Vascular week 2!

Not mine but an example :)

The second week of surg with the vascular team was no less exciting than the last! Well Monday we were excited and ready to hit the theatres again but the case was cancelled... minor flop but our ward rounds are still good and we had a nice tute with a registrar. In the afternoon we sutured Pig Trotter!! It was really cool learning how to suture and although i felt sorry for making cuts in a dead pigs foot i told myself that i was doing a fine job stitching him back up :P It was tricky even at the start to tie surgeon knots with rope but i eventually got it after a few practices, it is so satisfying when you get it! The intradermal stitch was hard to hide under the skin but also satisfying to get right.

Cannula's... for some reason i battle with these, i can't get into the veins although i am good when taking blood! After a few disheartening attempts, i finally did one on tuesday! :) AND i had to take blood at the same time which made it a little trickier, i am very thankful to the patients who let us do the procedures, so long as we have an air of confidence even when we don't feel it ourselves then they are happy. Some tips i want to remember though...

1. Align the vein by palpation with a marking on the skin i.e. a freckle, when the vein is not obvious

2. If you miss the vein on first entry, realign the vein and without taking the needle out and angle the needle to the vein and go in from the side

3. Once you get a flash back of blood showing you are in the vein you need to advance more at a lower angle/along the vein to ensure the cannula tube is inserted fully

4. Advance the cannula tip and hold the cannula in the vein when withdrawing the needle, this will also reduce blood exiting the cannula before the bung is placed on

5. If taking blood via syringe do this BEFORE any saline is inserted or bung is put on

6. Insert bung and saline solution

7. Clean up any blood on skin and tape/dress cannula to secure

That morning i also went in to theatre for an elderly patient who had a met call that morning from losing a lot of blood from a fasciotomy (fascia is cut to relieve pressure to treat loss of circulation such as in a swollen limb) resulting in a hypotensive crisis. Myself and another medical student followed the surgeons to theatre and prepared to watch them assess the fasciotomy wound and made an artery bypass. Only one of us was to scrub up initially so i was to stand on the side a little back but then got told i could scrub up also once the main surgeon came in. This is a 5 minute process to scrub up and be sterile, by the time i had scrubbed and walked in i was just a little surprised to see them have this man's leg fully open with everything cut except for the bone!! They said to me 'quick turn around Janelle this is the most fascinating part' and using what looked like a piece of string they cut the bone and were simply holding this mans leg from the thigh down in the air.... We were now doing an above knee amputation! Apparently in my 5 minutes scrubbing they had tested the muscles on the mans lower leg/calf and due to a lack of blood supply they were unresponsive and non-salvageable so they opted for an above knee amputation. This man was in his 80's with a number of co-morbidities and this was the best option to enable his survival, he was very unwell. What i didn't realise is how quick an amputation was! I always imagined it to be a tedious process of cutting layer by layer but i guess not! The longest part was probably the suturing at the end and the whole process only taking around 30 minutes if that, wow. 

I was so happy to have a break at the same time as Lex on Wednesday and had a lovely afternoon tea in the sun sharing our hot drinks and a citrus cake from Santis :) Having bought a few scratchies our luck increased a little more when Lex won $2!! :) Thursday was also a very interesting day! We had a lecture at 8.30am so the extra hour in the morning i squeezed in a gym session before heading to the hospital. After the lecture we sat in on a meeting and drug rep talk with all the vascular doctors before discussing patients and heading out to a late ward round with all vascular consultants present to get each others opinions.... wow a 15 person ward round was difficult to manage!! We weaved our way through ICU, 4th floor, 5th floor and 6th floor and at the bottom of the food chain us medical students were left huddling at the door trying to see the toe or leg of a patient but by the time we even worked out their name we were off to the next one! The main consultants are so tall and very imposing we felt a little small trotting along in their shadows! 

After a lunch break i made my way to surgery to watch a carotid endartectomy on a patient i had met the day before. He had classic symptoms and came in with left sided arm and leg numbing, tingling and weakness which lasted less than 24 hours, a classic case of a TIA (less severe than a stroke lasting less than 24 hours). He was a lovely man to talk to and i was happy to follow his case and scrub in on his surgery. I had seen one last week for my first surgery and had a little knowledge about the anatomy and felt quite humbled when i could answer the questions the surgeons gave me and remarked that i was answering correctly ones RMOs don't get and should become a vascular surgeon!! Apparently i even answered a question correctly that a medical student has not got for 2 years (i gave myself a silent YAY!!! :)) It was quite funny last time i learnt that when they put a stent into the carotid artery there is 2-3 seconds where the blood runs free through the cut artery which mean it escapes! Coming off the aortic arch from the heart the blood is under high pressure and i was directly in line with the artery... feeling a little unsafe i moved to the side just at the right time as a jet of bright red blood streamed 2-3m right where i was standing 2 seconds ago and hit the poor nurse behind me!! I thought 'yep this is surgery alright!'. There were a few minutes where i couldn't see too much of the process as my step was then covered in blood (yes i need one to see the patient on the table, i am just glad there is no BYO step haha) but i really enjoyed being thee and learnt alot!

Friday morning i went into another surgery and saw a lady have her femoral artery (in her leg/thigh) opened to remove a plaque... only this one we could not find an end to it, her poor arteries were so clogged and calcified its a wonder any blood was getting to her legs at all. So we opened up the artery next door and unclogged as much as we could of that one to give her leg some chance! The surgeon harvested a nearby vein to patch up the artery which was quite good to see, it was her longest deep profunda artery endartectomy the surgeon has done and took quite a while, 3.5 hours for this procedure. The patient was a smoker, and i just wished she could see what she was doing to herself, its a shame they can't see their own pathology its just like the Quit smoking adds seeing all the 'muck' clogging them up but would seeing it make a difference in their smoking habits?? Please do not smoke!!! It looked much worse than the image below, even the gangrenous/dead tissue on the foot looks mild these days after only 2 weeks in my surgical rotation!!

       

There was some bleeding complicating the closure but once it was fixed i was able to SUTURE!!! I only did about 6 but it was the first time i had sutured on a real patient! I think i did an alright job if i say so myself :P another tick off the surgical list :)

That afternoon i had an ultrasound of my foot which confirmed i have a thickened plantar facsia so the diagnosis of plantar fasciitis is confirmed and ruled out any other causes. It gets me down though i just wish it would get better :( I said no to the corticosteroid injection as i would rather monitor the pain to get it better for once and for all rather than masking the pain for a few months and not actually fixing the problem itself... what ever it is. Being so tired from the week and in a bit of a flop i didn't go to the gym but think i needed the break anyway to resettle myself and spent the night doing some study and preparation for an OSCE preparation day all day Saturday for our end of year exams (scary!). I think some sleep is in order for now... what an interesting week!