Thursday, August 09, 2007

The Skinny On My First OR Experience

By Britt:
Sorry it has taken me a little while to post this. I am 2 lessons away from finishing my summer math course, so I have been busy trying to get that done before the team leaves on Sunday so they can mail in my final assignments and exam.

I’m not sure how to go about writing about such an amazing experience. If I had to sum up my observation of Mme. Felius’ operation on Monday, I would use the words: incredible and brutal.

The whole thing just made my head spin (sometimes literally) … I wonder how what I saw differs from how a similar procedure in the United States. Dying to know what is vastly different, I’m going to give a quick play-by-play of the operation so that all of the medical profession readers can let me know the differences.

First of all, the surgeon, Dr. O was friendly, but cautious. He repeatedly told me and my dad that he’d had med students faint on him while observing similar operations. I assured him that I would be fine, and even showed him my medical portfolio to prove that I’d chopped off a toe bone and had some experience with blood and guts. He still wasn’t quite convinced (and for good reasons, I later found out) but he willingly allowed me to observe. It was funny, because he sat down with us at his desk first and explained everything to me – but I felt like he was kind of examining me. I’m not really sure what he was looking for, but I must have passed the test because shortly thereafter we were off to the OR. (I would love to know what his surgery-observing-criteria were …. I wonder what I could have done for him not to let me observe … I’m not mulling over it because I feel so blessed to have been there!)

I’ll try to do my best to describe my surroundings and give you a mental image. The hospital was two-stories, with roughly 15 rooms. Mme. F was in room number 9 which was upstairs, right next to the OR. To get to the OR, there was a hallway with two sets of doors. Dr. O told me that this is “proper procedure” – that there is a certain number of doors you must have in-between the outside general airway and the OR (for sanitary purposes, of course.) I think this is the case in the US too, but is 2 doors barrier “proper procedure?” (FYI – I am not asking this or the following questions because I disagree with the way the PAP hospital is set up; they’re doing the best that they can with what they have --- I just want to know what the OR “norm” of the developed world is.)

Mme. F was rolled into the OR before we got there. After walking through the door hallway (which was about 7 feet long and just wide enough to fit a hospital stretcher), Dr. O pointed me to a closet and told me to change into the scrubs on the shelf. I changed scrubs and put on feet/shoe covers, a cap, and a mask. Then Dr. O did the same. He told me that it was a privilege that I was being allowed to observe and that I shouldn’t abuse that privilege (okay, so this is largely paraphrased …. his broken English and interesting choice of words pretty much equaled that though.) I thanked him immensely, assuring him that I would stay out of the way and behave myself. (Wow, talk about a look into the future … being the underling. Good thing I am quite thick skinned. :) After that, he and I walked into the OR where Mme. F was with the anesthesiologist. I later figured out that she wasn’t put under completely --- the anesthesiologist (who was a Haitian woman – very cute and hip/sylish too) inserted a needle in her lower spine, like 4 vertebrae up from her butt (rough guesstimate). I was explaining this to one of the team members on the ride home from Bercy, and she said that this is similar to what she had for her C-section. So, in the US, would Mme. F have been “out” completely?? The anesthesiologist stayed at the head of the operating table throughout the entire procedure, monitoring Mme. F’s vitals, etc. and talking to her to see if she was okay. She had a saline IV in one hand and the donated blood in the other arm. It was weird …. both of her arms were extended way out, like as if she were going to be crucified instead of at her sides. Was that just to make sure the IV’s stayed in place?

After the anesthesiologist was finished, Dr. O did a final exam of the leg and then thoroughly cleaned Mme. F’s leg, from toe to hip. I thought that was interesting; normally a nurse would have done that and other prepping steps, right? Then he tied a string around her big toe of the fractured leg and tied the other end to an IV pole, so that her leg was dangling from it like a piece of meat in a meat cooler. I’m not really sure why he did this …. because it was only hanging like that for maybe 15 minutes, while he finished sterilizing the area, and lying out drapes to cover the rest of her body. He also tied her other leg down to the table and both of her extended arms down to the arm rests.

After she was totally prepped, we went out of the OR and into the room where the closet/changing room was located. Then we went to a sink and I learned how to properly “scrub in.” That was cool – I felt all official. ;) Dr. O told me that everyone has their own technique to scrubbing in, but that once you had one – you stick with it and do it the same way every-time. I was amused how the betadine brush thing stained my skin so that when I was done my Irish-like pallor appeared Indian-like. After we scrubbed, we walked (with our hands in the air – “proper procedure” acc. to Dr. O) back into the OR, careful not to touch anything. And I mean anything. I was like 3 feet away from one of the walls and Dr. O pretty much tweaked out on me, saying that I would have to go re-scrub. (I thought this was funny, considering the dusty canisters sitting on an equally as not-clean or sterile shelf were also contained inside the OR …. the corners of the floor weren’t clean either) Then a nurse helped me (without touching me … tricky) put on a sterile gown and then sterile gloves on-top of that.

So there I was, all decked out in surgical gear – ready to be amazed. In the OR, there were about 2-3 nurses, me, and orderly-type guy, the anesthesiologist, Dr. O, and his “partner in surgery.” Only one nurse, the two surgeons and I were in sterile-gowns; the rest were in scrubs, foot covers, masks, and hair covers. (In the US, wouldn’t everyone in the OR be required to be in 100% sterile garb?) The nurse was instructed to keep an eye on me and make sure I didn’t touch anything. Here’s a bullet point of the procedural steps:

1: Dr. O marked where his incision was going to go. Then he did it – in one, quick, efficient slice. That was cool, I was way impressed. With that incision, he had cut through about 2” of fatty tissue.

2: Then he used a cauterizing wand (ok, don’t know what that’s called … but you know what I mean) to stop the bleeding and also to break apart the fat and go deeper in the leg. The cauterizing tool was controlled with a foot pump and the end of it was about the width of half of a pencil. It made a high-pitched buzzing sound (that kind of made my head hurt after awhile).

3: At this point, I kind of had to take a step back from where I was standing (at the foot of the operating table, but enough to the side that I could see almost everything) because the smell of the burning flesh was kind of getting to me. (Yes, yes – everyone has a weakness. Mine is scents …. I gag every-time I change a diaper and still have trouble with Krispe’s weeping leg ulcer after regularly smelling that –horrible – scent for over a year) They poured sterile water into the now gaping-open (probably about as wide as the span of your open, stretched out hand) and then used a suction to suction it out, along with the pooling blood.

4: After he was done w/ the cauterizing part, Dr. O and his assistant got to business with a bunch of crazy shaped tools, pulling apart the leg and opening it up more to expose the broken bone. It was at this point, with the pulling and yanking, that I had to sit down. It was all going so fast and they were getting things in place so abruptly and … and … not-gently. I thought to myself, hmm, maybe he was right about the fainting thing. It wasn’t that I was grossed out – not that at all – it was a combination of: 1) the excited-tummy-ache-feeling, 2) getting dizzy from concentrating on the same thing for a while, yet from a distance so that I was kind of straining to see 3) standing in a spot where I couldn’t stand comfortably, but kind of awkwardly 4)the method of the leg separating 5)the remnant scent of burning flesh, 6)the gross-ish gurgling sound of the suction and 7)the pace at which everything was moving. So I sat down and tried to figure out which urge to fight against: vomiting or fainting. So there you have it, Britt wimped out.

5: So while I was sitting, I obviously couldn’t see anything very well, but they got the retractors in-place and got to work fitting and placing the plate. Her leg was tied down so that her toes were touching the table – resting to the side. I think this made the broken pieces of the femur align better.

6: After I regained my composure, I stood back up and watched as the surgeons worked together to drill and insert each of the eight screws. The plate was about 4” long, with eight holes for each of the screws. Oh, I forgot to say this – but the incision was/is close to 10 inches long …. about 2.5 times the length of the plate. They used this oddly-shaped tool to drill the holes. I don’t know how to explain it, but its tip was sharp and pointed and then it extended upward with a jutting-out place to put your hand and crank/turn it. My dad says this is way old-school …. I thought it was amazingly efficient. Who needs power tools? Take that, developed world medicine. ;)

7: They drilled one hole at a time, then placed the screw, then repeated for each screw. Dr. O’s “surgery partner” really seemed to do the majority of the physical work --- I couldn’t believe how much physical effort he had to put into screwing down the screws into the bone. This was done with what looked just like a Philip’s screwdriver. Weird.

8: While the second half of the screws were being put in place, I was allowed to come right alongside the table and look at it and I even held a retractor (which I’m pretty sure wasn’t doing a thing with all of the previously place cranks and retractors …. but I think they wanted me to feel like I was contributing … so I did... More pouring sterile water, suctioning … then they placed a drainage tube into her leg and sewed it in place where it exited, right below the incision. It stayed in place for two or three days, allowing the excess blood and fluid to drain.

9: I was dying to say “May I close?” like on TV or something -- just to be obnoxious, but knew better … Dr. O sewed the different tissues together – in two layers and then closed the incision completely with outside sutures. I got to assist while he sutured, clipping the ends.

A few other random things from the procedure: 1) The two surgeons joked and laughed pretty much throughout all of the operation …. it was hard to understand their Creole underneath their masks, so for all I know, I, the silly blan girl, was the brunt of the majority of their jokes. 2) The word "degaje" (make it work) was thrown around several times. I enjoyed that. 3) About every 5 minutes, a nurse would be instructed to come and remove Dr. O’s prescription glasses and wipe off his brow. The room was air-conditioned, but I had sweat pooling in the bent sleeves of my surgical gown (which was a weird material – like a rain coat … probably because they wash and re-use them). When Dr. O took off his surgical gown at the end, his scrubs were pretty well soaked. I like it when Haitians sweat as bad as I do. 4) Everything “sterile” came in a taped-up bundle. This was very odd. For example, my mask was rolled up in a different piece of material and taped, marked with what it was. This was the same for a lot of the surgical tools …. I wonder how and where they sterilize things.

Well, I think that’s everything. Hopefully you felt like you have a better idea of a third-world upper-level operating room. I don’t think I left out any details …. it was the coolest thing I have ever experienced and made me want to pursue something surgically-related even more. I also hope with this first official OR experience under my belt, the next one will go better and I won’t get the spins or have to sit down.