Today I got home before 8:00 pm! I have way too much to read and I have to be in the hospital by 6:00 am tomorrow. I must say that I am having a good time despite the hours.
The pictures above are of me and my chief resident harvesting veins for the procedure. The attending took these pictures on my Iphone. I did not realize he was taking the pictures and after the case he said "I left you evidence on your Iphone so you can prove to your wife that you really were in the OR and not on a date." I responded by asking "does this work for you with your wife?" he said "no! this is why I am on my 3rd marriage!" If you click on the pictures they will enlarge and you can kind of get a better idea of the scene. Really I just want you to see how cool I look (all 3 of you that read this blog occasionally) and you can do this much better is you enlarge the pictures by clicking on them.
Let me tell you about today's surgery. The patient is a 58 year old gentleman that has made his living as an accountant. Last May he injured his foot and it would just not heal properly. He spent several weeks agonizing over the pain and hoping that the ulcer (wound) would heal but it never did. In fact it got worse. Finally because the pain and the smell were bad enough and his family begged enough he finally decided to go to the ER one early morning at 3:00 am. The ER doctor took one look at the foot and knew this was a disaster waiting to happen. He could not find any pedal pulses which made him even more discouraged about a good outcome. He tried to explain to the patient that he most likely needed surgery which included an amputation.
So the man was referred to the Vascular surgery team. When the surgeons later saw the foot they were excited to operate and believed that they could fix the problem. This patient had a history of smoking, drinking and eating like Elvis. These talents brought him vascular damage and a whopping case of atherosclerosis that had not ruined his heart yet but had done some fairly decent damage to his lower extremity vascular system. Due to this damage his legs were not properly vascularized and so his injured foot was poorly perfused and could not heal. The vascular team finally scheduled him for surgery in June with the hopes of salvaging his left leg and foot.
In June they performed a "fem pop" with a graft. So they opened his femoral artery around his groin and sewed a gortex graft into the blood supply and then took the graft to his popliteal artery right behind his knee and connected it there. This bypassed the bad vessels in his thigh and restored blood flow to his calf and foot. The surgery went well and the patient's leg / foot began to heal. The family which is fairly extensive was excited that they would not have a gimpy father / grandfather. You would think that this would be the end of a happy story. You would be wrong.
Now fast forward to last week. The patient has horrible throbbing pain right behind his left knee and his lower leg and foot look like a cadaver's leg. His family dragged him kicking and screaming back to the hospital and the vascular surgery time. This is where I meet the patient. Now that I am on the vascular team I get to see the patient. I can tell as I walk into the exam room and read through the patient's chart that I will get to be in on and maybe even do some surgery. I examined him and used a doppler ultrasound but I could not find any pulses in his lower leg which means there is problems. My chief resident then examines the patient and concurs with my diagnosis and we schedule the patient for surgery on Wednesday 9/24.
On Wednesday in the OR we opened his legs and we soon realized he had an infected synthetic graft. Lots of pus flows out of the graft. For the next 12 plus hours we painstakingly removed all of the infected graft and followed it up from the knee to the groin until we were able to find areas that were clean (no infection). This took so many hours that we had to stop the surgery. We were were able to restore a little flow to the lower leg but the work was not done. Today we went back in and harvested the saphenous vein from his right leg which took several hours. Then we used this vein which can also be used for bypass surgery of the heart and we reversed the direction. You have to reverse it before you graft it into the bypass because it has 1 way valves. The saphenous vein normally brings blood back to the heart from the lower extremities but now we were using it in a bypass procedure to bring blood from the heart to the lower extremities. If you do not turn the vein around the graft will flow the wrong way and your graft will fail. This must also be done when you use this vein to bypass the heart. We harvested the vein and flipped it around and attached it to the femoral artery in his left groin and ran it past the knee (behind it) and to the lower calf. It was a below knee (say below knee fast and it sounds like bologna) to the lower calf human graft. By doing this we were able to restore the flow to the lower leg and hopefully save this patients leg and foot.
This was an amazing procedure to be able to help perform. The pictures I included are of me harvesting the vein from his right leg. It is a fairly bloody surgery as we cut up and down both legs. Fortunately I had excellent teachers helping me learn and do my part. It was great to see that as soon as we hooked up the graft and unclamped the blood supply his leg filled with blood and literally came back to life. I also got to close the wounds. I used sutures and staples and this took 1 hour to do, it was great practice. I was able to try a bunch of different suturing techniques. This is how we learn. Now we just have to wait and see and hope that the graft takes and that infection does not ruin it. These next couple of days - weeks are tenuous because at this point if the graft fails he will certainly lose his left leg. It was rewarding to work all day and hook everything up and to be able to feel pulses return to his foot.
At the end of the surgery I had the pleasure of going to talk to his 20 + family in the waiting area and explain the results of the surgery. His wife and daughters almost knocked me over with their hugs as they said thank you. The whole family had been crying / praying for the past few days as they waited for their dad / grandpa to get the surgery and hopefully get better. After talking with the family and explaining everything I had a few new patients to round on. I went and saw the patients and then was able to head home. On the drive home I kept thinking about how fortunate I am to be able to do this kind of stuff. I love it. One day I will actually get paid to do it.
Tomorrow I start bright and early and one of my new patients is a 25 year old African American male who took a gunshot in the thigh and will probably need a similar surgery / graft procedure as today's patient. However this young gunshot victim may not make it to surgery. He lost a lot of blood and when I went to check on him in the trauma ICU he was barely hanging on. His family was all there and very upset. I did my best to tell them what I knew and explain the situation. One case ends and another begins, every patient has a story and every patient has family and friends who are agonizing over their condition. Hopefully he lives through the night and we get a chance to try and put his leg back together again.
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