Monday, May 14, 2007

Operation, Deconstructed. One: preamble




With as much detail as is useful, and as descriptively as I can manage, I'd like to relate what it's like to do an operation, from before laying knife on skin to after placing the bandage. I'm a general surgeon, so I choose sigmoid colectomy as my prototype; it's always been one of my favorites, although the particular operation isn't the point. The idea is to let the reader into the operating room as much as possible. I figure it'll be several parts. Let's see how it goes.

First stop: the pre-op holding area, where my patient -- and most often family -- and I exchange greetings minutes before the operation. If I've done my office-job well, the patient is likely to be relatively calm and optimistic. I touch a hand, a knee, a belly, say something like "Seems like a great day for a colon resection." To the oft-said "Hope you're not hung over, Doc," I respond with a raised hand, deliberately shaking, saying "Steady as a rock." Laughs all around. Then more seriously, "Any questions since we talked, anything you want to go over again?" And a reminder of the plan: "You'll meet the anesthesia person any minute. You'll be sound asleep for the operation; we'll be making the incision right here. I'll numb it up with local before we're done so when you wake up there should be little or no pain. It does wear off, though, in a few hours, and we'll hook you up to a little push-button device so you can give yourself pain medicine whenever you want it. I expect you'll be up walking in the halls tonight. ("Tonight?! Really??" "Yep! It's the best thing there is for you. Gets the circulation going, gets those lungs working.") [To the family:] OK, I figure the operation will be give or take an hour, little screwing around before and after, I'll come out and talk to you soon as we're done -- probably an hour and a half. Don't get worried if it's a little longer. [To the patient:] See you in the OR." Exit, stage left.

I like that part. I suppose some of it is the awe-inspiring "I'm here and you're there" sort of thing. But really, it's about re-establishing rapport, giving a final injection of confidence, and, of course, making sure everyone's on the same page. Because for elective surgery I've hand-carried the paperwork the night before, there's rarely the cold shower effect of "Uh Doctor, we can't seem to find the lab work..." Occasionally I get the rhythm-interrupting "Did he get a preop EKG?" to which I reply "Yes. See, it's right here in the chart." Annoyometer needle rises just above zero.

As important as any of the steps is being there when the patient goes to sleep. I feel terrible on the rare occasions (emergency call, etc) when I'm not. (Reassuring as it may be, of course, the patient likely won't remember any of it.) Often, I'm already in the OR when they get wheeled in, because I've gone in to check that the instruments I need are there, maybe magnanimously tie up the scrub nurse's gown, bother the anesthesiologist. I help the patient onto the narrow table, checking to make sure the rear end is south of the table-break, just in case we need to change position for a staple-job. I don't expect it in this case, and prefer to have the patient flat, instead of in the modified lithotomy position. But the equipment's in the room. While the anesthesia person is doodling around, I talk with my patient. Small talk or big. My acquiescence to the time it takes to get off to sleep is inversely related to the acuity of the case and the number of operations I have scheduled to follow. And to whether my patient starts looking around nervously: why aren't I asleep, am I supposed to be asleep by now? As I see the mother's milk of morpheus going in, I say "Have a nice dream. We'll take good care of you."

The oxygen monitor beeps rhythmically in time with the heart and tonally in relation to oxygen levels. During a tough intubation it can descend an octave or more. I stand by, quiet, helping if needed. Pull out the cheek with a finger hooked in the mouth to widen the view; push the trachea this way or that. During the operation, those sounds are beyond my notice, unless they change.

As I've revealed previously, I'll likely do whatever shave is necessary, as soon as the patient is asleep. Today it'll be a lower midline incision. A few pubes might have to go, but I'll keep it to a minimum. If it's a male, I usually put in the urinary catheter if I want one. The reason is mainly to keep the bladder from filling up and getting in my way. Pretty routine a while back, I used them much less as time went on. I let the nurses do the women.

If I expect to be working into the dark recesses of the pelvis, I put on a headlight. Hold my thumbs together at the level of comfortable vision, make sure the beam is focused just there. Tighten the headband too tight, get a headache half-way through the case. All of this seems like pretty grown-up activity. Gray as I've gotten, I still can't quite believe I'm enough of an adult to do this stuff. Am I really allowed? Something there is that loves a dress-up party. But this is the real deal, and I never got over having a part of me watch the whole process in amazement, from just across the room. Yes, I think it's pretty cool.

The scrubbing ritual, done with intent, but also with that third eye, watching: grab a pre-packaged brush, impregnated with my favorite flavor of soap. Given a sufficiently brisk squeeze, it rends itself open with a very satisfying "pop." The champagne cork that starts the party. Done right, heads will turn and nod appreciatively. Hit the knee-controlled water switch. Quick on and off, just to get wet: I don't like to waste water. It used to be a ten-minute scrub, timers even, right above the sink. Now, couple of minutes will do, unless you get caught up in conversation. Orthopedist at the next sink: "Hey Sid, what's the real surgeon doing today?" "Yeah, general surgery, the queen of the surgical sciences. Little colon resection. How about you?" "Elbow. It's a living." There's a favorite nurse scrubbing across the hall: "Bridget, what's the deal? Hiding from us today?" "You know I'd rather be with you. They have me doing eyes." "The dark-room. Bummer." House-keeping aide walks by: "Dr Schwab! What's up?" "You are! How's the kid?" All this while cradling each finger with the flexible brush, flipping it from the scouring side to the soft side, one at a time, zooming the gap between each finger ("Johnny, Johnny, Johnny, Johnny, whoops Johnny, whoops Johnny, Johnny, Johnny, Johnny, Johnny"), then down the arm. (I like seeing my arm-hairs getting soapy. Again, from some distance...) Bang the water-trigger once more, dip a hand into the stream, scooping it upward, fingers apart, elbow last. Then the other. Knee-knock the water off, back my way into the OR door, dripping water off the elbows. (Now we have hand-sanitizer goo. Couple of pumps and the whole thing's over. Still do the water-zen first case of the day.) Some OR doors have handles, requiring a certain agility of the backside to part them. Needing more than one push definitely diminishes the drama of the entrance. The scrub nurse flips me a towel: it's lengthily rectangular, allowing the use of one end for one hand and arm, the other for the others. From the fingers down, elbow last; then laying the dry end over the wet hand, once more. Stepping into the gown, both hands in at the same time; little shoulder-shrug to get it settled, little rub of the elbows at the waist to seat the cuffs. The scrub holds the right glove open with two hands (except Jeanne: she always proffered the left. Her way, I always thought, of laying down the law. Or maybe some sort of superstition. She never told me.) I dive my right hand it, stretching the glove half-way to my elbow, and she lets it go with a satisfying snap. (Missing a finger hole is a spell-breaker -- less likely if the scrub waits half a beat before the up-move. Maybe she'll tug on the empty finger as if it were a deflated cow, or maybe I'll fix it after I get the other glove on. With that one, I can help: taking my gloved right hand, I pull the left cuff outward as I couldn't with an ungloved one. Bigger target, deep dive, no worries. Someone snaps or ties the back of the gown together -- often the anesthesiologist will leave the machinery to do this; some, I think, consider it too demeaning. There's a belt-like tie attached to the front, with a cardboard tag on it: the tag can be held even by a non-sterile person. I fold it for strength, hand it with my right hand to the designated holder, and pirouette on my heel, left hand down and rotated back and outward to catch the tie at the end of my spin. That's brought the gown fully around me, and I tie the tie to another tie hanging on the front. Sometimes the cardboard slips away before the ballet is over, and the tie drops: another flicker of the annoyometer, but not a big deal. I lean to the left, the errant belt falls away enough to be grabbed and tied, unsterile, behind. Not perfect, but ok unless I plan to back into the wound.

Draping the patient -- a daunting task during internship because we used multiple cloth drapes and each surgeon had his own way of doing it, differing wildly among various surgeons for the same operation -- is now a simple final step before commencing. Pre-packaged, shaped with various holes for various operations, containing adhesive strips at the edges of the holes, they simply require laying them on the middle of the patient and unfolding, first north and south, then east and west. It's a choreographed move, as my assistant and I move in unison on opposite sides of the table, each with a hand on the edge of the drape -- her left, my right -- fluttering it down the legs, then over the head. The anesthesiologist clips the head end to IV poles. Rhythmic gymnastics. Once every seventy-five or ten cases the drape gets handed to you wrongwise, causing the parts designed to cover outstretched arms to end up dangling instead at the feet, semaphoring stupidity. They actually have a little humanoid cartoon on them to show proper orientation, but these things happen... Finally, suction tubing and cautery pencil wires get distal ends handed off, proximal parts secured to the drapes. Back when we used steel towel clips, the sturdy clicking in place was like a signal of readiness, a one-minute warning. Now, it's velcro straps that come attached to the drapes. Ka-chickachick supplanted by zzzrrrrrippp. And finally comes the sshhush of the suction hose as it gets hooked up; like a cleansing breath, it's the last sound heard before I ask for the scalpel. More often than not, we clamp the hose off for silence until it's needed. When that's forgotten and remembered later, the sudden quiet is a surprising lift, like removing a heavy pack at the end of a hike. But now, we're ready to go...

22 comments:

scalpel said...

I'm a bit OCD too. With structure comes predictability. With predictability comes comfort. With comfort comes confidence. With confidence, anything is possible, almost.

I want to hear how you deal with the higher Annoyometer readings.

FetchingGal said...

Love the annoyometer image!

Anonymous said...

Great post. I received your book for Christmas, ate it up in a couple of hours, and now enjoy reading your blog. Thanks for insight.

SeaSpray said...

I am waiting with bated breath for the rest.

Also, considering my concerns of late - I am finding this somewhat soothing in a reassurance sort of way.

Things I assume and know intellectually but emotionally encouraging to be brought through the process - step by step.

Thank you :)

Dr. J. said...

It must be lovely to get gloves on so cleanly... Rugby has left the little finger of my dominant hand with a bend like the hook of a drop kick from the 22 that's way off.....close....then miraculously in.
I don't think it's ever gotten into a glove smoothly when I've assisted in the OR. No wonder I'm not a surgeon ;o)

Sid Schwab said...

Dr J: coincidentally, as I posted here, I have a rugby injury on my dominant hand as well. It's more of a problem with instruments than gloves, however...

Emily T said...

This is going to be a great series. I'm looking forward to the next episode.

Someonetc said...

general surgeons are always so calm and demure. in my mind (Patience young padawan ....), there is a lot more of the annoyometer beeping in my head causing me to have little arguments in my head. may be i need a beta blocker :)

(http://orthopaedic-residency.blogspot.com/2007/04/patience-young-padawan.html)

Bongi said...

our gloving is totally different. we don't have a scrub nurse. we gown and glove ourselves. who gloves the scrub nurse by the way?

p.s the way you feel as if you are watching yourself from a distance and have thoughts like this is the real deal. i thought i was the only one. i still keep on being amazed that i'm allowed to do what i do.

Anonymous said...

Wow! I loved that post. I'm supposed to have surgery for the first time next week.

Even though I enjoyed the glimpse from your vantage point, I now know one thing for sure ... I ain't going.

Looking forward to more ...

SeaSpray said...

I know how you feel anonymous.

I have felt that way too but I have found that putting the inevitable off only serves to magnify the anxiety (if any) and can exacerbate the initial problem.

Once I injured my knee from falling and chose to live on I-buprofen for a year. I worked in a hospital and around doctors and nurses all the time. I refused to be seen until I couldn't do my job because I could hardly walk.

So, I went to an Ortho Doc, he diagnosed me with a torn meniscus, I went right in for surgery and 2 days later I was feeling totally normal. I felt so good that I over did it and strained it but I ended up being alright.

In the end - we really do need to do what is best for us - seriously.

Good luck with your surgery.

P.S. I am possibly facing a surgery myself and so I can appreciate where you are coming from. :)

Anonymous said...

awwww, thanks seaspray. I was just kidding (I think). I have to go .. the pain is driving me to it.

going to check out your blog ...

amr said...

So why is it that little if anything is ever mentioned about most pts being mostly or completely undraped in the OR after induction during positioning and prep and at the end of the surgery during cleanup before transfer to the gurney?

Sid Schwab said...

In my experience, patients are undraped only insofar as the area to be operated upon needs exposing. I, and the people with whom I've worked, always take care that unnecessary exposure is avoided.

amr said...

Thank you for your input on the draping issue. What I have heard from a number of sources, especially with LAP surgeries is that the drape is removed because of the nipple to pubis prep. Also in positioning in the prone position. So in the surgeries that you do, the gown remains on the pt? For the sigmoid colectomy that you used for your prototype, what happens with the gown? I appreciate that you are careful with exposure, but as I understand it, good prep and steril field trumps pt modesty.

Sid Schwab said...

It's true that after the patient is asleep, depending on what needs to be exposed, modesty is gone. Still, we tend to respect it as much as possible: for most operations, the gown can stay on, rolled upward. If not, it gets replaced before awakening. If it's a belly operation, most of the time the gown goes upward, and blankets or other drapes remain on the legs. When possible, I leave underwear on, also.

Maybe I should post about it!

amr said...

Posting that this would be very interesting. Your sensitivity on this issue is to be commended. You I'm sure know more that I that concern for patient "integrity" is not universal.

But by the time the foley is inserted, heart monitors are placed, and the grounding pad is placed, and body alignment is check, although the gown may not be removed, to a certain extent, modesty is a moot point.

Would you post it here?

amr said...

Dr. On another note, where do you see the protection of patient privacy / modesty as it relates to the trend toward telemedicine where there are camera to cover every angle of the OR and the internet video streaming and /or capture to dvd or disc is now becoming the standard in new ORs. Although what is possible for the benefit of the pt is fantastic, it does tend to make the OR a "public" place.

Julie said...

bongi, the scrub nurses glove themselves. And it was always a matter of pride to get your cuffs perfect, difficult in particular with the horrible old fabric gowns we used to have, some of which had no stretch left in the cuffs at all.

At the hospital where I worked for over 20 years (Australia), the only time the scrub nurses were gloved by someone else was during preparation for total joint replacement, in the days of the walled laminar air enclosures. We still have a couple of enclosures around but the set-up process has changed a bit since then.

We also didn't glove the surgeons either. Which made for some entertainment at new residents' expense on occasion..... neurosurgeons were our only exception.

I believe all this does vary from place to place though!

Max said...
This comment has been removed by a blog administrator.
Sid Schwab said...

Nice try, Max. Read the statement about comments more closely next time.

Anonymous said...

Hello:

Appreciate this article. I am having a Right Hemicolectomy next Thursday for colon cancer. LAP, open if necessary.

My surgeon explained what to expect very well, but I was still curious about patient prep- anesthesia, draping, scrubbing abdomen, catheter, etc.

Only being put under makes me nervous. Had a general 15 years ago for achilles tendon surgery and they gave me too much, hard to come out of it. Plus I don't like the loss of control and awareness of what is happening.

Thanks,


LEM