Monday, January 14, 2013

Julia's Perspective: Patient Surgeries, Day 1

Julia is one of the high-school students traveling with us and participating in the work at the hospital. She's doing a great job of journaling her experience. Here's a slightly edited version of her account of the first day of surgery.
Our team's nursing director asked me if I wanted to help in the operating rooms. In short order I learned a long list of things, including how to:
  • Help the surgeons tie up their surgical gowns
  • Track surgery start/end times and patient weight on the patient record
  • pen sterile packages and put the contents onto a sterilized table without contaminating the area
  • Angle the overhead lights for the surgeons
The early part of the day passed by in kind of a haze of excitement. I got the bone saw for one case and fetched the casting material for several patients. I saw most of the team's surgeons and residents operate during the day. I helped whenever I could, watching in amazement when there was nothing I could directly do to help.



I saw a bilateral TAL (Achilles tendon lengthening of both feet), in which the surgeon makes cuts with a scalpel at three pre-designated spots on the tendon. The procedure creates an environment where the tendon can stretch as it's casted over 6-8 weeks at a 90° angle. (Ed. Note: The repair is done on patients who cannot flex their foot or put their heel on the ground.)

All that was before lunch. My favorite case though, was the very last one we saw today.

One very important lesson that I learned from this one was that: The only thing worse than blood is the absence of blood. That was the first thing that dawned on me as we walked into the room. Dr. Mullens explained it to me this way: Every single tissue, every single cell in the body needs oxygen to survive.

No part of the body can survive being cut off from the central blood supply. Seems simple enough – for a normal, healthy person. When your blood vessels constrict, the parts on the end, extremities like fingers, toes, and eventually entire limbs begin to lose their connection to the rest of the blood supply. Pretty soon, they get no blood at all. It’s worth repeating: without blood, all cells die.

That was the very situation that brought us to that final operating room this afternoon. The patient was a 29-year-old male. His height seemed normal, but he was completely emaciated. He weighed just 64 lbs (29 kilos), close to an average 10-year-old. A glance down his frame, sprawled haphazardly over the operating table explains why.

Though a sheet obscured most of his body, we could see his face and his limbs. He was missing two fingers, and had nearly all the rest bandaged. His face was round and appeared small. His eyes seemed to sink deep into his skull and hurry frantically from one face to another, constantly scanning the room. I can only imagine what was going through his head, but it did not seem happy.

All his limbs looked like his bones had decided to wear his skin like skinny jeans; there was virtually nothing in the way of visible fat or muscle. It was so bad that my first thought was, maybe he’s post polio? Many of the other post-polio patients had one or more limbs that looked similarly gaunt and thin because the polio had interfered with muscle development and thus substantially reduced muscle tone; even long after the disease itself had receded.

This, as it happened, was not a post-polio case. His blood vessels had constricted in all his extremities, but particularly in his feet. Cut off from their oxygen supply, those cells had died. On one foot he had lost a toe and two more were almost completely black (even the nails) and barely attached to the rest of his foot. That was the good foot.

It is questionable whether his other lower extremity could be accurately described as a foot. The big toe seemed okay, if you ignored the mold beginning to sprout from the oozing part at the top. But the big toe was the only one still on the foot. On the medial anterior (i.e. outside lower) side of the toe there were three bone protrusions, formerly metatarsals. Each was probably about one to two inches in length.

There were two striking things about the bony protrusions. First, they seemed to have had the tops intentionally removed. Our team’s doctors speculated that this was likely the result of a different, earlier surgery, despite no mention of any such surgery in this patient’s file. Second, and more striking, was that these bones were completely clean. The implications of the bones' "cleanliness" -- this man’s bones had been exposed for at least a month, possibly longer, for everything that attaches to be gone.

This would have had to have been extremely painful for the patient. Per the local doctor, "It would be like tying the top of your finger super tight with a rubber band, then sticking it in ice cold water and leaving it there for days... it’s also exceedingly unpleasant for the patient…”

The treatment is amputation. That’s exactly what I was about to witness, on both feet.

In the minutes leading up to the surgery, the patient got his IV line and saline bag, his spinal anesthesia, and a drape to obscure his view of the surgery area. Both legs were vigorously swabbed with iodine antiseptic to combat potential infection.

By that point he was shaking, much like patients who had preceded him. At first I thought the shaking was due to nervousness, but a nurse pointed out that the room is very cool compared to the hot, humid climate. The other nurse further told me that they use the air conditioning, not for comfort as I had assumed, but to keep the bugs away. It was evidently not more comfortable for the patients.

Each foot had two doctors working together. The plans for each foot were similar in certain ways, but differed in one important respect -- the extent of the amputation. There was considerable debate about whether or not a full amputation below the knee would be needed. The local doctors made the case for the drastic amputation, relying on a test that appeared to indicate that none of that area had blood supply.

Our team decided to break the surgery into two stages. First, they would cut around the area that appeared to have no circulation to see if there was any a little higher up. If there was, then perhaps the area between the knee and the heel could be saved. If not, the amputation would go all the way to the bottom of the knee.

The surgeons did find some blood flow in the lower part of the more involved foot, which was enough to merit trying to salvage the lower leg. After a complex process of suturing, both feet were bandaged. The team will check back on the patient in recovery.

Though obviously not ideal, the doctors predict that he will be able to retain limited independent mobility after the surgery, so long as nothing else needs to be amputated.

For me, the moral of the story was: DON’T SMOKE. EVER.

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