Day 4 started off with a morning meeting
that was prematurely cut off.
Regardless, the topic was very interesting. You may have read about the Taiwan MRT train
station stabbings that occurred a couple months ago. The victim with the most serious injury was
brought to our hospital. The
presentation was about his case and emergency care. The victim was a young male adult who
suffered a stab wound to the heart; however, from what I am told, the emergency
room doctor basically just sutured the wound without performing ultrasound or
any studies to figure out the etiology of his bleeding to try to stop it. The patient eventually expired of shock, most
likely hypovolemic. The rest of the
presentation was supposed to be about emergency care, but like I said, it was
sidetracked and halted prematurely. I
asked Dr. Chen to send me her powerpoint presentation because I am interested
in the subject.
On day 3, Dr. Ou told us that the next
couple of days would be rather uneventful; however, this turned out to not be
the case. During the final days of
general surgery, I saw a lot of hemmorhoidectomies; however, one of these was performed
as a stapled hemmeohoidopexy. First off,
to lay a background, the chief resident explained to me that we needed to preserve
the muscle in the anal canal and only excise the external part of the hemorrhoid. So, Dr. Ou began by suturing a purse string suture
to separate a ring of what we wanted to excise from what we did not want to
excise. Next, the device shown below was
inserted and clamped down around what was sutured. Following, the ring separated by the purse
string suture was excised and stapled at once using the device. This prevents excessive scarring in the anal
region and allows less post operation recovery time. Dr. Ou told me that the hemmorhoidectomy
patients usually report a lot of pain for the first 3 weeks after the procedure
and that this device was supposed to lead to almost no post operative pain;
however, this is not what most patients report.
The other surgery that I learned a lot from
was that of an elderly male patient who has a history of 2 CABG and 1 Mitral
Valve replacement 5 years ago. Now, he
has massive regurgitation and stenosis of the implanted prosthetic valve, which
is most likely attributable to endocarditis.
They also were contemplating another CABG if time permitted. Because his chest wall had been opened up so
many times, there was a lot of fibrosis and more importantly, adhesions between
the heart and the chest wall. Because of
this, the surgeon had to spend many hours simply opening the chest cavity
without rupturing the heart or the vessels of the heart. At one point, a vessel was ruptured and blood
squirted all over the surgeon’s face and he had to leave the room to clean it
off. Because this was a high risk
procedure, access to the femoral vessels was preliminarily acquired because if
too many vessels in the heart were damaged, the heart/lung machine would have
been inserted through the femoral vessels and up a catheter to the heart to
maintain a circulation while the surgeon fixed the damage to the heart.
After the surgeon fully opened the chest
wall and exposed the heart (which took 5 hours within itself), the heart/lung
machine was started and Plegisol (cardioplegic solution) was administered to
stop the heart. The machine basically
replaces and bypasses the pulmonary circulation by taking blood from the right
atrium, oxygenating it, and pumping that oxygenated blood back into the aorta
distal to a clamp on the aorta. The
patient is also administered heparin to stop coagulation. The machine can only be continuously used for
up to 4 hours because the coronary circulation is bypassed, and any longer
would lead to permanent ischemic damage to the heart. The surgeon then continued with the actual
mitral valve replacement. He removed the
old prosthetic valve, which had one leaflet immobilized. After inserting the new mechanical valve, one
of the leaflets was not moving very well.
After half an hour of problem solving, we finally figured out that it
was because one of the valve leaflets was getting stuck on a pledget used to
secure the old valve in place. After the
valve was fully in place, the patient had already been on the heart/lung
machine for more than 3 hours, so it was determined that it was time to take
the patient off of the machine. The machine
was stopped at 3.5 hours. We took the
clamp off of the aorta, allowing the cardioplegic substance to be evacuated
from the heart, which allowed the heart to beat again; however, the blood
pressure was very low. At one point it
was 36/30. In addition, blood was still
being suctioned from the heart, continuously.
I asked for the etiology of the bleeding and if there was a vessel that
was nicked or that needed to be sutured.
The perfusionist told me that it was “oozing” due to the heparinization
of the blood. We give protamine sulfate to reverse the effects of heparin, but
it needs time to counteract the heparin and counteract the oozing. Despite waiting for 45 minutes, the blood
pressure was still very low, so an IABP was on standby in case we needed it
(explained in a blog from week 1). After
thirty more minutes, the patient stabilized and I went home because by this
time it was already past 8 o’clock.
All in all, the surgery took over twelve
hours. The surgeon, the nurses, and the
perfusionist did not eat or drink a single bite or a single drop within this
time. I was, am, and will be forever
amazed at the hard work and sacrifice.
Stuff I learned apart from what
was already explained:
·
I noticed that every now and then, the patient
would become tachycardic and then go back to being bradycardic
o
Apparently, when using the electric cutting
tool, the electrical current can cause the tachycardia
·
I noticed that every now and then the heart that
was supposed to be stopped would beat. I
was told that this was not supposed to happen, but since everyone is different,
sometimes it just happens.
·
Monthly national healthcare insurance fee for
each Taiwanese citizen is only 600 – 700 NTD per month (20 USD). Although already cheap, the government covers
those who cannot pay or who say that they are too poor to pay. Because of this, less and less people every
year are paying for their insurance. In
addition, those who do pay seem to expect more from their doctor and expect
better service.
·
Because our hospital is a government hospital,
the doctors are not paid by cases.
Because of this, some doctors see considerably more patients than other
doctors. Patients don’t understand this
and will often complain when a busier doctor cannot spend as much time with
them.
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