SURGERY!!!

AHHHH!!! AWESOME!!! WOOOHOOOOOO

I was in surgery from 7:30 to 2 today. Saw a scope and two total knee replacements. Incredible, incredible experience.

I was a little nervous once I got in because I've had no exposure to the OR, which is a pretty serious place. I really had no idea up to that point about proper protocol and whatnot. I finally figured out where surgery was in the hospital, and the guy whom I'm going to call the policeman of the OR was like "WHERE ARE YOU GOING." He unlocked the door for me to get back to the lounge where I would change. After changing, they lead me to the main store room/center of operations, and a nurse threw me a hair net and mask (which I had no clue how to put on, haha), and led me back to OR #5.

The surgeon I was following worked with an anesthesiologist, a surgical tech, and an RN for the first surgery, a chondroplasty (repair of the cartilage), but done as a microfracture. Based on what I saw and understand, her cartilage was worn away in some places, and the bone on bone had caused some grinding. In microfracture, they use a surgical pick to dig holes into the bone, and blood from the bone marrow (where blood cells are made) seeps up and pools where the cartilage should be. That helps the joint articulate (move)somewhat smoothly again. With this particular patient there was question as if he was going to go through with it, because her meniscal damage was big and not contained at all. He ended up doing it, but because there was so much damage, he predicted that she'd need a total knee replacement.

This is what the setup for arthroscopy looks like:



The doc actually goes in there and can cut and shave off all the problem cartilage. The shaver is like a pencil that is rotating, that is inside a hollow cylinder. I guess the best way to explain is imagine taking off a thumbnail, hollowing out your thumb, and sticking a rotation rod in there. That is what the shaver is like. It's pretty spectacular if you think about it, beacuse all those tools are no wider than a pencil. He definitely used an small ice pick type instrument to do the microfracture. He stuck it where he wanted the holes, then told the tech to bang on it with a hammer. The blood started pooling, and he was out.

Also cool was in the beginning he gave me a little tour of the knee. Although I would have never been able to pick out all the structures of the knee on my own, it was encouraging that as he was whipping through all the landmarks I knew what he was talking about. Medial and lateral epicondyles of the femor, lateral and medial mensici, ACL, head of the tibia, etc.

After that surgery he told me everything I would do as a PA in that situation, which was nice of him. The good thing was that he talked about how great of a career PA is, and how he had seen a lot of pro-PA literature in this area. There are still many places that don't like the thoughts of PAs unfortunately. He also talked about how PAs can essentially double the output of a practice, so docs love them for that (aka, we make them a lot of money).

After we had that talk, he had to go to do something so he told me to go back to the lounge and wait for him. Well of course it's a maze back there between the center of activity, ORs, medical day care and recovery. I wandered around a little bit, and that is when I ran into "The Policeman" a second time: "WHERE ARE YOU GOING." He showed me the way, and I sat there and waited for the next surgery.

Next surgery was a total knee replacement, which I had heard is an awesome surgery to watch because you see everything. It absolutely is. It's also a very invasive and messy surgery, and yes, I did have blood and body tissue flung onto my scrubs and goggles even though I was ten feet away. It's a good thing that stuff doesn't bother me. They start out, make a big long cut off to the side of the patella, then open the skin up like a door, pulling the patella and patellar tendon away from the inside of the knee. There you see the bones!! Orthopedic surgery is like medicine for woodworkers, it's all about the tools. Chisels, hammers, saws, drills, files, you name it, it was used. The first guy had no cartilage left so he was walking bone on bone, which is extremely painful. Then he cut off a centimeter slice from the end of each bone, and then put a special stencil type thing to use as a cutting guide. Then he'd saw and chisel away. He'd also grind off the bottom of the patella to smooth it out, and to attach the patellar part of the knee replacement. Here is what a knee replacement kit looks like:There's a piece of metal on the femur (thigh bone), one on the tibia (shin bone), and a piece of plastic in the middle there the join moves over. They have special cement that they use to make them stick, as well as they drill in a couple of holes. Before they put the actual implant in, they use a practice size in order to get the sizing right. I'm not going to post pictures of what it looks like because I know my audience, but it's definitely worthwhile to check out! At one point he was just ripping out all the bone spurs and even the lateral mensicus. It was about half as thin as it should have been, but again oh so cool that I literally got to see it right in front of me.

After this patient was done, we went on rounds for a bit and checked on a couple of other patients. Then he had to make a few phone calls, so I went back to the lounge. At some point I heard him being paged overhead saying that the next surgery team was ready for him, so I decided to just head to the OR myself instead of waiting for him to get to me. When I got back into that central activity/storage area, one of the nurses was like "Oh, you're gonna see another patient! Great! But you need to go get a new mask. They are over there." She pointed to a general direction and then disappeared. I went over to this big shelf with a bunch of white boxes that all looked the same, trying to figure out what was inside all of them, when "The Policeman" happened to spot me and said "WHAT ARE YOU DOING?!." He showed me the mask, and I hopped right back into surgery for the next knee replacement.

The next case was interesting, as about six weeks prior he was actually having the original replacement, but when they got in they found that the knee was severly infected as a result of some illness beforehand, so they couldn't put the implant in. They put an antibiotic concrete spacer in between the bones instead and started treating him with heavy antibiotics. When they went in today, they couldn't actually put the new implant until they knew that the infection was gone. No matter what though, they had to take the cement out. That's when he got out his chisel and hammer and was just breaking it all up. They sent done a sample of blood and tissue from the knee, but the lab called up and said that there were a couple of neutrophils present (they're a kind of white blood cells that fight infection), but they weren't really able to tell if the infection was completely gone. So they had to quickly get another sample and run it down to the lab, because they couldn't proceed without the findings, but the longer the knee is exposed the higher the chances for infection, obviously. In the meantime they just started irrigating (flushing out with water) as much as they could. I was taught the phrase "The solution to pollution is dilution." That means just cleaning everything out with water.

They finally got the ok to proceed with surgery, when they realized that in the process of chipping all the cement out, the epicondular processes (the two bumps stick out at the end of the thigh bone) were loose and wiggly. That meant that they had to be especially careful putting in the implants, holding the cement and implant in place for a long time. After that, it was pretty much smooth sailing. It was great because during the two knee replacements, the official rep from the company that makes the implant stood beside me and explained everything that was going on.

After that surgery, I went into the central room and was debating about what to do with my hair net and gloves and goggles. I figured that I didn't have them when I initially entered the room, so I could just throw them away there. WRONG. Guess who found me...yup, "The Policeman." I was actually talking with another surgeon waiting for his surgery to start, because he's actually my neighbor and I babysit his girls. I literally had the hair net off for ten seconds when The Policeman yells from across the room "HAT!!!" I told him I was leaving and going to the lounge, and he pointed to the door and said "OUT!" The surgeon laughed and I walked out. They take keeping things sterile pretty seriously in the OR (which is how it should be). There was one point during surgery where I took one step toward the table and came within a foot of the instrument bucket, and the tech said "AHHH! YOU WERE SO CLOSE!!" I'm glad they all yelled at me though, because in all honestly I would be very, very nervous if I was in their shoes and had a student around who had no clue about what she was doing. It's a huge mess and a lot of work if any of the sterile environment is contaminated, and as much as I joked about The Policeman, I was very thankful for him because he kept me from doing anything really stupid.

I was invited back anytime, which is super exciting. The funny thing is that I was invited to stop by tomorrow, but I couldn't because of other engagements. Well I just found out that one of the cases tomorrow is the grandmother of the boys that I live with/nanny for.

Also, I've been on a big oatmeal kick lately mainly because it is so good for you, but also because it keeps me full for such a long time. I had a big bowl of it this morning because I didn't think I'd get a chance to eat lunch, and I was never hungry, even when I got home at 2:30. I mix one packet of the flavored crap with a half a cup of the plain stuff, and I am good to go. Mmm Mmm.