Tomorrow I have a new patient. A very young stroke patient just admitted this afternoon.
Thursday, July 24, 2008
following my patient through surgery
Wow, today was amazing. I have a patient that has many issues, recovering from a major abdominal surgery on two weeks ago, and suddenly needed neck surgery. Somehow the planets lined up just right for me and I was allowed to observe his surgery. I went with him to pre-op and observed how they handle patients getting ready for surgery. He did not want to cooperate though, he refused the TED hose and didn't want the intermittent leg inflation machine either both are used to help prevent blood clots from forming in his legs. He answered all the OR nurse's history questions though and was consistent in denying his diabetes even though he is on glucose monitoring and insulin injections. Then I followed the OR nurse like a puppy into the locker room, donned surgical scrubs, booties and cap. We went into the OR to prepare the room. I met the anesthesiologist and the OR tech. Watched them get the sterile field ready, get the gurney set up, count all the sponges, sutures, an other things. Then I helped wheel my patient into the OR and transfer him to the table. Since he is obese, this took several of us plus the lift team. The surgeon came in and the anesthesiologist put him under. They sedated him first, then paralyzed his muscles then intubated him and put him on a ventilator. Everything is monitored, breathing, brain function, heart, blood pressure, temp. They make sure there will be no breakthrough awareness. Once he was under they put that intermittent leg inflating machine on and arranged his limbs and tilted his head to expose his neck. The OR nurse cleaned the area with betadine and the surgeon draped him with sterile drapes leaving only the front of his neck exposed. The anesthesiologist sat at the patient's head and watched a bank of monitors and adjusted medications. He could see the patients face under all the drapes but unless he stood up, he could not see the surgery. I was allowed to stand at arms length from the patient and watch, they explained some things that they were doing, the nurse was very good about telling me what the steps were and what they were watching for and concerned about. The surgeon pointed out the thyroid and parathyroid as she was going, and called me to step closer to get a good look. I felt very privileged to be there and didn't interrupt with many questions. As she started to cut (after carefully marking his skin) and cauterize the vessels, the OR tech kept handing her instruments and using suction and sponges to mop up the blood and fluid. He seemed to know what she needed, the surgeon did not have to ask for much. There was an assistant surgeon that came in to help after the thyroid was exposed. The OR nurse spent most of the time during the surgery charting at the computer what was going on and getting things like the clean bucket for waste, and step stool for the other surgeon. They found the mass on my patients parathyroid and were able to excise it from the thyroid pretty cleanly. The parathyroid and the mass was huge, the pathologist commented that it was the biggest he has seen. He took it away to analyze it to make sure it was parathyroid tissue that was removed. Then they had to obtain a blood sample within 10 minutes of removal of the parathyroid to check the PTH level. That was a challenge. I got to hold the sheet up for the anesthesiologist to get in to use a foot vein to obtain a sample, while the surgeon tried to get a sample from one of the neck veins in the open part of the neck. Neither one produced enough blood for the sample, finally the surgeon dug around to get at the internal jugular vein and was able to get plenty. That got sent off to the lab STAT and they started to close him up after the pathologist confirmed that the tissue was indeed parathyroid tissue. The assistant surgeon left at this point and the surgeon sewed the subQ tissue first and then the outer skin. They chatted about their own lives at this point, they no longer had to focus so much on the surgery. Then they counted everything, on the table and in the wastebasket to make sure nothing was left in the patient. After they removed the drapes the OR nurse came over and help the anesthesiologist rouse him. I guess that once you stop administering the anesthesia, it wears off pretty quickly, although the nurse said he would have no memory of this time period. My patient was slow to arouse however. He did not respond to commands or seem able to breathe on his own. He could initiate his breaths but did not take in a deep enough breath to oxygenate his body. They have criteria the patient has to meet in order to remove the trach tube, one of them is ability to follow commands, and the other is the strength to squeeze the doc's hands and lift his head up for 5-10 sec. My patient could do neither. They were also concerned about his blood pressure which was dropping pretty low. Finally the anesthesiologist decided he should remain on the ventilator in the recovery room until he could breathe better on his own. So we waited till they got all that equipment ready for him in the recovery room (PACU as it is called at this hospital) The nurse was pointing out to me that it is much safer for the patient to remain in the OR while on the vent until they were ready because he could crash at any time. They were all pretty calm considering what seemed to me pretty dire situation for my patient. When they were ready we wheeled him into the recovery room and a new crew of people swarmed around to work on him. The respiratory therapist was there to work the ventilator, the anesthesiologist stayed, the recovery nurse started her assessment with the help of a couple of other RNs. This is where I felt in the way. I didn't really know what to do and there was a lot of activity right away all around him. The RT was watching the ventilator to see how deeply my patient was breathing, to determine when they might remove the tube. The surgeon came in to check on him and examined the wound from his previous surgery (done by another surgeon) and ended up cleaning it, culturing it and repacking it with gauze. I watched all this pretty carefully. Meanwhile the patient was coming around a little more and was agitated about the pain in his abdomen and the tube in his throat. He wanted it out. The nurse wanted to give him some pain meds but the anesthesiologist (who was still sitting there) didn't want him to have any since it would affect his breathing. But the patient was in pain and agitated so he let him have some, and it helped immediately. He wanted the tube out though. They drew a blood sample for arterial blood gas test, the RT did this, I understand nurses don't usually do this procedure. I got to watch that too, but I couldn't really tell how you know you are drawing from an artery and not a vein. He use the patient's wrist. The anesthesiologist decided his breathing was getting stronger, (an hour in recovery) and he could be extubated if they put him on the BiPAP machine. It is a machine that delivers positive pressure to the lungs on inhalation and also a lower pressure on exhalation but through a mask instead of a tube. However my patient got very upset about this, and waved the machine away as they were bringing it to his bedside. He didn't want this machine. The anesthesiologist then decided not to extubate him then. He just didn't trust that the patient would be able to maintain his airway and reintubating him after neck surgery would be extremely difficult. So they ordered an ICU bed for him. At that point I had to go back to the floor since he would be going to a different unit and I would no longer be able to follow him. All in all it was a very exiting day for me, although quite a difficult time for my patient. I wish I could follow up on him to see how he does after a night in ICU. The report that his PTH levels were decreased was good news but it will be a few days before we hear if the mass was cancerous or not. I was relieved that I was able to watch the procedures without getting grossed out, or fainting or even feeling sick. You never know how you will react until you are actually in the situation and I am glad I did fine. It was actually really fun. I wonder if I might like working in surgery, who knows.
Posted by knitwitmama