First OREX Day — October 2008
By Joo Yeon Jenny Ryu, OREXer ’08-09
The day started at 5:15AM—one of the earliest I’ve voluntarily woken up, and it was pitch black! I was certainly lucky that I have a flashlight-keychain on my keys, and that Starbucks opens at 5:30 (yay! Breakfast!). I successfully got to the lecture room—but was unsuccessful at getting the door open by ringing the doorbell. But there are instructions on the side which directed me to go the to the bridge on the left. Through that way, I met Dr. Harken and was able to get the lecture room (really early).
I didn’t get the first-OREX email before I went, so I kind of sat meekly as the residents and med students piled in. I was able to talk to the resident beside me about why I was here, but everyone else was in the dark. And the lecture was AWESOME! It was fun, enlightening, and completely worth waking up at 5:15am. If this is what you learn in med school, I really REALLY can’t wait to go! Dr. Harken presented a case about a man that came in yesterday: a 20-year-old male with an ice pick in his heart. (so it wobbled like a weird cardiogram). We went through differential diagnoses with just his diastolic/systolic pressure, heart rate, and respiration rate: what you should rule out, what you shouldn’t, how you can test, what umbrella treatment to give—it was very much like lab or detective work. Did you know that adding 25ccs of liquid into a 20-or-so-year-old’s pericardium won’t do anything to your ability to pump blood? And another 25, another 25? But by the fourth 25ccs, the blood pressure will drop, but the heart rate will increase to make up for it, so that the resulting cardiac output is the same. However, if that liquid was put in slowly over the course of months/years, a liter worth of liquid in the pericardium won’t change the heart’s ability pump blood. The human body is amazing!
After lecture, I got directed to Dr. Kim who paired with Brynenn, but as with Robert, she showed me the women’s dressing room and dropped me off with Dr. Kim. I wasn’t too sure what was supposed to happen, but I stayed with Dr. Kim for his first surgery. Luckily, I met a couple med students (Emily and Mike) who were also observing that day. I just followed them around. As Robert, had already mentioned, you need to take off T shirt and pants and dress in OR scrubs, but you must have your badge with you at all times. Dr. Harken let me put my valuables in the closet in his office which was good because all your belongings will be out in the open in the locker rooms.
The first surgery I watched was the removal of the left superior parathyroid (paratyroidectomy). The gentleman (Mr. V) tested for high calcium levels which indicated hyperparathyroidism because parathyroid hormone is secreted in excess causing release of calcium from reserves in the bone. When it gets really bad, it can case calcium stones in the kidneys, but this did not yet happen with Mr. R. In ultrasound, the parathyroid was found to be nodular, so it was suspected to be an adenoma. Mr. R talked about Nascar while he was being put under by the anesthesiologist. I watched Dr. Kim and Dr. Liu carefully cut through to expose the parathyroid. I always wondered how those surgeries on TV never had much blood pooling anywhere; now I know why. Instead of cutting with, say, a scalpel, surgeons use a really cool device that burns the tissue—but only when it contacts metal! It’s brilliant. I noticed that when they got to what I could tell were blood vessels, they both each clamped the blood vessel, burned through, and tied it up. I later found out that these were blood vessels that would lead to the part that they would cut out. So they did not reconnect these cut blood vessels later on. Since the parathyroid is in the dorsal side of the throat, I didn’t really get a good look at it when it was still inside Mr. R. But Dr. Liu said that only you can only feel the parathyroid if it has an adenoma because usually there is enough fat that you can’t feel it. Of course, since I wasn’t scrubbed in, I didn’t get to feel it. But Dr. Kim and Dr. Liu confirmed that they felt a large lump on the parathyroid and proceeded to cut it out. When it was taken out, I got to see it properly. It was a dark red lump about the size of a mini tootsie roll (that had small lumps). It was sent to pathology to confirm, then the other parathyroid was checked. Dr. Liu talked about the strange difference in the opinion of UC vs. other areas. UCs tend to take both thyroids out if they both have adenomas. Other areas tend to leave them in. Then it was time to patch up Mr. R. On the right side (where they did not take out the parathyroid), Dr. Liu and Dr. Kim placed “surgi-silk.” I asked the scrub nurse Bill (By the way, the people who are in charge of all the equipment are called ‘scrub nurses’) later what it did, and he told me that ‘surgi-silk’ helps in even clotting to aid healing. The UCSF med students, Emily and Mike, who were watching with me were kind enough to explain a lot of these tings to me. Mike also pointed out that when closing the incision, the stitching is all done subcutaneously and then pulled tightly closed so that none of the stitches are exposed on the skin! It minimizes scarring and heals better. And the stitching is made of material that melts away, so it doesn’t need to be removed. But during this process, the patient started to wake up! He started to move while his neck was still wide open! Oh no! Dr. Kim and Dr. James (who was the assisting surgeon) had to bodily hold Mr. R down until the anesthesiologist quickly increased the meds to bring him back under. It was rather scary.
After the surgery, I helped move Mr. R to a gurney. It was hilarious because all six females tried to heave this rather large gentleman on the gurney while the two males in the room stood and watched. Of course fun jesting followed afterward—it was really fun.
Then Dr. Kim suggested Emily to go the next door to observe the tracheotomy, so I followed her. I had taken off my face mask while we transported Mr. R to the floor, and I mistakenly forgot to put another one on when I tried to enter the OR room. Bad mistake! I got yelled at by Nurse Lee (deservedly). I actually went into the OR room a little before Emily, and had to explain who I was and why I was there. They key thing seems to be name an actual employee (not a med student), I was ‘off the hook’ once I told her that Dr. Kim knew I was here.
Soon Emily joined me, and we watched Dr. McDonald and Tony (I didn’t catch his last name) perform the tracheotomy on Mr. F (who only speaks Spanish. I really need to learn Spanish.). What is a tracheotomy? Do you remember that anti-smoking commercial long ago that featured a woman who smoked so long that she needed a hold in her throat to breathe (and smoke)? That is a tracheotomy. Dr. McDonald cut through to the trachea and then secured a plastic tube to the neck with stitches. I couldn’t get a good look, so I got a stool from the previous OR room that had stools. So, all you OREXers who are “not-tall” like me, there are small transportable platforms that you can stack up to get a better view. Be sure to get one. (Nurse Lee laughed when I showed up with one. I think she thought I was amusing for wanting a better view of something she probably sees a lot.) Mr. F had smoked a lot, so he developed a tumor on his larynx which extended to the base of his tongue which was starting to impede his breathing. Then Dr. McDonald had to get a lot of biopsy samples. At this point, he inserted a very long trach tube to get a better look at Mr. F’s throat. Dr. McDonald was really nice and let us one-by-one see down the trach tube to see the stomach-esophagus junction (it filled up with fluid and puckered), the trachea, and the larynx (normal part and tumor part). The tumor was a white globular thing sitting atop the larynx. The larynx looked exactly like the pictures I remember from bio 1a. Then Dr. McDonald proceeded to get biopsy samples, and it was rather sad to see because poor Mr. F was chocking and coughing a lot from blood pooling. I hope he gets better soon. The biopsy samples were small red balls of tissue which were deposited in separate jars filled with what I assume is some kind of preservative.
Lastly, Dr. Kim was doing another parathyroidectomy (this one was smaller. Scrub Nurse Bill measured it as 16×9 mm^2 to confirm when I commented on its smaller size). Oh yes, Bill also had to remind me to stay back 18 inches from the ‘blue area.’ I’m sure I didn’t touch anything, but I was leaning in a lot to get a better look. So 18 inches away is the official distance. Dr. Kim recommended that I go next door to see something different: they were going to put a tube into a patient’s stomach by putting a camera down his throat. I got to see the inside of the stomach! The stomach is really weird: it has a lot of vein-like motifs that run through the inside surface. It wasn’t what I expected. This particular patient had a very sharp turn in his stomach. I watched from the inside as the assisting surgeon put a tube in and secured it. And then, I had to go because I had a class at 3pm that I thought I shouldn’t miss. But all in all, it was unbelievably amazing!