Sterilized Instruments, Contaminated Instruments and the Journey between Them – Surgery Rotation

Surgery was a very eye-opening and worthwhile rotation. Half of the rotation was spent in the OR, while the rest was spent taking histories, examining patients in the Falahi OPD, and checking out multiple patients in the Surgery wards that were assigned per student. Overall, this rotation has left me with many beautiful memories and learning experiences and what struck the most with me was that it invigorated my interest in two sub-specialities in the Surgery department: Orthopedics and Anesthesia.

Orthopaedics:

In the first two weeks of my surgery rotation, I had to rotate with an Orthopedics consultant and with my prayers answered, I was thankful to rotate with Major General Sohail Hafeez (R). If you follow the Shifa Student Society’s Instagram page, you’ll come across Dr. Sohail Hafeez’s ‘Humans of Shifa’ interview, which I conducted while in my OB/GYN rotation. Hence knowing the kind of doctor and person he was, I was excited to learn from him.

Dr. Sohail’s OR days were Monday and Friday, so I went to the OR, where he was operating on a patient’s arm. As I entered the OR and introduced myself, he told me to tell him what he saw on the patient’s X-ray. Having just come out of OB/GYN, I had suddenly forgotten the English language to describe an X-ray. However, seeing a mass around a long bone with a “sunburst appearance”, I proudly said, “It’s osteosarcoma, Sir.” He calmly replied, “I said to describe the X-ray.” After doing an imaginary face-palm, I figured out that I had to say, “There is a mass located in the midshaft of the left humerus.” which won his approval. With time, I understood how to describe X-rays, but that didn’t mean I wasn’t told to control my urge to point and touch the X-ray when explaining it but to use my words only.

On that same day, the entire midshaft of the humerus containing the osteosarcoma was removed and replaced with a vascularized fibular graft. Dr. Sohail was beneficial in explaining the logic behind how such grafting works, and I appreciated it when once the graft was placed, he told the staff there to move aside and called me to come close and see how it looked. On a humorous note, when the plastic surgeons were working on retrieving the graft, I was amused by Bon Jovi, Michael Jackson, Adele and any other classics that the speaker had to offer.

Furthermore, there were many procedures to witness in the OR; the open reduction and internal fixation, closed reduction of fractures, total knee replacement, arthroscopy, ACL reconstruction, bipolar hip replacement and even a leg amputation! I’m grateful that Dr. Sohail answered all my eager questions about each procedure; I remember him explicitly making a diagram about how arthroscopy works and in which situations the menisci of the knee are repaired and in which they are removed. It was pretty interesting seeing how mechanical orthopaedic surgeries were, with all the instruments required in a workshop or construction site; nails, screws, drills, hammers, and even cement (bone cement)! In addition, the knee prosthetics were so smooth and shiny that I couldn’t help whispering so many times to my friend who was with me, “It’s so shiny!” Considering how much strength was utilized in using them to heal fractures and perform replacement surgeries, it’s evident that one must build up their upper body strength before coming to the OR. The staff was incredibly particular that no un-scrubbed person comes even close to the instruments for fear of contamination, which can result in post-operative infection because osteomyelitis is no joke, especially after a costly procedure.

Some hurdles I faced in the OR were that it would be so cold that I was shivering most of the time! In addition, surgeries for fixing fractures that required screws and nails needed frequent imaging by a C-arm device. Because of the regular radiation exposure, everyone had to wear a lead-lined overall for protection, which was so heavy that when I was asked to hand over a stool, I couldn’t get up after stooping down to grab it. Nevertheless, I went to the OR so often, even on non-OR days, that I might as well have a mattress to sleep in and then wake up for another day in the OR.

Tuesdays through Thursdays were his OPD days, which was a very wholesome, learning and fun experience. We saw an array of patients from the common complaints of osteoarthritis of the knee, follow-up cases of total knee and hip replacements, fractures of upper and lower limbs as well as back, to relatively newer cases such as trigger thumb, ingrown nails, de Quervain synovitis, avascular necrosis of femur heads, developmental dysplasia of the hip, synovial chondromatosis, septic arthritis, osteomyelitis and a clubfoot to name a few. Dr. Sohail Hafeez would show me the X-ray of every patient and ask me what the findings were before counselling his patients. In the OPD, one should know that half the time spent with a patient is counselling them about the disease and what can be done to fix it, and the rest is guiding the patient to the best possible outcome. It was beautiful seeing them smile or relax afterwards. Furthermore, there were minor procedures that would be performed in the OPD, such as intra-articular steroid injections, arthrocentesis, removal of casts and splints, removal of an ingrown nail and carrying out the Ponsetti method in an infant with clubfoot (I remember having to hold the infant steady while in one ear, it screamed into my ear and in the other, Dr. Sohail asked me questions about clubfoot, utterly unbothered by the noise)

Lastly, by the end of the week, we had an Orthopedics workshop run by Dr. Sohail, where we were taught the essential background of the types of fractures and how to heal them. There were alternating lectures and hands-on learning in making casts, splints, and inserting screws and intramedullary nails. It was an inspiring experience especially cast-making, which officially invigorated my interest in Orthopedics.  

Anaesthesia:

I took my nostalgia for Orthopedics to the next sub-speciality – Anesthesia. We had a brief introduction to what anaesthesia is and was told to do as much hands-on work as possible. The staff didn’t let us work in the first few days, but when I brought it forward to Dr. Shoukat, he immediately notified the ORs to let us learn anaesthesia properly. After that, I didn’t feel like leaving the OR.

Dr. Shoukat showed us how to attach an IV line, and soon after that, with the assistance of a senior anaesthetist, I inserted an IV line myself which was quite an exhilarating experience as well as a sigh of relief that I didn’t trigger a significant haemorrhage. However, that was the only time I could attach an IV line as most patients already had it.

Following this, I was allowed to administer the relevant drugs, i.e. Midazolam, Fentanyl, and Propofol, through the IV line. The anaesthetist told me the exact quantities to infuse and to do it slowly, so I did just that. It was fun turning the knobs of the line to control where the fluid would travel, placing the syringe into the nozzle and slowly squeezing the drug into the patient’s system. Once I was taking turns in infusing drugs with a senior anaesthetist, and every time I began infusing them, the patient would flinch, but whenever the anaesthetist did it, the patient was perfectly comfortable, to which the patient said to him, “Whenever Madam gives the medicine, I feel pain, but whenever you give it to me, I feel fine.” That, as you can imagine, was not embarrassing at all. Nevertheless, it’s fun to have the power to put people to sleep (evil smile intended).

After the drugs are given, the patient starts becoming unconscious, which is when the patient is given an inhaled anaesthetic through a face mask. That, my friends, requires some practice in making sure you made a proper seal with one hand so that the air doesn’t leak out, pumping the Ambu bag with another hand at a steady rate while watching the chest expansion and CO2 graph and vitals on the monitor simultaneously. Whereas I had trouble maintaining a seal with both my hands, which improved with time, I was repeatedly told to keep my back straight for comfort, and my hands would tremble while holding the mask for so long. A junior anaesthetist told me that when she was learning to do this, her hands would be tremulous for the rest of the day; hence practice makes perfect.

The last step of anaesthesia induction I was allowed to do was intubation, which used the laryngoscope to allow for visualization of the vocal cords, followed by inserting the tube between the vocal cords into the trachea. Initially, I struggled when I couldn’t figure out how to move my arm so the laryngoscope could adequately move the tongue aside. Fortunately, I could do it independently in front of a senior consultant, which felt like a great sense of accomplishment. However, the next time I did it successfully, the anaesthesia staff asked me for a treat. I hope they’re not on a quest to find me.

General Surgery:

In the previous sub-specialities, I was on my own, but in general surgery, half of my rotation group was with me. On Mondays and Fridays, we had OPD, where we took histories, did relevant examinations of patients and presented and discussed those cases with our preceptors. The OPD was fun as we saw a lot of interesting cases, such as hemangiomas, AV malformations, breast lumps, varicose veins, diabetic ulcers, sebaceous cysts, goitres and inguinoscrotal swellings, to name a few. It was beneficial that our examination findings could be confirmed on the spot, which made for a good learning experience. Furthermore, we saw how ulcers were treated; sutures were opened, bandages were placed for adequate healing, etc. I got to open a few stitches, which was exciting. Interestingly, the same patient who came to the OPD with varicose veins whom we examined came to our OSCE, and while I was formally introducing myself to get consent, I couldn’t hold the urge to stop and say, “You came to the OPD before!” so that station went well.

IPD days were interesting, although very demanding. Each student was assigned seven beds, which he is meant to check regularly, and on IPD days, he has to present the cases in all the beds, including history, examinations, investigations and management. A person like me, who enjoys doing things calmly as long as they’re done right, struggled these few weeks because I could barely prepare one case thoroughly in time, and even then, there would be some flaws in that presentation. Nevertheless, IPD was exciting, and I saw multiple patients with cholecystitis, cholelithiasis, pancreatitis (one patient had ascites, and it was a learning experience knowing what fluid thrill felt like), hematochezia and intestinal obstruction, to name a few. The case-based discussions were very informative, interactive and more beneficial to understand when you meet such patients face to face that you read about in books, yet not all conditions only have bookish signs and symptoms.

Furthermore, we learnt how to use more hands-on techniques in emergency scenarios.

_ _ _ _ _ _ _ _ _ _ _ _ _  _

That sums up my Surgery rotation. How was yours? Let me know in the comments below

Nahin Sani

MBBS Class of 2023