While a majority of Dr. Spector’s flap cases are performed in general surgery with the same familiar team of OR techs and circulating nurses, this particular case had been scheduled in ambulatory surgery with only one of the usual OR techs. When it came time to start microsurgery, and the flap was already detached from the donor site (i.e. no blood flowing to supply the living tissue with oxygen, nutrients), the circulating nurse had not started up the microscope correctly. When this was finally resolved, the microscope was not to Dr. Spector’s usual settings and he was unable to see clearly through the lenses. By this time (mid/late evening), the main OR staff had already gone home and without the usual circulating nurses he could not locate the appropriate microscope for the procedure. A resident and med student fetched one from general surgery (for those who don't know, it is 7 floors away and in a different wing, and the scopes are very large), only to be told that the scope they had brought up was used by a different team and would not work for Dr. Spector’s purposes. With the clock ticking, phone calls were made to the knowledgable staff who had gone home, and finally we got permission to take the plastic surgery scope from general. As quickly as we could, we moved the second scope out of the room while the third (correct) scope was located and brought up to the room. After more than an hour of ischemia time, the right scope was finally in the room. As soon as it was set up, the first scope was navigated carefully around it and moved out of the room. For the rest of the procedure, we had an additional circulating nurse in case there were any other issues. With such time-sensitive procedures happening, I still wonder why things like this occur. The success of a procedure is dependent on every person in the room playing their appropriate role. However, in this case, some were not equipped for the job, and others had to compensate for this because we were under the wire. This put into context how critical it is to have a standard operating procedure in any OR and to always have staff who understand the demands of the particular case. We were fortunate to have had our usual and amazing OR tech for almost the entire procedure, as well as several proactive members of the plastics team, without whom the case would have been an absolute disaster. Luckily, once the correct scope was set up, the procedure was completed without much further delay, and the patient has been recovering well since.
Monday, July 20, 2015
Week 6: Musical scopes: ischemia edition
This week we observed a major flap case—ALT free flap to reconstruct the foot/ankle of a patient that the plastics team has been seeing for almost all of immersion term. After a fall and ischemic injury to the lower extremity sustained in the home country, this patient has had little to no motion and or sensation below the knee. Dr. Spector has been recommending a below the knee amputation since his first time seeing the patient, and as such had not performed any major reconstruction in the case that the patient and family agree. We have seen several irrigation and debridement procedures for this patient in the OR, and recently saw the ankle pinned in place and the wounds closed with integra and autologous skin graft. The patient has been healing well from these procedures, thus the family seems optimistic that reconstructing the foot may be a step to recovering function below the knee. For this case, Dr. Spector’s team took a perforated flap from the ALT, consisting of only skin and fat, and divided it into two portions (to cover one wound on the foot and one on the ankle) both supplied by the same vessels. However, after already experiencing a delay at the start of the procedure, we encountered an even more critical one in the middle of the procedure, and even worse—in ischemia time.
While a majority of Dr. Spector’s flap cases are performed in general surgery with the same familiar team of OR techs and circulating nurses, this particular case had been scheduled in ambulatory surgery with only one of the usual OR techs. When it came time to start microsurgery, and the flap was already detached from the donor site (i.e. no blood flowing to supply the living tissue with oxygen, nutrients), the circulating nurse had not started up the microscope correctly. When this was finally resolved, the microscope was not to Dr. Spector’s usual settings and he was unable to see clearly through the lenses. By this time (mid/late evening), the main OR staff had already gone home and without the usual circulating nurses he could not locate the appropriate microscope for the procedure. A resident and med student fetched one from general surgery (for those who don't know, it is 7 floors away and in a different wing, and the scopes are very large), only to be told that the scope they had brought up was used by a different team and would not work for Dr. Spector’s purposes. With the clock ticking, phone calls were made to the knowledgable staff who had gone home, and finally we got permission to take the plastic surgery scope from general. As quickly as we could, we moved the second scope out of the room while the third (correct) scope was located and brought up to the room. After more than an hour of ischemia time, the right scope was finally in the room. As soon as it was set up, the first scope was navigated carefully around it and moved out of the room. For the rest of the procedure, we had an additional circulating nurse in case there were any other issues. With such time-sensitive procedures happening, I still wonder why things like this occur. The success of a procedure is dependent on every person in the room playing their appropriate role. However, in this case, some were not equipped for the job, and others had to compensate for this because we were under the wire. This put into context how critical it is to have a standard operating procedure in any OR and to always have staff who understand the demands of the particular case. We were fortunate to have had our usual and amazing OR tech for almost the entire procedure, as well as several proactive members of the plastics team, without whom the case would have been an absolute disaster. Luckily, once the correct scope was set up, the procedure was completed without much further delay, and the patient has been recovering well since.
While a majority of Dr. Spector’s flap cases are performed in general surgery with the same familiar team of OR techs and circulating nurses, this particular case had been scheduled in ambulatory surgery with only one of the usual OR techs. When it came time to start microsurgery, and the flap was already detached from the donor site (i.e. no blood flowing to supply the living tissue with oxygen, nutrients), the circulating nurse had not started up the microscope correctly. When this was finally resolved, the microscope was not to Dr. Spector’s usual settings and he was unable to see clearly through the lenses. By this time (mid/late evening), the main OR staff had already gone home and without the usual circulating nurses he could not locate the appropriate microscope for the procedure. A resident and med student fetched one from general surgery (for those who don't know, it is 7 floors away and in a different wing, and the scopes are very large), only to be told that the scope they had brought up was used by a different team and would not work for Dr. Spector’s purposes. With the clock ticking, phone calls were made to the knowledgable staff who had gone home, and finally we got permission to take the plastic surgery scope from general. As quickly as we could, we moved the second scope out of the room while the third (correct) scope was located and brought up to the room. After more than an hour of ischemia time, the right scope was finally in the room. As soon as it was set up, the first scope was navigated carefully around it and moved out of the room. For the rest of the procedure, we had an additional circulating nurse in case there were any other issues. With such time-sensitive procedures happening, I still wonder why things like this occur. The success of a procedure is dependent on every person in the room playing their appropriate role. However, in this case, some were not equipped for the job, and others had to compensate for this because we were under the wire. This put into context how critical it is to have a standard operating procedure in any OR and to always have staff who understand the demands of the particular case. We were fortunate to have had our usual and amazing OR tech for almost the entire procedure, as well as several proactive members of the plastics team, without whom the case would have been an absolute disaster. Luckily, once the correct scope was set up, the procedure was completed without much further delay, and the patient has been recovering well since.
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