Guide by: Alexandru Nica and Alyssa Stockard
Edited + Censored by: Isra Abdulwadood
Hey ya'll! We wanted to write a little blurb so that people know what to expect for this selective and everything I wish I had known (and studied) prior. A lot of logistic info applies specifically to the ARZ campus and hospital, sorry Rochester 😛.
Accurate as of June 2022.
Logistics:
Come to the hospital dressed in scrubs and comfortable shoes. I recommend bringing a stethoscope, pen + paper, water bottle, and snacks.
Room Sp1-226 is the transplant surgery fellow’s workroom (there are 4 fellows), and is where you’ll meet the fellows on the first day. They may have an extra desk in that room where you can sit and access EPIC, or you can use the computers in the hall just outside of the room (between Dr. Reddy’s office and the workroom).
Aim to be in the clinic (Mayo PHX 2 Specialty Building Sp1-226, towards the east end of the of the long main hallway, if you see the Transplant sign on the wall going into the hallway and the offices of Dr. Khamash, Dr. Singer, and Dr. Reddy, you’re in the right place) by 6:15-6:30 am to do pre-rounding on patients you have seen prior.
Bring your stethoscope (fluid balance is important and hard to get right on many transplant patients, so you’ll probably listen to some lungs).
“A sharp pencil is more important than a sharp mind… why aren’t you writing this down” – Dr. Singer.
Go in EPIC, look up the patients you’re pre-rounding on. Get a fishbone diagram of their electrolytes and values to go with you.
Important Things to Get + Ask About for Pre-Rounds
Speak to the nurse before the patient as they can best tell you what happened overnight. Shift change is at 7:00 am and this is a hectic time so ask before or after handoff.
Any overnight events?
How are they feeling?
Is pain well managed?
Vitals
Physical Exam (can be largely abridged):
ENT (inspect eyes, conjunctiva, EOM, and mucous membranes of the mouth, especially)
Pulmonary and Cardiac auscultation
Neurological (mostly are they awake, alert, oriented x3)
Abdominal:
Listen for bowel sounds
Observe the incision and drain sites and comment on appearance, discharge, basic wound care
any undue pain around incision
how often was a bandage changed
Drains (explained in medical knowledge)
Output
Color
Discharge
Always ask if there’s anything else concerning them that you can bring up to the attending, resident, fellow.
Day 1
For day 1 you can come in a little later (7:00 am) since you will not have any patients to pre-round and thus will go on morning rounds with your preceptor (usually one of the residents or fellows). Try to get their cell number early since you do not have access to the surgical schedule. On the first day, you might be sent to get a list of currently active patients being cared for by the service into your EPIC portal. If you do not have access to that list, do this instead:
Enter EPIC -> Patient Lists tab -> Available lists (left hand side underneath "my lists") -> Arizona Hospital-> Units -> PXMH 5E (Almost all liver trxp are here and most kidney)
After pre and initial rounds, Transplant Sit In Rounds are at 8:30 am in the 5E conference room (on the left after the nurses station when turning into the 5E wing). Here, there will be liver transplant sit-in followed by kidney transplant sit-ins. Take notes, pay attention to the medications being used for immunosuppressive regimens, common co-morbidities, and get a general impression for the patients discussed since chances are you will see them later that day, or tomorrow morning, or at some time during the week by yourself.
After liver sit in, hepatology goes and does group rounds on the patients discussed while kidney is going on. After kidney sit it, nephrologists go and do rounds on patients (talk to Dr. Khamash, he is incredibly nice, *Dr. Nica is terrifying but also good to talk to). I would recommend the first day going with PA Morgan Paige after rounds (if she is there) as she’ll show you how to write a transplant progress note and this is one big way you can make docs life easier- writing this and having them approve it saves them and the residents a lot of time. She will share the preferred template (.PEM note) that is highly automated and saves you a lot of time. For the remainder of the days, I would follow the preceptor for rounding, but make sure you round at least once with Hepatology and once with Nephrology.
*Dr. Nica is technically under the AKDHC group and only consults for Mayo's transplant nephrology. She’s only there in clinic 3 days a week, so it’ll probably be less than high yield for future people on the service to be looking for her
Usually in the afternoons, you will be in the OR (or in the morning, if it's in the schedule and then you skip all the above usually). The schedule is very variant for procedures though since they’re dependent on organ availability, prep, and arrival so that ischemic time is minimized.
Medical Knowledge to Know:
The procedures you’ll observe are relatively straightforward in-terms of relevant anatomy. When transplanting organs you focus on arterial perfusion, venous drainage, and exocrine/miscellaneous drainage.
Liver Transplant (approx. 5 hours total):
Arterial perfusion:
portal vein- 75% of blood flow to liver, high nutrient, medium-low oxygen
25% proper hepatic (high O2, low nutrient)
Venous drainage: Right, Middle, Left, Short hepatic veins draining into IVC, but often procedure is cava-cavotomy
Common bile duct
Gallbladder is also removed and bile leakage is one of the most common complications.
3-4 JP drains are placed in the abdomen and taken out when they stop producing a lot of output (make sure not obstructed though). They are named numerically with the lowest number being the most lateral to the patient’s right. The most important drain is number 2 as that one is inferior to the liver and most likely to show a chyle leak (when the discharge is yellowish or milky white in this).
You’ll probably be asked to observe and help out with the back table prep of the donor organ which is a really fun “cleaning up” process. Know how to hold Debakey’s and practice your knot tying and suture skills.
Stay alert throughout procedure, you’ll be asked questions, or asked very quickly to help hold or retract. If you have some experience, you may help staple the final incision (hold the stapler VERY parallel to patients body, use the little arrow to get direction right).
Know:
indicators of liver function
signs of liver failure
tripartite immunosuppression maintenance regimen (note that it's different depending on the organ so don’t assume it’s not, as well as common side effects of tacrolimus, cyclosporine, mycophenolate, prednisone)
common causes and etiologies for liver failure as well as co-morbidities (hint: the vast majority of patients you’ll see do not have normal body habitus).
Kidney Transplant (approx. 3 hours total):
Arterial perfusion: renal artery which can be very variant.
Most common variants are multiple renal arteries going to superior and inferior poles.
Number of arteries affects the length of procedure as they must all be anastomosed.
Venous drainage: renal vein, know the differences between left and right renal vein.
Right has no anastomosis with adrenal veins or gonadal vein [usually], whereas left has both)
Ureter to bladder anastomoses
Review the anatomy of renal blood supply and venous drainage ahead of time. This is a frequent topic of conversation while you help with back table prep of the donor kidney.
The right renal vein is shorter than the left, so in transplants using right donor kidneys, they can/may staple the donor IVC to extend the renal vein.
Very important to not nick the ureter during the back table procedure as this is the most difficulty anastomosis to perform in the kidney and most prone to complications and leakage. This is because patients with poor renal function do not urinate frequently leading to bladder constriction so when ureter is connected, change in bladder size can greatly affect the connection and sutures.
Know:
indicators of kidney function
signs of kidney failure
immunosuppression maintenance regimen (note it's different depending on the organ so don’t assume it’s not).
common causes and etiologies for kidney failure as well as co-morbidities (hint the vast majority of patients you’ll see do not have normal body habitus).
Combined Liver-Kidney Transplant (approx. 6-7 hrs):
Legitimately just a combination of the above procedures sequentially, starting with the liver. Make sure you have the right shoes to stand in for the length of this procedure. Compression socks really help! Eat, drink, and pee before. If you’re addicted to enough caffeine to make a horse uncomfortable like myself, the cafeteria sells Reign (300 mg caffeine) which are great so you’re not crashing 4-5 hours in. This bad boy is long, but incredibly cool to see, and there’s very few institutions that can do this so appreciate it.
Cardiac Transplants
No idea, but I’m not entirely sure that they’re even part of the same service/fellowship here at AZ. Did not see one and worked only with Kidney and Liver, but in the future, someone can fill out this section.
In the OR
Much of this is borrowing from my blurb on how to be in the OR, but I’m not gonna start writing references or citing my sources.
Review your scrubbing and gowning videos beforehand, trim your nails, take off your apple watch.
review our Success in the OR guide too!
You’ll have to change into hospital scrubs before entering the OR. Scrubs are on the second floor of building 3. There’s a long hallway that connects buildings 1, 2, and 3. If you’re starting out in the fellow’s workroom, take the elevator in the specialty building to the 2nd floor, take a left into the long hallway, and walk until you see the scrub cart opposite to the windows.
Aim to be at the OR before the surgeon you’re shadowing.
If first case of the day pre-scrub your hands with soap and water then head inside.
Introduce yourself to the nurses (they’re always super cool and will let you know what to do to stay out of trouble) and surg tech, and make sure to write your name and year on the board (in a not obnoxious place) for documentation purposes.
Know your glove and gown size + grab two gloves and gowns and ask where to put them.
Gloves and gowns are kept through the door in the back of the OR (on the wall opposite the door you came into the OR).
Ask to see if you can help out with anything to prep pre-op or help later to position the patient.
One thing you can learn how to do is placing a foley catheter, so ask if you can be taught that once the patient is in the room and going under.
Talk to the anesthesiologist as the liver and combined transplant are a very involved procedure from them since you are really f*cking about with the patients hemodynamic stability (think of the CV changes from removing a high resistance cirrhotic liver and clamping the IVC. Also this is a massive blood loss surgery requiring FFP, plasma, and blood units put in).
Scrub in around the time your surgeon or fellow does, maybe a little earlier since you’re slow, but make sure there is a nurse also scrubbed in before you to help gown and glove. All of the surgeons and fellows use a surgical rub (avagard) when they scrub in. If you’re new to scrubbing in, I’d recommend first using a surgical scrub and sponge, then use a regular paper towel to dry off. After that, use a surgical rub (like Avagard or Sterillium) before entering the OR. This process can take a while, so give yourself enough time.
For any subsequent cases, you can just use the surgical rub. If you use Avagard, it can take a while to dry so be mindful of that. A fellow recommended using Sterillium because it dries faster.
Even if you can gown and glove yourself, don’t on the first day so that the team can get comfortable with having you around. Once you demonstrate competency in and around the surgical field, you’ll probably be trusted to gown and glove yourself reliably.
Walk in backwards with your hands up, but not too high up- you’ll look silly.
You can put your (gloved) sterile hands on anything blue and you should for the majority of surgery (it makes those around you less nervous if you put your hands down).
Don’t reach for any tools unless you’re asked or you’re preventing something from slipping from the surgical field.
Do not assume you have to do anything unless you are addressed by name or clearly told to do it, but do not be scared to help when asked.
Exercise good judgement when asking questions during procedure (i.e. not when an artery is about to be re-perfused and surgeons working quickly to address any leaks as there is blood squirting everywhere).
After the incision has been closed, you’ll help clean up the patient’s skin and apply the dressings. For this, you’ll stay scrubbed in and remove the outer pair of gloves to expose the clean gloves underneath.
Make sure to stay for post-op to help move the patient. It is good practice to escort them all the way to the PACU and greet them after they’re woken up.
Always get the MRN and OR time for patients whose procedure you’re going to be observing. In case you get separated, you can ask the front desk where a patient will be.
Generally, liver and combined transplants happen in OR 21, while Kidney can happen all over the place. Same team works on these procedures so you’ll get to know them well.
If a preceptor remarks at how well prepared you are, feel free to name drop Alex Nica or Alyssa Stockard. I need all the help I can get for residency and references.
Cheers :)