Appendix I: Surgical Procedures

AAA: Abdominal Aortic Aneurysm. The aorta, the large blood vessel leading from the heart, develops a bulge (aneurysm) that weakens the walls. The aorta's walls can then dissect themselves, leading to heavy internal bleeding and death. The AAA procedure requires making an incision in the midline of the body and dissecting down to the aorta and the location of the aneurysm, then implanting a graft to strengthen the aortic walls. With modern imaging a AAA can often be diagnosed long before it becomes emergency, but on occasion an aneurysm can dissect acutely and require emergency surgery.

Vein Stripping: The patient presents with varicose veins, veins that run close to the surface of the skin on the legs and are painful. These veins can occasionally lead to higher chance of blood clots, and so to reduce the pain and reduce the chances of a clot, the patient may undergo vein stripping. In this procedure, the most common stripped vein is the greater saphenous vein. An incision is made in the crease of the leg near the groin, and the saphenous vein is cut and tied off where it joins with the other greater veins of the lower body. The surgeon then makes several smaller incisions along the path of the vein and uses a curved hook, much like a crochet hook, to reach beneath the skin and pull up a portion of the vein. The vein is removed either in small pieces or one large piece, depending on the strength of the vein walls, diameter of the vein, and patience of the surgeon.

Arteriovenous fistula creation/repair/shunt graft: A fistula is a created hole connecting two structures. In this case, the patient must undergo dialysis, and continual access to the veins for dialysis without intervention will cause vein collapse. This procedure creates a fistule between an artery and a vein that strengthens the vein. An incision is made in the lower arm and the surgeon selects an artery (blood flowing from the heart) and a vein (blood flowing to the heart) and cuts them, then sews them together end-to-end. Over time, this strengthens the vein sufficiently to allow access for dialysis without danger of vein collapse. In some cases, the surgeon may elect to use a graft (artificial implant) to strengthen the vein walls; in this case the graft is a shunt, often a tubular length of Goretex, that is slid inside the vein before the surgeon sews the vein and artery together. In a repair, the fistula is not healing correctly, and the surgeon must either reconnect the ends or select a different vein and artery to connect.

BKA: below-knee amputation. Catastrophic infection or bone death that will lead to infection necessitates the removal of the leg below the knee. A tourniquet is placed on the upper leg to control bleeding and a surgeon very carefully dislocates the knee and cuts away the tissue, removing the lower leg. She will leave a skin flap to close over the stump of the leg after she reconnects vital blood vessels. This procedure is often performed by an orthopedic surgeon, but shewill likely partner with a vascular surgeon to reconnect the larger blood vessels.

Extracorporeal Shockwave Lithotripsy: or ESWL (ez-wall). The patient presents with kidney stones that are too large to remove through normal ureteroscopy. A large C-shaped machine that can move freely around the bed is placed. This machine will deliver concentrated ultrasound waves to a pinpointed area where the stone sits. This ultrasound will crush the stone into smaller pieces that the patient can pass on their own or the surgeon can remove. An ESWL is performed by a radiology technologist or radiologist under the direction of a surgeon. In this type of surgery there are no incisions or entrances into the body.

Transurethral Resection of the Prostate: or TURP. The patient presents with an enlarged prostate gland. The surgeon, through a cystoscope, whittles chips of the prostate from inside the urethra to enlarge the urethral opening and relieve the discomfort of the enlarged prostate gland.

Cystoscopy/Ureteroscopy: the use of a scope to visualize the bladder or ureters. The scope - a long lens apparatus attached to a camera, which broadcasts to a video screen - is inserted into the patient's urethra and manipulated into the bladder. Occasionally, thing flexible wires are fed through access ports in the scope to allow for easier navigation and use of instruments for cauterizing, biopsying, or stone crushing via laser.

Laparoscopic Cholecystectomy: or Lap Chole. The patient's gall bladder must be removed. The surgeon makes four small incisions in the patient's abdomen and places ports in the incisions to access the abdominal cavity. Using long-handled instruments and a scope for visualization, the gall bladder's arteries and veins are clamped, the gall bladder is dissected away from the liver, and it is removed through one of the ports.

Appendix II: Surgical Specialties

Vascular/Cardiovascular/CVPV: A vascular surgeon specializes in surgery of the blood vessels and the heart. A cardiovascular surgeon focuses more specifically on the heart itself and the vessels connected directly to it. A peripheral vascular surgeon focuses primarily on the vessels throughout the rest of the body. A CVPV (cardiovascular and peripheral vascular) surgeon will perform surgeries pertaining to both these regions.

Urology: A urological surgeon specializes in surgeries of the urinary system, including the kidneys, ureter, bladder, prostate, and urethra. Because of the structures involved, often a urologist will treat abnormalities of male genitalia, including the testes, as well. Urological surgery is most often achieved through the use of scopes inserted into the urethra, with long, slender instruments then inserted into the access port of the scope to perform the procedure.

Gynecology: A gynecological surgeon specializes in surgeries of female genitalia, uterus, Fallopian tubes, and ovaries. A surgeon who performs procedures directly linked to pregnancies is an obstetric surgeon, whereas a surgeon who focuses on all other aspects of the female reproductive system are gynecological surgeons. Often a surgeon will specialize in both, and are called OB/GYN (oh-bee-guy-nee) surgeons.

Plastics: a plastic surgeon performs reconstructive procedures for aesthetic results. While much of plastic surgery is to enhance or change physical appearance, many plastic surgeons perform aesthetic surgery to lessen the appearance of a previous surgery, or to enhance the patient's life. For example, a plastic surgeon may perform a breast reconstruction after a mastectomy which removes the patient's breasts due to cancer, or a surgeon may perform a blepharoplasty to remove excess eyelid that is reducing a patient's vision. Plastic surgeons must be very mindful of the natural tension of the skin and how the fat under the skin will effect appearance. They will often perform procedures in which a cancerous lesion must be removed from the face.

ENT: Ear, Nose, and Throat. What it says on the tin. Tonsillectomies are the meat and potatoes, though they also perform various sinus surgeries. Ear surgeries, like the installation of cochlear implants or drainage tubes, tend to be a specific focus.

Orthopedics: An orthopod performs surgery pertaining to joints and bones. Scopes are often used within joints, to avoid draining the joint of the lubricating fluid it produces. Broken bones are fixed in orthopedics, as well as joints replaced and extremities removed when it is deemed necessary. Orthopods will often specialize further and become hand, foot, shoulder, hip, or knee surgeons.

Ophthalmics: An ophthalmic surgeon performs surgery on eyes. Most common are cataract surgeries, in which a cloudy or opaque lens is removed from the eye and replaced with a clear implant, restoring vision. Other ophthalmic specialists may concentrate on correcting eyes that do not focus together by lengthening or shortening the muscles that control the eye.

Neurology: A neurosurgeon specializes in the brain, spinal cord, or peripheral nerves. While all surgery is precise, neurosurgery leaves very little room for error, as a single millimeter too far may kill the patient or render them paralyzed. This is a specialty for steady hands.

General: a general surgeon typically catches any procedure that does not belong to a particular specialty. They often deal with organs or organ systems as a whole, removing gall bladders and appendixes, repairing hernias, removing cancerous tissue - there is a lot of removing things in general surgery. A general surgeon may specialize in a particular organ or organ system, opting to focus on stomach surgeries, intestinal surgeries, thyroid surgeries, etc.

Appendix III: The Surgical Team

Surgeon: The MD performing the surgery. This doctor will have spent four years in medical school, often another four in a residency, and may have spent additional years in a fellowship to specialize. Depending on the complexity and scope of the procedure, more than one surgeon may be present.

Anesthesiologist or CRNA: An anesthesiologist is an MD. They will have spent four years in medical school and another four in a residency. A CRNA is a Certified Registered Nurse Anesthetist. They will perform with the supervision of an anesthesiologist, and will have attended nursing school along with an additional two years of anesthesiology specialization.

Circulating Nurse: A Registered Nurse, or RN, who is responsible for documentation during the surgery as well as ensuring that the room runs smoothly. This can include running to get supplies or instruments the surgical technologist forgot or didn't know they needed, but this makes the circulator grumpy. Though patient safety is the responsibility of the entire surgical team, the circulator leads the team in this regard. The RN will have completed nursing school and may have completed additional specializations.

Surgical Technologist: The team member responsible for ensuring all supplies required for the procedure are present, opening said supplies in manner that keeps them sterile, and arranges all supplies and instruments to be easily accessible during the surgery. During the procedure, the surg tech will act as the assistant to the surgeon, passing instruments and being an extra pair of hands when required. The surg tech must know the steps for every procedure as well as the surgeon to anticipate the surgeon's needs. The surg tech will have completed a certificate program at a technical college or may have received training in the military.

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Physician's Assistant: Occasionally a surgeon will need an assistant that has a wider scope of practice than a surg tech (eg, will need to be qualified to manipulate tissues, suture, inject anesthetic, etc). A PA has completed graduate school training of some duration and may be a full MD.

Radiology Technologist: This team member is responsible for the C-arm, which is the X-ray machine that curves over the top and underneath the surgical bed. They are also responsible for the ESWL machine. This team member performs diagnostic or visualization X-ray during the procedure, allowing the surgeon to see if a bone has been aligned properly or if a kidney stone has been crushed successfully.

Anesthesia Technician: May have a wide scope of duties that vary by state and hospital. Often assists the anesthesiologist or CRNA in their duties.

Vendor: Not a member of the hospital staff, these people are employees of a company that sells equipment and instrumentation to the hospital. They are present as expert consultants on the instruments or equipment in question. They are invaluable when using instrumentation such as plates and screws for fracture repairs, as these sets have hundreds of pieces and require expert knowledge to use properly. They may also operate equipment themselves, as is the case in many laser surgeries where the laser equipment is leased from the company.

Med Student: They will inevitably end up holding retractors or suctioning cautery smoke, or any other dirty/tiring/boring job the surgeon, surg tech, or PA doesn't want to do. Hey, they're an extra pair of scrubbed hands.

Resident: Will often fill the PA role.

Surgical Assistant: Will run to get supplies, help get the patient into and out of the room, and assist in cleaning the room between cases.

Charge Nurse: the RN who is essentially the air traffic controller for all the surgical suites. He or she coordinates scheduling, ensures that the surgeons will be available for certain time slots, orders the supply carts, assigns teams to rooms, and a thousand other things that make the OR floor run smoothly. The charge nurse is God.

Management: Nobody knows what Management does. They stand there, in their masks and hats, and say nothing. When you look up again, they have vanished back to their offices, as though they were never there.

GLOSSARY

TERMINOLOGY

ABG: Arterial Blood Gas. A blood test that determines the percentages of oxygen, carbon dioxide, and the like in blood.

Anastomosis: the act of reconnecting two severed tubular structures (nerves, vessels, etc) in which care must be taken to reconnect them in the correct orientation.

Aseptic technique: Also known as sterile technique. A set of learned behaviors that maintain the sterility of the surgical field. Never touching the face or lap, never touching anything unsterile while you are sterile, and opening sterile supplies in a certain way are all aspects of aseptic technique.

autoclave: also known as flash sterilizer. A pressurized chamber that creates requisite pressurized steam of a temperature that kills all microorganisms on contaminated surgical instruments. Used in emergencies or when there is no time to wait for the full 8-hour sterilization process of Central Sterile Processing.

Biological: a daily test run on sterilizers throughout the hospital to ensure that they are killing spores. It is a package that contains a vial of spores. Once exposed to the minimum standard for sterilization, it is allowed to incubate for 2, 4, or 8 hours. If the incubation produces no growth, that sterilizer has passed its biological. Biologicals are also run with any load that contains implants, like screws or plates, and if the biological is not passed, a recall is issued for every instrument that used that autoclave since the last passed test. If those instruments were used, hospital policy may require alerting the patient and putting that patient on prophylactic antibiotics.

Central Sterile Processing: the hospital department responsible for the sterilization and assembly of surgical instruments and other sterile supplies. This department decontaminates, cleans, disinfects, assembles, then sterilizes all used instruments. This process is called "turning over." CSP is a vital part of surgical services, and one that is often overlooked.

CHG: Chlorhexadine gluconate. Many hospital scrub solutions are made with this, as it is a very potent antiseptic safe for skin. Dries you out like a motherfucker, and the version that you don't rinse off is all tacky and gross and squishy inside your gloves even when you let it dry. I have feelings about CHG.

Closing: the act of closing a wound. Often done in several layers, depending on which anatomical layers have been incised. Can be done with suture, staples, or glue.

Counts: a surgical technologist and circulating nurse must count sponges, needles, hypodermics, blades, and sometimes small instruments before the procedure begins and when it is over, as well as whenever the surgeon closes a layer, to ensure that nothing is left behind in the patient.

Decontamination: removal of visible debris from an instrument or surface. It looks clean, but you wouldn't want to eat off it.

Disinfected: also known as "surgically clean," this state is used to refer to a surface that has been washed thoroughly with a disinfectant like iodine, CHG, or other antimicrobial. It is not sterile, but is safe for use in non-sterile areas like the mouth or rectum. Examples include non-sterile gloves, blades used to insert breathing tubes, and speculums.

Electrocautery: the use of electricity to cauterize or coagulate flesh. Most often used in hemostasis, but also occasionally used to incise without causing bleeding.

Hemostasis: the act of controlling bleeding in the surgical patient.

Indicator: Often a color-changing strip of paper or tape indicating that the package it is on or in has been subjected to sterilization. The color only changes if the package has been exposed to proper temperature and pressure for sterilization. A changed indicator ONLY indicates that the package has been subjected, NOT that the contents are sterile (for example: if the instruments were not properly decontaminated, and a bone chip remained in a ronguer, nothing in that set should be considered sterile, even if the indicator says the package was sterilized).

Iodine: Often used in surgical scrub and prep solutions, as it is an excellent antiseptic. Kind of an icky yellow color.

Scrub: Used in several different ways. Refers to the action of "scrubbing in," which is a two- to five-minute thorough hand wash with an antiseptic soap and scrub brush, using aseptic technique, in preparation for donning a surgical gown and gloves. Refers to the person who has scrubbed in to assist the surgeon ("scrub tech"). Refers to the surgical attire of the scrub top and scrub bottoms, which are often reversible cotton garments that are able to be cleaned at very high temperatures and are comfy as hell. I'm wearing scrubs RIGHT NOW, that I went out and purchased for my very own to be lazy in.

Sharp: any instrument that can penetrate gloves, skin, or drapes. Examples: knife blades, hypodermic or suture needles, skin hooks.

Spore: a dormant phase of a microorganism that is extremely difficult to kill, but can reactivate and cause infection once it is in a favorable environment. An item is not considered sterile until all spores are killed.

Sterile: this instrument harbors absolutely no living microorganisms, including spores.

Suture: stitches, or more precisely, the material used to create stitches. Comes in many different sizes and types, with many different needles.

Ties: Suture without a needle. Surgeon will use ties to tie off blood vessels for hemostasis.

Tools: We don't use tools. We use instruments. Don't call them tools. Please.

INSTRUMENTS

Hemostat: a clamp used to occlude a blood vessel for hemostasis. May also be called a "snap," depending on which coast the doctor trained. Kellys, criles, mosquitos, and schnidts are all hemostats.

Retractor: holds the edges of a surgical wound open so that the surgeon can see what s/he is doing. These can be self-retaining, holding the wound edges by tension within the instrument, or hand-held, requiring an assistant to hold the instrument.

Ronguer: Plier-like instrument that snips away at bone or cartilage.

Speculum: That thing that looks like a duck that the doctor uses to open your cervix (if you have one). Can also be used to open your rectum, gentlemen. I mean, ladies have a rectum too, and a speculum can be used in lady bums as well as gentlemen bums, but gentlemen have fewer places where one can be used. Let's move right along, shall we?

Vein hook: also known as muller hooks. A curved, crochet-hook like instrument that a surgeon can insert into an incision and twist to bring a vein up to the surface for vein stripping procedures.

Weitlaner: The unofficial mascot of this story, the weitlaner is a self-retaining retractor that can be sharp or blunt, have varying numbers of teeth, and come in multiple sizes.

SPONGES

I am giving sponges their own category. Sponges are used to absorb blood to keep the surgical site visible. Sponges used during surgery will always have an x-ray detectable strip embedded in them, so that they can be seen on x-ray if they are left in the patient. Some sponges now contain RFID strips, so that x-ray becomes unnecessary, but that's a bit fancy for the likes of Summit Surgical Center.

Kittner: also known as peanuts or cherries, although those names can also refer to different sizes or shapes of small sponges like this. These are often clamped on the end of a hemostat and used for blunt dissection (pushing tissues apart rather than cutting them).

Laparotomy: or just lap. You'll see these more often in surgeries with lots of bleeding or larger incisions, like abdominal or thoracic surgery. Very absorbent and very soft. If a surgical package contains laps and the tech knows they won't be used, they will often pass them off the field so they don't need to be counted. And then, since they were not present during the surgery, the nurse, scrub, surgeon, and anyone else around will often argue over who gets to take the laps home instead of throwing them away. Because laps are awesome and you want to have them around at home. (I have 60.)

Raytec: Most commonly used sponge, also called a 4x4. Incredibly absorbent, can be unfolded and folded again into different shapes and widths, and very easy to lose inside a patient, thus those blue x-ray strips. Raytecs are often the first items counted when counts are done, since they are so easy to lose.