University of Illinois at Chicago
After being told the next patient wasn’t English-speaking, the resident quickly called for Ivan. A few minutes later, a tablet fixed atop a cart (see picture above) was wheeled into the patient room. Ivan is the department’s on-call option for translations. Once in the room, the tablet-based service functions as an audio call that connects translators to patients and physicians at the point-of-care. A few quick notes on the process can be found below:
-Restricted audio. While the patient was clearly relieved to be able to communicate her symptoms in her native tongue, I circled around the tablet to find a dial pad display on the screen. While the service is no doubt effective, one must wonder if a patient would feel even more comfortable if the translator were able to “facetime” in providing visual feedback to create a more organic interaction.
– Surprising quality in communication. Despite the fact that all patient-provider interaction was funneled through Ivan, the encounter may have been one of the clearest I have observed to date. While there were some issues with audibility at the beginning, knowing that everything he said had to be translated almost seemed to force the physician to communicate as clearly and succinctly as possible—a skill that could no doubt benefit patients who don’t need a translator as well.
-Limited interaction. While the content of the conversation was clear, it was admittedly asymmetrical. The physician would direct himself towards the patient when speaking, while the patient would direct herself at the translator (functionally, at the table on wheels) while speaking. The difference in attention no doubt capped the comfort with which patient-physician interaction occurred.
It was equally interesting to see how language can affect patient autonomy. As the translator spoke, I’m not quiet sure she realized that the individual she was speaking to was actually the patient’s family member, and not the patient herself. Healthcare technology is often seen through the lens of diagnostics, but Ivan is a great example of how technology affects care delivery, rather than any actual treatment.
For our final procedure in Urology, we had the chance to visit the operating rooms of the clinic located at 900 N. Michigan Ave. With only five operating rooms compared to the nineteen at UI Hospital, it made for a much more relaxed environment. Although it was difficult to fully assess the capabilities of this smaller space in only a day, it didn’t seem that the doctors or nurses lacked anything they needed which was encouraging.
After seeing our first vasectomy last week, it was very interesting to see the same procedure reversed today. The most shocking difference was the increased need to access the vans deferens. With the vasectomy, the vans deferens were pulled through the skin and clipped before being reinserted which kept the incision site very minimal. The reversal, on the other hand, needed incisions so large that they could completely pull the testicles outside of the scrotum. This is done because doctors need to actually find the location of the vasectomy.
After reaching the vasectomy location, a couple of issues need to be assessed. The main concern is the extent of scarring after the surgery. First, the vans deferens are cut on the urethral side of the vasectomy and saline is injected into the tube. If the saline flows easily, that means there are no significant “downstream” blockages. Next, the viability of the testes portion of the vans deferens needs to be assessed. To do so, the epididymis is massaged until it secretes fluid. This fluid is collected onto a slide and examined under a microscope. The doctors then look for the presence of sperm cells on the slide. If they are present, this means that there are no significant “upstream” blockages.
Assuming both of these tests are successful (as they were in our case), the ends of the vans deferens can be connected and the patient is once again able to procreate.
In our last week of this rotation, we spent a lot of time talking to doctors about why they chose to specialize in Urology. The common thread in their answers came back to the use of technology. Urology got its start by using scopes to see inside bladders, something that wasn’t commonly used in other fields. This trend of heavily utilizing technology has remained a staple in Urology as we saw with the utilization of things like the da Vinci robot.
All in all, it was a very enlightening and exciting program that I am very glad I could be a part of. Thanks for reading!
The most interesting procedure that we had the chance to observe during the beginning of our final week of the program was a prostate biopsy. The patient expressed elevated levels of prostate-specific antigen (PSA) and had difficulty during the prostate exam. These are both indicators of prostate cancer and he had to be brought in for a biopsy to confirm the presence of cancer. The biopsy is done with the assistance of a transrectal ultrasound probe. This probe is inserted anally and used to help the doctors target the prostate and ensure that the samples are taken from a variety of locations throughout the prostate.
This was very interesting from an engineering perspective mainly because of the difficulties with the biopsy instrument. To begin with, the instrument is not intuitive at all. It is a cylinder with a long extrusion that contains the forceps. The scrub nurse must first twist the bottom of the cylinder multiple times to load the spring. While there is a display port indicating if the probe is ready, this is also not clearly marked and caused confusion and delays at the beginning of the procedure.
Next, the doctor inserts the biopsy gun into a port in the ultrasound and maneuvers it until he can see it pressed against the prostate on the ultrasound. After clicking the fire button, the forceps spring out and bite off a portion of tissue. This is done twelve different times at six sites throughout the prostate. After the gun is handed back to the scrub nurse, the nurse must remove this miniscule bit of tissue from the instrument and transfer it into a specimen container. This also proved to be extremely difficult and time consuming.
Due to the size of the tissue sample, it is very difficult for the nurse to tell if an adequate sample has been taken, if at all! This is compounded by the transfer process. The scrub nurse can either swish the tip around in saline within the specimen container and hope it detaches, or they can wipe the tip against a piece of wetted cloth. In both instances, it takes an extremely sharp eye to confirm that the sample has transferred properly and that the biopsy gun can be handed back to the doctor. As you might have inferred, during this entire transfer process, the doctor is sitting there with nothing to do. While a second instrument might help decrease operating time, it would also increase associated costs.
All in all, it seems like a much better biopsy gun would greatly improve the ease and efficiency of this procedure.
It’s the end of the second week in Urology and I can’t believe how fast the time has gone by. Mainly this is because they are in the process of moving the Urology clinic, so all of our time has been spent in the operating room (OR). Time in the OR flies by because even if you’re observing a surgery you’ve already seen, there is usually at least one wrinkle that makes this patient unique and changes something about the procedure.
The first surgery we observed this Thursday was a Urethral Stent Exchange. The plastic stent that had previously been implanted had degraded and needed to be replaced. Metal stents can be in place for up to a year, so the doctors chose to replace it with a metal one. These metal stents look like a tightly coiled spring and curl both at the kidney and bladder ends to keep it in place. This is a fairly straightforward procedure but there was one hiccup that may be easily addressed. The doctors used metal forceps to reposition the stent in the body but because the forceps and stent are both metal, they kept slipping and made it difficult for the doctors to control the stent as much as they would have liked.
Another surgery of note at the end of this week was a typical cystoscopy. The patient came into the clinic complaining of monthly recurring urinary tract infections that had been going on for the last ten months. A quick cystoscopy could narrow down the potential causes and normally would be done under local anesthesia in the clinic. However, with the clinic in the process of moving buildings, there isn’t an established space and this patient had to have the procedure done in the OR with general anesthesia. A urine sample was collected at the very beginning of the procedure to test for interstitial cystitis. Other than that, the procedure was done in a manner of minutes. A quick, yet thorough confirmation that the bladder was normal was all that was needed.
Lastly, I got to observe a staple of Urology, the vasectomy. In this procedure, a small segment of each of the vans deferens are removed. The most interesting thing I learned from this procedure is that the ends of the tubes that connect to the testicles are cauterized because sperm is immunogenetically foreign and can cause chronic pain. During this procedure I also saw another trick used by the surgeons that I found very interesting. Sometimes, while pinching some tissue with a pair of tweezers, they would apply the Bovie to the proximal or middle portion of the tweezers. The electric current would pass through the metal and cauterize the tissue in contact with the tweezers. This was an ingenious method of acquiring more precise cauterization.
During the first week of a new rotation, it’s almost entirely spent trying to understand everything that is going on and this makes it impossible to look for improvements. After having already been through a rotation, I knew that at the beginning of this week I wanted to focus on looking for those potential improvements.
The first procedure I observed this week was one that I had already seen before, a Greenlight Cystoscopy Transurethral Resection of the Prostate. However, this procedure was slightly different because the patient had a large bladder stone that also needed to be destroyed. While tools exist that can mechanically crunch bladder stones into pieces that are small enough to flush out, these were not available. Instead, a holmium laser was used to break up the bladder stone and the green laser was used to remove the excessive prostate tissue.
The main issue with the addition of the bladder stone process is that the stone and the prostate are destroyed by different wavelengths of light, which requires two completely different lasers in the operating room. While the fiber optic that aims the laser at the tissue is about the size of a strand of pasta, the laser itself is similar to the size of a large bedside table. If both of the lasers could be generated from a single machine, it would cut down on the number of machines in the room and make this type of procedure much easier for the doctor.
Another procedure of note at the beginning of this week was a Robotic Ureteroneocystostomy. This is done because of a stricture of one of the patient’s ureters near the bladder. To fix this, the impeded portion of the ureter needed to be removed and the healthy remaining tissue reattached to the bladder. There were a number of very impressive technologies at work aiding this surgery. First, a dye that is visible with X-ray was injected into the patient at the site of the bladder and ureter. This allowed the doctors to determine the extent of the blockage and how to proceed with the surgery. Next, a cyanine dye called indocyanine green (ICG) is injected into the affected ureter. This allows the doctor controlling the da Vinci machine to select an alternate camera that filters all of the tissue to grayscale, except for the ureter with the dye which shines bright green.
Last week, I noticed almost all of the da Vinci attachments have the ability to cauterize tissue. However, some are labeled as monopolar and some as bipolar even though they might both be very similar tools physically. This is because monopolar tools use a ground on the patient’s skin (typically the leg), for their electrical discharges. Monopolar tools have a larger effect but are not very precise. Bipolar, on the other hand, passes electrical charges between the opposite ends of the instrument. This allows for much more precise cauterizing, but cannot be as powerful.
Lastly, during this surgery I saw a workaround that I almost couldn’t believe (pictured above). During robotic surgeries, precision is key and the doctor will often ask a technician for a suture of a specific length. While a technician’s kit does include a ruler, it is ridiculously small and typically only used as a reference for the technician to draw their own, larger ruler on the sterile cloth!
I spent the last couple days of the first week in the Urology rotation solely in the operating room. The sights were awesome and the smells were… less so. I had the opportunity to observe two prostatectomies, one robotic and one “old school.” It was really interesting contrasting the similarities and differences between the two. In both, samples of the lymph nodes surrounding the prostate were removed for future biopsy. This is done to determine if the cancer has spread to the nodes, which raises the severity of the diagnosis. Beyond the precision and less invasive nature of robotic surgery, it also has the advantage of containing the smell of burning flesh during the cauterizing process. Even so, you could still hear the clipping of the scissors through the skin and organs. That was not something I was prepared for.
During an abdominal mass excision, I saw a useful tool that I hadn’t seen utilized before. This was an endoscopic surgical stapler that is used to clamp a piece of tissue, and then it simultaneously staples the edges while cutting the tissue in the middle. It allows the surgeon to separate a piece of tissue while minimizing bleeding.
We also observed a cystoscopy on a patient with urinary incontinence. These are done to determine the specific cause of the patient’s problem. The cause of the problem was quickly determined. While interior organs are supposed to be smooth and supple, they can become muscular and striated. In this case, it is called trabeculation of the bladder lining. This is a result of long term bladder outlet obstruction and will require medication to treat.
Lastly, we were called to a patient’s bedside in the hospital. The patient had sustained an injury to his urethra seventeen years prior, and had been using a suprapubic catheter to collect waste from the bladder. These catheters need to be replaced monthly and should be done by a medical professional. In this case, the patient chose to replace these himself and had been up until a month ago, when he noticed blood during the exchange process and wanted professional help. It took him weeks to get an appointment and by the time he came in, the hole had begun to close. This made it impossible to get another catheter in and the hole had to be dilated, much like the urethra from my previous post. It was incredibly painful for the patient and he had to be given morphine for the pain. While this was a long shot to do at the bedside, it would save the patient a trip to the operating room. Luckily, they were able to get a catheter in and saved the patient an expensive trip.
Well my first rotation is up and it’s on to the next one: Urology. My introductory reading on the subject informed me that this particular discipline focuses on the urinary tract system and male reproductive organs. The main reason that Urology was at the upper end of my preferred rotations is their extensive use of the da Vinci surgical robot, which is one of the coolest and most advanced pieces of medical technology around today.
Right off the bat, we observed a transurethral resection of the prostate using cystoscopy. The patient was having difficulty urinating due to an enlarged prostate, which had to be trimmed down. To accomplish this, they used a laser which is tuned to the specific wavelength of blood vessels. This allows the doctors to clear away the obstructive tissue without bleeding, very similar to the cauterization tools like the Bovie which I saw used extensively in Orthopedics.
The actual implementation of this involves pushing a scope through the urethra up to the location of the blockage, and then passing this laser through the scope to precisely target the tissue. Now, you may be thinking that this sounds like a lot of things to be passing through a urethra and you’d be right. I’m going to try and describe this as clinically as possible but seeing it in person was much more visceral. As we were told by one of the doctors, “The urethra must be dilated to fit all of the equipment.” This is done by inserting rods of increasing diameter into the urethra to stretch it out until it can handle having a relatively large scope pushed through it. After that initial trauma, the rest of the surgery went smoothly and was very fun to observe.
The next surgery we had the opportunity to see was a robotic partial nephrectomy. We finally got to see the da Vinci machine in action! This patient had a tumor on top of their kidney that had to be removed and seeing it happen had to be one of the coolest procedures I have seen to date. Here’s some awesome things I noticed while watching the da Vinci machine at work:
- Two camera feeds allows the operator to see the operation take place in three dimensions. At first, I was skeptical about how useful this would actually be (thanks 3D movies), but I was truly blown away after sitting at the operator’s station. It was like seeing it in front of you, it was incredible.
- There is a special screen in the operating room which can be written on by other doctors much like an NFL commentator. These annotations can be seen by the operator and used to target specific tissues.
- The da Vinci also allows the doctors to place a an ultrasound feed beneath the main screen of the operator. With this enabled, they can use an ultrasound probe and see what is beneath the tissue in front of their instruments.
The first half of the first week is mainly about getting used to the new rotation and taking it all in. I’m very impressed by everything that has happened already and can’t wait to see what will happen during my time in Urology.
After three blazingly fast weeks in the Orthopedics department, my rotation has come to an end. First, however, I’d like to focus on everything that happened in the last portion of this final week.
After Frank’s casting class, we attended another lecture to all of the residents led by Dr. Gonzalez. The topic concerned hip implants, something we had not seen yet in the operating room, but had been seeing in x-rays and hearing about since the beginning of the program. This was very convenient because we would be seeing two different hip procedures the very next day. That afternoon was spent in the clinic and was a very atypical experience due to the low number of patients. The only real moment of note was a patient that had torn their ACL and meniscus. While talking the patient through the procedure, Dr. Goldberg explained that it could be done using the patient’s own tissue, or taking the tissue from a cadaver. A patient electing to use their own tissue faces lower rates of infection or rejection, but also loses about 10% of their knee flexion strength (not enough to be noticeable to the patient). Most patients see this as a fairly easy decision to elect for their own tissue and this patient was no exception.
Thursday was our last day in the operating room with the orthopedics team and it did not disappoint! As I mentioned earlier, we had the opportunity to begin by observing our first total hip arthroplasty. While I could probably write a whole post just on this procedure alone, I’ll stick to the moments I found to be most interesting. For starters, the patient needs to be held on their side during the procedure. This is accomplished by rolling up edges of the bedroll and inserting posts into the bedframe which brace the patient on their side. I also noticed levels of sterilization within layers of sterilization. For example, the patient must be sterilized, draped, a “sock” applied to the body part of interest, and lastly, an Ioban surgical drape must be applied to the skin around the point of incision. There’s the whole overview. You may, as I previously did, consider these steps to be singular. The interesting part I noticed was during the sterilization of the limb with the betadine surgical swabs. Even then, you sterilize the dirtier portion last (in this case, the foot), without going back over the surgical site with the now “less sterile” sterilization swab. A little confusing, but also makes a good deal of sense.
We also had the opportunity to observe some more carpal tunnel release surgeries with the endoscope. One we missed completely by observing a different operation in another room. While we were walking back to check in on it, we caught Dr. Gonzalez leaving the room. He had taken just thirteen minutes from incision to suturing to complete the entire procedure. This was very impressive to me and I took it as a revealing glance inside just how effective and efficient modern medicine can be.
The next surgery was not quite as smooth. This patient was in for a hip arthroplasty revision, meaning that they were having issues with their current implant and need it removed and repaired. In this case, the implant hadn’t been sized properly for the patient and had wiggled in the bone, eventually breaking through the bone wall with the distal portion of the implant. While removing the implant and drilling a new hole for the new implant, the femur fractured. This required additional work where wires had to be wrapped around the femur to keep it in place. Six hours after incision, the procedure was finished.
We spent our final day in Orthopedics back with Dr. Gonzalez in the clinic. Where we gave a patient a steroid injection for trigger finger in his pinkie. He claimed to have had corrective surgery to each other digit, but only wanted the injection for now because the recovery time would prevent him from attending Burning Man. Whether it’s the patients, the residents, or the doctors themselves, you never know what to expect in the medical field.
Next week I’ll be starting a new rotation with a new partner. I hope to learn as much as I have these first few weeks and I’m sure I will. I can’t believe this program is at the halfway point!
To start our final week of the first rotation, we met at the Innovation Center and participated in a workshop geared to get us thinking about empathy. As I’ve written about previously, the one thing that has surprised me about my experiences so far is how quickly and easily I detached myself emotionally from the patients. It’s very easy to be so concentrated on the procedure and the problem getting fixed that the fact this is a living person drifts to the back of your mind. We spent that afternoon in the clinic with Dr. Chmell. After seeing a total knee replacement done with using cemented implants, I wanted to know why he chose to use the cementless implants with hydroxyapatite. While he had a number of reasons for doing so, he emphasized one particular point. He said, “Academic institutions should be at the forefront and using the latest and best technology.” I was not expecting an answer like that and was very impressed. It makes a lot of sense to me that the medical students should learn the newest technology because that is what they will most likely be seeing a lot of early in their careers. Obviously the technology will continue to improve over their career, but by starting out their careers with experience at the bleeding edge, they are more capable and knowledgeable.
Next we got permission from the Scheck and Siress representative to go down to the basement and get a tour of their workshop. This was definitely one of the coolest experiences for me so far. My admiration for prosthetics was one of the driving factors for be choosing to get a bioengineering degree and seeing all of the different varieties up close and personal was awesome. One thing that stood out to me right off the bat was how realistic some of the prosthetics were. I’d seen pictures but what blew me away was the fact that even in person and up close, it would be almost impossible to notice any difference. While I think I would personally want something more robotic looking, some patients have psychosocial concerns and want to blend in more.
We also met a patient who lost their knee to cancer at thirteen years old. Instead of living with a complete above the knee amputation, he elected for a rotationplasty. This is where the tibia is fused to the femur and the foot is rotated completely, allowing the ankle to function as a knee. I certainly had my doubts about the viability of the ankle being able to support weight and bend to the degree that is done by the knee but these were quickly silenced. It turns out that the patient is a record holder in the high jump at the paralympics! He had come in because his new knee was having some slippage with the prosthetic when he was running. The machinists were able to quickly attach some velcro straps that held the heel of his foot (now in the location of the patella), more securely. After a couple of incredibly fast practice runs down the hall, the velcro was doing its job.
We spent Tuesday with Dr. Gonzalez at the Illinois Bone and Joint Institute and it ended up being a pretty slow day. In one of the lulls, Dr. Gonzalez took the time to give us a lecture on the biomechanics of the digits which covered that anchor points of the muscles, tendons, and ligaments and the physics of how these work together.
Finally, on Wednesday morning, we sat in on a class taught by Frank, the orthopedic technician. Frank’s class covered a lot of interesting differences between fiberglass and plaster casts including the whens and whys between the two. In his experience, the older clinicians prefer the plaster because they’ve used it throughout their careers but he hasn’t seen a preference in recent years graduates.
I can’t believe that I only have a couple days left in orthopedics! Even when consciously trying to take it all in and process everything (which is pretty much impossible in the medical environment), it has flown by so much more quickly than I expected.
Wednesday was spent back in the clinic and was mainly uneventful. Even after roughly a week of experience in the clinical setting, some of the symptoms that patients came in for were starting to feel routine for me. That’s not to say that I am anything close to resembling an orthopedist, but you can only see so many people with carpal tunnel or trigger finger before they all start to feel similar and predictable. In one regard, I find it incredible that we’ve identified such specific and universal physiological markers of underlying disease that can be easily measured. In another, especially as a passive observer, watching a doctor tap on a patient’s wrist is only novel for so long. A couple of patients were entertaining purely due to their unshakable belief that they knew more than the doctors. I don’t think I’ll ever understand the reasoning of a person that goes to a professional for a diagnosis and then argues with them if they don’t like what they are hearing.
Thankfully, the next day we were back in the Operating Room with Dr. Gonzalez. The first procedure was a total knee arthroplasty, something I observed the previous week with Dr. Chmell. Having already seen the procedure twice before, I was feeling pretty confident that this would be right in line with expectations. And, for the most part, it was. Until they began prepping the inner portion of the implant with a thick paste. My mind scrambled, “Where’s the hydroxyapatite?” It turns out that doctors are actually given a significant amount of freedom to choose the tools that deem best for each surgery. While one doctor may feel that the bone ingrowth onto a hydroxyapatite-plated implant is significant enough for use, another may feel that the cemented method is more reliable. If there is no significant consensus in the literature, both are allowed to perform the surgery in their own way. While I do have some reservations about this degree of personal choice, I’ve ultimately decided that it’s probably best for the doctors to be as comfortable during surgery as possible.
Next up were a couple of closed carpal tunnel release surgeries using an endoscope with a blade attachment. This was a very cool procedure to observe because the endoscope was attached to a large screen and the point of surgery was very easy to see, unlike some of the other operations we had seen in the past. The advantage of doing this surgery “closed” is that the doctors only need to make one small incision for the endoscope instead of cutting open the whole wrist. However, the correct ligament is sometimes more difficult to find. In one of these surgeries with a fairly obese patient, the ligament was lost in all of the fat tissue and the surgeons were having so much difficulty locating it that they almost switched to an open surgery.
We closed the day by sitting in on a ligament reconstruction. The patient had torn a ligament in their thumb and had lost significant functionality. The doctors solved this by removing a vestigial tendon in the wrist and reattaching it to the thumb. This degree of resourcefulness really impressed me. As we learned later, artificial tendons and ligaments still have yet to be developed and so doctors have discovered a non-functional tendon from the patient’s own body that they can simply remove and “reinstall” somewhere else entirely.
Friday morning was very slow due to abundant patient cancellations. The heat index at 105 degrees was very likely a contributing factor and I can’t say I blame them! In the afternoon, Dr. Gonzalez presented a very insightful overview of the engineering applications within orthopedics.
At the beginning of the second week of our program, we once again met as a group to discuss the specifics of our final reports and catch up on the progress of the other students. Hearing the differences in the daily routines within each specialty was very interesting. We also discussed different ways to extract information from the professionals we were observing without being too intrusive and interfering with their job. To help present our initial observations to the rest of the teams, we built a design board with post-it notes under three different categories: Equipment, Process, and Observations (pictured). Lastly, Naz and I talked about which “problem statement” we were going to identify in our final report. While I had reservations about this due to only having one week of experience to draw on, as we talked about our interactions with all of the medical staff it became clear that there was one thing on everyone’s mind: time inefficiency. With so many patients to see in a given day, any sort of delay in the process has massive effects on everyone involved. For example, a delay of one hour in the operating room makes every subsequent patient wait another hour (at least) before being seen, costs the hospital $4,800, and keeps the doctors and nurses at work and away from their family for an additional hour (again, at least). We agreed that any process or product that could assist more efficiently leveraging time in the operating room would be gratefully received.
That afternoon, we were back to clinical rotations. Right away we were introduced to a new medical procedure that heavily utilized engineering principles. It is called a “reverse shoulder replacement” and works by replacing the “ball” and “socket” portions of the shoulder with titanium implants and switching their natural orientation. This is due to the physics of the musculoskeletal system. To lift your arm, the deltoid takes on most of the load but also requires activation of the rotator cuff. In patients with a torn rotator cuff and a regular shoulder replacement, this is very difficult because the deltoid is only able to lift the arm partially. With the reverse shoulder replacement, the ball portion of the joint is attached to the scapula, allowing the deltoid to “roll” the joint up the ball and raise the arm on its own.
There was a patient at the end of the day that came in for a third opinion. He was a seventy seven year old man experiencing some shoulder pain. Two previous doctors had told him that they wanted to do a reverse shoulder replacement and he wanted to confirm with Dr. Goldberg that the surgery was his only option. After examining his range of motion, Dr. Goldberg told him that he could get the surgery if he wanted but if there wasn’t significant pain and his movement wasn’t inhibited, he didn’t need the surgery unless he wanted it. The patient was very happy to hear this and said, “I’ve been told twice that reverse shoulder replacement is [the only option] by doctors that never asked about my quality of life.”
The next day was spent with Dr. Gonzales at the Illinois Bone and Joint clinic on Michigan Avenue. We observed seventeen patients over the course of six hours which kept things at a steady pace without feeling too overwhelming. One thing on the mind of many of the doctors was the recent release of surgical complication rates by ProPublica. While doctors support transparency, there were some issues with how ProPublica decided to define complications. For example, readmissions are counted toward a doctor’s complication numbers. Additionally, there were concerns that this type of ranking would negatively impact patient care. Doctors concerned about their ranking may be inclined to not accept patients needing procedures with a high risk of complications, such as infections.
After wrapping up the Orthopedic Conference, we attended training for the first year residents led by Dr. Mejia. While the training videos about suturing and other skills were interesting, Dr. Mejia’s anecdotes about real-world benefits and drawbacks helped make the lessons more applicable. One comment from Dr. Mejia concerned the practice of “signing your site.” This is where the surgeon writes his initials on the body part to be operated on before the surgery starts. Apparently, before this was implemented, 24% of orthopedic surgeons would accidentally operate on the wrong side of the body at least once in their career. I, for one, am thankful for this change in policy.
Another surprise for me at my first look “behind the curtain” of healthcare was the physicians use of the internet. It’s very easy to assume that physicians are a walking encyclopedia of medical knowledge and let the title “Doctor” mask the fact that they are real people, with the same limitations as the rest of us. The medical field is so advanced and full of information that many caretakers will take a moment to refresh their knowledge of the specific issue the patient is presenting in order to provide the best possible care.
Dr. Mejia said something during our clinical time that really changed my (biased) view of how doctors treat patients. A patient arrived that was supposedly suffering from “trigger finger,” a condition in which a patient’s finger will sometimes lock in a fixed flexed position. However, while the patient had been recently asymptomatic, they were very insistent on receiving a shot to help with the ache. Here is my poor attempt of paraphrasing what he said, “Everything in medicine is a risk assessment. Even if the patient wants something, the shot could lead to an infection, a diabetic reaction, or other negative things. The odds are low but it is still a risk. There is no risk for wearing a splint.” As an engineer, I feel like I’ve had a bias to jump to the solution, any solution. Think a shot will help? Sure, let’s go for it? Reoccurring pain? How about surgery? This statement made me realize the emphasis in the medical field on starting with treatments that are as minimally invasive as possible and only once all options have been exhausted, moving up from there.
On Thursday, we spent the full day in the clinic working with patients. This was also my first time seeing one of the coolest pieces of technology I had seen so far; the “lidocaine popper,” also known as the J-Tip syringe. This syringe uses compressed carbon dioxide instead of a needle to deliver the drug through the skin.
Friday was spent entirely in the operating rooms with Dr. Mejia. The day began with two carpal tunnel release procedures. For these, I was most impressed with the efficiency of the tourniquet. With how highly vascularized the hand is, there was essentially no blood until the end of the operation when it was released just before suturing. We also had the opportunity to observe a mass excision which is pictured above.
The last patient required a finger amputation as a result of severe frostbite. Even after my short two days spent on the opposite side of the surgical knife, it became easy to dissociate with the patient in surgery. Until this final patient. While waiting for the anesthesia to set in, his teary gaze remained locked on his hand. It was one of those moments in where you feel like you know a stranger’s thoughts. The empathy came back quickly as I realized he was looking at his finger on his hand for the last time.
What a way to end my first week.
After just the first two and a half days in the program, I am already impressed with the wide array of experiences I have had the pleasure of being exposed to. My first rotation is in the Orthopedics division and I spent the first afternoon observing outpatient procedures with Dr. Chmell.
The most engineering-focused case was when Dr. Chmell showed us some x-rays from a patient with a tibial fracture. This patient had a titanium rod inserted through the tibia to assist with healing. Until fairly recently, these rods were typically stainless steel but titanium has surged in popularity due to the fact that it’s modulus of elasticity is more similar to that of bone. However, the rod was now bearing the load instead of the bone. This greatly reduces the force of compression at the point of injury, which is actually what stimulates the natural calcification healing process.
The next day was spent in the operating room (OR). Here we began by observing two total knee replacement surgeries. These were fairly routine procedures for the team on staff and I was very impressed by their speed and efficiency. The distal portion of the tibia is actually sawed into a boxy shape and then the titanium replacement is fitted onto it, without the need of sealant to fill the gap between the bone and the implant.
Here are some of the most interesting observations from these surgeries:
- Before the procedure begins, blood samples are taken from the patient. The platelets are extracted from the samples and concentrated during surgery and then injected back into the patient at the site of injury to speed the healing process. Emphasizing as natural as possible solutions was something I hadn’t previously considered.
- Representatives from the company that designs and builds the implants were actually in the OR during the procedure and advising the doctors on which size implants to use. The doctors all spoke highly of the depth of knowledge of the reps with regards to their products and were glad they were present for the operations.
- At the interface between the bone and the implant, the implant was coated with a layer of hydroxyapatite. This encourages bone fixation and allows for the implant to be attached to the body without the use of cement.
The last surgery we observed on that day was a young male with a severe tibial fracture as a result of a gunshot wound. This involved screwing a titanium plate onto the tibia across the fracture. To constantly gauge the progress of the surgery and check the location of the screws, there was a constant stream of x-rays taken; requiring us to wear a lead jacket throughout the operation.
Due to the rarity of operations like this, the industry representative was even more instrumental in the success of the surgery. He continually talked the doctors through the correct implementation of the proprietary instruments. While extracting the bullet was ultimately not feasible, the plate was attached successfully.
Lastly, the first portion of our third day was spent in the audience of an Orthopedic conference. Doctors and medical students took turns presenting different case studies or specific injuries to the group. Occasionally, people would be called on to answer questions about the anatomy or treatment so you had to be on your toes!
Over the first couple of days in this program, I have had an incredible array of experiences. From the OR to the clinic to the classroom, there is always something new to learn.