Itzanami Hernandez

Everything happened quickly. I took the elevator to the third floor, checked in with the front desk, changed into scrubs, and the next thing I knew I was in the operating room. Dr. Alkureishi was operating on a chemotherapy patient who recently underwent surgery for tumor removal. The previous surgery left the patient with a hole in his head. There was exposed bone and a granulation pattern beginning to form, so Dr. Alkureishi’s plan was to remove the gracilis muscle from the leg and transplant it to the affected area.

Good Design: Venous Coupler

A: Dr. Alkureishi cleaned the fibrous lining of arteries and veins. He informed us this step is crucial, because it prevents a clotting cascade. After Dr. Alkureishi finished this step, he utilized a tool called the Venous Coupler to connect a vein from the gracilis muscle to a vein from the patient’s head.

E: One team of doctors worked to remove the gracilis from the leg. Another team prepared the affected area for transplant. Both teams effectively communicated and worked together to ensure a successful gracilis muscle flap procedure.

I: Dr. Alkureishi and a resident worked diligently to prepare the affected area for the transplant. There was another team of doctors who were responsible for gracilis removal. Both teams updated one another on where they were in the procedure. This communication is important because the entire team needs to consider the ischemia time. The ischemic time tells us how long an organ is viable for transplant after removal.

O: The Venous Coupler is a handheld instrument.

U: Dr. Alkureishi and the resident

Bad Design: Microscope

A: Once the gracilis was successfully removed, the team quickly set up the microscope, so Dr. Alkureishi could begin the transplant. However, various issues arose. Initially, there was a problem with the light intensity on the microscope. Then, the lens looked “fuzzy” and “hazy.” This was a concern for the doctors, nurses, and techs, because the ischemia time was running.

E: Doctors and nurses all attempted to fix the technical issues with the microscope.

I: The team attempted to fix the technical issues by changing all of the settings. A registered nurse was responsible for setting up the microscope. He attempted to resolve the problem by changing a few settings, but this was time consuming and the team was clearly becoming anxious.

O: Microscope. I didn’t make note of the brand.

U: Dr. Alkureishi, residents, nurses

Primary Data Focus

7/2 We spent that morning shadowing Dr. Alkureishi in the clinic. Two stand out patients were individuals who were suffering from pressure ulcers. Pressure ulcers are wounds that result from prolonged pressure to the skin. These injuries are common in paraplegic patients due to the lack of sensation below the waist, and tend to develop on the buttocks. Pressure ulcer reconstruction is a procedure in which the wound is cleaned thoroughly and closed. Although surgery is a great solution to the problem, surgery doesn’t guarantee no reinfection. As previously mentioned, pressure ulcers result from constant pressure at a certain area. Before performing the surgery, physicians look for signs of healing on the wound, because this lets them know the patient is being compliant with the instructions given to manage/take care of the wound. After speaking with Dr. Alkureishi, it became apparent that there’s a need for improved post-op care for patients who underwent pressure ulcer reconstruction.

Literature Review

A 2005 study looked at the effectiveness of an alternating pressure air mattress for the prevention of pressure ulcers. Recall, pressure ulcers result from a constant pressure applied to a certain area. One of the toughest challenges in pressure ulcer care and post-op pressure ulcer reconstruction is with the patient’s compliance the physician’s instructions. In order to prevent pressure ulcer development, the patient needs to routinely change positions, in an effort to relieve pressure in those areas. In this article, there was a control and experimental group. The researchers found that there was significantly more heel pressure in the control group than in the experimental group. Furthermore, the researchers found that there was no significant difference in incidence of pressure ulcers between the two groups (15.6% in the experimental group and 15.3% in the control group).

Patent Review

“Methods For Controlling and Monitoring Inflatable Perfusion Enhancement Apparatuses and Associated Systems”. Introduction of methods to interpret contact pressure applied to a human body by the surface of an object, such as a chair. The controller is placed in between the patient and the contact surface, and monitors the pressure in two chambers over time.

US-20240239065A1

references:

Vanderwee, K., Grypdonck, M. H., Defloor, T., Effectiveness of an Alternating Pressure Air Mattress for the Prevention of Pressure Ulcers. Age and Ageing. Vol 34, Issue 3, May 2005, Pg 261-267

Primary Observation: One of the earlier procedures I observed was an ear reconstruction. Prior to beginning the surgery, the attending surgeon located arteries and veins using an acoustic doppler. The user locates the arteries and veins by listening for a whooshing-sound. Therefore, the doppler is a fairly simple device, but was time-consuming given the surgeon took extra time to verify they didn’t miss anything.

A: Attending plastic surgeon located veins and arteries utilizing a doppler prior to ear reconstruction

E: Operating Room

I: Surgeon hovered doppler over area of interest. Listened for whooshing-noise and marked artery or vein location.

O: Acoustic Doppler

U: Attending plastic surgeon and residents

Secondary Observation: A 2014 study looked into improving Doppler wave characteristics utilizing repeated electrocardiogram-guided measurements. The researchers concluded addition of ECG training and measurements improved acoustic Doppler wave interpretation.

Needs Statement: Improved methods of identifying arteries and veins to reduce time-consuming step in surgery.

TAM: I based the TAM on ear reconstruction and pressure ulcer reconstruction, because I observed the acoustic Doppler being used in both procedures.

Number of Procedures: 4,713 ear reconstruction performed in 2022 in the US.

2.5 million individuals develop pressure ulcers in the US annually.

Cost of Device: $200

Total TAM: $400,942,600

Needs Statement:

Improved methods of identifying arteries and veins to reduce time-consuming step in surgery.

Needs Statement Revised:

For surgeries requiring artery and vein identification, the acoustic Doppler needs improved methods of attenuating noise in an effort to maximize time efficiency.

The following diagram is a storyboard for a free flap procedure. It’s not shown in the image, but the storyboard begins with a wound consultation. My team observed a pressure ulcer reconstruction, and we constructed this diagram based on what we observed from the clinic to the OR. There’s also a closer look at the post-operative component of the storyboard:

Post-Op planning includes monitoring, confirming flap viability, long-term clinical follow up

Conclusions & Advice to Future CIP Students:

If you’re considering applying to CIP,you should go for it. I learned so much from this experience and I’m so grateful that I had the opportunity to participate in this program. Although the hospital setting is intimidating, don’t be afraid to ask questions. In my experience, the attending, residents, nurses, and techs were all kind and welcoming. The attending surgeon informed us of upcoming procedures. I feel like I could’ve improved my experience by doing some research beforehand. Nevertheless, I still learned a tremendous amount, especially in the clinic. In the clinic, you observe patient-doctor interactions, which is meaningful because the surgeons has time to explain the health concern and what their plan is to fix the issue. For example, one day we saw multiple pressure ulcer consultations in the clinic, and later in the day we saw a pressure ulcer reconstruction in the OR. Oftentimes, we get desensitized to all the procedures we observe and we forget the procedure actually means so much more for the patient.

Something I could’ve improved on was time management. We all get busy with personal things and I felt Iike that was the case for me. I think I could’ve managed my time better to get the most out of the program and reduce stress.