was very impressed by how similar they tried to make the room look like an actual OR or examination room (refer to the image attached). That day we met Morgan and Alex, the adult Laerdal mannequins. They are made to simulate all signs actual patients might show in different scenarios except for movement and skin temperature. That’s what the simulation tech is there for though, she answers questions the students might have about the simulation without providing a solution for the task at hand. What’s interesting is that while discussing with someone from the Simulation lab, he knew there are better options out there, but UIC just doesn’t have them yet. This seems to be a recurring theme in the hospital. For example, the difficult IV pumps, an easy fix for better accuracy and more user friendly features comes in the new products. I think the reason it might seem like the hospital is a little behind in technology, is completely due to costs and politics. At the end of the day, the financial people in an office away from all the clinics and physicians can’t justify the cost of replacing all IV pumps. For example, every pump in the hospital would need to be changed for compatibility with all IVs in the hospital and to train all those people on the new device would cost a great sum. There is also a risk of inefficiency due to delays for the time it takes to simply replace them; similar to what we observed in the Surgicenter the first day.
Today, Tuesday, we were lucky to join a very passionate surgeon for a gastric bypass surgery. He was passionate for making sure the patient has a high success rate with their weight and health after surgery. He also took the time to voice his concerns for the technology used in laparoscopy. “In ten years, your students will go to the museum and tell you about this outdated equipment,” explained the physician while showing us the laparoscopy surgical instruments. We very obviously see that there isn’t a very wide range of motion with the long skinny graspers that go into the patient. The physician is in an uncomfortable and unnatural position leading to possible carpal tunnel. Coincidentally, the surgeon today had an injured wrist and had difficulty using the device. The movements associated with laparoscopy are also paradoxical, meaning that to grab something from the right the surgeon’s hand needs to go left; with this comes a large learning curve, making it a more procedure that requires more training time. Compared to the Da Vinci robot, the Da Vinci allows for a wider range of motion and more natural motions for the surgeon leading to comfort, accuracy and efficiency. It seems to me the concept of laparoscopy might become “ancient” as this physician said with the development of more advanced robots.
The first day of clinical rotation on Tuesday afternoon, was short and sweet. We met with our mentor, Dr. Edelman and he showed us the Surgicenter, where small procedures are done. The hospital had taken advantage of the long weekend and they were reorganizing for better efficiency. He showed us the monitors and the importance of balancing privacy and patient information. He voiced his concern of not having enough computers to complete patient paperwork, something the hospital could easily be avoided if the hospital invested in a tablet for each room to be used as the patients’ charts. We also noticed that each room was separated by curtains and there was not much privacy for the patient and their family and I can only imagine how loud it gets when each room is being used. Next, we saw a small procedure OR. The room was teeny-tiny and the anesthesiology station took up three-fourths of it. Although the computer automatically inputs all the ventilation parameters into the web chart, the IV data needs to be inputted manually.
Day two of my anesthesiology rotation started with a class about airway management and the devices that are used in maintaining an airway. We saw the mac and miller blades used to push the tongue back and open the mouth to the proper position to place an endotracheal tube. They were metal and the doctor teaching mentioned the caution needed because they can hurt the patient. We also saw a laryngoscope and a glide scope that showed video feeds into the mouth for better endotracheal tube placement. The main draw back I saw was that although the device had a small screen it still felt chunky, in the way, and inconvenient. The surgery we saw next was such a miracle to see, and also the one I thought could’ve been so much more efficient due to the little things. It was a Mya Mya, which is rare and an acute constriction of internal carotid to the brain. So the surgeon needed to make an opening in the scalp and connect the external carotid to the constricted internal carotid to supply blood to the brain. In order to identify the exact location of the donor artery, we saw the surgeon us a Doppler device; she struggled with it for a little bit and the sounds were not very clear, there was more interference than I expected. Also that day, anesthesiology’s IV warming device seemed to interfere with the EEG signals and cause noise. The prep of the patient took so long and the mess of tubes and wires did not help; there was some time spent with the surgeon try to find the best location to put wires and tubes so that it is not in the way of surgery. I also noticed the sterile pens used to right on the patient’s scalp would die out really quickly and they constantly need to get replaced. The pins used to the the patients head in place on the operation table was a very heavy and difficult contraption to maneuver that definitely made the surgeon’s life very difficult initially. Also there were some things I just did not expect to see, like when it was time to wash the patients’ scalp before surgery, the water just spilled onto the floor were a towel was just thrown after and the water dripped down the EEG wires, which I’m pretty sure could be very dangerous no matter how insulated the device is. I also noticed the light source the physicians had to use to power their headpieces was like a projector and each time the surgeon moved, someone outside the sterile field had to undo the connection and connect her to another one; something that can be made battery powered and wireless.
First week of observing anesthesia and surgery has been an amazing and impactful experience and I look forward to all the future procedures to see.
There are four stages of anesthesia as explained by Dr. Edelman: anxiolysis, monitored anesthesia care, deep sedation, and general anesthesia. Anxiolysis describes minimal sedation, the patient is still able to breathe for themselves but they have reduced anxiety. Monitored anesthetic care is next level of anesthesia where the patient is sedated and is only responsive to physical stimulation and loud noise; the patient has a safe airway and can still breathe for themselves. Deep sedation is when the patient responds to obnoxious stimulation and may need assistance breathing. General anesthesia is a state when the patient is unconscious, unaware, numb, amnesic and needs the anesthesiologist to basically breathe for them. When the patient wakes from anesthesia, it is called emergence.
Let me tell you, waking up at 4 am to leave my home by 4:45 am and drive to the city by 6 am to park and walk 15 minutes to the hospital has put me in quite the trance this week. Especially with my religious holiday, Eid, having been on Wednesday, I wasn’t getting much sleep when I got home either, because of celebrations. So, every day felt like I was under some anesthesia probably somewhere around the second or third stage, where my thought process was slower and I could barely make out what I did each day. The first day of surgery, I saw an IV being put in. I have a serious fear of needles, I can watch an open heart surgery being done but once I see a needle entering a vein, I get very light headed and dizzy and want to throw up. Each day that has been getting easier. I’m starting to really get the hang of the schedule and watching some really uncomfortable procedures and hope to remain at the stage of anxiolysis, where I know exactly what is going on, but don’t get anxious.
So far, from what I have been seeing, Anesthesia is an art more than a science. Although there is a protocol for how to handle situations, I have seen many anesthesiologists playing it by ear, going with the “IV” flow, and making the most of the resources they have. But I have also seen so much time being wasted on detangling tubes and wires, making sure their devices don’t cause electrical interference for other devices, sitting there waiting on lagging equipment. Precious seconds that could save the hospital thousands of dollars and, in a life or death situation, save a person’s life. Anesthesiologists are natural problem solvers finding solutions for these problems all on their own, including using an unused ventilation tube and cutting it longitudinally to place all the IV tubes in when transferring the patient from the OR to the recovery room so people do not accidentally tug on the IVs. There are so many physicians, nurses, techs, and more that have really taken from their precious time to explain to us and teach us, and for that I am so grateful; Dr. Edelman especially has been very patient, understanding, and passionate to help us learn and grow.
This is a photo of how an anesthesiologist’s work station might look like in a small procedures operating room. Notice the tangling of tubing and wires.
This past week although hard, has been the most amazing and inspiring four days of my entire college career, with feeling truly privileged to see some procedures that most people do not see. I have come to deeply appreciate the human body for its strength and resilience. The human body is the most well oiled machine that is the greatest teacher for any bioengineer, and I look forward to learn more.
Stay tuned for another post with everything I have seen this past week.