Junior surgery gets divided into two phases- cadaver and live surgeries, mostly spays and neuters. You would think it would make sense to have your cadaver surgeries before your live surgeries, to learn how to actually perform the surgery. Apparently the size of our class makes that impossible though, and I was one of 12 lucky people to have our first live surgery scheduled before having any of the cadaver surgeries. I was pretty close to a full on panic attack, and all I could do was obsessively read the lab manual and hope I understood what was going on and what to do.
For my first live surgery, I was one out of two anesthetists for the group. We performed two surgeries, a spay and a neuter. One anesthetist has the role of the main anesthetist for one surgery while the other is the recorder, writing down all of the patient's vital signs on the anesthesia record, and then for the next surgery the roles switch. I was the main anesthetist for the first surgery, a neuter of the cutest little puppy named Marty. Obviously, I was terrified of doing something wrong.
The first thing I had to do was induce Marty, which just means giving him the drugs to knock him out. The day before the surgery was scheduled I came into the hospital to prepare all my drug dosages for the mixture of Telazol, Butorphanol, and Dexmedetomidine. This is just a quick IM shot into the quadriceps (thigh muscle), but apparently it's pretty painful, because all of the dogs yelped when they got their shot. This didn't help my nerves or my confidence. But the next part was easy, just petting Marty until he got sleepy and laid down on the table.
Then I had to get the catheter in. I've never put a catheter into a small animal before, let alone a puppy. I'm used to giant horse veins, which you'd have to be blind to miss. Even after all my blood work in Africa I wasn't too confident, because even a sable's ear veins were larger than Marty's cephalic vein. It was easier getting the catheter in though than it was trying to take blood from him the day before the surgery though, because at least he wasn't squirming around. I didn't hit the vein on the first try- that would have been a miracle- but at least it only took one stick and some wiggling the needle around. I always feel bad when I have to continuously have to stab to hit the vein, especially since I hate when nurses do that to me.
After the catheter is secure I had to pick out an endotracheal tube. That was an adventure. I had absolutely no idea how to appropriately size an endotracheal tube. I grabbed like 4 different sizes and brought them all over to hold up to Marty's neck. Of course, they don't differ so much in length, but in diameter, so that didn't help too much. You want the largest diameter size you can fit without traumatizing the mucosa, and I still don't get how you know what that is. I guess just practice. I got the right size with the help of an anesthesia tech, and then I managed to slip the endotracheal tube down between the arytenoids and into the trachea. Now I was feeling a little more confident.
We finished setting up all our equipment after turning on the oxygen, and then we prepared to move from the induction room into the surgery lab. All of our animal shelter live surgeries take place in junior surgery, where our labs take place as well. We wheeled Marty in and got him hooked up to the anesthesia machine and got all of his monitors on. Now for the duration of the surgery it was my job to make sure Marty didn't wake up. I had his oxygen flowing, I had the isoflurane on, and I was constantly checking his blood pressure, pulse, and respiration. I gave him a sigh breath (manual breath) every 5 minutes or so, and if I thought he was getting a little light I would up the isoflurane. To check that he was still under and wasn't getting light, I obsessively checked his palpebral reflex and eye position. For the palpebral reflex, you tap the inner corner of the eye. In the awake dog when you do this, the dog blinks. If the dog is under anesthesia there should be do palpebral reflex. The eyes should also be pointed ventral, or looking down. So if I saw a little bit of a blink, I upped the isoflurane until I felt I could bring it back down again. My nerves went away during the surgery and I stopped worrying that I was going to kill the patient, but it did take constant attention and adjustment to keep Marty's levels good.
After the surgery was done, and I had turned off the isoflurane, it was my job to sit with Marty until he woke up. For such a little dog that had seemed to be not so deep at all during the surgery, he took a long time to wake up. He almost went past the 30 minute mark, which then would have to be marked down as a complication. But I can't complain; I got to sit there cradling him and rubbing his back, waiting for him to either cough or swallow so I could pull the endotracheal tube out. Then I carried him into recovery. I don't know how anyone goes through junior surgery, let alone the animal shelter rotation, without wanting to adopt every dog that goes through the program.
For the second surgery, a spay on a puppy named Topaz, I was the recorder. So I didn't have to place any catheters or endotracheal tubes, I just helped hold Topaz in place for them. And during the surgery, every 5 minutes I just had to record blood pressure, pulse, respiration, end tidal CO2, saturated O2%, and the flow levels for oxygen and isoflurane. And every 15 minutes I took a temperature. This was definitely much less stress than being in control of the anesthesia machine, plus I didn't have the nerves or stress that comes from not knowing what to expect or what to do. So I just stood a little off to the side, and every 5 minutes I checked all my instruments and wrote the values down. Not bad at all. Until Topaz decided to wake up halfway through the surgery and had to be given an extra shot of propofol through her catheter. That was some excitement I could have done without. But at the end of the day, both Marty and Topaz had successful surgeries and were able to go home immediately afterwards.
The next week I had two surgery labs, where I would be acting like the assistant surgeon and primary surgeon for our cadavers. On our first lab we did a spay, celiotomy, and placed a chest tube. For the second lab we did a neuter, gastrotomy and gastropexy. Celiotomy just means we explored the abdomen. For the chest tube, you have to force a tube through the thoracic wall into the thoracic cavity. It's an emergency procedure used to eliminate any excess air or fluid that's in the thoracic cavity. A gastrotomy is opening up the stomach, which is a procedure that's rarely performed, but might be done if an animal ingested a foreign body. Gastropexy is suturing the stomach to the abdominal wall. It's done mainly to prevent GDV, which is a life-threatening disease in dogs where the stomach kind of twists up on itself.
The first lab took forever, because again we had no idea what we were doing. Our first incision was not so pretty, and neither was our attempt to suture it back up. Our spay was also not the neatest job in the world, but at least it was done, and would have been a completed, successful surgery if it had been done on a live dog. It took us forever to suture up our incision, since for a spay you normally make a super small incision, but for a celiotomy you are cutting from the xiphoid to the pubis, or the entire abdomen from the rib cage to the hips. We were still trying to figure out the suture patterns, and since we were supposed to be using a simple interrupted pattern, that just naturally takes longer.
Our second lab went much smoother. Now we knew what to do, which helped a lot. Our initial incision still wasn't perfect, but it was better. At least it was through the linea alba, or the thin white line where the abdominal muscles join together, and not through muscle. The technique behind a neuter is pretty much the same as the spay, so now we knew how to use the three forceps technique and how to tie our transfixing knots and were able to move through that quicker. Plus a neuter is always just faster than a spay. The gastrotomy required a new suture pattern, the Lembert, which makes the stomach lining invert on itself to produce a better seal. But by halfway through closing that incision I really got the hang of it, so not only did it go smoothly, it looked pretty good. Same with the gastropexy; once it got going we were on a roll, and it looked good too. Our closing also went much smoother- our suture knots were much neater on the closing of the external rectus sheath. Our simple continuous pattern for the subcutaneous layer (which we couldn't even do the first lab because of our botched incision) looked consistent, and our skin closure had a little bit of puckering but overall wasn't too bad, and was still much better than our first attempt. I finally get why they make us do so much suturing and so many knots; it it so confusing at first and easy to overthink and mess up, but the more you do it the more it becomes second nature and you stop thinking and just let your hands move. By the end of the second lab I was even getting the pencil grip of the forceps down better, something which I can assure you does not come naturally.
I still don't feel like I really know how to do a spay or a neuter, but I definitely know more than I did a week ago. And I definitely know how to suture now, though the incision could still use some work. I have a little bit of a surgery break, but pretty soon my schedule is going to be nothing but surgery. I have all of mine this semester, which I think I'll appreciate next semester. For this class we have 7 surgeries as the anesthetist, and on our last one we play the role of both anesthetist and recorder for both surgeries. We have three surgeries as the assistant surgeon, and three surgeries as the primary surgeon. I'm still nervous for those. I really have to work on my aseptic technique, which we practice in our cadaver labs but it's easy to forget or ignore, since we usually mess up so much since we're still learning it. At this point I think that's actually what I'm most worried about. I think (and hope) that with three surgeries being able to watch a 4th year perform the procedure correctly I'll be able to do them myself as well. And then at least I can say I can do it and feel confident about it.
No comments:
Post a Comment