My first day of general surgery rotation was started with the meeting with my preceptor Dr. Chin-Chang Kuo. He told me that compared to just applying knowledge from the book in specialties like internal medicine, surgery is more like a skill that requires a lot of time to practice. Since I am new and unfamiliar to the field, I will not be allowed to actively participate in any operation. But I still can go into operating room and just observe the operation. Because he would be very busy this morning, he decided to leave me alone to self-study the surgery textbooks he recommended. But he also mentioned that he will have a tracheostomy surgery later in the afternoon, and I can go into the OR to observe the whole process. Before he left, he showed me the device used to practice laparoscopy and told me that I can play with it. During the self-study time in the morning, I read and took notes about tracheotomy from books in order to maximizing what I can learn from observing real surgery.
In the afternoon, I met Dr. Kuo in the conference room of surgery department. He first taught me the difference between –otomy, -ostomy and –ectomy. –otomy means that operation opens a hole on the organ but the hole will be closed later. The –ostomy means operation opens a permanent hole on the organ. And –ectomy means totally cut-off of the organ. He then gave me a talk about tracheostomy. For example, horizontal skin incision is preferred over vertical one because it will make healing scar less obvious and provide better closing of the wound. He also explained why tracheostomy is better than long-term tracheal intubation. The long-term use of endotracheal tube (ETT) increases the risk of thrush (oral Candida infection) because patient will have his/her mouth open all the time. It also has negative influence on vocal folds since the tube keeps the vocal folds open too. And long ETT can cause pressure necrosis and finally result in tracheoesophageal fistula. Compared to ETT, change a tracheostomy tube is easier, and tracheostomy provides better access to suck the sputum out.
After the lecture about tracheostomy, Dr. Kuo told me to meet him in operating room on third floor. When I walked into the OR with my scrub on, the nurses were moving the patient from her bed to the operating table. The patient is an unconscious female in her eighties. When anything was set up and almost ready to start the operation, the patient was found to have pCO2 level as high as 90 mmHg (normal range is 35-45 mmHg). Wheeze was noticed in upper thorax during auscultation of lung, and it was suspected due to smooth muscle constriction of trachea or/and bronchi. Aminophylline was injected but the pCO2 went down really slow. Dr. Kuo called and had a discussion with her attending physician. They finally decided to not to perform tracheostomy on her today. Besides to her family members, Dr. Kuo also explained to me why he thinks it’s not a good idea to do tracheostomy on her now. If the patient has the constriction or obstruction near the upper part of trachea, tracheostomy may give some benefits since it can provide the access to solve the problem. But in this case, the site of constriction or obstruction is down to the bronchi region, so tracheostomy will not give any benefit at all. And since tracheostomy is not an urgent surgery the patient needs to keep her alive, it’s a better idea to put it on hold.
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