This post was authored by both Annie Lehatto and Jennifer Ries.
A few months back, members from the LA healthcare group made our way down to UC San Diego Medical Center in La Jolla for another one of our exciting behind-the-scenes adventures (you may remember the Horgan Experience). This time, we witnessed an awake craniotomy, which is a neurological procedure where the patient is awakened after their brain is exposed in order to best remove a tumor. The procedure was performed by Dr. Bob Carter, Chief of Neurosurgery at UCSD, and one of our favorite users. These types of experiences have become an important part of our LA office healthcare practice and mentoring program. We are striving to understand and experience not only the physical spaces in a hospital but also the ritual and emotions for the patients, their families and the staff.
The group of us who braved this adventure included Jim Cleaton, our client from UCSD, Carlos Amato, Annie Lehatto and Jennifer Ries from our LA Healthcare group. We also invited along one of our senior designers from the Yazdani Studio, Nadine Quirmbach. The UCSD Jacobs Medical Center was the first healthcare project for Nadine, and she really embraced the experience. She was very excited but nervous at the thought of seeing a brain surgery! “I did not know what to expect. I was nervous with anticipation. I thought it would be like what you see on TV. It wasn’t… it was much more personal,” Nadine said. This truly was a great eye-opening (or mind-opening) perspective for her.
We began this tour with a lot of waiting, since the procedure was delayed for a couple of hours. We were already dressed in our scrubs and in the OR core. The gang filled the time not only observing and taking notes on the detail of the OR corridor but also peeking in the windows of other procedures taking place. For some reason, that day, carts holding thousands of breast implants lined the halls. We took a few silly photos – please the note the photographer on these adventures was our client.
After spending some quality time in the corridor, we were told that we could head into the OR. Carlos really wanted to talk to the patient, like we had been able to do in our previous experience. He ended up walking next to the patient in the corridor on his way to the OR. One of the ideas that Carlos is passionate about is the personal experience of all involved in healthcare. The point where the patient crossed the threshold into the OR was the point of no return for him, and we all found this to be the most emotionally charged moment of the day.
While the patient was being prepped, we were stopped by Dr. Carter in the corridor. He mentioned that the procredure would be starting soon and told us in passing that, “for some people, including my medical interns, the smell and sound of the skull being drilled makes them feel faint.” He said this very calmly and matter-of-fact, as if he was saying, “Some people like the color blue” and then advised us that if we did feel sick, we should leave the room and put our heads between our knees. We all probably looked like a bunch of deer in headlights. Opening someone’s skull to Dr. Carter is nearly an everyday experience for him, like designing an accessible toilet to us. The real meaning of healthcare design was slowly sinking in…
At this point, we were introduced to the patient. He was very somber and guarded. This was a very different situation and mood from the last time we witnessed a surgery at UCSD. Dr. Carter then explained to us the amount of prep work required before the craniotomy could begin. He also told us that the patient preferred a “no shave” technique. This means they don’t shave the patient’s head but instead comb the hair in the affected area with a disinfectand and part it along the incision line. The patient was planning on returning to work very quickly and did not want his coworkers to be aware of his operation.
For the first part of the procedure, the patient was anesthetized as they set his head in place and then removed a piece of his skull to expose the brain. Some of us had to step back during the drilling portion because of flying debris (we won’t elaborate). The piece of skull was wrapped in a wet napkin and set aside on a table like a kid’s retainer. This procedure was being performed in one of the existing ORs built in the 1980s. There was a ridiculous amount of equipment in this room. In order to get the Brainlab imaging equipment to the patient, they had to move a large microscope and many other items out of the room. We were happy to note the new ORs we have designed for them will be much larger. After all was in place, the patient was woken up and asked to speak to a staff of doctors while the tumor was removed. When he first woke up, the first thing the patient asked was,” is the surgery done? Or just beginning?” and Dr. Carter explained to him it was just starting. We felt bad for the patient and were sure he wished it was over already.
Also in the room that day was a neurological psychologist who was there to monitor the patient’s speech patterns and responses. Soon, he began to ask the patient to count, recite his ABCs and list the days of the week or other simple progressions. As he asked these questions, Dr. Carter and his team would probe the patient’s brain around the tumor to make sure they wouldn’t hit any of the brain’s speech centers as they removed the tumor. At one point, the patient was asked to count to ten and as they probed a certain part of his brain, he would say, “One, two, three, ffffooouuuurrrrr, eight nine, ten!” This response helped the team know this was an area of the brain to avoid. They then spent a good deal of time investigating, because as they told us, this particular area of the brain was not usually involved in speech. They finally seemed to determine that it was a motor-function issue that was freezing the muscles in his face, making him unable to actually say the words rather than making so he couldn’t think the words. This was apparently a big distinction to the medical team.
During all of this, there were side conversations going on between Carlos, Jim Cleaton, and one of the neurologists about the new ORs and how to improve the flow and equipment layout. At one point, Carlos drew a little sketch of their future state-of-art intraoperative suite and explained how we felt it would vastly improve their working environment.
While doing all of the testing, we kept noticing that every once in a while, the patient’s brain would seem to swell and expand, causing the doctors back off for a second. After about the third time this happened, the doctors asked the patient if he had to cough. He said he did, but he was trying to suppress the urge. That’s what was making his brain swell. None of us will ever think about coughing the same again.
At some point during this, we noticed that Nadine was about two feet away from the action on the table and was standing on her tiptoes to get a better look and to get a good camera angle. She looked at us and said, “This is awesome.” Gone was the woman who was worried about fainting; she was replaced by the new Nadine, seemingly ready to grab a scalpel and pitch in.
It was finally time for the team to begin removing the tumor. This was done with an instrument that sucks out small pieces of the tumor a little at a time which were saved and sent to pathology. The tumor was a dark greenish color. This is where a physician walks the line between art and disaster. As this was being done, we were invited to behind the scenes, under the surgical drapes to see the patient. This was very strange to be face-to-face with a man whose brain you were just staring at.
The exciting part was over and it was time for the patient to be anesthetized once again and for us to be on our way. Many hours had passed at this point, but it did not feel like it. On our way home from the surgery, we all stopped and ate Mexican food and all we could say was, “Wow” as we ate guacamole (remember the greenish part?) and discussed and we had seen, experienced and learned that day. It was interesting to hear how the certain parts of the experience impacted each of us differently. It was truly an amazing experience that I don’t think any of us will ever forget and will resonate with us as we continue to design healthcare facilities to best meet the needs of doctors, patients and everyone who relies on these spaces.
Susan Welker, AIA - 18 May 2013
Exactly! I did research during my Masters in Architecture about how more w...
Yen Cao - 15 May 2013
Way to go Brian! Congrats.
Air Monitoring - 15 May 2013
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Don Wesley - 14 May 2013
Sara: What an honor, and so well deserved! You have always been a very sp...
Bob Farwell - 13 May 2013
Sara: Congratulations! I have always been impressed by your talents,work e...