The most pronounced observation of
the week was during another ALT free-flap procedure, in this case used to
reconstruct soft tissue coverings for the patients exposed ankle/heel regions.
We had seen a number of these type of procedures throughout the summer, most
often utilizing the ALT as a well vascularized/large surface area donor site
requiring relatively minimal post-op wound care, to cover these deep tissue
wounds wherein a skin graft would be insufficient/pose low chance of healthy
integration due to the lack of an underlying vascular bed (exposed bone). We
have seen this patient throughout most of our immersion term, whom after
sustaining a significant/traumatic injury to his leg months back in his home
country, has resulted in significant tissue ischemia and little to no
motion/sensation below his dislocated knee-joint. Since day one, Dr. Spector
had been recommending a BKA (below knee amputation) as the best possible
scenario to return functional use of his knee. The complications with his
injury made the integration of the muscle-flap and/or skin grafts unlikely,
would induce further trauma in the donor sites, and would not return functional
usage of the foot anyway. The family and patient remained adamant about saving
the remainder of his foot/leg despite these recommendations, and thus had
undergone a slew of tissue debridements/irrigations as well as attempted
closure with both Integra and autologous skin grafts. While unsuccessful in
fully integrating/recovering, the patient wound sites appeared to be making
some progress in that direction, leading to the optimistic family to push for
the free-flap reconstruction.
For this procedure, Dr. Spector and
team segmented the ALT donor tissue in order to cover both defect sites whilst
still supplied by the same artery/vein for anastamosis. However, the procedure
was complicated by a “hiccup” during a critical point in the procedure – the
ischemic window. For starters, the operation was set to take place in the
ambulatory surgical wing (where Dr. Spector hardly if ever perform these flap
surgeries) and from his usual team, only one of his seasoned OR techs was in
the room. When it came time for Dr. Spector and his fellow to perform
microsurgery for the detached muscle flap, the circulating nurse had not initiated/setup
the microscope, and we further found that this particular scope possessed a
nonfunctional eye-piece. By this time, late in the evening, the main OR staff
and those whom he could normally contact to obtain a replacement had already
gone home. The circulating nurse had no idea of how to locate another scope, at
which point Dr. Spector sends off one of his residents and med students to
search for one in general surgery and bring it back, a difficult ordeal. When
they returned, the scope they had brought up was not suited/sufficient for his
intended usage. Eventually, we were able to get ahold of one of the
knowledgeable staff members from home, getting permission to use his regular
scope in general surgery (which thankfully, was no longer being utilized by
another surgical team) and the procedure was finally able to be completed after
an additional couple of hours for the micro-anastamosis.
This complicated series of events
has made me question how prevalent these type of issues might be. The successful
execution of these major operations depend on everyone apart of the surgical
team fulfilling their respective roles, each functioning as an integral
component in the clockwork nature of the OR. Any breakdown in those roles (e.g.
improper setup, equipment checks, etc.) can bring the whole operation to a
standstill. I could only imagine Dr. Spector’s level of frustration, but
outwardly you would never really have thought it, exuding his usual cool/calm
demeanor. I guess operating as a surgeon for all these years cultivates these
type of nerves of steel to tackle these complications/issues which are bound to
emerge, but really, the system should have been such (inbuilt checks, etc.)
that they don’t come up in the first place.
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