University of Illinois at Chicago
Yesterday we gave our final presentation to Dr. Jeon. During part of our presentation we mentioned deficiencies we noticed in the da Vinci system. After the presentation we continued on to discuss robotic surgery and it was interesting to hear about Dr. Jeon’s thoughts.
To Dr. Jeon robotic surgery is nowhere near being used for all types of surgeries. He still believes that kidney transplants are actually more effectively done by hand. Part of the reason he says, is the design of the robot itself. He brought up several good points.
First off he mentioned that changing the instruments takes too much time. “It’s not a robot” he said, “if can’t do that on its own”. He brings up a good point. Many robotic surgeries actually take longer than their hand counterparts. This could be a reason why.
Along the same lines he mentioned that in robotic surgery, the surgeon is not in complete control. He began to describe the differences. In surgeries done by hand the surgeon is right up against the operating table he is the closest to the patient. Whatever he needs is handed to him by an assistant instantly. With robots there’s just too much lag. From our observations I could not agree more.
Finally he brought up what we had noticed in the OR. Communication is just too difficult with the da Vinci system. The speaker system is not built for direct communication with so many people in the OR doing their jobs.
Overall I can understand and agree with Dr. Jeon on a lot of points, but in the end we both came to the conclusion that it is a system that is slowly improving every day.
On Friday we discussed our ideas with Dr. Jeon for the first time. Several interesting ideas surfaced. One of the things we talked about first was the way Dr. Jeon used hemostats during surgery. As noted in an earlier blog, Dr. Jeon cauterizes tissue by first making contact with his hemostat and having an assistant touch the cauterizer to the tool. The tool passes current through to heat the targeted area.
Upon discussing this, we realized that surgeons from all fields of surgery use this very same technique to cauterize tissue. To us it was just interesting enough that surgeons would use these tools together in this way that they were not meant to be used, so we continued to ask if there were any drawbacks. To our surprise there were many.
Dr. Jeon said that in many instances, the current might momentarily pass through his fingers instead of the patient. Additionally he said the hemostats sometimes reached a high temperature. The photo above shows his index finger with several small burns from surgeries he performed.
Our discussion eventually led to talk about existing solutions. We learned that there were many, but that this was still the simplest and most sure way to go. We feel that continuing to explore this issue may lead to important conclusions.
In hemodialysis clinic patients come to use dialysis machines do to impaired kidney function. I learned that these patients come to clinic a few times each week for a total of 12 hours in order to filter their blood using a dialysis machine. In order to send out enough blood, patients have to allow access to a large artery. Sometimes the subclavian is used, but that happens to be incredibly inconvenient for the patients as the port would be on their chests.
The solution to this is creating a fistula. A fistula is the joining of an artery to a vein in order to create a higher rate of blood flow. Generally these fistulas are created in the arm of the patient. It can happen by directly connecting an artery to a vein or by using synthetic tubing between the two in a graft.
The potential problems associated with creating a fistula are many. For one blood can be directed away from the hand sometimes leading to ischemia. The second is increased diameter of the vessel leading to increased preload to the heart which may lead to heart failure. Most commonly however, the site is very vulnerable to infection. A large percentage of fistulas become infected very early leading to corrective operations. One patient we saw had come in 3 times only to be in for another infection the day we visited. The fistulas are also often cosmetically unappealing as they are raised above the skin and surrounded by scar tissue.
It interesting to see how complex taking blood out and returning it to the patient can become. I do feel that there is potential for better solutions to this issue.
On Thursday we saw our first kidney transplant surgery. The surgery was about 6 hours long and took place in two separate operating rooms. In one of the rooms a patient’s kidney was removed using robotic surgery, and in the second the recipient received it. Two surgeons were required for the length of both surgeries.
As Dr. Jeon performed the second half of the surgery on the recipient I noticed that he would occasionally use the hemostat as a channel to conduct the current from a cauterizer. It is, as he mentioned in our talk, very useful to be able to spread the heat of a cauterizer so that it could target a specified area between two plates. Closing a vessel often requires a hemostat. He simply extended that purpose by using it in combination with a cauterizer.
Periodically throughout the operation when he felt he had the hemostat in a position he felt was suitable, he gave the signal and a resident would touch the cauterizer to the hemostat. It seemed to work well as nothing unexpected happened and the method was used throughout the surgery. I did feel it was interesting that although so many products were constructed for this very purpose, Dr. Jeon preferred the familiar feeling of a hemostat in his hands. I remembered his claim that it was the first tool ever made specifically for surgery. To me it makes a lot of sense that he’s most comfortable in continuing to use it in place of newer, less familiar equipment.
Tuesday was our first day in transplant surgery. We met in Dr. Jeon’s office and he began to to talk to us about the history of transplant surgery. We discussed cauterizers and the difficulties involved with keeping an organ alive as it transitions from donor to receiver. Additionally we talked about the system that transplant surgeons go through when an organ is ready for transplantation.
Dr. Jeon described to us two types of cauterizers currently in use. He started by giving us the background we needed to understand how they worked. In simple terms cauterization is the heating of tissue using electric current which passes from one part of the tool into the other. When using a monopolar cauterizer, the current travels through one tip and into a plate on the patient’s leg. In the dipolar type, current travels from one tip to the other and the tissue in between is heated. In order to prevent tissue damage by overheating, the cauterizers have been made to pulsate current which allows them to heat tissue more slowly. Dr. Jeon felt that this was a space that could benefit from innovation.
Next we talked about keeping organs alive as they are transferred from one patient to another. We talked about what an organ needs to remain functional and various methods people have tried and the problems they ran into. In the end we got valuable insight on how these limitations effect the lives of transplant surgeons. When organs can last for a few hours outside of the donor’s body, it means surgeons have to be on call all the time in case the match comes in one day, even if it happens at 4am in the morning. As it is right now, completely random events dictate the schedule of transplant surgeons.
During our second day in the operating room we saw a set of procedures we had not previously seen. We saw two complete hip replacements, one of which was done anteriorly and one which was done posteriorly. We learned that the anterior method was slowly becoming the more preferred procedure because fewer muscle had to be cut and reattached to the femur. Instead a pocket could be made anteriorly between muscles.
The tools used for both types of procedures were impressive. Since the anterior method required more movement of the leg, the patients leg was attached to a lever which made changing the orientation very easy. The procedure seemed to take a longer time, but many of the residents had not done it previously which could have been the reason.
We noticed that during both procedures several steps required estimation. This included orientation of the cup and placement of the implants into both the femur and the pelvis. We felt that this estimation could be reduced to improve results. Particularly in obese patients, we noticed it was difficult to estimate where bones were and how they were oriented using only surface anatomy.
Overall it was interesting to see two ways of putting in the same type of implant.
On Thursday we spent some time in the operating OR with Dr. Gonzalez. It was definitely a change of pace. We all arrived at 6:30 am ready to see the types of surgery that people we had seen in the previous two weeks needed. There were full knee replacements and a hip replacement.
In full knee replacements I noticed that very little was ever estimated by the surgeon. The cuts made on the tibia and femur were completely guided by jigs that were standard. The alignment of the jigs was determined by a computer which could be mounted on the tibia. As the surgeon shifted the patient’s leg forward and back, side to side, the computer used information it collected to compare the motions to it’s database of previous patients. Based on this the surgeon knee where to place the parts of the implant.
One thing I noticed was that the spacing for the polyethylene plates often required several tries before the correct size was determined. To get a good idea first, the surgeon spread the tibia from the femur using a specific tool. Once the space was apparent, the surgeon estimated the size of the plate and tried several. He tested the size by extending the leg and seeing if it could fully extend. To me this part of the process felt very qualitative. It seemed like the only step which required some kind of guess and check.
Overall our first day in the operating room was amazing. I really enjoyed seeing the variety of surgeries that were performed.
Today our team visited a separate orthopedics clinic with Dr. Mark Gonzalez. The clinic, Illinois Bone and Joint Institute (IBJI), was located at 150 N Michigan Ave in the middle of the city. It was interesting to note the many differences between this clinic and the one we had visited previously.
The overall environment in the clinic was the first difference we all noted. At IBJI there was only one resident and about 15 patients scheduled for the entire day. The atmosphere was incredibly relaxed and the physician had plenty of time to sit down and personally look at x-rays for an extended period of time compared to physicians at UIH’s clinic. At UIH some of the physicians we spoke to scheduled upwards of 60-70 patients per day. This along with the 10-15 residents and students that would regularly walk the halls and collect information created a much more cluttered and busy environment. We definitely got the impression that this was a less stressful environment because of the nature of the work.
Additionally, the rooms at IBJI had flags outside that marked the room number. The numbers indicated which patient was in first. This was a system analogous to the one Dr. Mejia had come up with using magnets. The flags at IBJI were managed by a PA and not the physician nor the resident themselves.
As a side note having less patients gave Dr. Gonzalez a chance to talk to us about some of his research. He also presented to us slides from his lectures and gave a brief presentation on engineering in orthopedics. To me it was incredibly helpful in getting a good idea of the types of innovations that are happening in ortho right now.
Overall I look forward to returning to the clinic next week and seeing more of the inner workings of this specialty.
Our first week of immersion has been productive and fairly interesting. I’ll use this entry to quickly mention the diversity of small issues we’ve identified as a team. One thing I’d like to point out is that I’ve noticed our diversity as a team allows us to identify a fairly wide variety of problems that one person alone would not be capable of seeing. Brief and intermittent group discussions about our finding are incredibly useful in getting to the bottom of a lead someone might have. Here are a few of our findings.
The attending often has issues with rooms that are around the corners. He said that keeping them in mind was hard because they were not in the same hallway as the majority of other doors. For that reason, rooms that are around the corner are most likely to be missed for a little bit longer. Michael pointed out that a simple mirror could solve this issue and easily make looking down a single hallway sufficient. One resident pointed out that people sometimes bump into each other near those corners. This could solve that issue as well.
Mohi realized pretty early on that no one really knew where the attending was at any given time. Plenty of people both residents and nurses would regularly ask for his location amongst each other, yet his whereabouts in the clinic always seemed to be information that simply was not available to everyone. His responsibility in the clinic makes it so that it would definitely be useful to know where one could find him at any given time.
Upon speaking with a resident, Annmarie noticed that patients wasted a lot of time waiting for a resident or physician to send them to x-ray, when they’ve been told they need one before the visit. It would often be marked on their main sheet and yet they were sent to a room in the clinic to wait, upwards of 20 minutes sometimes, for someone that would just move them along in the process. Being sent directly would be helpful.
There were lots of other issues we identified that would improve overall efficiency of the clinic and I’m sure even more that we haven’t. A realization I made this week is that a group of different people is definitely helpful in identifying non-obvious problems.
I spent my first few days of IMED rotation in UIC’s Outpatient Care Center. There I sat in the orthopedic dept.’s clinic and watched as residents ran back and forth to their attending physicians while patients worked their ways in and out of the clinic’s many rooms. At first it didn’t feel like there was much to observe. Everything that happened seemed completely routine and the system chugged along in a relatively regular fashion. In an effort to better understand the inner workings of what was happening, the engineer inside of me gravitated towards the most stressed out looking person in the vicinity.
I walked past what seemed like thousands of residents to the one and only scheduling nurse Jackie. Jackie had a lot on her plate. She moved patients into the clinic, collected information from them, and occasionally directed residents to specific patients’ rooms. I spoke with her while she worked and it soon became clear that there were plenty of little inconveniences in many aspects of both her work and the work of other employees in the clinic. As we spoke I noticed what seemed to be a misplaced bag of refrigerator magnets on her desk. “Oh these? Dr. Mejia uses them to label doors when the clinic is busy.”
I soon learned from Dr. Mejia that keeping track of patients in the clinic was not as simple and straight forward as it seemed. After I pointed out the bag, he was more than happy to stop what he was doing and demonstrate the purpose of his refrigerator magnets on Jackie’s desk, in this clinic, at UIC’s Outpatient Care Center.
In short the magnets were numbers he used on the door frames to signify the order in which patients entered the clinic. A few of them were letters which he occasionally used to mark a room for what its patient needed next. The numbers ensured that everyone could keep track of which patients arrived first and that they were addressed in a timely manner. Here I’ll recall a resident’s account of the occasionally forgotten patient, in the room of the clinic that just happened to be skipped one too many times. Dr. Mejia’s creative solution is an attempt to prevent that from occurring too occasionally. For him it works, and his marking of the rooms with O’s (Operation) and B’s (Brace) are helpful in maintaining the steady flow of patients in to and out of the clinic. In a structure with so many doors, his solution seems to convey a helpful bit of information that is just enough to keep things running smoothly for him and his residents.
While it’s convenient, it’s also kind of not. Every time a patient leaves, each number suddenly belongs on a different door. This amounts to a lot of walking as Dr. Mejia or Jackie try and make this shift of numbers possible. Watching Dr. Mejia make this shift happen for a situation with just four patients seemed like more work than most physicians would sign up for, but to him it was worth it because of the benefit it brought to his patients.
My first few days of watching the dept. of orthopedics functioning have been a learning experience in several ways. In trying to imagine an orthopedic specialist at work, most might picture a surgeon in the OR sawing and drilling in an effort to make some kind of repair to a damaged or dysfunctional segment of a patient’s musculoskeletal system. While this description is partially accurate, I’ve learned it may not encompass many aspects of a surgeon’s work he/she may consider most stressful. Managing patients in a clinic, I’ve learned, is one of those aspects. I look forward to further analyzing our findings together as a team in future conversations with Dr. Mejia and other physicians.