December 2008

By Lucy Ogbu, OREXer ’08-09

I had an exciting time on my third day in the O.R. and I cannot wait to share it with you all!

After my arrival, I was immediately joined by Dr. Derek Williams (Dr.W.), a resident from Albany Medical College applying for transfer into Highland’s program. We struck up an interesting conversation and he brought up a new legislation that is in the process of being passed from the Institute of Medicine that seeks to reduce the number of hours residents were allowed to work consecutively without sleep to around 16 hours maximum as well as reducing the maximum 80 hour work week to 60 hours. He elaborated on some of the implications that this might have on residents who are required to complete a certain number of cases, as well as it potentially resulting in removal of floor work and lengthening residency period for some specialties.It was a rather interesting talk as it brought a resident’s perspective into a topic that I have been hearing a lot about lately.

I finally met Dr. Harken (yay!) and I was very fascinated by his very detailed and interesting lecture on the vast risks of acidosis in patients and the importance of maintaining the body’s pH levels at their standard levels. I would love to go into details here but for the sake of brevity I would refrain but I would love to further elaborate on the lecture if anyone is especially interested.

I followed Dr. Gonzalez (Dr.G.) to the O.R. as he had some cases lined up for the morning. The first surgery was a skin graft procedure. Dr. G. and Dr. W were going to be performing the surgery. The patient was a 53 year old man that had major infections that had resulted from a past ileostomy with mucous fistula. I inquired from Dr.W what an illeostomy and mucous fistula (abnormal sort of tunnel connecting the rectum to the exterior part of the body) consisted of. He informed me that an illeostomy involves the small intestine being attached to directly to the abdominal wall thus bypassing the large intestine—making an artificial opening on the stomach with the illeostomy bag attached to it for waste discharge. The patient was at a high risk of infection and the skin covering his stomach was left open for two months because he was undergoing many operations and the doctors had decided to leave his wound unclosed. When his stomach was exposed, it was merely just pink flesh with no exterior skin covering. The entire round region of his stomach area was bare and exposed with no membrane over it. Imagine the inside of a watermelon after it has been cut in half and you might get a mental image of what his wound site looked like. Dr. G. causally whispered to me that I should investigate the effect of nutrition on wound healing and infections. According to him the patient’s poor nutritional diet following his surgeries exacerbated his wound and inhibited healing and increased his infection risks. Thus we had to wear the yellow protective gown before entering the surgery area.

The main purpose of the day’s surgery was to remove skin from his thigh (a very elastic part of the body) and use it to cover up the exposed wound on his stomach. They measured the different sections of the stomach wound in order to determine the amount of skin needed to cover each area. Then they injected the thigh with Lidocaine with epinephrine in order to reduce blood loss while providing greater tissue turgor to facilitate graft harvest. Dr. G. then used a dermatome—a surgical tool used to remove the skin—to literally peel the skin off the thigh. A dermatome looks like a huge electric shaver only its sharp edges are modified to be adjusted to facilitate the removal of the graft in such a delicate manner that no interior muscles or tissue is damaged—just the skin is cleanly removed. I was amazed at the whole procedure because it looked like a lot of effort is expended in such a skillful and delicate manner as the skin is removed and the region is being simultaneously stretched while the dermatome is working. The removed skin layer was then put on a mesher which is used to expand the epidermal layer provide coverage of a greater surface area at the recipient site. About four different skin grafts were removed from both of his thighs in order to completely cover this stomach. Dermabond was now applied all over his bare thigh region now white and free of any kind of covering. Dermabond is a liquid skin adhesive applied on wounds that form a microbial shield aiding in healing and is used in place of stitches.The skin grafts were then sewed onto the stomach completely covering the previously exposed region. It was a really nice and delicate surgery to watch.

As I was looking at the surgery schedule board to find which surgery to go into next, I ran into Dr.W. and we proceeded to discuss the previous surgery and my interests in surgery in general. I am not sure how it came up, but a discussion on the process of scrubbing emerged and to my own delight and absolute joy, he took me to the sink where the surgeons scrub in and actually step-by-step showed me how to scrub in. It was amazing and although I was a very slow learner and at times bumped my elbow or finger against a surface after already washing it, I finally did it correctly and to my amazement, he actually told me that I could “scrub in” for the next surgery! I thought I had died and gone to heaven J. The whole process is so meticulous and painstaking in the efforts to achieve as disinfected and sterile of a state as possible. I would love to describe the whole thing in detail at perhaps a later time if anyone so desires to hear more about it.

It would seem like my day could not get any more exciting but I was about to be proven wrong. The next surgery was a perineal debridement of a 54 year old patient with advanced rectal cancer. He had a massive non-healing wound in his perineal region (the area between the rectum/anus and the scrotum) due to his rectal cancer. Additionally, he had Fournier’s Gangrene—a severe infection usually affecting male genitalia and it causes necrosis— premature cell death and at times decay. Since he had let his rectal cancer go untreated for a very long time as he was self-medicating on opiates such as cocaine, his infection had spread throughout his entire perineum. It was the “rawest” looking wound I have ever seen—a huge gash of infected area, dripping with mucous, pus and blood—and tinged with a slight shade of green! The purpose of the surgery was to perform a debridement—the removal of loose, contaminated and necrotic tissues and debris on the wound—in an effort to hopefully optimize wound healing and decreased infection rate. According to Dr. Wan (Dr.W), the lead surgeon for the procedure, the patient’s rectal walls have been completely eroded; causing an abscess and bacterial proliferation and it had gone untreated for a long time. As the blood was dripping into a bucket underneath the surgical bed, I watched in utter fascination as the doctors cut, electro-cautherized and tried to clean out this very damaged region. They also removed the skin off his scrotum as it too was necrotized.

At this point, Dr. Sadjati (Dr.S.), the attending physician entered the room and he proceeded to join the doctors. At one point during the surgery, Dr. S exclaimed that he “could feel his cancer everywhere.” I then timidly asked “what does cancer feel like?” He laughed and said “Do you want to feel it?” My eyes nearly bulged out of my head as I furiously nodded “yes yes!” He asked if I scrubbed in and I proudly said yes, and then he told me to put on two gloves. I did as I was instructed, in the mean time my heart rate has sped up as I approached the operating table. He then told me to insert my hand in a hole that looked to be just around the region just above his rectum and to move my hand “7 o’clock.” I inserted my hand down there and I felt what I could only describe as little round bumps, all clustered together. They were semi-hard and bumpy, like soft beads spread everywhere. At this point, as my hand is inside of him gently probing around, I feel like I am in a fantasy, a dream-like state of some sort, where I am actually directly participating in a real surgical procedure! It was definitely one of those defining moments for me and although it may seem trivial or minor, to me it was probably the coolest thing that I had ever experienced to date. Dr. S. looked me and seeing the look on my face, he said, “If this small act gives you so much pleasure, maybe you are cut out to be a physician after all.” I understand that the sheer act of feeling a guy’s rectal cancer should not induce such a state of elation for me, but the simple fact was that it did and it is not a moment that I will soon forget. More than anything else, I want to be a physician, and through my experience with OREX, I am getting a deeper insight as to what that really entails. And the more surgeries I see, the more I am reaffirmed in my belief that this is exactly what I want to do in life: To make a difference in people’s life by working towards improving their quality of life through medicine. I wish you all a wonderful holiday season.