University of Illinois at Chicago
After a rather slow second week, our last and final day in the orthopaedic department was spent watching a multitude of surgeries. It was probably the best ending of a rotation that I could have asked for. The first surgery was a hip surgery. It was interesting to see how different surgical “teams” interact with each other. By changing just one of the members in the team, the dynamic within the OR is completely different. Regardless, the operation passed quickly with no complications. The second surgery was a carpal tunnel and a DeQuervain release. I was extremely exciting to finally see a carpal tunnel release surgery after hearing how simple it was from the people from the last rotation. The incision for a carpal tunnel release is no longer than an inch long at the wrist. Once the incision was made, a cut is made to the ligament and an endoscope is used. The endoscope had a single camera, this made it difficult to see if it got dirty, and an extremely bright light so that the doctor can see where the scope is when inside the wrist. When the scope is far enough to decompress the nerves, a blade is engaged and the scope is pulled out. The scope is reinserted into the wrist to ensure that the surgery was done completely. This entire process took twenty minutes.
I found the carpal tunnel surgery rather impressive in comparison to the hip replacement surgery. There was less technology to perform the surgery, but it required more attention to detail. This was only proven further when a nerve repair surgery was performed on a child. Previous nerve repair surgeries appeared difficult enough to perform when done on an adult. However, my favorite surgery overall was the tendon repair. Not only did it entail a repair of the tendon, but pinning as well. This procedure was often referred to as a goalkeeper. The tendon had separated from the thumb and had to be sutured back together. There is a ligament that lies on top of this tendon and when the tendon breaks, the ligament shifts down. With the ligament moved down, the tendon cannot repair itself. The finger was pinned to ensure that the tendon was repaired straight and correctly. The ligament was then cut so that the tendon could be sutured first. The tendon rolled back on itself, so this was essential for proper healing. The ligament was repaired next. This was a complex surgery and by far the most interesting in my opinion.
I truly enjoyed my time in the orthopaedic department and this internship. In the orthopaedic department I was able to experience the clinical side of the medical field that I wasn’t able to see in anesthesiology. I learned so much about the medical field and gained an interest in industry medical device design. I hope to use the knowledge that I learned in this wonderful program next year in senior design and for all my future endeavors. This was a wonderful experience that I won’t forget!
After two weeks in the orthopaedics department, and five weeks total in the immersion program, I thought that I would come into my final week well prepared and ready for what was coming this week. But I was definitely wrong. Compared to last weeks, this week’s clinics were jam packed with patients with various symptoms and ideas with how they wanted their treatment to be.
Monday’s clinic, albeit just the afternoon, was mostly filled with surgical follow-ups and older patients that were experiencing pain. What I noticed was that some patients come into the clinic with a problem, but have certain limits on the type of treatment they wish to receive. Whether or not their desired treatment option is available or not is a completely different story. While many doctors consider cortisone injections as minimally invasive for joint pain, some patients do not agree. While many patients seem more than satisfied to accept physical therapy as a treatment option, others request pain medication. The complication that I have seen regarding medication prescription is that not all patients understand the rules that the physicians must follow in regards to prescription. While it is sad to see patients in pain, the physicians cannot risk their licenses. I think that it is important that some level of health care informs patients about such specifics, their privileges, and constraints.
Going back to patient desired treatment, patients with carpal tunnel are often hesitant to undergo surgery. One would hope that a pain in the wrist or tingling of the fingers would have a simple solution, but this is not the case. For these patients, there is no real in-between period. Doctors always want to ensure that surgery is not performed when it isn’t needed, so they perform diagnostic tests, ask for history, and order for an EMG to be done. Unfortunately, physical therapy does not help since their symptoms arise from the compression of the nerve by the ligament. The doctor does not tend to push towards surgery until the patient begins to lose feeling in their fingers since this could put the patient at risk for injury. While this is more of a doctor directed problem, it would be great in order to improve patient satisfaction and quality of life.
Last week on Thursday, we were only three knee replacement and one hip replacement surgery. After Tuesday’s clinic, we reached a total of 10 hand procedures to be performed this Thursday. Hand surgeries are much shorter than total joint surgeries so having ten procedures is normal for these surgeons. The patients that were added to the schedule on Tuesday were cases in which the risk of complications increased the longer the surgery was put off and since our mentor will not be available the following week, they had to be scheduled. A few of the patients that we saw were cases in which the patient had put off their appointment because of work scheduling, improper diagnosis elsewhere, or denial of injury. One case that stood out to me was one patient who was screened at a physical therapy location to see if their finger was fractured or not. They were given a splint and told that their finger was only sprained. After several weeks, the finger did not improve and patient still experienced pain. Coming into the clinic, the patient’s x-rays showed that they had a dislocated fracture that was beginning to heal in place. In order to go about fixing the fracture, the surgery will most likely include rebreaking the bone, aligning them properly, and pinning or screwing them in place. At this point even I had to agree that a proper diagnosis cannot be made without an x-ray.
Between scheduling conflicts and patients thinking that they didn’t injure themselves too badly, patients can go several months without seeing a doctor. If the patient waits too long, the risk of the procedure increases or the procedure may not be performed at all, which could cause more problems done the road.
On Thursday we were able to go to the OR once again. This week three total knee replacements and one hip replacement. After having already watched a total knee replacement the previous OR day, we were able to observe more of the actual procedure rather than being lost in the environment.
The procedure begins by making an incision to the knee. Apparently different surgeons have preferences on the length and location of the incision, which was surprising because all the patients, even ones that did not have surgery at University of Illinois Hospital, seemed to have similar incisions. The patella is shifted and flipped to the side while the surgery takes place. Knee Align, a disposable device, is put on a tool on the knee that ensures that the cut that will be made on the bone is straight. If the bone is at an angle after it is cut, the bone has to be shaved down until it is leveled. Before, if the bone was uneven a wedge was placed under the implant to level it out. This method was ruled out several years ago due to shear stress. While Knee Align is especially useful to show the residents and medical students the ideal alignment of the knee before a cut, this tool is used by attending primarily to ensure accuracy. To ensure that the femur is aligned correctly, a rod is placed in the femur all the way to the tip to keep the leg straight. This practice is still used in many ORs. Over the years, and through practice, the alignment of the knee becomes easier and more accurate. The use of Knee Align, in our experience in the OR, is used to confirm the surgical decisions already made. Of course, not all surgeons use this device. I wonder if the use of Knee Align will become more popular with younger surgeons, much like the use of other new medical technology. I have noticed that the tools that are often used in orthopaedics are very simple and basic. The tools for surgery are similar to those of carpentry and the tools used in the clinic are also very simplistic. With training, even the use of some of these tools are not completely necessary.
One thing I noticed during surgery that I found interesting was the use of ARISTA. Last week I brought up the use of a potato starch that the surgeons put on the patient before suturing the outer layer of skin. At that point I wasn’t sure if the “fairy dust”, as some jokingly called it, was actually made of potatoes or if it was just another joke. This week I found out that the product is called ARISTA. It is a hemostatic powder that helps in the healing process for various surgeries. The powder helps with clotting during surgery. Once in contact with blood, the fluid is absorbed and turns into a gel type mixture. This is used as a precaution during surgeries before the tourniquet is taken off. I believe that this product is relatively new in the department based on how much it is talked about and how surgeons have told other surgeons to try it out.
The hip replacement surgery was a very quick procedure. After the incision was made, the entire implant placement process took less than an hour or even 45 minutes. Unlike the knee replacement surgery, it is much harder to watch a hip replacement surgery since it is not as exposed. A saw was used on the hip and the femoral head was taken out. The surface of the femoral head is supposed to be smooth. In this case, there was an indentation on the surface of the bone because the hip was collapsing on itself. The hip implant components include a hemisphere, a liner, and a stem. In order to create a compressed fit, there are drills that resemble the stem and the hemisphere that allow the bone to reach the ideal shape for one of the implants. Once this is done, the hemisphere is inserted at a forty degree angle. It has to be forty degrees and not more to replicate the natural physiology of the hip. After inserting the hemisphere, the liner is placed to prevent any metal on metal interaction between the implants.
I cannot wait to see what the next OR day has in store for us!
While most of our time in the orthopedic department is spent at University of Illinois Hospital, every Tuesday we follow Dr. Gonzalez as he does clinic at the Illinois Bone and Joint Institute. The first thing that I noticed about the clinic was the amazing view that overlooks the lake, museum campus, and soldier field. I immediately felt that this place was completely different from the hospital clinic. With only eight rooms available, only a couple of physicians were present to attend to patients. Unlike the university hospital where we see about 80 patients a day, we saw about 20. The schedule wasn’t extremely packed and there would be downtime in between spurts of cases for the resident to dictate.
The Illinois Bone and Joint Institute has orthopedic doctors in various specialties in different locations around Chicago to attend to patients. Like at the university clinic, we see a lot of knee replacement follow-ups, carpel tunnel follow-ups, broken bones, etc. So far in this rotation we have seen quite a few trigger finger case. Trigger finger occurs when the causing the finger to be stuck in the bent position and extremely painful to straighten. The tendon develops a nodule that can cause irritation to the sheath that provides a tunnel. This irritation can lead to inflammation and the tendon can no longer fit through the tunnel. The first line of treatment for trigger finger is a cortisone injection. This both numbs the hand and reduces the inflammation. If the condition does not improve then the tendon is released from the tunnel.
Another case that we saw the first week was cupital tunnel release follow-up. At that point I had no previous knowledge that this was an actual condition. On Thursday we were able to see the procedure for this. It occurs when the ulnar nerve is being compressed, much like the conditions of the more standard carpal tunnel release. After watching the diagnostic testing for carpel tunnel syndrome, I would like to observe the diagnostic process for cupital tunnel. No advanced technology is used to diagnose a patient with carpel tunnel. The doctor generally tests for tingling or numbness. First he taps the patient on the wrist to see if the patient gets tingling in the fingers. Then, he holds both arms out, hand facing down to see if there is tingling there. If there is, he generally gets the patient to stand up and bends their neck side to side. If there is tingling in the fingers when he does this, it could be indicative of a neck problem. If patients do not get tingling or possibly have lost sensation in their fingers, he uses a paperclip test. Using the paperclip that holds the labels to the patient’s records, he bends the paperclip so that there are two prongs. He then has the patients close their eyes as he places either one or both ends of the paperclip to different areas of the finger. If the patient’s condition is very bad, they begin to lose feeling in their fingers. For some patients, it is not until this test is done that they are convinced that they have carpel tunnel. The doctors may also send the patient to get an EMG. The problem with the EMG is that 10% of people with carpel tunnel have regular EMGs. In general, the diagnostic testing for carpel tunnel is very simple, utilizing the limited resources within the department, but also effective.
One thing that stood out to me the most during clinic at IBJI was the way layout. Each office had two or three desks for the different physicians at the clinic, although each time we have been there the other physicians are not. The patients are sent back to a room, which is located in hallway near at the end of the suite. After the resident attends to the patient, Dr. Gonzalez will look at an x-ray that is near the hallway if there are any or will directly see the patient and talk to them. When explaining the patient’s condition, he tries his best to explain the condition to the patient. Occasionally, he draws pictures to show what is happening to the patient. Other times, however, it is best to show the patient the x-ray. The patient walks into the hallway where there is a cart to look at x-rays. Now at the university clinic, there are 2 x-ray monitors for 22 rooms. Since all the residents and physicians have to share the monitors in order to check on their patients it is difficult to get time or room in the attending room to have the patients look at their x-rays. When I was a patient, looking at my x-rays helped me to realize how bad my condition actually was and later reassured me that things went well during the surgery. There is a reason people say a picture says a thousand words. When a patient is told that they have to undergo surgery, they are often hesitant or unwilling. Other patients are convinced that there are things wrong with their body that aren’t and want surgery badly. Being able to show pictures or patient x-rays could reduce the amount of time consulting with patients telling them that their knee is no longer good or that there is no real problem with their bones.
Ossama and I just finished our first week with the Orthopaedics department. While most of our week consisted of observing the attending in the clinic, I think that it is safe to say that we were both excited to see the surgical procedures. Thankfully, Thursday we were finally able to go to the OR. I was looking forward to seeing similar surgeries to those we saw patients in clinic recovering from and scheduling. I was surprised to find out that although orthopaedic surgeries are invasive, patients are allowed to leave as soon as the procedure is done and go in for a follow-up within a week. Because of this, I was really excited to see a few procedures and possibly see the follow-up the next week.
Although I have had the opportunity to spend a lot of time in the OR with anesthesiology, the experience was still extremely new. After arriving in the OR at 7, we got to watch a total knee replacement in progress. The doctors had just used a knee align device that ensures that the leg is positioned properly and not at an angle. From there, there was a lot of hammering, sawing, clamping, and drilling. A trial knee replacement, both the femoral and tibia components, was placed on the knee. The doctors then bent and straightened the leg and moved it from side to side. The movement seemed very rough on the leg but it was necessary to check the fit of the knee replacement. The entire process to check the fit of the prosthetic was very rough and repetitive. If the replacement wasn’t the right size or the shifting of the knee was not normal, corrections were made and checked by moving the leg over and over again. Once the correct implant was chosen, the doctor tells the medical vendor the sizes of each of the implants. The vendor has a pretty good idea of what kind of knee replacement that will be used but in case the implant size changes, there are a variety of implants in the room ready for use. The cement is mixed and applied to the patient’s knee. The implants are placed inside and the patient sutured up. During the procedure, the vendor said that there were different types of knee replacements for men and women. The knee replacements for men were narrower than women knee replacements. Since people have different bone structures and frames, these characteristics have to be taken into account when considering the knee replacement.
During the course of the day we were able to watch a few surgeries. The digital nerve repair and cupital tunnel release surgeries were very fast, taking a little over an hour at most. The nerve repair procedure was interesting since it utilized an absorbable implant tube to guide two ends of the digital ulnar nerve back together. However, the most impressive surgery in my opinion was the hand reconstruction. The patient had rheumatoid arthritis. Her hand and fingers were bent in various directions and angles, not allowing her to be able to use them. The procedure consisted of the doctors replacing her metacarpals with silicone transplants. An incision was made across the knuckles and one by one the knuckles were removed and holes were drilled for the implant to connect the fingers and palm. As each metacarpal was removed, the prosthetic size was determined. After all the fingers were prepped and measured, the doctors checked the sizing of in the trial implants one more time. The actual implants were installed in the patient’s hands and motion was tested. In order to straighten the hand some more, suturing was tighter on one side of the hand than the other. This helped to straighten out the hand instead of allowing it to go in different directions. While suturing the patient, potato starch powder was sprinkled at the incision site. I would really like to know about the reasoning behind this.
Overall, I wish that we had more OR time. In clinic there is not a great deal of technology, especially in comparison to the OR. While I feel as if I better understand the clinical aspect of orthopaedics, the surgical aspect still has a lot that is explored. I feel that at least one more day in the OR a week would allow for a more in depth analysis of the technology used.
This week began my orthopaedics rotation. During the first rotation a few groups discussed that they enjoyed being able to see the interactions between patient and doctor. While I was able to get glimpses of this before the patients were anesthetized, it was never to the extent of the other groups. Going into orthopaedics, I was excited to finally experience the clinical aspect of the hospital that I had missed during my anesthesiology rotation.
The first afternoon was a little rough. Some people seemed confused that new engineers had shown up instead of the old group. I feel that this is a problem that several of the groups have faced during this clinical immersion program. Dr. Chmell, the attending we followed Monday, is a hip and knee specialist. In the few hours that we were in clinic we were able to watch the doctors drain a patient’s knee, give cortisone injections, and watch “The Gel”. The gel, actually called SYNVISC, is used for patients with knee problems, often osteoarthritis of the knee. First used in racehorses to increase their racing career, SYNVISC is marketed to cushion the joints. However, the gel actually changes the pH of the fluid surrounding the joint. The injection contains sodium hyaluronate which in theory will help the hyaluronic acid within the body. The doctor first locates the area of injection, clean it, and numbs it with “freezy spray”. The needle is placed and the gel is placed behind the patella. The injection is given one of two ways. The first way, the patient lies on the table and the area opens up. The needle is then placed above the kneecap and inserted towards the center from the inner thigh. The second way has the patient sitting on the table and the needle is inserted from the outside in. Both ways were painful for the patients, so it was really a matter of which way was the lesser of the two evils. In order to get the gel out of the syringe, the needle was big and so it was predicted that a lot of the pain comes from that. One patient complained that it was not necessarily the needle that hurt her, but rather the pressure from the gel once it entered her bad knee. While several patients received the gel injection, others prefer to stick with the standard cortisone steroid injection. Studies have not shown that there is a significant difference between the cortisone injection and the gel injection. In fact, some countries do not even offer the gel.
Monday afternoon was considered a slow day even though we got to see a handful of patients. I would like to see how this changes from day to day for the next few weeks. I enjoy the communication aspect of the clinic. For anesthesiology, we often met the rest of the surgical team and the anesthesiologist in the OR after the patient had already given consent for the procedure. In clinic you get to hear all of the patient’s concerns and questions regarding their conditions and/or procedures. Sometimes of their thoughts spark curiosity and others just make you laugh for hours. I can’t wait for the next few weeks.
The past three weeks were spent primarily in the OR observing different procedures from various specialties. By the end of the third week it felt like we had seen everything that we could see and were ready to become anesthesiologists ourselves. However, in search for fun things to watch we were able to discover things that we had not seen before.
We were able to watch a mandibular facial reconstruction. The patient had part of their jaw removed previously due to cancer. During this procedure more of the jawbone was removed. The medical company was able to 3D construct the patient’s bones and plan where the metal and replacement jaw would go. Previously, during surgeries the surgeons would have to use tongue compressors to make measurements and bend metal. Now, the metal comes pre-shaped and the types of screws, where they are located, and how the bone is cut is planned ahead of time. These plans were placed on the wall in the OR. Whenever there were questions with the surgery, the surgeons would either defer to the wall or ask the company representative. One team of surgeons worked on extracting the fibula while the other worked on the jaw area. Once the fibula was extracted, it was cut with a shape guard to ensure an accurate cut. The bones were then placed above the metal on the jaw to remodel the jawbone. The fibula was used as a bone donor because apparently we do not really need our fibulas to walk…
Since all of our time was spent in the OR, I had never though about what occurs when a patient is experiencing chronic pain. At UIC there is a pain clinic that helps these patients by either providing the refills that they need to relieve the pain or giving them a steroid injection. In the cases that we saw cortisone was injected into the patients’ area of pain. For one patient, they injected the cortisone near the peripheral nerves on both sides. The other patient received the injection as an epidural. The procedures are very short and are performed in a small room. There is a desk, procedure table, monitor, x-ray machine, and cart in the room at all time. The patient is led to the room by one of the doctors and asks about the pain that the patient is feeling. Once the patient enters the room, the x-ray technician stayed in the room with the patient and talked to them. I felt that rather than leaving the room this made the patients more comfortable before seeing the doctor. Once the anesthesiologist comes in, they ask the patient once again about the type of pain they are feeling. Afterwards, x-rays are taken of the patients back while the doctor is in the room. From there, the spinal area of cortisone injection is determined. The x-ray is left near the patient to help the doctor place the needle in the correct location. This requires changing the angle of the x-ray to constantly. When the cortisone is being injected, a live scan is performed so that the anesthesiologist can monitor the distribution of the steroid. There is still pain after the procedure, and it takes a few days for pain relief to begin.
The pain clinic also makes lesions on pain causing nerves. We didn’t get too see this performed, but hopefully one day I will. I was surprised by how many procedure cancellations there were at the clinic. There was a long list of patients that the clinic sees for the entire day. Many of the patients were refills, which doesn’t require an elaborate procedure. However, there were still several procedures that were scheduled to occur that never showed up. Considering that these patients are experiencing chronic pain, I thought that they would definitely show up to relieve them of their symptoms.
I have learned so much in the past few weeks in anesthesiology. I really appreciate Dr. Edelman and entire anesthesiology department for showing us around. It was truly an amazing experience I won’t soon forget.
So far this week has been all about the needles. Generally when I think anesthesia, I automatically think ventilation tubes; however, anesthesiologists have to be pretty handy with a needle. As we followed different anesthesiologists in the past few weeks, we have seen various nerve blocks, epidurals, and even a few arterial lines. Sometimes the process took a matter of minutes. Other times, we watched as the anesthesiologist continuously tried to find the right location. It was not only a matter of the anesthesiologist who did the procedure, but also the patient. Occasionally in the OR we would her the attending tell the resident something along the lines of “Well it took me awhile to get it, it wasn’t just you. They were a difficult stick.” With the relatively new technology introduced to the field, such as using an ultrasound to determine where the needle is located inside of the patient, you would imagine that everything would be smooth sailing. However, all this new technology still requires lots of training.
To practice being anesthesiologists we used simulations. The first one that we tried allowed for us to practice extracting from the subclavian vein and internal jugular vein. We had seen an internal jugular vein catheter inserted in a surgery awhile back and it looked relatively straight forward. Before we even took an ultrasound of our own internal jugular vein. Depending on the patient’s position the vein would either expand to a giant circle or lay flat like a pancake. So we get to the simulation and the only thing that helps us identify the vein is the apex of a muscular triangle. So inserting the needle, not too deep and off to the side, we pull back the syringe. You are aiming for a blue liquid to come through the syringe, which means you got the vein. Red liquid means that you stabbed the artery. If nothing comes into the syringe, you haven’t hit anything. If air comes back, it is possible you punctured the lung. So after a punctured lung or two, I managed to get the vein! This was definitely a lot harder than I was expecting. During the surgery that we watched the anesthesiologists didn’t use an ultrasound to help them, which I find really impressive. Apparently, only those are not confident in finding the vein or if faced with a patient with no landmarks do they then use ultrasound. The subclavian vein was even harder. No ultrasounds were used here. On this simulation, ultrasounds have terrible resolution and it’s better to find the vein based on landmarks. There should definitely be better simulations for residents. I’m sure that real patients are nothing like muscular chunks of plastic. For the subclavian vein, you have to find the curve of the clavicle and go underneath it until you reach the blue liquid. If you go too far, then you’d probably hit the artery. So this was a little easier in my opinion, but I won’t be trying to do this again anytime soon.
So we moved on to practicing ultrasound guided nerve blocks. Before ultrasound, these blocks were done blindly. Patient feedback would be used to determine if the correct nerves were blocked. Now with the ultrasound, anesthesiologists are able to see where they are putting the drug. We have seen various nerve blocks since we started our rotation, and the process is never straight forward. First, different patients have different ultrasound resolutions. There were two patients back to back that needed a block in the same area. The first patient had a very blurry ultrasound and it was difficult to see the nerve. However, the next patient had such a clear ultrasound that even I could differentiate the different layers. After finding the nerve, the next hardest task is knowing where your needle is. The needle needs to follow the centerline of the ultrasound probe in order to register on the screen. The trick is to keep the probe steady and advance the needle. If the needle bends, then the tip of the needle is lost and you have to find it again. There are also false tips. It means that you think that your needle is in one location, but it actually further down. We had to check this by moving the needle back and forth ensuring that the tip that we saw was actually the tip of the needle.
Although these simulations and ultrasound guidance has made regional anesthesia easier, it is a difficult specialty and needs lots of practice. Hopefully more technology will come around to make the process simpler
As technology continues to progress, there have been discussions about using technology to perform certain medical jobs. As other groups have mentioned, it seems as if there are certain roles, such as interviewing a patient that could be done using a computer. While in theory this seems like a logical improvement to the medical field, this topic is quite controversial. These discussions have been brought to various specialties including anesthesiology.
There are various benefits of automating some of the processes in the anesthesiology field. One example of this would be the use of machines to automate the administration of anesthetics. This could reduce the number of people within the operation room; therefore, reducing the chances of contamination. Using medical history and comparisons to similar patients would help decrease the “trial and error” nature of general anesthesia while allowing the anesthesiologists to focus on other cases that are more challenging or require a person to perform them. People who are pro-machines have said that by training a non-anesthesiologist to perform the tasks of the anesthesiologist as preparation for the surgery, a lot of money could be saved, and the doctor could work on other cases.
The thing with anesthesiology is that there are many factors to take into consideration before anesthetizing a patient. While after some time a nurse may be able to situate a patient in proper sniffing position to incubate a patient, or place catheters on the patient, the drug administration portion of anesthesiology is very important. It is also extremely important to remember that despite prior medical history or other patient files, a patient could require more or less drugs for sedation. For a GI procedure we saw, one man required 4 MACs before his procedure started. At one point the patient burped and moved (but didn’t wake up), and one more MAC was given. Firstly, the patient’s records showed that the patient has not always needed such a high dosage of medication. If after administering the first MAC, the GI doctor or a nurse would have to get the machine to give another dosage. But at which point is there enough medication? Or is there not enough? These questions can be easily answered when the anesthesiologists are present. The GI doctor was a little nervous when the patient began moving. The endoscope was already deep within the patient’s intestines performing a surgery; there was no way to drop what he was doing to help sedate the patient further. Thankfully the anesthesiologist was nearby to quickly administer more drugs before more movement occurred. Another problem is that if there are no anesthesiologists in the rooms, if a problem such as the ventilator pump stops working or the patient is no longer breathing, there is no one in the room to quickly help the patient. When a doctor is called, there is still a few minute delay before their actual arrival.
There is also an issue with the empathy component of the anesthesia process. Before procedures, the anesthesiologists meet with the patient and review records. After explaining the type of sedation that the patient will have for the procedure, the anesthesiologist often walks with the patient’s bed until they reach the room. If needed, the anesthesiologist calms the patient, especially if the patient is nervous. By understanding the patient’s body language, the anesthesiologists are able to react and make the experience less painful for the patient. The interactions between the anesthesiologists and the patients are often understated and neglected while trying to improve the process. As a potential OR patient, I feel more secure with a person putting me to sleep than a machine. The machine might have accuracy, but it does not undergo the stress and pressure that anesthesiologist go through day in and day out as they put people to sleep, wake them, or even control their breathing process. I know that even if they might not remember my name at the end of the day that they still cared for my life and the fact that I woke up. For example, a patient who is nervous about their procedure would require more drugs to help them calm down. While a machine might be able to detect an increase in heart rate, anesthesiologists also have to quickly take into consideration the patient’s medical history before administering more drugs.
Apparently there are already machine prototypes that are used to aide in the general anesthesia process. The anesthesia machine provides the patient’s vitals that are taken into consideration when sedating the patient, which could be interpreted by a machine. However, taking into account how the surgery is going and the actual science behind anesthesiology requires more than a computer algorithm. While this seems ingenious, a lot of improvements need to be made.
So far in our anesthesiology rotations Julie and I have had the opportunity to see numerous surgical cases. Whether the cases were brand new to us or if they followed a similar procedure as another case, they provided a new experience. In medicine it cannot be stressed enough that each person is different; therefore, even if the end goal is the same, the way to go about it may be different. Even the same procedure on the same person can have variations. For example, one patient was having a procedure for the third time and the amount of anesthetic needed to put them asleep was significantly higher than his other two procedures. While it may be simple to predict how the procedure may go, nothing is for certain.
On Tuesday, we had the opportunity to view two cataract surgeries back to back. There were a few commonalities between these cases. Both used a topical regional gel anesthetic that comes in a tube and is spread around the eye. There is a temporary loss of sight when this gel is used. Thank goodness. This method is used for regular or simple cases. Another option for regional anesthesia is to insert a nerve block at the corner of the eye. If the patient is an adult and has no problem, it is best if the procedure is done while awake. Anesthesiologists need to be prepared in case the anesthetics do not work properly. They can give more sedative, give pain medication, or perform general anesthesia. At least the patients are awake to notify the surgeon. The surgeon requires that the patient does not attempt to strain their eyes during the procedure, which could cause delays in order to prevent accidents. I would like to avoid imagining myself in that situation so I need to look into some preventative measures for cataracts soon. Cataract surgery is an outpatient surgery. So after the procedure is done, patients are sent to recover and go home as soon as they can.
The first case used a laser to detect the location and thickness of the cataract. The machine then gives the parameters to the surgeon. The laser cuts a cylinder in the cataract with four pieces. This allows for about 40% of the surgery to be performed outside of the OR. The patient is then transferred to the OR where the topical anesthetic is used. The surgeon then makes small incisions to the eye and removes as much as they can of the cataracts. An emulsifier is then used to remove the rest of the debris from the eye. This machine was pretty awesome. There were three functions that were operated using a single foot pedal. The first provides fluid to the eye so that it maintains its shape, the second function “eats”/ vacuums the soft tissue, and the third function uses ultrasound energy to break down the soft tissue. After the surgeon removed all the debris, the lens was folded up and inserted into the eye. After the lens was unfolded, the surgery was done. The second case did not receive the laser treatment in the beginning so the procedure was more invasive. Extra incisions were made to insert hooks to keep the iris open during the surgery. The cataract was broken down slowly and shaved away until the cataract was gone. This surgery had more tools and we got to see the different tips that could be used with the emulsifier. The surgeon continues to break down and remove the cataract and then the lens is inserted like the last case. Very thin sutures were used on this patient.
The first time watching a CSE (continuous spinal epidural) I felt uneasy and freaked out. There was a huge needle being pushed to the patient’s spine until the doctor felt a “loss of resistance”. That’s not vague at all. If the doctor pushes further, the epidural turns into a spinal tap and can produce a spinal headache due to loss of CSF. It appears that the only way to be good at performing epidurals is by continuously practicing.
Even then, those who have been in the field for years can also have difficulty with such procedures. Anesthesiologists use surface landmarks and spinous processes to determine the location for the epidural. After cleaning the location, the doctors feel for the process and numbing the area. Once again checking for the spinal processes, the epidural needle is placed. Depending on the location of the spine, the angle of the needle insertion must be different. We had seen a case where a CSE was being placed in the thoracic region. Due to poor landmarks and the patient leaning to the side, the epidural needle did not properly pass the ligament all the way. After several attempts of placing the needle, the catheter was placed and the patient was taken to surgery. We asked the anesthesiologist why the procedure was so difficult and she stated that for patients with no distinct landmarks, doctors have to depend solely on the spinous processes. In areas of spine where the spinous processes are pointed downward, it proves challenging to get the correctly angle for the needle. With larger patients, patients with curved backs, or any patient that moves during the procedure this process becomes even more difficult.
Julie and I were able to use the epidural simulator that residences use to practice epidurals and spinal taps. The extremely high tech simulator was a plastic lower back and butt with a tube inside filled with water. We were told to search for two spinous processes so that we could place the epidural needle in between. The goal after was to successfully pass through the ligament, which would supposedly crunch like if I were walking on sand, until there was no more resistance. So, after inserting the needle about 2cm inside the back, a tap-tap-advance technique was used. To check for loss of resistance, two taps are done using saline and an air bubble in a hub and then the needle was advanced slightly. Instead of busting out the saline, we settled for air. It worked just fine for our experiment. This technique is done until there was both a loss of resistance and the drug easily leaves the hub. Afterwards, the spinal needle was inserted. This needle unlike the epidural needle has a pencil tip with a hole in the side to allow drug to enter the system. But since we were practicing a CSE, we added the spinal needle and then inserted the catheter. Using a very sophisticated push catheter- pull needle technique, the CSE was complete. For our next attempt to become anesthesiologist, we placed a spinal needle between two spinous processes and advanced through the tissue. The spinal needle is much thinner and moves more easily than the epidural needle so it was difficult to ensure that it was going in a straight line. We continued to push the spinal needle through the ligament, feeling the crunch, until there was a slight loss of resistance. This was a lot less subtle than with the epidural needle, and I really had no idea when I needed to stop. After the loss of resistance, we were to push a little farther until there was resistance once again and puncture. When the needle was in the correct location, water (actually CSF) comes out of the needle where it is collected.
My thoughts throughout this experience included:
“What exactly am I supposed to feel?”
“Is this far enough?”
“Did I just paralyze my patient?”
“Was that a loss of resistance? Oh wait, nope; have to keep going”.
To imagine that before this simulator there was no way to practice epidurals is absolutely horrifying. Do not sign me up. One suggestion to improve the simulator was to make the feel across the tissue and ligaments more realistic. Apparently, giving an epidural to a patient, if they were completely still like the plastic model, is easier than performing one on the simulator. The simulator also does not take into account the movement of patients, especially those in pain. Other suggestions included using catheters with pressure gages or ultrasound to determine where in the spine the doctor is so that there would be less error.
Tuesday begins with a brief anesthesiology lecture for the residents. Of course the lecture is at 6:30am. I mean, because why not? Residents are coming into the room in scrubs ready to start rounds once the lecture is over. And in the kitchen there are two beautiful pots of coffee just waiting for people to drink it. It appears that coffee is a requirement around here.
After the lecture, we head to the radiology department to prep for a surgery. Unfortunately, the surgery is postponed, but we still get to look at the set up. There are a great number of tubes, each one long enough to extend from the anesthesia machine to the patient beyond the lead panels. Lots of tubing appears to be a norm for surgery, I’m more surprised that the anesthesiologists are limited to a single cart for their supplies and drugs, and their machine. While prepping before the surgery, calls had to be made to get some missing supplies from a different floor. Although it seems like an inconvenience, there is not enough free space to fit much more in the room.
In search for an awesome find, we find a cardiovascular oblation patient who is ready to be intubated. This time a video assisted laryngoscopy (VAL) was performed. For some reason, the tube does not pass the vocal chords, so the process is repeated with the standard laryngoscope. The tube still doesn’t pass and the doctors must perform an airway rescue. The anesthesiologists work to ventilate and wake the patient. While people rushed to prepare for an awake fiber optic intubation, the patient woke up, consenting to the procedure. The patient was absolutely amazing, completely understanding the need to do the procedure and even cracking jokes. After the tube was inserted, the patient was anesthetized once again.
Ten o’clock rolls around and we head back for more coffee. After the pick me up, we head to the OR. We head first to see a neck dissection for thyroid removal. The doctors use an EMG to alert the surgeons when they are too close to nerves and vocal chords. When the muscle is touched a deep beeping noise goes off. The surgeons purposefully test this before incision and during the surgery. There are four people standing around the patient during surgery, two with headpieces for magnification. With so many people around I was constantly nervous that someone would trip over the tubes or wires. Everyone calmly maneuvers around with ease, because obviously, unlike me, they have done this before. Still afraid of tripping, we stand on a stool far from the wires watching the surgery. Watching the surgeons dissect and remove the thyroid was fascinating, but had me holding my neck by the end.
We leave the neck dissection to see a CSE (continuous spinal epidural). The CSE is an epidural procedure that inserts a catheter that allows pain relief when needed. The diameter of the epidural needle is one over the length in inches of the needle! Honestly, looking at the needle was intimidating enough. This doctors begin by first inserting a nerve block where they intend to place the epidural. The epidural needle is then inserted until there is no resistance, the spinal needle is fed through it to puncture, and is removed to insert the catheter. With the catheter in the space, the epidural is removed, and the catheter is taped to the patient. After the catheter is in place, we take off for the day, prepping for another early start on Wednesday.