Thursday, September 25, 2008

"Picture a white sandy beach and a pina colada in your left hand..."

A peek inside the operating room. (Started a few weeks ago, finally finished today.)

Last week of OB. It's been quite an experience. Lately I've been doing a lot of benign gynecological surgery cases. I'm still getting used to the idea of it, and am fascinated with the process of putting someone to sleep and then tormenting them without their knowledge. Here's how it goes at UW Hospital:

0700- If you're scheduled for an 8:30am slot, you'd typically arrive at the hospital around 7:00 and be assigned to a small booth just big enough for your bed, where a nurse comes to do one last pre-op physical, put in your IV, the surgeon (and assistants, me and a resident) meets you and answers any last questions, and an anesthesiologist gives you a sedative to calm you down (an alcohol-like effect). You're then wheeled back to the OR where the scrub nurse and float nurse are preparing the sterile tables full of tools, exactly the way the surgeon wants them. There's stainless steel everywhere. Large trays (fresh from the steam autoclave) full of stacks and stacks of scissors, clamps, tags, needle drivers, foreceps, scalpels, retractors, staplers, and other specialized tools with notable surgeons' names attached to them (e.g. the DeBakey foreceps) are all laid out in a specific manner so that the scrub nurse can find exactly what is needed.

0800- Due to the sedative effect of the benzodiazepine, you probably won't remember the trip down the long, long hallways, zigzagging, through multiple double doors, and then down to one of 22 large OR "suites." They seem more like garages to me. Everything is cold. Cold colors, cold steel, cold bed. The nurse removes your gown and covers you with fresh warm blankets from the blanket warmer. And then they tell you to shuffle over to the OR bed, which looks like a narrow black bench. Many of our patients overflow the sides of the bed, but we strap them in so it's okay. 

Suddenly there's ten people on you at once, the nurse putting compression boots on your legs to prevent clots, the anesthetist is hooking up cardiac leads, a pulse oximeter, IV medications, and then comes the oxygen mask. The resident approaches and asks for a "time out" to verify that we've got the right person in the right room, on the right date, for the right procedure. 

You might see a medical student staring at you, trying to stay out of the way, getting yelled at by the scrub nurse for standing too close to the sterile tables, tripping on all the cords that snake from various machines to you, the center of attention. You might notice the three 3-foot diameter Halogen lamps all pointed at you, or the large, dusty stereo speakers perched atop the anesthesia machinery in a corner. And then someone tells you your IV might burn and sting, but to ignore it and think of a white sandy beach...

0820- The patient, just before being paralyzed instantly and completely from head to toe as they drift off to neverland, is told to take a big, deep breath through the oxygen mask. This is because the anesthesiologist is about to administer a big dose of induction anesthetic (fentanyl) as well as a paralytic that totally shuts off your breathing. He/she then has a couple of minutes to intubate - first visualize the vocal cords, then thread the tube between them, inflate the air bubble that lodges it in place, tape it to the face, listen to each lung to make sure the lungs, not stomach, are inflating by hand-squeezing a football-shaped bag. Then the mechanical ventilator takes over. The eyelids are taped closed to protect the eyes from drying out. 

Now under general anesthesia, the doctors and nurses are free to do whatever they need. Drapes on windows are pulled for privacy, and all clothing is removed as the body is placed in the appropriate surgical position. The scrub nurse turns on the radio if the surgeon didn't bring his/her iPod. Heels together - Foley catheter inserted. For gynecological surgery, this is the time we do our last physical exam to estimate uterus size and get an idea of whether we can, for example, remove a uterus through the vagina, or the abdomen. 

The float nurse does the surgical prep with big iodine-soaked sponges, creating a brown-yellow mess that extends 1-2 feet beyond the surgical site. The pre-packaged surgical drapes come next, custom-made by 3M for whatever surgery the patient may be having and usually large enough to cover a king-size bed. If the adhesive surgical window doesn't stay on well, it may be stapled to the skin. 

0830- Meanwhile, the resident and medical student have pulled their glove size and type (the doctor's are prepared by the scrub nurse along with all special tools as indicated on the Doctor Preference Card) and the surgeon is being paged. The medical student and resident scrub in, using a disposable brush and sponge, a plastic toothpick for fingernails, and going all the way up to the elbows. Rinse from hands to elbows, then raise your hands up in front of your chest and keep them between shoulders and waist for the entire surgery. The scrub nurse then hands you a sterile towel to dry your hands, and a sterile gown and gloves. It's like a carefully choreographed dance, scrutinized by the scrub nurse. Student and resident discuss the surgical plan while nurses catch up on the latest gossip.

0840- The surgeon(s) enter and the atmosphere of the room changes instantly -- now under full control of the surgeon. Music might be turned up, or changed, or turned off. Things may need to be adjusted - bed raised, tilted, step stools for the shorties, lights repositioned, thermostat adjusted, monitors and machine settings tweaked, new tools found if the appropriate ones aren't available, etc. etc. The personality and nuances of the surgeon's style command the attention, or ease the stress, of everyone in the room. The anesthesiologist sits back in a chair comfortably, but must remain alert and ready to act on any verbal orders from the surgeon. He usually ends up crawling on hands and knees at various times during surgery to enter the patient's un-sterile world under the drapes, and adjust the pulse-ox monitor, or cardiac leads, or breathing tube. He uses a large mirror at the end of a flexible pole (like a dentist's mirror) to peek under the surgical drapes as needed.

0850- Incision is made. The patient may jump, quiver, and shake, indicating that the level of anesthesia is insufficient. Despite this, surgery continues while anesthesia is adjusted. Theoretically, you remember nothing and feel nothing. The smell of burnt flesh fills the room as the electric scalpel cauterizes off any bleeding vessels, little plumes of smoke rising up and scattering the bright halogen lights. And the surgeon is totally in his element.

1130- The first thing you see is the medical student's smiling face as you're rudely awakened from a deep, groggy sleep by the anesthesiologist barking at you to wake up and take a deep breath. You reach for your face... your IV... your arms are restrained gently. You'll probably forget the tube suctioning your stomach contents and saliva and the gagging sensation of the tube pulled out of your mouth. In fact, you'll probably groggily try to yank your IV and roll out of bed to "get up in the morning." We'll gently remind you, over and over, that your surgery is finished and that (most likely) all went well.


jamestownboys said...

interesting Logan.
Having had a surgery myself recently, not general anesthesia luckily, this was interesting.

It's funny to me that while I am scared for my life etc.. that the surgeon is "at work" and the conversation is much like one you would hear employees having back and forth from their registers or drive up window. Only a bit more educated.

Sounds like your having fun :)

Edith said...

yes, very interesting, it is just a job for them, but kind of makes me not want to have surgery any time soon, or ever.
The staple part if the drape doesn't stick is funny, but kind of gross and I would hate to be that person with staples used.