A Lesson in Pallative Care

~Warning- some pictures in the following post may be considered graphic~

When you really enjoy what you do for a living it doesn’t always feel like a job. Sure, the early mornings can be killer and there are some days that you just wish you could go home and never come back. But if you have a real passion for your work the majority of your days are filled with a sense of accomplishment and pride.

Being a surgical tech is one of the most rewarding things I’ve ever done. It’s not glamorous and it’s not full of recognition. But every day I know I helped make a difference in someone’s life. Maybe I helped relieve their pain. Maybe I assisted in giving them back their range of motion so now they can play with their grandchildren. Or perhaps I helped perform an emergency surgery that saved their life. The patient often has no idea who we are and the only part of our face they see is from the eyes up. But that’s okay because when they wake up from their surgery they can hopefully look at the faces of the people they love and know that they’re going to be just fine.

Sadly though, that’s not always the case. Sometimes we can't cure what ails them. And the only thing left for us to do is to try to improve their quality of life and give them the most pain-free time we can give them.  This is called palliative care.

 I first heard of this back a few years ago when my grandfather suddenly got sick. My family and I waited for days in the hospital waiting room praying that the doctors would be able to give us good news. But it never came. We had two options. Keep him on life support or realize that he lived a full life and let him pass away peacefully with no pain. I can tell you that it was the hardest decision our family has ever had to make. You never want think that there is no more hope. You never want to give up because what if……..but we knew it was the right thing to do.

What television and movies don’t tell you is that when you take a person off a ventilator they don’t die instantly. By any means. So the doctors told us that they were going to move my grandfather to the palliative care floor. There he would be given a practically endless supply of pain medication and they would simply continue to care for him but no live saving measures would be a part of his care. It was the right choice.

In surgery palliative care means that we perform a surgery or surgeries that will alleviate a patient’s pain or will give them a better quality of life until they die. We can’t cure whatever is wrong with them, usually cancer. When you find out that you’re performing a palliative procedure on a patient, your heart sinks because you’re used to fixing people. The prognosis is usually good. But in these cases you know better.

Recently, I had a patient coming in for an exploratory laparotomy. This means that we make a long midline incision in the patient’s abdomen to expose the bowel.

Then we basically look around (not always knowing what we’re looking for) and try to find the source of the problem. For this patient it was gastrointestinal cancer.  In this case the cancer had metastasized to other organs and there was nothing else that could be done to cure it. The patient had already had a partial gastrectomy (removal of part of the stomach) but the original tumor was in her bowel and had grown large enough to cause an obstruction (blockage) and was causing her considerable pain.

Once we located the tumor (which turned out not to be too hard…it was the size of a softball) it was just a matter of deciding how best to proceed. 

The surgeon decided that the best outcome would come from a Roux-en-Y procedure. This is named after the surgeon who developed it, Cesar Roux, and the way the final product looks (the letter Y).

After clamping the bowel on both sides of the tumor we used a stapler to both close the bowel and cut it.

Bowel surgery is very delicate because the contents of the bowel are highly contaminated with bacteria and it’s very important that we don’t let it spill out into the abdominal cavity. Once both sides had been stapled shut and were cut we were able to remove the diseased portion with the tumor. Then it was just a matter of reconnecting the remaining portions of the bowel to what remained to her stomach and to each other.

All in all the surgery took about four hours to complete. It wasn’t easy and to be honest, I wasn’t entirely sure I was ready to scrub on it by myself but I tend to underestimate myself and did just fine. As a team we did exactly what we set out to do. We took out the source of our patient’s pain and gave her a little more time to spend with her family. That’s all we could do. But at least we did something.

LIttle Bugs, Big Mess

Being a surgical tech is hard work. I'm just now realizing this. It's not just a physically demanding job. Oh no that would be easy. This job also gets you mentally and emotionally. After an eight hour day at the hospital I am just spent. And its taken two months working at the hospital as a surgical tech for me to finally start feeling like I'm hitting my stride and that I can fly solo on most of my cases. And I'm excited about it.

Most days I really like my job. I don't like working the 7am to 3pm shift because I am in no way a morning person but I'm tolerating it. I have very few bad days where I just hate what I'm doing and question if this is where I want to be. However, a little while back I had a very bad day that I'd like to share with you because it ties in to my previous post about microbiology. I will pick back up on that two part post next time but I wanted to really shed some light on what all those nasty little bugs can do to a person’s body. *Caution- a few of the pictures may be a little graphic*

Not long ago I was working in General surgery with my favorite doctor and was having a routine day of laparoscopic cholecystectomys (where we take out the gallbladder through a series of little ports called trocars instead of one big open incision).

These are the trocars that we use for laproscopic surgery. They are put through the tissue layers and gas is instilled in the abdomen to inflate it to give us room to work. Then long, thin instruments are passed through the trocars.

Around lunchtime the charge nurse came into our room and told us that after lunch we were getting an add-on case. It was a woman with a decubitus ulcer or a bedsore on her butt that had gotten infected with staph. Typically, these things are fairly small so we didn't think it was going to be a big deal.

After I got back from lunch I set up for this case thinking that the rest of my day was going to be a breeze. Boy was I wrong.

Let me give you a little background on my patient. The patient was a female in her late thirties, about 400 pounds, who suffers from muscular dystrophy (refers to a group of hereditary muscle diseases that weaken the muscles that move the human body). Because of the disease she couldn't walk or really get around by herself. However, she managed to live by herself. Which was just fine except for the fact that she had no sensation below her waist and had no idea this ulcer had formed.

Decubitus ulcers are lesions caused by many factors such as: unrelieved pressure; friction; humidity; shearing forces; temperature; age; continence and medication; to any part of the body, especially portions over bony or cartilaginous areas such as sacrum, elbows, knees, and ankles. Although easily prevented and completely treatable if found early, bedsores are often fatal – even under the auspices of medical care. They can be very serious and most of the time they are discovered quickly because they are very painful for the patient and because for those at high risk there are normally caregivers who check for them.

In this case, the patient had no caregiver and no lower body sensation to alert her that something was wrong. She was wheeled into the room and she was in very high spirits. I thought this was going to be routine until the other nurses who were trying to move her onto the O.R. table shifted her to one side. I couldn't see the ulcer but I could smell it. Try to think of the worst smell you've ever come across. Now multiply that by about 1,000. No I am not exaggerating, it really was that bad. The first wave hit me and I had to immediately regroup before I threw up in my mask. The smell was literally that of rotten flesh and I was not at all prepared for it.

This shows the four stages of these ulcers. As you can see the longer they go untreated the deeper they go. This patient had a stage 4 ulcer.
As they worked on getting her onto the table, one of our team members began to frantically search for the children’s Chap Stick that we keep around. When you rub the Chap Stick on the outside of your mask the fruity smell helps to cover up the nasty one.

Finally they got her on the table and under general anesthesia. They rolled her onto her side and for the first time we got to see what we were working this. This was not a small ulcer. It was her entire backside from the bottom of her back to the top of her legs.  It was so bad that the only thing the surgeon could do was remove all the dead tissue, clean it the best we could, and put a dressing over it. There was nothing left to suture together. The ulcer was so deep in the tissue that we could see her coccyx (her tailbone) and the infection had gotten into the bone so the end of it was so soft that it broke off when the doctor gave it a little tug.

The staph bacteria from her skin thrived in this wound because the ulcer had given it an ideal place to live. It was dark, moist, and wasn't regularly cleaned. All these bugs need are a place to get into our bodies and they can quickly get out of control, as was the case with this patient. No, in this case the infection wasn't cause by something we did in the O.R. but a surgical incision is nothing more than a break in the skin (and unbroken skin is our first line of defense against bacteria). This is why we are so crazy about sterile technique.


Always,
Lisa Marie

First day.......boobs!

I recently started my first hospital surgical tech job and I can’t tell you how excited I am about it. Granted, up to now I had been dreading it because I love my job at the college and I didn’t want to have to cut back on that but I’ve since changed my mind. The minute I scrubbed in on a surgery the other day all the love and excitement for the clinical aspect of my job came flooding back.

Being new is never fun but I’ve tried to make the best of it. So when the “mentor” I had been assigned to for the day told me that I could jump in whenever I was comfortable I knew that it was do or die time. See, the O.R. is a lot like high school. You have your groups of people who stick together no matter what, you have your catty women who you know you need to watch out for, you have the jocks that make you swoon, and you even have the silly boys who always go for the cheap laughs. And just like back in high school, these people can smell your fear. When you’re new, you can’t hesitate when someone gives you the chance to show your skills. It’s a timing thing. If you try to observe and learn the lay of the land for too long…..it’s going to be a feeding frenzy. And just like high school, you’ll never recover from it.

So anyway, I knew when she told me to take over when I was ready it was time for my first test. So I observed for another three to five minutes and I took over the table. At this point the surgery was underway so I didn’t have to worry about setting up my table or draping or anything like that. All I had to do was run the table, pass instruments, handle specimen, and maintain the sterile field. After the first minute or two of holding my breath, I exhaled, relaxed, and found my groove. It was fantastic and I didn’t realize just how much I missed it until right then.

The case I took over was a bilateral mastectomy with breast reconstruction. What does that mean? Well basically the patient was at high risk for developing breast cancer and decided her best chance would be to have both of her breasts surgically removed and then have a plastic surgeon reconstruct them using implants. This is what we call a prophylactic surgery-surgery done to prevent a disease. At first it may seem like a pretty radical step when thus far the patient was healthy but when you’re faced with the knowledge that there is a very good chance you could develop cancer you look at it as a live saving decision.

This was not the first mastectomy I’ve done and they have never bothered me before ( I know that sounds harsh but in order to cope with this job, once the patient goes under and is draped out I stop thinking of them as a whole person. Otherwise, I’d never be able to stop thinking about what the patient might be going through.) Anyway, recently I had a student drop out of my program after observing a mastectomy because it disturbed her so much that she decided she was on the wrong career path.

So, as I worked on this woman I got to thinking about what this might do to her psychologically. Would she wake up and feel like less of a woman? Would she feel undesirable and be afraid to let her husband see her? Would she feel ashamed every time she went bra shopping because those weren’t really “her” breasts?

Let’s face it- what is one thing that makes most women identify as a woman? I’ll give you a hint…look down. Yep, breasts. And why wouldn’t they be an identifying factor? I don’t know if you’ve noticed but our society is obsessed with them. Water bras, cleavage baring tops, those “chicken cutlet” inserts, Pam Anderson….and every day woman have elective cosmetic surgery to enhance their own, um, assets. These things not only make them feel better about themselves but can also make a difference in how other people look at them.

My point is breasts are not just an accessory that just happens to be connected to our chests. They make us feel feminine. They instantly set us apart from men and are desirable objects. What would it do to the way we identify with ourselves if they were suddenly gone? Would you feel like damaged goods?

All of this ran though my mind from the first incision. The tissue was dissected away from the skin with the cautery and removed and a pocket for the implant was created below the pectoralis major muscle using cadaver skin. As the first implant was inserted, I realized that this patient should not feel like any less of a woman after surgery. She made a decision that will potentially save her life, not to mention spare her the heartbreak of developing cancer. She opted for reconstructive surgery so that she’ll still look the same physically but even if she hadn’t, she could have altered herself perception. One body part doesn’t make you who you are.

By the time this amazing plastic surgeon finished, we had used 124 sutures (which was super fun to keep track of by the way), two pieces of Alloderm (cadaver skin), three implant sizers, and two silicone implants.  From first incision to wound dressings the surgery took about four and a half hours and seven surgical team members. It was routine. But what we gave that patient was anything but. When she woke up in the post-surgical recovery until, she had piece of mind that she had just undergone something that will save her life. She won’t have to worry every time she does a self exam or has a mammogram. She doesn’t have to live in fear of that “C” word.

Yes, being a surgical tech is a job. It pays well and it’s fun. But it also gives us a chance to help people in more ways than you could ever imagine.

Always,
Lisa Marie