OREX Feb 2017 Meeting

Some wonderful pictures from our meeting on 2/18/17! We had great student-led discussions on several issues including the rigors of surgical training and the imposter syndrome, over-reliance on EMR, therapeutic communications skills, strategies to ace the NCLEX and MCAT exams, and preparation for job interviews. Everyone participated and it was great learning exercise for all in attendance!

img_7956img_7961img_7966img_7965

December 29,2016

 

Written by Olincia White (class of 2016-2017)

My first day in the OR was very exciting. I woke up early and anxious to arrive on time. I showed up to AO2, nervous but excited. After reading all of the journals, I could only imagine what the topic of the discussion would be. I arrived at about 6:55am to find the light off and the room empty. This made me very nervous and tons of thoughts went through my mind. Was I too early? Surely everyone wouldn’t magically appear at 7am sharp. Luckily there was a nice lady sitting quietly in her office, across from the room. She informed me that there were no meeting on Thursday and that although she didn’t know much about the program I should probably head to the OR. More confusion set in. How would I find a resident? How will they know who I am? I made my way to the 5th floor and asked the first person I saw to help me. He was very kind and walked me over to the nurses station. I was greeted by a nice nurse, Wendy, who informed me that all surgeries started at 8:30am on Thursdays. She recommended that I go have breakfast and return. I returned at 8:15am, got changed and made my way to the board. I noticed that the board only had 3 surgeries. Hesitant to stare at the board for long, I picked an OR but I didn’t just want to walk. Luckily Wendy reappeared and helped me pick a surgery that hadn’t yet started. This allowed me to introduce myself to the female resident at bedside and the surgeon, Dr. Geoffrey. I introduced myself and we proceeded into the OR.  

Procedure #1 Left Breast Abscess Excision

The staff explained that it was uncommon to see a lot of procedures scheduled at the end of the year and that it was superstitious for patients of Asian cultures to have surgeries before the new year. This patient was having a small abscess excised from her left breast. The patient reportedly works out at the gym 5 days a week. They suspect that the abscess is a result from sweating and daily wear of her constricting bra. After sedating the patient, the resident made a small incision, cut down to healthy tissue and excised the abscess. Dr. Geoffrey stood at bedside, giving minimum instructions on what to do next. After the abscess was removed, the empty space in the breast was “stuffed” with healthy tissue (tissues in the breast were rearrange to make sure there weren’t any empty pockets) and the incision was nicely sutured. During the procedure, Linda the Nurse Anesthetist, showed me how to insert an Esophageal Tracheal Stethoscope! I have never seen one of these used and Romello, teased her for only showing off her toys when guests were there. Either way I was excited and she complimented me for my enthusiasm. The ET stethoscope went direct into the patients airway and had a small earpiece connected to it that allowed Linda to listen to her lung sounds and heart rate. From a nursing standpoint I thought it was pretty cool.

The entire procedure took about 45 minutes. After the patient was sutured up, Linda, the Nurse Anesthetist, prepared her to be extubated.

The circulating RN, Romello, was very nice and immediately began asking about my career goals and interest in the medical field. I explained that I had recently graduated as an RN and word traveled fast! Linda was made aware and welcomed me with open arms. During the procedure she schooled me on her every move and explained why she was adjusting the ventilator, what numbers she was paying attention to and what to do if things didn’t go as planned. As soon as she extubated the patient she began quizzing me in front of all the MD’s (there were 3!). We begin discussing nasal cannulas vs. simple face mask. She asked how much oxygen would be delivered via face mask.. my mind said 40-60% but I was so intimidated that I uttered 40. SMH, always go with your first mind and be confident. We then talked about the Fio2 and what percent we all breathe on room air, 21% of course. Where was my mind. I kicked myself all morning for not being the sharp me that I know I can be. It was humbling to say the least. Once the patient woke up, we wheeled her to recovery and I thanked everyone for their time.

Romello recommended that I check out OR #2 so I headed that way.

Procedure #2 L5 Laminectomy

I entered OR 2 to find a patient lying supine with a cushion box over his face. He was being prepped for a Lumbar Laminectomy. The cushion was going to provide comfort for his face once he was turned over into the prone position. He had cancer in his spine and the surgeons figured if they removed L5 the tumor would have more room to expand and would not compress on the nerve endings as much, saving him from further complications down the road. Without this he could become incontinent and lose his ability to ambulate. This OR was much more crowded, Romello was there so I felt like I knew someone. I was immediately greeted by Larry, the PA, who I absolutely adore! He was a lot of fun, had a lot of jokes but just as much knowledge to offer. He explained the procedure and pulled up the patient’s X RAYS to help me get a better understanding. Larry explained that we were waiting on the surgeon, Dr. Castro-Murell, which he said in a funny tone. He prompted me on how to say it so that “He would be my best friend” and sure enough Dr. Castro-Murell and I hit it off well. He was also full of jokes and laughter. I also had the pleasure of meeting Dr. Thurman Hunt who is the anesthesiologist and supervised both procedures.This entire procedure was scheduled to take about 4 hours but I only had about 2 more to spare.

The Rep

I spent a lot of my time with the representative from the company that offered a machine that would be used in surgery. The rep was super nice and really enjoyed talking with me. Every chance he got he was showing something else on the machine or making small talk about his previous experiences. He was there to ensure that the doctor could accurately align the prons on the device he was using (poor description but I can’t recall what it was called, and had never seen anything like it). The device had  sensors that were facing a camera. Dr. Castro-Murell made 21 virtual markings on the patient that he would later be able to use as reference points. The rep had a machine that had a 3D image of the patient’s lumbar spine. The goal of the machine was to help the doctor find the proper trajectory. Without the device there would be lots of x rays needed. There were cameras on the end of each point and it was up to the doctor and the rep to ensure that it was aligned correctly. Dr. Castro-Murel had no problem with this and things continued smoothly. Unfortunately I had to leave shortly after.

Reflection

Just watching the patient lie face down with his entire lumbar spine revealed was shocking and interesting. I wish I could have stayed longer but my toddler needed my attention. I felt so fulfilled by it all that I was beaming from ear to ear and signed up for the next earliest day available. I am looking forward to going back.

One thing that was really cool is that a lot of the staff noticed how many pins I have on my badge, (a total of 5) and thanked me for my service!! How nice is that? I absolutely love Highland for days like this! It started off rough but ended well. I am very grateful for the opportunity. Thank you!

 

December 25, 2016

Written by Bianca Salaverry (class of 2016-2017)

My second day of OREX turned out to be even better than the first! I’m still getting used to things, so when I first got up to the OR, I was a little confused because it seemed like the surgeries listed on the board weren’t all where they were supposed to be. I wanted to observe a total knee replacement (TKR), but there was a sign on the door to that OR that said not to go in because of the infection risk. I stepped into the room adjacent to it thinking I would observe a surgery in there, but it hadn’t quite begun and the nurse anesthetist urged me to go watch the TKR instead, but to go in through a side door. I went in and sure enough, everyone in the room said it was fine to observe, but just not to go in/out through the exterior door.

There were six main people in the room: a senior resident, a junior resident, a scrub tech, a circulating nurse, an anesthesiologist, and a sales rep. When I first arrived, I was instructed to get goggles because things get a little messy. I remembered Lucy saying this about Ortho surgeries at our orientation, but wasn’t sure quite what to expect. The man who helped me with that was the sales rep, someone I hadn’t encountered in the ED before. One of the most surprising things about this surgery for me was seeing how involved the sales rep was, how much instruction he gave the surgeons, the degree to which they deferred to him despite him having no medical training, and so on. Although all the surgeries I’ve witnessed so far have involved hundreds of tools, this one was at a whole other level. There were drills and saws, rulers, screws; generally just too many devices to count. The sales rep was incredibly knowledgable about every tool, frequently directing the surgeons to use a particular instrument, or instructing them about how something should fit (e.g. “That shouldn’t be so hard to remove,” or “Pinch there and then open it from the top.”). He navigated back and forth around the room between the OR tech and his tools and the surgeons doing the action.

This surgery played out much differently from my previous OREX day in a few ways. First of all, because there were only two doctors at the table, I was able to see what was going on much more easily.

For most of the surgery, I stood at the foot of the operating table, about three feet from the edge. My view was amazing! Secondly, I had heard this before, but this surgery was much more gruesome than ones I’d seen previously. There was a lot more blood (including some spurting arteries), the incisions were much deeper and generally done a lot more quickly than in abdominal surgery, and of course, there was a lot of sawing and drilling involved. After the initial incision, the surgeons flipped the patella out of the way to access the knee joint. Over the course of the next several hours, they proceeded to saw the ends off of the femur and then tibia.

The initial cut, off the end of the femur, was perpendicular to the axis of the bone, but then the doctors made several additional cuts at different angles forming a precise shape that I couldn’t quite capture in my drawings, but which looked roughly similar to this with a groove running down the middle of the femur end.

Screen Shot 2017-02-19 at 10.15.42 AM.pngAfter each piece of bone was sawed off, a guide was screwed into place so that the next bit of bone would be removed at the proper angle. Obviously this stage involved a lot of sawing and at one point I got flicked with some blood/bone droplets, some of which got on my skin. I definitely wondered at that point about how the surgeons themselves are able to avoid getting splashed with a lot of bodily fluids since they’re right in the middle of the action. I’ll have to remember to ask someone about that sometime.

Once the cuts were all made, the scrub tech mixed some cement to attach the metal pieces that would form the artificial knee. One surprising thing about this step — the cement was really nauseating to me. I don’t have a very good sense of smell, which I think is a huge advantage working in a hospital. I’ve never had a problem before, even with the most pungent odors I’ve been exposed to in the ED, but I almost had to step away from the table because the cement smelled so strong. It was awful! Another surprise: the cement wasn’t mushy like the kind you see used in construction; the texture was more similar to fondant, a kind of sugar based “clay” that bakers use to cover cakes.

At this point, Dr. Krosin, the attending, came in and the surgeons showed him their work. They moved the patient’s leg around, bending and straightening it, and observing its rotation. At one point Dr. Krosin came and stood next to me, and I had the opportunity to ask him a bunch of questions about his experience in Orthopedics. He was very friendly and seemed happy to talk about his work. Dr. Krosin is the chief of Orthopedic Trauma at Highland, so he sees a lot of severe injuries. He talked a little about how orthopedic surgery has this reputation as being less cerebral than other fields of medicine, but that he doesn’t think that’s true. He also touched on how important it is to consider the psychological needs of patients who’ve experienced these major traumas. I was especially impressed by that, because there’s also a stereotype that surgeons don’t see the patient, they only see the part they’re working on, and that was obviously not true of Dr. Krosin or his residents.

After that, we talked a little about the patient at the table and he took me over to the computer and showed me some X-rays of patients he’s worked on recently. One was a young girl who had fallen from a tree, and another was a man who had been hit by a car. I asked about how the recovery would be for the man and he said very matter-of-factly that either the man would heal on his own, or his leg would have to be amputated. No wonder Dr. Krosin emphasized the psychological needs of these patients! I can’t even imagine how I would feel in that kind of situation. One piece of advice Dr. Krosin gave — if you ever get in an accident on the freeway, stay in your car! He said he sees a ton of people come in to the hospital after surviving a car accident only to get injured worse because they got out of their car and were hit again.

Once the artificial joint was put in place, the rest of the surgery consisted mainly of irrigating the area, soaking it in betadine, and stitching the patient up. Overall, this was easily the most interesting surgery I’ve seen to date. At this point, I took a short break, had a bite to eat, and then hurried back to the OR so I wouldn’t miss anything interesting.

It happens that the second orthopedic surgery I got to observe that day was with the exact same team. The patient in this case was an older woman who had suffered a fall and gotten a small fracture towards the end of her femur. The surgery started off roughly the same as the TKR, except that everyone in the room had to wear a lead jacket during the procedure because after the break was repaired, they would need to do multiple X-rays. The initial method for this surgery also involved cutting around and flipping the patella out of the way to expose the knee joint. I don’t know the anatomy of the femur very well, but I believe the break was through part of the medial condyle. It didn’t go all the way through the bone (i.e. there wasn’t a piece of bone that was floating completely separate from the rest of the femur) so the main aim of the surgery was to insert screws to hold the broken part in place until the bone could heal naturally.

As the doctors were working, it seemed like something wasn’t quite going right, and Dr. Krosin scrubbed in to help. Once he was done, he said it seemed like I had a question, so I told him I was a little confused and hadn’t been able to follow what the problem was. His answer was essentially that they were being perfectionists, and that they just needed to accept that their work wasn’t exactly a “textbook” job. I appreciated that piece of advice because it’s the kind of thing I struggle with. There’s a saying “Don’t let the perfect be the enemy of the good,” which essentially means the same thing — don’t get stalled because you want the thing you’re doing to be perfect instead of just good. Once the doctors had decided their repair job was good enough, they took several X-rays from different angles and saw that, in fact, they had done a great job and everything looked as it should.

At this point it had gotten late and was time for me to go, so I thanked the surgeons who had let me spend the entire day with them and said goodbye. All in all a great day!

December 22, 2016

Written by Himakar Nagam (class of 2016-2017)

Waking up at 5AM, ready for my usual commute, I woke up with a different feeling today– one full of excitement and anticipation. Today was my first day of OREX, and it was all that I thought it would be and more. I put on my scrub pants and my gray t-shirt, walking out of my house in Fremont wondering what I would be observing for the day.

However, my day did not start off as expected. I got to the hospital early, around 6:50A.M., and went to the conference room in OA2 where we had our orientation, only
to find nobody there. Confused, I asked a lady in the adjacent room why nobody was there. She said that on the last Wednesday of every month, they have a special conference with the ED department physicians as well to discuss trauma cases in Classroom A on the above floor. I made my way to classroom A, sat down, and looked around nervously as Dr. Harken had not yet arrived. Eventually, he did, and I introduced myself to him and introduced myself to an attending that I was sitting next to. In came our speaker, Dr.Jeffrey Deweese, Director of the Saint Francis Bothin Burn Center in San Francisco and his 120 slide powerpoint presentation.

He had a lengthy presentation on the largest burn center in Northern California (with 16 beds), specific patient cases, as well as how physicians at Highland could improve their treatment of burn patients before sending them over to the burn center. One thing that Dr. Deweese emphasized was the importance of their burn nurses and the level of collaboration in their burn center. I remember in one picture specifically seeing physicians of all different specialties meeting together to discuss cases as well as hearing him say that their patient bed numbers are limited because of the amount of nurses they have.

With regard to treating burns, he talked about conducting both a primary survey (with the pneumonic ABCDE—you can learn about this more in detail at https://www.americannursetoday.com/abcdes-emergency-burn-care) and a secondary survey to assess the patient. He talked about not immediately putting ice or cold water on the patient contrary to popular belief and wanted physicians to monitor fluids and not put on this common gel used to treat burns called silvadene.

He also discussed determining the TBSA (Total Body Surface Area) of the patient that was burned by using the Rule of Nine’s (which I learned about in my anatomy class this semester!) and using the Parkland’s Formula to estimate how much replacement fluid the patient needs after incurring a burn to remain hemodynamically stable.

Then, he discussed various cases. There was one case about a woman who was window shopping in San Francisco when a transformer blew up right above her and made her fly across four lanes (!) of traffic across the street. In another one, a lady was lighting candles for a religious celebration when her dress caught on fire. Normally for other cases they use pig skin grafts temporarily, but she was vegetarian, so they had to obtain skin grafts alternatively. One boy was working with his dad in the fields when some black powder exploded; for this case, he discussed the usage of a Q-Switch Laser to remove scar tissue and also remove tattoo ink in other patients. I was really impressed with the burn center by the end of the presentation, and it was time to go to the OR. By then, Dr. Harken had left the room with another colleague, and I did not see other residents leaving (I think there may have been another presentation going on afterwards), so I left to go upstairs by myself.

Everybody is right when they said you will know who the scary nurse is; she immediately asked me who I was and what I was doing there once I entered the department. I grabbed my scrubs from the vending machine after she showed me where to get the card from and wandered off in the hallway when Dr. Krosin, who I previously knew, told me to come watch the surgery he was performing—a total right knee replacement revision. I was super excited as I put on my mask and entered the operating room.

The patient originally had a right knee replacement done in February but was not satisfied with the job done—she was complaining of some midflexion instability. The resident, Dr. Nguyen, showed me this was the case because she could not hyperextend, but could flex a full 90 degrees, and then showed me the wobbliness when flexing around 45 degrees. So, in order to fix this, they had to lower the joint line by putting in different hardware in the knee joint. The ACL (Anterior Cruciate Ligament) was taken out in the previous surgery, but now they had to take out the PCL (Posterior Cruciate Ligament) but would keep the MCL and LCL intact (Medial and Lateral Collateral Ligaments).

The one thing I immediately noticed was a checklist on all of the walls of the operating rooms. I read about the importance of them, especially within medicine, with regard to preventing unnecessary infections and mishaps in a book called The Checklist Manifesto by Atul Gawande (which I would highly recommend), so that made me really happy. They made sure they injected the proper amount of anesthesia, antibiotics, made their marks, covered the rest of the body, etc., then got to work by making the first incision and moving all the fat out of the way.

They used a cauterizer (known as the Bovie) to remove excess scar tissue and cement from the last surgery as well. They had to make sure to cut around the Patellar tendon as well as the quadriceps tendon then moved the patella to the side. This was all very interesting to me because I had seen these muscles and bones on cadavers, but I had not seen them in an alive person. They used these tools called gelpies to pry open the cavity so that they wouldn’t have to hold it open themselves.

Screen Shot 2017-02-19 at 9.31.28 AM.pngAfter moving the patella as well as the tendons connected to it to the side, I saw the silver hardware that replaced the condyles within the prior surgery as well as the other hardware that covered the intercondylar eminence. Using various tools like a saw (apparently this is what it is literally called), Dr. Krosin took out the old hardware attached to the condyles of the femur, the plastic in between the tibia and the femurs meant to replace the menisci, as well as the metal stem that was inserted in the tibia through the intercondylar eminence.Screen Shot 2017-02-19 at 9.32.01 AM.png

In order to place in the new hardware, the surgeons had to re-shape the femur and the tibia to fit the new parts. Dr. Krosin increased the size of the reamer placed within the tibia one by one so that the actual stem that would be placed would eventually fit. For the femur, he used the saw again in combination with a broach to make lines on the femur that would fit within the grooves of the metal replacement. He used a reamer for the femur as well. This was a very lengthy and tedious process, and one of the residents accidentally chipped off part of the patellar surface of the femur, which Dr. Krosin said was fine because the metal would be covering that anyway. This showed me one thing: that even doctors can make mistakes. I should not be too hard on myself because although that may be in my nature, it is important to stay cool and collected in all situations as a leader.

Screen Shot 2017-02-19 at 9.32.13 AM.pngI noticed a few other things as well: the first was the importance of teamwork and communication. An operation will only go well if the team that is operating communicates properly and works together efficiently. Every member of the team is crucial to the success of the operation, from the nurse anesthetist, who anesthetizes the patient, to the surgical assistant, who hands the proper tools to the surgeon when he/she needs them. This is something that Highland instills in its volunteers—the importance of communication in a well-oiled machine, and is something that Dr. Deweese emphasized in his talk earlier in the day as well. The other thing I noticed is the authority that the surgeon possesses; despite recommendations on what knee hardware replacement would be best for the patient, he is the one who has the “trump card” as the assistant put it. He can overrule other peoples’ opinions and do what he thinks is best for the patient because of his position; this is part of what makes me want to be a physician. I want to be the leader who has the ability to call the shots, and I saw this first hand today. Lastly, I noticed the importance of an attending physician teaching his residents. Medicine is a profession in which people will constantly be learning and teaching other people, and seeing an attending physician mentor his residents today is something that I appreciated and something that motivates me to become a physician one day because of my passion for teaching.

Going back to the procedure, they put in temporary metal just to assess the fit, and took measurements of all the pieces they would need. I smiled as I heard the hardware “click” into place and saw the knee joint flex properly and fully hyperextend, which was a good sight. So, after taking all the temporary metal, they laid out all the actual metal they would place in the knee on the table. The resident, Dr. Nguyen, irrigated the joint cavity with fluids and cut off blood supply so that blood would not dry up once the new hardware was placed on the bones. Then, they put in all the new hardware (one component for the tibia, one for the femur, one for the cavity for everything to glide on). They also mixed some chemical powder and fluids to form the cement to hold everything together in the cavity.

 

December 19, 2016

Written by Jenny Luong (class of 2016-2017)

Apologies for taking some time to write on my first day, but I must say, it was VERY fascinating. I had arrived about 10 minutes early and sat in the corner. 7AM came and went, and I was starting to wonder if there was something wrong. Wrong place? Time? Cue the internal screaming. Then a resident comes in, looks past me and sits down with this glazed look on his face. I was about to ask him if he was feeling okay but more residents sat down and had the same look while they checked their phones. Dr. Harken was late as well, as he just started talking immediately and kept watching the clock. I realized that it was a Monday. Nobody likes Monday.

Dr. Harken gave the students a case study from another hospital. Patient is a 50 yrs old  female who comes in with 50% TSA (total surface area) burns. It’s mostly on her trunk. Her blood pressure (BP) is 100/70. Heart rate is 140. Respiration rate is 28, and her temperature is 38.5. The question posed was, how do you replace her fluids if so much of her body is burned? Everyone was so quiet, I could hear the heater turning on. Apparently the accepted answer is that the IV can still be placed despite the burn. The increased breathing and heart rates are due to the patient becoming hypermetabolic and the immediate concerns are the ABCs (airway, breathing, circulation).

Another study the group seemed to be interested in was a study done on several young men. After being exposed to carbon monoxide, the young men were found to recover more quickly after oxygenation and mild exercise. Dr. Harken then explained the importance of adequate and effective oxygenation for all patients, not just burn victims.

Everyone seemed to have the Monday blues because no one wanted to talk and everyone shuffled away after. I made it up to the 5th floor myself and went to the nursing station to ask for the vendor card. The nurse kindly nurse told me that someone else had it. Upon feeling very lost and walking into the women’s locker room, no one was there. I kept chanting, “Be invisible” to myself, so I was loathe to return to the nursing station. What if nurse Julia was there and she was scary? I braced myself and went back. The kindly nurse smiled at me and gave me her card to get scrubs. I rushed back into the locker room, elated, and then took a look at the name card. Nurse Julia Wang. I almost dropped the card. A resident on the way out shot me a strange look when I let out a “Meep.”

Looking at the board, I watched, somewhat horrified as Nurse Julia crossed out all the surgeries on the board. Not sure if that meant canceled or already happening. I thought she was updating the board until she turned around and directed me to OR 1. I was really thankful and scurried over there after thanking her a bunch. At that point it was 7:54 and everything was still being set up. I talked to the residents and got some names. Dr. Jerry Merriman was very kind in answering any questions and telling me about what was going to happen. Dr. Mike Krosin then walked in with a red lead apron on. It felt like I was in the presence of a celebrity! He told me that I would get to see a lot today and I would need a lead apron for this surgery.

This surgery would take over 7 hours. The patient was a 36 year old female from LA. She was working construction and got her foot stuck in the mud. When trying to get out, she fractured her right tibia. Due to her weight and the accident, the fracture was quite large. This surgery would be a right tibia plateau ORIF (open reduction internal fixation). An ORIF is a surgical procedure to fix a severe bone fracture, or break.

The surgery took a while to start because they had taken a pregnancy test and found out she was pregnant despite the patient not knowing she was. The RN, Benny, let the patient know about the possible risks. She signed a form and told Dr. Krosin about how she didn’t know and she didn’t have a primary care doctor. Overhearing the hushed conversation, I heard that a social worker would be called and that the doctors were concerned that the patient would not follow up with her care once she went back to LA. I am glad there are doctors that consider these types of obstacles to getting care and pick up on the nuances of what is left unspoken.

I felt well-equipped with a lead apron on. The surgery involved making large 3-4 inch cuts on both sides of the right leg, a little above and below the knee. The tissue was slowly cut until Dr. Krosin reached the bone. He scraped off as much tissue as he could from the bone. There were power tools and drills and screws being fit in. The plan was to place two plates to buttress the bone. I would like to describe it more, but here is a poorly drawn picture instead.Screen Shot 2017-02-19 at 9.16.36 AM.png

I have never thought of surgeries as carpentry, but in this case, the surgical techs told me all the same tools were used, just with different names. I ended my day at 3PM because my back was killing me from standing in the one spot watching this surgery. There were many moments where I thought, “This can’t be real.” I realized how difficult it was to get the screws in, how slippery the blood was after a screw was dropped, how hard it is to see where a screw went in unless there was an x-ray.

I don’t regret staying in this single surgery, because while it was lengthy, I saw how teamwork and conversation occurred in the OR. The importance of voicing out concerns and observations is important in producing good outcomes. Dr. Merriman caught that the patient didn’t have a lead apron. Dr. Jackie caught that one of the screws were not the correct length. This was an amazing learning experience.

Other interesting tidbits:

Dr. Mike Krosin has a tendency to randomly sing a line of lyrics from the DIY speaker (a cellphone inside a cylindrical container).

When the patient is strapped in, the doctors will say “Airplane left” or “Airplane right” to have the tech turn the patient toward them. I didn’t understand until I say how they strapped in the patient’s arm and she really did look like an airplane.

 

December 8, 2016

Written by Courtney Pasco (class of 2016-2017)

Yesterday was my first day in the OR and it was easily the best day I have had in a long time. I got to the morning meeting a couple of minutes late and walked past the stares of twenty or so residents gathered around the table. I snagged an empty seat and settled in to the morning’s discussion on melanoma.  I thought the give-and-take style of teaching was quite effective, with the attending presenting hypothetical cases with pictures and asking the residents how they would proceed and why. I was expecting the morning meeting to go way over my head, but I actually learned a lot and all of the talk about childhood sunburns, naturally freckly skin, and melanoma mortality statistics made me want to get to a dermatologist immediately.

After the meeting, I proceeded up to the 5th floor and went to get my scrubs. It was pretty obvious I was new because I made mistake after mistake just getting ready. Once I was, though, I was pretty timid about walking into an OR. All of the surgeries scheduled for 8am were crossed off and it was 8:10, so I didn’t want to walk into an ongoing surgery and disrupt anyone.  Eventually, though, one of the ortho attendings (I think it was Dr. Krosin) told me if I “promise not to breathe or move” I could watch a total hip replacement.

The surgery took about two hours in total and the patient was an older arthritic Greek woman who had already had her other hip replaced.  At first I was standing by the nurse anesthetist, Linda. She was very kind and explained the purpose of each of the medications she was giving the patient and what she was responsible for monitoring. From my vantage point, I couldn’t really see much past the incision, but I have anxiety and was feeling pretty apprehensive so I was grateful to just get the chance to get acclimated to the room and machines and instruments. However, when the residents who were performing the surgery (Jackie and Jeff I believe were their names), saw that I couldn’t really see into the incision, one of the nurses, Tim, brought over another stepping stool and moved me to the side of the patient.  By this point I was over my initial nervousness and could focus on how cool it was to be seeing an actual hip joint! Once the joint was exposed, the attending stepped into assist the residents. Jackie grabbed the saw and within seconds, the entire ball-and-socket had been removed.  The next steps of the procedure involved carving out a new socket in the pelvic bone and inserting the new metal joint. With all of the sawing, grinding, and pounding, it seemed more like construction work than surgery!  Everyone in that room was really nice about chatting with me and making sure to answer my questions.  

In the afternoon, I decided to observe an exploratory laparotomy on a young African American man who had been shot four times that morning. He had one bullet wound in each arm and another two in his abdomen.  The surgeons, led by Dr. Palmer, opened him up and after observing the wound to his liver, began to run his bowel.  That was easily one of the most amazing things I have seen in my life. I mean I’ve studied the anatomy of the digestive system on models and cadavers, but to see it all pink and alive was simply incredible. After they had determined there was no major injury to his intestines, they observed an injury to his right kidney and closed him up.  They didn’t repair either the kidney or the liver and are just counting on the healing on their own.  At the end of the surgery, ortho was supposed to come and splint his right arm, where the through-and-through bullet wound had completely shattered his humerus. Ortho is scheduled to fix it on Friday, but there was a lot of bleeding so Dr. Palmer wanted to see if the bullet had nicked an artery before having ortho come in.  He widened the hole and he could actually stick his finger all the way inside and feel that it was bone marrow that was pouring out, not blood from an artery.  So he proceeded to pack the wound with gauze and wrap him up before ortho did the splint.  During this surgery, I talked a lot with the surgical tech, Ana Maria. She was absolutely lovely and taught me a lot about the different instruments and then walked me back to show me how they get sterilized.   

Nine hours really flew by and I can’t believe how much I learned, not just about the medicine, but also about myself. For a while now I’ve had this pipe dream about becoming a surgeon, but I’ve never seriously considered it because my anxiety crops up in more intense situations and going into the OR I assumed I would have to excuse myself almost immediately to calm down. But I didn’t. I got nervous, sure, but only for the first hour and then my excitement and curiosity took over.  I’m starting to think that this is something I could not only handle, but really love.     

November 30, 2016

 

Written by Katie Darfler (class of 2016-2017)

I arrived early and grabbed a corner spot in the room. Soon, as most everyone has noted, the sleepy residents began to trickle in. A doctor began lecture by proposing “something new.” [I did not get the doctor’s name, unfortunately, because he didn’t introduce himself before and he was busy discussing surgery cases after lecture.] He suggested proposing a trauma scenario and running through it in assessment and care with the residents. He told them that this would be helpful preparation for their boards, and it was really cool to be a part of.

The scenario was a thirty one year-old male in a high-speed MVC (motor vehicle collision). The patient’s vitals were: a systolic blood pressure of 90 (which, he noted, is an ambiguous blood pressure, so it is great practice for the boards) and a heart rate of 110. The leading doctor then cold called various residents to go through the steps to assess this patient in a trauma bay. The first resident claimed that they should assess the airway. To that, the doctor responded “yes” and told the resident that the patient had a GCS of 7. I remembered from pathophysiology that GCS is short for “Glasgow Coma Scale” and is noted as the most common scoring scale for determining a patient’s level of consciousness following potential brain injury (brainline.org). A patient’s GCS can be anywhere from 3-15. A patient receives a number for various subcategories of assessment: Eye opening (1-4), Verbal Response (1-5), Motor Response (1-6). Each number in the subcategories corresponds to the way a patient responds to a stimulus. Any GCS of 3-8 is considered a severe injury. To learn more, you can visit: http://www.brainline.org/content/2010/10/what-is-the-glasgow-coma-scale.html. So, I now know that this patient is considered to have a relatively low GCS. Okay, so back to the resident who decided to assess the airway. At this point, several other residents were chiming in with their own thoughts and ideas. One resident said “RSI!” which I now know is “Rapid Sequence Intubation.” I learned that RSI, a method that uses anesthesia, is the ideal method for endotracheal intubation for patients in the ED because it “results in rapid unconsciousness (induction) and neuromuscular blockade (paralysis)” (emedicine.medscape.com). After the lead doctor asked which drug they should use for RSI, one resident chimed in and suggested that they use etomidate, an anesthetic. The doctor then followed up and asked that drug’s adverse effects. Several residents said “adrenal insufficiency.” The residents seemed to all agree that they should not use propofol or ketamine for the RSI. At this point, the doctor asked about what types of paralytics the residents could push. Several residents said “polarizing or depolarizing.” Another resident suggested using “sux” (Suxamethonium chloride), apparently a short-acting paralytic.

The next step in assessment would be to assess bilateral chest sounds. Another resident chimed in that the next step after that would be to check circulation: central pulse, blood pressure, and access. At this point, the leading doctor asked about what size IV to use. One resident said that the largest bore IV possible is ideal, located in the ACs. At this point, the doctor asked what to do if a nurse brings a “triple lumen” IV. Everyone at the table seemed to know this was a big “no no” and responded that this particular IV should not be used. The doctor asked what to do if achieving a large bore IV was not possible in the ACs. The residents agreed that they should now try for a central line or go IO (intraosseous infusion). If they had to go IO, they would try for the sternum, the humerus (ideal), or the tibia. The doctor asked, “What next?” and one resident responded, “Give blood.” All agreed to begin O negative blood because, as the lead doctor suggested, a main reason for hypotension in trauma is loss of blood.

The residents continued their primary survey and then decided to get a chest x-ray and a FAST, especially because he was involved in a blunt trauma from the MCV. The FAST is short for “focused assessment with sonography for trauma,” and basically means a rapid bedside ultrasound that looks for blood around the heart (pericardial effusion) or trauma to abdominal organs. Then, the residents decided to move into the secondary survey. They found that the man’s pelvis was unstable. After several suggestions about using a pelvic binder to “compress form to tampenade venous bleeding,” there was a short debate about binder efficacy. Another doctor in the room suggested that all orthopedic literature suggests binders for all pelvic fractures. They called this type of binder a “T pod” and discussed proper placement on the greater trochanter for greatest effect. The next resident suggested to do a PAN scan. The doctor then said that the patient’s blood pressure is decreasing and asked what to do. A resident suggested giving more blood. The lead doctor agreed and insisted on not using “crystal light.” (I could have sworn this was a sweet drink found in vending machines, but I think that is what they said!) The doctor said whole blood is best (with a 1:1:1 ratio of RBC, platelets, and (I believe), clotting factors). The residents then suggested repeating FAST, looking for pelvic bleeding, activating DPA, and then potentially ligating the internal ileac vein bifurcation. (Things were moving very quickly at this point, and I was trying to keep up with notes!) The doctor then discussed REBOA, a method that replaces an aortic cross clamp by putting a balloon in the aorta and occluding distal bleeding. However, apparently this procedure takes a while and would not be ideal for an immediate trauma.

Surgery 1: OR3, Abdominal Ex. Lap. Fascial Closure, Dr. Sadjadi

I arrived in OR3 to see a patient on the table with most of his small intestine visibly exposed. A sweet doctor came in and explained what was going on with this patient. He said he’d been stabbed and had significant damage to his liver. He had already had one round of surgery, but explained that the patient would likely need several more to get his “guts” back in and close the wound. Basically, in the crudest of terms, the surgery was attempting to push the exposed organs back in and sew the man’s abdomen up partially. I was eagerly welcomed to view the surgery and everyone was very friendly. I was really impressed with how all the doctors approached the surgery with such humility. They asked questions of each other and talked about decisions being made, all without a hint of ego. One doctor asked if the other was going to excise the liver. The lead surgeon said that he would not because the liver was mostly dead and he was worried about bleeding. With the help of a resident, Dr. Sadjadi made stitches in the fascia, alternating the top and bottom of the approximately foot-long opening. It was almost like a corset closing, but the organs inside were so inflamed, so it was not possible to fully sew the man up. One resident worked to push the organs back in while Dr. Sadjadi continued his stitches. At this point, the team took out the rag that was covering the organs and put in a plastic sheet, then covered that with wet gauze, and then covered with something called an “ioban” sheet, which I assume is to keep the area as clean as possible. One doctor asked Dr. Sadjadi how he knew if the skin was close-able. Dr. Sadjadi said it is a lot about how the skin feels, its turgor. The surgery was relatively quick, from 8:23-9:02. On the way out, Sarah Bradford, a kind resident, took me under her wing and allowed me to follow her into the next surgery, which was already underway.

Surgery 2: OR6, Female ejected from vehicle, two broken legs, one dislocated right knee, questionable pulse in right foot (potentially from an occluded popliteal artery)

Dr. Bradford helped me put on my “leads” because there were many x-rays occurring in this patient’s room and we needed to protect our bodies from radiation. The first thing I noticed when I walked in was a doctor literally power-tool drilling into this patient’s femur. I learned that these drills would be essential in setting up the “external fixation system” (shown below) that would stabilize this woman’s bones, which had been broken in multiple places.

Screen Shot 2017-01-14 at 8.42.49 PM.pngThroughout the drill process, an x-ray technician took multiple shots of the bones in her legs and her knee. She had dislocated her knee in such a way that many of the doctors said they had never seen before. Apparently, the dislocation not only tore her ligaments, which is to be expected, but it also sheared off the top of her tibia (I think). The doctors were concerned about this because it would affect her cartilage as well, and lead to a long recovery.

Interestingly, the woman came in with what I understood to be a weak or absent pulse in the foot. I learned that bones must be realigned or vasculature can be occluded, so that’s why the doctor was working on the bones before addressing the vasculature. I think, from what I understand, realigning the knee helped the pulse come back in the foot. The doctors used a doppler machine to find the pulse in the foot.

While this was occurring, a few people were working on closing up gashes on the woman’s head and forehead and shin. I watched them irrigate and prepare for suturing. I also got to watch them close up the gashes. As I listened to some doctors discuss her forehead wound, they mentioned that she would likely have a large scar. Apparently, when she got in her accident, she hit her head in a way that removed a big chunk of tissue, so it would be difficult to close the tissue (1), and it would heal in a way that went against natural collagen fibers (2).

This lady has a long road ahead of her, which made me feel sad, but I realized that all of these people were helping her take that first step. It was really an honor to be a part of the day.

 

November 30, 2016

Written by Bianca Salaverry (class of 2016-2017)

The day of my first OREX shift, I got up at 5:15 hoping to shower and get ready without disturbing my family, but no dice. My 6-year-old woke up loud and full of energy, ready to turn on all the lights and welcome the day. Luckily I had kid-interruption time built into my morning schedule, so I still made it out the door in time to reach my favorite coffee place before they opened at 6:30. I bought a quick coffee and forced myself to have a bite to eat before heading to Highland. I got to OA2 a few minutes before 7 and grabbed a seat at the table, determined to get the most out of the experience. Dr. Harken arrived a few minutes later and started his lecture with a broad question: Why do we treat the same symptoms or presentation differently in different patients? He gave a few hypothetical scenarios where the patients differed in age, health history, and reasons for coming to the hospital. The lecture was interesting, but for the most part over my head. I was able to follow a little of it by reaching back into the depths of my memory from my time working as an EMT in college…pneumothorax, I know what that is!

After the lecture, I introduced myself to Dr. Harken who looked for a resident to walk me up to the OR. The only person going up was an intern who seemed like he was in a rush and not particularly thrilled to have me in his charge. We walked up to K5 together, and he left in a hurry after showing me where the card was to get my scrubs. It was exciting to suit up in official hospital scrubs for the first time. I looked at myself in the mirror and felt giddy just looking like a doctor. I wondered if the surgeons I would be observing felt any of that excitement still, or if it had become totally rote to them.

With my scrubs on, I made my way to the board to pick out my first surgery. It was a little daunting, but I picked a procedure that sounded promising…only to find that the assigned OR was empty. Not wanting to attract attention by walking back to the board, I went into the first room I could find where a surgery was getting set up. The patient had fallen and gotten a compression fracture in their thoracic spine, so the doctors were going to fuse the vertebrae — the exact procedure my grandmother had just a week or two ago! I was stoked to watch and tell my grandmother about the experience, but unfortunately, the circulating nurse told me they wouldn’t be getting started for half an hour and recommended I come back then.

Although I really wanted to see that surgery, I didn’t want to stand around for half an hour arousing suspicion, so I ducked into another room where a different surgery was being prepped. This operation was a proctectomy (removal of the rectum), ileal pouch anal anastomosis, and diverting ileostomy. I didn’t get a full run-down of the patient’s history, but my understanding was that he had had an ileostomy placed previously because he suffered from diverticulitis. In recent months another doctor prescribed high dose ibuprofen for the patient’s back pain, which led to the development of a perforation in his bowel. From what I could tell, the gist of the surgery was to reverse the ileostomy, remove the rectum, and reconnect the remaining tissue to his anus to restore gastrointestinal continuity.

There were four doctors on the floor from the beginning of the surgery and a few others who came in and out at various points. Dr. Miraflor seemed to be in charge of everything. I didn’t catch  the other doctors’ names, but there was a senior resident who led the surgery with Dr. Miraflor instructing and advising him, as well as a junior resident and an intern. An OR tech assisted the surgeons at the table, handing them tools, helping them with their gowns and gloves, keeping track of supplies, and coordinating with the circulating nurse. We chatted a bit and she shared an interesting fact about the blue loops on the lap pads. I had assumed they were there just to visually detect the laps, but she explained that they’re actually radiopaque, which means if one is missing and the docs can’t find it, it will show up on an x-ray. Crazy!

The surgery began with the doctors detaching the ileum from where it had fused to the patient’s abdomen. This was a long and meticulous job; Dr. Miraflor described and modeled every move for the senior resident. She mentioned repeatedly how critical it was that they avoid accidentally cutting through the intestinal tissue. It took about 90 minutes and was done almost entirely by the senior resident.

Screen Shot 2017-01-14 at 7.48.13 PM.pngOnce the intestine was completely free from the abdominal wall, the doctors used the device shown here called a proximate linear cutter. It clamped around the end of the intestine, simultaneously sealing it and cutting the excess tissue off. It looked vaguely similar to the end of a tube of toothpaste when it was finished. They pushed the sealed ileum through the hole in the abdominal wall and moved on to the next part of the procedure.

The doctors started by making a midline incision from the patient’s sternum down to his pelvic floor, curving around the umbilicus. Once they had the patient open, Dr. Miraflor was dismayed to find that his intestines and mesentery were “all tangled up.” He had a lot of adhesions and so instead of the intestines being one long loopy piece, sections of it were held together in a jumble by thin membranes that all had to be carefully cut with the bovie. Apparently adhesions are a fairly common result of abdominal surgery, so these likely formed when the patient had his ileostomy put in.

At this point, it became a little hard for me to see because most of the work was being done deep in the patient’s abdomen. There were five or six people around the table, so I couldn’t visualize much and had to go by what they were saying. After removing all of the adhesions, the doctors carefully dissected out the rectum, removing a piece that was roughly 8 inches long. As they were completing this stage of the procedure, the senior resident stepped away from the table for a moment and began quizzing me about rectal anatomy. I tried to stammer out some answers, but Dr. Miraflor told him I wasn’t a med student and had no reason to know anything he was asking. I have to admit I was a little disappointed — I don’t know much anatomy, but I was happy to make some educated guesses and be wrong.

Although there was a lot I couldn’t see or make much sense of, I read a little about the procedure at home afterward and learned that after removing the rectum, reversal of the ileostomy involves using a section of the small intestine to create a pouch that will serve as a reservoir for stool — essentially recreating the function of the rectum. I couldn’t see this happening at all, but several hours in, the docs announced that it was done. With the ileal pouch made, they were ready to move forward with the anal anastomosis.

In order to attach the anus to the ileal pouch, Dr. Miraflor planned to use an end-to-end anastomosis (EEA) stapler shown here.

Screen Shot 2017-01-14 at 7.48.21 PM.pngThe doctors were getting ready to do that when they found that the staples closing the end of the anus had come out (or hadn’t fully set in the first place). Things immediately got very tense. The surgery had been going on for several hours with no break, and everyone had assumed they would be wrapping up in about an hour. Now it seemed clear that was an unrealistic expectation, but in the absence of any idea about what went wrong, the timeline became muddy. The only explanation anyone could think of was that one of the staplers had malfunctioned and they hadn’t noticed for some reason. Dr. Miraflor called Dr. Victorino, one of the attendings, and they had a hushed and somewhat anxious conversation about what to do. She decided to try to sew a purse string around the section where the staples had come out for fear that if they tried the stapler again, they would risk ripping apart the tissue. Despite her best attempts, the purse string didn’t work, and everyone’s anxiety levels continued to rise. As they tried to come up with another solution, Dr. Miraflor kept updating the anesthesiologist, “Okay, it’s going to be at least another two hours,” and he kept assuring her everything was fine.

Finally, Dr. Victorino decided to scrub in and assist with the surgery. Initially he sat between the patient’s legs (which were in stirrups) and physically pushed on his perineum to give the doctors working in the abdomen a little more access to the internal end of the anus. After the purse string failed, they decided to try a contour stapler, but it wouldn’t fit around the Allis clamps holding the end in place.

Screen Shot 2017-01-14 at 7.48.34 PM.pngThis led to another meticulous (but creative!) task where they individually placed ~25 loops of prolene thru the end of the tissue, each with a clamp hanging off of it. Once they were all in, which took about half an hour, one of the attendings pulled all the threads taut and Dr. Victorino was able to get the contour stapler into place. It seemed successful and everyone started to breathe a little easier.

As they prepared again to do the anastomosis, Dr. Victorino went down to the patient’s anus and reached inside to determine if the staples were holding. Dr. Miraflor reached down to the stapled area from inside the abdomen, and all of a sudden they realized they could feel each other’s fingers. There was a lot of cursing then, and Dr. Miraflor resigned herself to the fact that she would have to be there for another several hours. At this point I had to leave to go to class so I didn’t get to see how it all resolved. As I was leaving, Dr. Victorino called in Dr. Bui, another attending, to fill him in and hear his opinion. Dr. Miraflor spoke to Marisal, the circulating nurse, to give her a list of the tools and equipment she needed for the ensuing procedure. Everyone was upset and exhausted, so it seemed like a good time to call it a day.

UPDATE: Apparently the surgery continued until around 7 pm, a full four hours past when I left. See Cici’s Day 1 notes for the end of the story!

November 22, 2016

Written by Terry McGovern (class of 2016-2017)

I arrived early for my first OREX shift  in order to get situated on time. A few residents arrived early then the rest poured in, just moments before Dr. Harken came in. He immediately began with (hypothetical?) case studies for the senior residents to discuss. Quite complex cases that they had to figure out how and what to treat on the fly. I grasped much of it, but plenty of it was beyond my learning. Only the senior residents partook while the others listened.

One 3rd year medical student sat next to me. She said. “Are you OREX?” Why yes.

“I was too” she said.      WHATTTTT!!!!!

Alexis Colley is a 3rd year medical student at UCSF, and is now doing a rotation at Highland. She had previously volunteered in the ED for 3 years and participated in the OREX program 5 years ago.

I politely asked if she could show me the ropes in the OR and she immediately said ‘Of course! Someone showed me the ropes on my first day and I’m happy to show you”.  I felt the first day jitters fading. Then she added, “If you want, you could come to the surgeries that I’m partaking in with Dr. Russell (3rd year resident) and Dr. Harken. I jumped on that as fast as I could. But before I could say “Yes Please!” she had introduced me to 2 other residents who had interesting surgeries planned as well.

I got into the OR for surgery #1, installation of a porta Cath. A porta Cath provides chemotherapy access directly into the aorta. Dr. Harken, who somehow already knew my name, told me that it is a preferred manner by which to deliver chemotherapy drugs as they can cause great damage to the tissues of the arm thru a peripheral IV.

I had some familiarity with the device going in to the surgery but was intrigued to see how it would be placed. Dr. Harken, who is truly an amazing teacher, insisted that I get up right next to the ultrasound screen and the patient, to watch.

Alexis tried a number of times to get the needle into the vein, but it kept collapsing. after a few minutes. Dr. Harken said “This is almost impossible. I don’t know if I can even get this one.  This is not fair for you Alexis”.

She had just about got it, but handed it over to Dr. Russell.

He then manipulated the needle into the sub-clavian vein.  Dr. Harken then slid a guide wire into the vein, then the expander.  They made a second incision point where the port would be implanted and the tube that would carry the chemo to the aorta.  

Once the bulk of the surgery was done, leaving the stitches to the resident and Medical student, he said “C’mon Terry, let’s go see what other surgeries are happening before our next one.” We went onto OR 1 and there was laparoscopic myomectomy going on. This patient had a broken T 12 vertebrae that they were trying to stabilize with pins and screws

Then we went to see a laser Lithotripsy (laser breakdown of a large Kidney stone). Dr. Harken told me watch either one of these for a while and come back to OR3 in 30 minutes.

I returned to the surgery in OR3 just as it was to begin. This was a AV fistula being placed. An AV fistula is the joining of the cephalic vein with the brachial artery in order to make a better access for Dialysis. It is a meticulous vascular surgery. An hour and a half later, it was stitch up time.

As the surgery was completed, Dr. Harken asked for a “sleeve” from the OR tech. I didn’t know what this surgical implement was or how it would installed. A moment later the OR tech Asked for my right hand, pulling a sleeve on me and gloving me up. “I want you feel the thrill” said Dr. Harken.  A thrill is a buzzing sensation felt under one’s finger upon palpation at the location of a AV Fistula. I had felt one in nursing clinicals previously, so I had some expectation of what to feel. I was amazed to have had the opportunity to feel it immediately post-surgery.

An AV fistula takes about 6 weeks to “mature”, or until it is ready to be used.

The third surgery I saw was truly sad and very intense. It has taken me some time to try to process it, and it is likely to have a very strong impact on me for quite some time.  The patient was a multiple gunshot victim who had been in ICU for about 10 days. In order to keep her alive, they had used many medications including Levophed/Norepinephrine to vasoconstrict her blood circulation in order to maintain cardiac output and blood perfusion to her brain, heart and organs. This drug is usually used after severe hypotension or shock. One very dangerous side effect of the drug is that there can be decreased perfusion to the extremities due to its vasoconstrictive action, ischemia results and necrosis can occur.

After the patient was brought in, everyone in the room was noticeably affected by the condition of this patient. This was described to me as a “life or death surgery”. The head resident, Dr. John Swanson, said to me “You are now seeing the horrible side of the marvels of modern medicine”. The tragedy of this person’s situation was felt by every single person in the room.   (2 surgeons, 4 residents, 1 third year med student, 2 CRNA’s, 1 OR tech, 1 OR nurse). Both hands and both feet needed to be amputated to give the patient any hope of survival, as necrosis had affected all of her limbs. I will not go into the details of the surgery, but it was not an easy thing for anyone in the room.

The head resident again spoke with me to warn and prepare me.  “Have you ever witnessed anything like this?” No, I responded. He said “Just be careful because we have had people faint in these procedures.” I took extra precautions and positioned myself at a distance and paid keen attention to my own reactions. Thankfully, I did not faint. It was intense but I did watch, and after the initial amputations, I did watch the bandaging and cauterization fairly closely. Afterwards, there was a somberness in the room I will never forget.

From my experience volunteering at Highland in the ED, I have seen many victims of senseless gun violence. Every single victim has some effect on me, but the impact that this patient had on me is profound.  

November 23, 2016

Written by Sammi Truong (class 0f 2016-2017)

November 23rd, 2016 did not go as planned, but was so much more than what I had expected. I was a nervous and excited wreck when I arrived in the conference room at 6:45AM. I was finally able to calm down, when a doctor comes in and asks if I were here for the morning conference. I answered with a yes and was about to do the whole OREX student spiel because I thought he was suspicious of me. However, he told me that the meeting was replaced with a larger conference in some classroom and he did not know where or what room number it was, so I ran out of the room with five minutes left until it the stroke of 7. I vaguely recalled my Highland volunteer orientation two years ago, which was held in the only classroom I knew of at Highland. Luckily, I was right and managed to find the room in time before I interrupted Dr. James Betts from Children’s Hospital as he began his lecture on pediatric trauma and emergency care. I had expected twenty people tops, but there were the usual residents and interns, as well as Children’s staff and Highland applicants. By the time I found a seat, my heart was racing and my hands were shaking as I lifted my coffee to my lips. Dr. Betts discussed the general protocol and procedures in pediatric care and shared many heartbreaking and encouraging cases. It was inspiring how dedicated he is to his work.

After the lecture finished, I located Dr. Harken from a distance, but some medical students or applicants beat me to him. It was also already 8:30, so I made my way to the OR by myself. I was a bit disoriented and since I was already sticking out like a sore thumb, I just asked people in the hallway where things were and was able to successfully change into scrubs. And with my luck of course, all of the surgeries on the whiteboard were scheduled for 8AM. I was a little bummed and lost. As I made my way to pre-op and post-op to search for something to do, charge nurse Nathan spots me and was very nice in asking me who I was. He then brings me to OR 3 and introduces me to the staff. It was a colostomy takedown performed by Dr. Bullard (I believe) and Dr. Gupta. I was quite nervous, but Dr. Gupta was playing music and ‘No Scrubs’ by TLC came on and it was very fitting and just perfect.

I missed the first part of the surgery, when they opened up the artificial opening for the colostomy bag. One of the nurses, Romal was very chatty, welcoming, and willing to answer any questions I had. They began opening up the patient’s abdomen. “The Lamborghini of retractor sets”, which referred to a gold self-retaining retractor set that attached to a bedpost, was brought in and set up to hold open the abdomen. I wasn’t the biggest fan of the contraption, as it was blocking my view of the anatomy. Romal thoughtfully asked if I wanted to observe a more interesting surgery multiple times, but I politely declined as I did not want to interrupt another surgery and I already thought this surgery was very interesting, since it was my first surgery ever. After an hour or two of abdomen work, Dr. Gupta repositioned to the patient’s anus and prepped to use an endoscopic curved intraluminal stapler, which she referred to as “the most stressful part of the case”. During this brief transition, Dr. Bullard was super nice and walked over to me to introduce herself personally. I stuck my hand out to shake her hand, but quickly pulled back as I realized I was not sterile. Dr. Gupta then inserted the stapler into the patient’s anus and with very precise coordination with Dr. Bullard, who viewed the instrument from the abdomen, the staple reconnected the intestines. Dr. Bullard then calls me over to the operating table to take a look. In my head, I was screaming to myself repeatedly, “DO NOT FACE PLANT INTO THIS MAN’S JEJUNUM” (not quite sure why specifically the jejunum). I’m sure everyone else thought I was way too close to the sterile blue; the scrub tech told me to take off my badge and Romal was even pulling back my oversized scrub sleeve, but Dr. Bullard told me to get even closer, so I wasn’t going to say no. She pointed out some of the anatomy and the staple in the distal sigmoid colon. The only abdominal anatomy I had seen prior to this was in a two year old cadaver. It was really amazing to compare and apply what I had learned before to a live human body. They ended up having to redo the staple because it was not completely sealed, then they closed the abdomen and removed remnants of the ostomy from the colostomy opening.

The first surgery wrapped up around 12:45PM. Scrub tech Ana Maria asked if she could show me around the department. It was a great relief as there were no other surgeries scheduled until 2PM (I should have actually used this time for lunch, but I got too excited). She told me about her occupation as a contract technician and taught me about all the protocols, procedures, and many many instruments used during and in preparation for different surgeries. We took a quick break for some water, then I helped her prep for another rectal case. The patient came in just on time and was in a lot of pain. I really wished to help comfort him, but he only really understood Spanish. As they positioned him and his groin area was exposed, so was the most vile smell. Nurse Romal was a lifesaver and put toothpaste on our face masks.

Dr. Gupta led a group of residents in an EUA (exam under anesthesia) and perineal debridement. They reassured me that this case was not normal and was exceptionally bad. The patient had a necrotic rectal cancer as well as a crazy infection. I was asking myself what I was looking at; his anatomy was quite disfigured. Under his scrotum, were two openings (yes, two) with greenish-grey “stuff” coming out of them along with some blood and below that, a baseball-sized mass in his gluteal cleft. It was quite the sight. Dr. Gupta started just feeling around, and pieces of dead flesh just fell right off. The doctors were aware that it was impossible for them to extract all of the cancer, so they aimed to clear out as much of the infection as possible for the comfort of the patient. The procedure was much quicker and less precise than the previous operation. The doctors simply cranked up the Bovie to maximum power, cauterized everything, and extracted anything that was dead or infected. I was amazed by Dr. Gupta and the other residents and how they got down and dirty, literally. All the other staff were barely able to handle the smell, let alone having the cancer be a foot away from their face. When the doctors were finished, the two holes were opened to form one large hole and it was large enough to easily fit my fist in to. Urologist Dr. Blaschko then used a Cystoscope (small camera on a thin tube that is inserted into the urethra) to visualize the inside of the bladder. It was expected that the patient with such an extreme form of rectal cancer would show signs of bladder cancer; however, the cystoscope was nondiagnostic and “suspicious”.  They dressed him in a wet dressing and some mesh underwear before sending him to the ICU. Unfortunately, ICU beds were also all full, so he was sent to the PACU for close observation.

My terrible ankles were dying by 4:30PM, so I thanked all the staff for their kindness throughout the day as they left for the PACU and excused myself. Ana Maria and I further discussed how crazy the last surgery was and she shared some of her other extreme cases, as we got ready to leave together. She was so very kind and even thanked me for letting her show me around, when she was the true lifesaver. She also told me to tell all of you that if you want someone to show you around, just ask for Ana Maria!

As I stepped out of the hospital, I noticed that the sun was setting and the sky was about the same shade as when I arrived in the morning. I realized that most of the doctors inside probably missed all of the daylight. Their energy and resilience are incredible. I was just standing and I was exhausted. I am glad how everything went on my first day and I can’t wait for what else I will experience this next year!