Musings from the Operating Room

This week at my clinical site, I got to run the C-Arm in the operating room for the first time. Other than seeing occasional surgeries on TV, I had never actually witnessed one myself.

I suppose my first impression was that surgeons really are just butchers. There is a lot of blood everywhere - all over their aprons and gloves, dripping all over the floor, soaked up by surgical towels.

Furthermore, when they are installing hardware to repair broken bones, they are literally using carpenter's tools. Drills, hammers, rods, nails, and screws. I don't mean specially-designed surgery screws, for instance. I mean actual screws that differ from the screws you use to hang a picture only in that they have been sterlized in an autoclave. These are screwed into place with screwdrivers with specially-modified handles.

Additionally, I always had the impression that surgery was very gentle and careful. You see shows on TV with neurosurgeons using computer-guided robots to carefully and precisely go into veins and arteries - very sensitive procedures where a slip of even 1 centimeter might mean catastrophic results.

In regular old surgery, however, it's not like that. They are standing with legs apart for good support, and hammering away with big strokes at rods that are being placed inside a bone. They are opening the flesh and then straining to hold it back with clamps and other wedge devices, exposing all the blood and gore and tissue beneath. It's not unlike watching a butcher cut up a rump roast.

Another thing about surgery is that most people think of what surgery looks like, but they rarely think about what it smells like. The smells were sometimes very bothersome. It literally smelled sometimes like a slaughterhouse. When they cauterize bleeding vessels, you get the pungent whiff of burned flesh.

Finally, if anyone has any delusions about dignity during their own surgery, they can forget them. During the procedure itself, only the area being worked on is exposed. But before and after the procedure, the person - still asleep - is literally just laying there buck naked, everything showing, being turned over and moved and oriented like a corpse. Tubes are in their mouth and nose, and their eyes are taped shut and they are drooling and their lips are all swollen and hanging open, and they essentially look like a vegetable in a loony ward, or a dead person. I saw them insert a catheter into a 15-year old boy's penis, and the catheter was about as thick as the shaft of a pen - maybe thicker. WAY thicker than what you'd expect could fit into that opening. Another person was having a hip fracture repaired, and he was laying on his stomach, buck naked, with a sanitary cloth under his butt to catch any fecal matter that might come out, and someone was literally perched over top of him on the table shaving the hair on his butt and back.

All told, I saw five procedures this week. The first day was the aforementioned 15-year old boy, who was having a pretty serious elbow fracture repaired. I walked into the room and saw nothing but an arm protruding from under the sterilized sheets, completely laid open from mid-triceps to mid-forearm. I could see one of the broken bones - a sharp peice from the bottom of the humerus - jutting out like a spear head. I could also see the base of the humerus, which is essentially like a spool of thread, that the elbow rotates against. It was cracked as well. There was very little blood because they had a tourniquet on his arm to keep all the blood above his shoulder. So the arm was white and limp and wrinkled and orange from antiseptic, and the doctors were busy putting in screws and plates. When they finished, I watched them sew up the opening.

Later that day, I was in the room for a broken hip - this was the aforementioned butt hair patient. After they started the surgery, only his left butt cheek and upper thigh were visible, and they basically opened him up all along that portion of his body, then held the tissue back with tools that looked like door wreath hangers. There was one person there - perhaps a med school student - whose only job was to hold these in place and keep the opening nice and wide and gaping.

The following day I saw two cases where patients were getting rods and screws placed to fix broken legs, and a third case where they were inserting a "portocath" into a woman's heart. She was awake for the procedure.

I was able to do a lot with the C-Arm, positioning it where the doctor wanted and then taking spot films. They use the C-Arm - which is fluoroscopic (meaning, sort of like a "video" X-ray...or real time X-ray) - to see where the screws and rods are that they are putting in. So we took a lot of spot films as they determined exactly where they wanted to drill, hammer, and screw. The blood was so thick on the floor of one of the femur patients in the spot where it was dripping that it had the consistency of jello.

When I wasn't in the O.R. this week, I did a bunch of portable X-rays on inpatients there at the hospital. These are difficult because you are X-raying people in their beds inside their rooms, using a portable X-ray machine. Depending on how sick they are, you usually have to lift them and turn them and orient them to get the picture, and they usually have tons of IV's and other tubes and wires all over them, which are easy to pull out if you aren't careful. We did a number of people in the various ICU wards, including one man in the burn unit who was so badly burned across his torso that he looked like he was rotting. We did another guy who had just been moved from his room down to the ICU because he had coded (meaning he started dying and they revived him), and so we had to go down to the ICU to do his picture there. He had severe emphysema and other lung problems, and was gasping for breath so hard that I could see the entire outline of his sternum and ribs beneath his chest each time he gasped for breath. I could even clearly see his xiphoid process, which is the very lowest tip of the sternum and which is even hard to feel on a patient, much less see. I thought he was literally going to die right there on the table.

So it's been an interesting week, and while its disturbing and depressing, it's also something new and exciting for me. I really think I would enjoy working for a big city hospital like this, a level 1 trauma center. And I haven't even been to the E.R. yet.

I was glad that the surgeries didn't bother me. I never got queasy or woozy or anything, and I was able to watch and even get pretty close to see what was going on, without having any problem. Because the patients is completely covered during the procedure, and because the skin is white and wrinkled and orangish with antiseptic, its almost hard to imagine that it's a real human being. It looks more like a rump roast in the Kroger meat market. It doesn't look human. The only thing that really bothered me was the aforementioned smell. You have a mask on, but it doesn't keep the smell away, and in fact it sort of traps it in front of your nose and its hard to get away from it.

Despite not being physically bothered by the surgeries, I think I was psychologically bothered, even though I didn't realize it at first. The reason for this is that last night, after my third day, I had really bizarre, violent, gory, bloody dreams. I woke up feeling very disturbed and with the recognition that the dreams had occurred as a result of being in those O.R. rooms. At the time, when I was still groggy with sleep, I actually thought to myself that I didn't want to go back there again. I don't feel that way now though.

I'm scheduled to be on another week of O.R. rotations, and then 2 weeks of E.R. rotations. My final week there will just be on the floor, doing fluoro exams and portables.