(no subject)
Wednesday Nov 28:
On Sunday afternoon I took my patient to the Operating Room to have his abdomen washed out. He was shot four days prior--in his right upper thorax, almost in his axilla through his lung, diaphragm, then through his liver, ricocheting through his stomach and spleen. He was in the middle of a surgical treatment protocol pioneered at the University of Pennsylvania called the damage control abdomen; the patient is taken to the OR promptly from the Trauma Bay and opened up, all immediate life threatening injuries are identified and mitigated. The patient's abdomen is left open, packed with surgical towels and closed with an Ioban dressing (sort of the equivalent of surgical saran-wrap). In the ICU, the patient's ensuing acidosis/coagulopathy/hypothermia and other life threatening secondary injuries are managed, and the patient is taken back to the Operating room a day or two later for additional repair/washout (literally just pouring warm saline into the abdominal cavity and sucking it back out) and the abdomen is closed, thus preventing other complications from compartment syndrome and missed injuries during the initial damage control procedure.
It's now late november and I have less than a week left in orientation, this Friday will be my last day as an orientee. I've taken care of plenty of damage control abdomens during the 20 week ICU orientation process, but I had yet to see the exploratory/washout procedure done (washouts are done at the bedside in the ICU sometimes, if the patient isn't stable enough for transport). The two trauma surgeons-- a fellow Jay and a chief resident Adam--performing the procedure that day, were excited that I was almost off orientation and asked me if I wanted to watch the washout. My preceptor, Carolyn, offered to look after my second patient in the ICU that day, and I stayed with my patient in the Operating Room. I scrubbed in as an anesthesia resident induced the patient (it kind of sucks that CRNA's aren't utilized at HUP, but I guess there are too many residents who need OR time. If I stay on the CRNA track I hope I get this kind of acuity).
Anyway, long story short, I had my hands in this dude's guts and it was awesome. It was not only a wonderful anatomy lesson, but it really crystallized what I had been observing in the ICU. Of course his surgical dressing was turning uncomfortably yellow and his drains were filled with a disconcerting bilious-sanguinous fluid; I could see now that the 3 inch liver gash probably had something to do with that.
"Man that's big."
"Yeah."
"What do you think we can do about that?"
"When Pryor (an attending) was in here (the abdomen) before said he though we could probably just Argon the shit out of it and stuff some omentum in it"
"We could Argon the shit out of it and stuff some omentum in it."
"Yeah let's just Argon the shit out of it"
This exchange re: the liver injury exemplifies why I love trauma and the people who work in trauma. The Argon Beam Coagulator is probably the coolest surgical toy I've seen so far. It's like a Bovie cauterizer in size and shape, but emits a stream of Argon gas which is ignited to form a blue-green beam of Star Wars quality light and heat. Jay and Adam, probably in part putting on a show for me, who was enthralled, giggled as they waved the Argon coagulator over the liver lac, quickly turning the gash a bubbling black, stopping the steady trickle of blood and bile. They then snipped and pulled a stringy arm of peritoneal omentum and quite literally just stuffed it in the black, bubbly hole of cauterized liver. Jay de-gowned and phoned the attending to make sure there wasn't any more injuries he saw initially that they could have possibly missed this time around, and I held the patient's intestines aside while Adam proceeded with the washout portion of the procedure. The surgeons weren't able to close the abdomen this time around--sometimes it takes a few rounds and this patient's intestines were still too edematous. So they put a vacuum-sealed dressing on and closed the case.
I really like my job. I have plenty of bad days and feel stupid way too often, but some days it is just a lot of fun. I was high for the rest of the day. I recovered the patient back in the ICU, and he had the final closure of his abdomen yesterday.
On Sunday afternoon I took my patient to the Operating Room to have his abdomen washed out. He was shot four days prior--in his right upper thorax, almost in his axilla through his lung, diaphragm, then through his liver, ricocheting through his stomach and spleen. He was in the middle of a surgical treatment protocol pioneered at the University of Pennsylvania called the damage control abdomen; the patient is taken to the OR promptly from the Trauma Bay and opened up, all immediate life threatening injuries are identified and mitigated. The patient's abdomen is left open, packed with surgical towels and closed with an Ioban dressing (sort of the equivalent of surgical saran-wrap). In the ICU, the patient's ensuing acidosis/coagulopathy/hypothermia and other life threatening secondary injuries are managed, and the patient is taken back to the Operating room a day or two later for additional repair/washout (literally just pouring warm saline into the abdominal cavity and sucking it back out) and the abdomen is closed, thus preventing other complications from compartment syndrome and missed injuries during the initial damage control procedure.
It's now late november and I have less than a week left in orientation, this Friday will be my last day as an orientee. I've taken care of plenty of damage control abdomens during the 20 week ICU orientation process, but I had yet to see the exploratory/washout procedure done (washouts are done at the bedside in the ICU sometimes, if the patient isn't stable enough for transport). The two trauma surgeons-- a fellow Jay and a chief resident Adam--performing the procedure that day, were excited that I was almost off orientation and asked me if I wanted to watch the washout. My preceptor, Carolyn, offered to look after my second patient in the ICU that day, and I stayed with my patient in the Operating Room. I scrubbed in as an anesthesia resident induced the patient (it kind of sucks that CRNA's aren't utilized at HUP, but I guess there are too many residents who need OR time. If I stay on the CRNA track I hope I get this kind of acuity).
Anyway, long story short, I had my hands in this dude's guts and it was awesome. It was not only a wonderful anatomy lesson, but it really crystallized what I had been observing in the ICU. Of course his surgical dressing was turning uncomfortably yellow and his drains were filled with a disconcerting bilious-sanguinous fluid; I could see now that the 3 inch liver gash probably had something to do with that.
"Man that's big."
"Yeah."
"What do you think we can do about that?"
"When Pryor (an attending) was in here (the abdomen) before said he though we could probably just Argon the shit out of it and stuff some omentum in it"
"We could Argon the shit out of it and stuff some omentum in it."
"Yeah let's just Argon the shit out of it"
This exchange re: the liver injury exemplifies why I love trauma and the people who work in trauma. The Argon Beam Coagulator is probably the coolest surgical toy I've seen so far. It's like a Bovie cauterizer in size and shape, but emits a stream of Argon gas which is ignited to form a blue-green beam of Star Wars quality light and heat. Jay and Adam, probably in part putting on a show for me, who was enthralled, giggled as they waved the Argon coagulator over the liver lac, quickly turning the gash a bubbling black, stopping the steady trickle of blood and bile. They then snipped and pulled a stringy arm of peritoneal omentum and quite literally just stuffed it in the black, bubbly hole of cauterized liver. Jay de-gowned and phoned the attending to make sure there wasn't any more injuries he saw initially that they could have possibly missed this time around, and I held the patient's intestines aside while Adam proceeded with the washout portion of the procedure. The surgeons weren't able to close the abdomen this time around--sometimes it takes a few rounds and this patient's intestines were still too edematous. So they put a vacuum-sealed dressing on and closed the case.
I really like my job. I have plenty of bad days and feel stupid way too often, but some days it is just a lot of fun. I was high for the rest of the day. I recovered the patient back in the ICU, and he had the final closure of his abdomen yesterday.