Monthly Archives: May 2012
By Jennifer Devereaux, OREXer ’11-12
First Flora and I went to Grand Rounds, Dr. Krosin talked about Orthopedic Damage Control. Ortho doctors use metal plates, pins, and screws to support bones that have been broken. He also mentioned that multiple surgeries are sometimes needed to repair a broken pelvis for example. So ortho will recreate the pelvic bone structure, then another set of surgeons will repair the vasculature but then ortho will have to modify their work and destroy all the vasculature work and this could go on several times. I took away from Dr. Krosin’s presentation that if the surgery can be organised then the patient will be facing less risk.
My first surgery was the repair of a nose following the removal of a large squamous cell carcinoma. The student did most of the repair and used incisions called “dog ear incisions.” The look of the dog ear incision was much like a spiral to create a more spreadable and stretchable flap of skin. The doctor stretched the skin over the nickel size area and stitched up the work. The surgery was very short.
My second surgery was wonderful and I am glad I saw it. Dr. Harken was the surgeon and he had a student with him as well. The patient needed to have his right femoral epicondyle plus about 2 inches of proximal bone amputated. The patient’s lower leg was already amputated. The patient came in with a bandage around his existing wound, and the wound was weeping blood. A pneumatic tourniquet was applied around the patient’s thigh, but despite the tourniquet the patient’s tissue weeped blood throughout the whole surgery. The doctors cut away tissue using cauterization. Then they cut off the portion of bone to be removed using a wire saw. Then the remaining tissue was folded over the bony stump and sutured. The student surgeon did a great job. For such a dramatic surgery the whole undertaking took just a few hours.
By Jimmy Lam, OREXer ’11-12
Alarm went off at 6:30am and by 6:38am I was already out the door eager to embark on my seventh day at OREX. As usual, I arrived at the A2 wing just a few minutes early. Unusual today, Dr. Harken was not here yet. Medical students and medical residents begin to trickle in and the room began to fill with medical conversations about patients and new surgical techniques. We waited for Dr. Harken and to my dismay, he was absent today. I guess even doctor’s need a break here and there and can get sick. Despite Dr. Harken’s absence, I did happen to learn something new. I learned that the medical residences are quite nice to each other and try to help one another finish their rounds if they happen to finish their’s early. How nice of them I thought. As I was bummed out that we had no lecture today, I was quickly picked up by realization that would get the pleasure of observing surgery an extra hour. How can you be down from that?
Being more experienced now at OREX encounters, I know better now to grab breakfast first before entering the operating room. As I was checking out the scrub card, I had the pleasure of meeting Mark, one of the new administrative assistants. He was very nice and smiley and liked to crack a lot of jokes. My acquaintance with Mark reminded me how much fun and exciting it can be to meet new people. Within minutes I was all scrubbed down and geared up to enter the operating room. My highlight surgery of the day goes to an endoscopic sinus surgery with Dr. McDonald. The patient has developed some over grown sinus in his nose that now occluding his airway and made it very difficult to breathe. After talking to Dr. McDonald, I unraveled that the doctors tried to treat his sinuses with steroids first to stunt and reduce the sinus growth, however that did not work which prompted the necessity for surgery today. I was in for a treat today because the nasal camera feed live video to a screen overhead that would allow me to see every step done in this procedure today. Super awesome!
Light projected out of the ends of some fiber optic cable endoscopic camera permitted us to see into the nasal cavity. Fine and slender instruments were used to probe around the nasal cavity. Looking at the video feed, I would never have guessed I was looking through the nasal cavity as it looked very foreign. This ignorance I feel is naturally common as our daily encounters with the nose consist primarily on the outside (well at least for me). As I watch Dr. McDonald navigate through the nasal airway, I am astound at how dexterous he is. One hand held a suction tube and the other the fiber optic video instrument, all the while managing to probe about the nasal cavity which was a very small opening. It is incredible how these surgeons are highly specialized. I can’t even know what tissue is supposed to be there or not. I guess I need trained eyes of a nasal surgeon to distinguish that. As Dr. McDonald ventures deeper and deeper into nasal cavity, he maneuvers both instruments concertedly, being very gentle not to cause damage to the surrounding tissue. He uses one of the suction instruments and begins to suck what appears to be mucus and tissues that are preventing him from entering deeper into the nasal cavity. An hour of this goes by, slowly inching through the nasal cavity, cleaning and sucking what appeared to be stray tissue and drainage. I was beginning to think that this surgery was like a chimney cleaning just a very fine and miniature version with much more at stake.
Eventually Dr. McDonald reached deeper into the nasal cavity and there hung an abnormally large nasal turbinate. The best way to describe how the nasal turbinate looks like is to imagine an oversized uvula that was large at the base. Now the nasal cavity itself was made of very smooth tissue while the nasal turbinate looked quite tumorous from the growth. Dr. McDonald then switched to a different instrument that had, I thought, little chompers at the tip. I wish had asked what it was called but I am going to refer to it as the chomper. Dr. McDonald inserted the chomper into the cavity and directed it at the base of the nasal turbinate. Now describing it as nibble is most likely an understatement because man, can this make quick of the nasal turbinate. Sure enough, after a few minutes that nasal turbinate was gone and was replaced with a large pool of blood. In came the suction tube again to drain out the blood. The issue was more blood came out and still more came out. Dr. McDonald then inserted long strips of cotton into the nasal cavity in hopes of, for lack of better descriptive wording, plugging the nose bleed. I thought to myself, how is that going to work? There is so much blood coming out there is no way that is going to work! And indeed it wouldn’t work. But Dr. McDonald didn’t tell me that these cotton strips were soaked with epinephrine. Now I remembered from my course work at Cal that cocaine can be and is used as a topical vasoconstrictor to prevent bleeding. I am certain that epinephrine must work in a similar fashion. But in any case, it worked beautifully. You learn something everyday.
Once the cotton strips where removed, and we all got a better view of the nasal cavity, it was hard to believe how much different the nasal cavity looked. The nasal cavity appeared three times more spacious. All the blood was gone. It was as if a plumber came in and fixed a running clogged sink and now I can see the bottom again. This is just going great I thought. The patient is definitely going to enjoy being able to breathe through his nose again. As Dr. McDonald was wrapping up the surgery, I asked if any nasal function was compromised due to the removal of the nasal turbinate or just from the procedure alone. Luckily no glands or major tissue was removed so there would be no loss of functionality at all. Now I did not mention that throughout the surgery, Dr. McDonald was addressing both nasal cavities and performing the nasal turbinate removal in both nasal cavities of the nose; switching back and forth between the two nasal cavities. I explained it as such because it didn’t occur to me that he was doing that until I saw the other nasal turbinate. I thought it would be interesting to have you, the reader, experience that jump in realization as I did that day. I am certain that Dr. McDonald has been specializing in this for a very long time because he executed the surgery magnificently. I felt like I was watching a well-orchestrated performance and the punch line was, “and then there were two.”
In the end I had, as expected, an amazing time at OREX. Other surgeries I had the pleasure of seeing was tibula and fibula ankle clamping with a special wire technique, an anal fistula, and a broken ankle hardware removal. As usual, I am always disheartened at how much space I get to describe my amazing experiences here at OREX. Not to mention how I didn’t get to stay till my usual 7pm because all the surgeries were done. There is never enough time in the OR. However, I can always manage time to give a shout out to Mark who is super friendly, Dr. McDonald for a job expertly done, Dr. Farrell who has been very helpful, and easily one of my most favorite surgeons, Dr. Krosin, who I always wonder how he can be so rockin’ yet down to earth. These surgeons, two words: top notch. It has only been 24 hours since I left the OR and already am I excited for my next OREX encounter. Until next time, Jimmy out.
By Elliot Chan, OREXer ’11-12
I arrived this morning and went to OA2, to find it completely empty. This is no longer a surprise to me, as for some reason I never seem to catch an OREX day with a normal morning meeting. I knew there was the potential for another trauma meeting, so I scoped out the Classroom and it did look like they were setting something up. After a little delay, as the projector was stuck in traffic, a trauma meeting was held to take note of an interesting case from earlier in the week. Patient was brought into the ED for severe dehyradation and disorientation. The presentation was very very interesting, as it detailed the thought process of an Emergent physician versus a General physician. The patient had to be treated ASAP for her deficiencies, or she would die – she was given a saline IV with dextrose to replenish her immediately, and many lab tests were ordered. This was a very interesting case that they used to call attention to the differences in how medicine works for the ED. As a general physician, you have time to order labs, analyze results, and call your patient a few days later; in ED, you have to treat immediately for the emergent situation, then get pieces of the puzzle back from labs as you are treating the patient. It’s much harder to get the big picture in ED, where you have to keep your patient alive as you learn what’s wrong with them. So they ordered all these tests, and she seemed indicative of sepsis. But, they could not find a source of the sepsis. Then, one of the doctors showed how he came up with the correct diagnosis, showing all the flowcharts that were going through his mind and why he was able to eliminate certain diseases. Very very interesting stuff.
The meeting did run late though, so I did not get into the OR until much after 9. However, the surgery I ended up observing was also running late, and did not start until close to 11. Dr. Victorino was overseeing a right lobectomy, with Dr. Lee operating. The prep required for the procedure was lengthy as the patient was pretty overweight, and hard to maneuver. The patient was a male of about 35 years of age, and had been a smoker for about 20 years. He had developed a lung cancer in his right upper lobe of his lung, and was to have the whole lobe removed. Prep also took a while because the patient would have to have 2 tubes put in for anesthiology – one for his left lung, which would remain untouched, and one for his right lung, which was actually going to be deflated during the whole operation. The surgery was open, and I was excited because I had not seen an open procedure in some time. Dr. Lee made the incision about 12 inches under his armpit, and crossed about 12 inches wide so he could have full access to the chest cavity. After some cauterizing, they had entered the fascia and were looking at ribs. Using the metal spacer, they dissected between the 5th and 6th rib and spaced an opening – before I knew it, I was looking into the chest cavity of the patient! This might have been the second coolest thing I’ve seen in OREX yet (first being the craniotomy).
Dr. Lee had a medical student also observing named Simon, and Dr. Victorino took some time quizzing him on anatomy. As the patient was a heavy smoker, you could already see many black discolorations on the lungs. According to Simon also, the lung felt quite dense and hard already, which is also indicative of years of smoking. Using imaging they had previously taken, they located the cancer on the lung, which did not look as I had expected. They identified a small, circular, puckered area on the upper lobe, almost looking like a cigarette burn. It was distinct, but not as much as I had thought. Removing the lobe required a lot of work though, as all bronchioles and blood vessels supplying the upper lobe had to be cut off, and carefully. Dr. Lee went very methodically through the upper lobe, tying off any vessels going to the lobe, before staple-cutting them. He had to make sure he was not accidentally snipping another artery, which would introduce a lot of bleeding. Once he had accomplished this, they just lifted the lobe right out of the lung! To test to make sure they had no leaks, they asked the anesthiologist to reinflate the right lung. At this point, I had forgotten the lung was deflated, but as soon as air was put into the lung you could see how big it normally is. Just like a balloon, the lung was reinflated and you could see it was holding air – no bronchioles were left untied.
The procedure was done, but closing took almost as long. The mediastinum was cleaned and irrigated heavily, before having to reclose the ribs and suture them together tightly. Closing of the ribs, fascia, and dermis took a very long time even with Dr. Lee and Dr. Victorino working both sides. Once the dermis was sutured (they let the medical student do this one) they stapled the incision and wrapped the patient up. This was a really great procedure, albeit a long one. I was only able to watch this surgery as it was 2pm by the time we left the OR, and I could not get out of work today. But it was a great one!
By Flora Chang, OREXer ’11-12
On my OREX day, there was no morning meeting at 7AM. I’m not sure if this is true of every Wednesday, but apparently the meeting was moved to noon?
The first procedure I witnessed was a closed reduction of a nasal fracture. The patient was a young male who appeared to be in his twenties. I later learned from one of the visiting medical students that the patient suffered his injury as a result of being punched by his brother.
Not surprisingly, most nasal fractures result from fist fights, impact from contact sports, or falls. The nose is actually the third most commonly broken bone in the body and the most common broken facial bone. Nasal fractures can affect both bone and cartilage, and they may affect breathing. A septal hematoma, which is essentially a collection of blood, can sometimes form on the nasal septum.
Dr. Park was the main surgeon for this procedure; Dr. Williams and Dr. Isom assisted. The doctors used nasal speculums, nasal pledgets, forceps and another tool called the elevator. They basically realigned the nose, packed the inside with gauze and put a cast over the patient’s nose.
Next, I watched an umbilical hernia repair. Dr. David Boudrealt was the surgeon. Dr. Miller was the anesthesiologist, and a young lady named Lisa was on her anesthesia rotation. She was responsible for manning the entire anesthesia aspect of the surgery.
This patient was a middle-aged Hispanic woman. Umbilical hernias often occur in infants but can also occur in adults. They can occur in patients who have health issues that create pressure in the belly, such as being overweight, pregnant, or having too much fluid in the belly. Other health problems can also cause umbilical hernias, such as chronic cough, constipation, or problems urinating as a result of an oversized prostate gland.
After the patient was intubated and anesthetized, the surgery team began by cleaning the patient’s belly button area from in to out. Dr. Boudrealt then injected a local anesthetic and drew the incision line with a black marker. He drew a short, crescent shaped line about an inch below the patient’s navel. Next, he cut along the line with the scalpel and pushed any bulging tissue back inside the belly. Finally, Dr. Boudrealt closed the wound transversely with stitches.
The final procedure I watched was a colonoscopy with a possible biopsy. Most colonoscopies are actually done in endoscopy rooms at Highland. Every once in a while, however, these procedures are performed in the OR. This particular procedure was done in the OR because the patient was difficult to anesthetize. She was an elderly woman with perhaps some mental issues.
The physician inserted the colonoscope through the rectum and searched through the patient’s colon. The view of the large intestine on the monitor reminded me of an endoscopy or a laproscopic surgery. As he moved the scope around the intestine, he pointed some hemorrhoids and some polyps, a few of which he deemed as “definitely cancerous.”
By Hannah Kang, OREXer ’11-12
Today Dr. Harken gave a lecture about how standards dictate the quality of care that is given. He questioned the interns regarding whether hospitals should lower their standards in order to treat more patients, or maintain their high standard, but consequently only treat a smaller number of patients. This lecture was thought provoking, and reminded me of the complexity in overcoming health disparities that are present, today.
After the lecture I observed a left tibia sqeuestrectomy operation conducted by Dr. Krosin, in Room #2. I learned that the patient was suffering from an gram + bacterial infection in his tibia. Due to the condition of the infection, Dr. Krosin told me that they had to remove the part of his tibia in hopes to help overcome the patient’s infection. During the procedure, the assisting surgeon’s glove ripped, so there was an immediate call for hepatitis and HIV tests to be delivered. Dr. Krosin encouraged the assisting surgeon to sit out for the remainder of the surgery.
Additionally I was able to observe a surgery conducted on a college student. This appeared to be a mystery case, as the college student had no idea how he got injured—his skull was dented, and his dens was broken. As a result, the surgeon drilled a circular region out of the patients skull, hammered the dented region to be more rotund, and then screwed it back onto the patient’s skull. Next, the surgeon conducted a few x-rays to get shots of the broken dens on the patient’s spinal cord. Once this was completed, they inserted screws to connect the dens back onto the second cervical vertebra.
Today’s experience reminded me of the things I had learned in Microbiology, and Anatomy. I was amazed to see how drastically a bone can wear down due to a gram + bacterial infection, and I was fascinated to see how drills can replace such a fragile, and crucial, piece of the spinal cord. I’m truly thankful for Dr. Krosin and the nursing staff that allowed me to gain such a memorable experience in the OR, today.
By Priscilla Huang, OREXer ’11-12
I’m really glad I went in to the OR today. This was my first time to have an opportunity to see an ophthalmology surgery, which I have been interested in for a while. The attending was Dr. Gill and the resident was Dr. Wilkes. The operation they performed was on a patient with thyroid eye disease, Grave’s disease. People with Grave’s disease have eyes that are bulged out, mostly due to the muscles behind the eyes swelling. This patient’s swelling was compressing her optic nerve, resulting in impaired vision. The operation performed was a bilateral orbital decompression, where they made incisions on the floor of the orbital, and chipped away pieces of the bone and removed some fat tissue. All of this helped create more room for the eye to expand, and improve vision. Upon the end of the surgery, they also inserted contact lenses into the patient’s eyes to help with the pain due to corneal abrasion from the surgery. Dr. Gill and Dr. Wilkes were both really nice, along with the intern too. They answered a lot of my questions and walked me through a lot of the procedure. Dr. Gill even taught me how to tie a square knot. After the surgery was done, the intern explained to me the different types of sutures and blades. I went with them to talk to the patient post-op, and it was great giving good news to a patient. She was able to see with both eyes, and move her eyes bilaterally and up and down.
The second surgery that I saw was performed by Dr. Harken and Dr. Wood (resident). The patient was diagnosed with renal failure, and had to have an atrial venous fistula put in to make dialysis possible. Upon getting into to the left arm, the veins were so weak and small that the doctors decided that they needed to graft it. Sewing the graft onto the veins and connecting it ot the artery was the most difficult part of the surgery. The needle they used to sew on the graft was incredibly tiny, and Dr. Wood had to be really careful not to tear any of the tissue. He accomplished this by pushing the needle straight through the wall of the vein perpendicularly, rather than twisting the needle up. After they secured the graft, which cost around $1000 for a little tiny piece of tubing, they created a path for the graft to go with the two preexisting incisions to the arm that was already made. This was pretty gross, as they just forced the object in subcutaneously.
By Edna Miao, OREXer ’11-12
I was excited to see what I was going to learn today from the OR! I met Dr. Palmar after their morning session. Dr. Palmar is a third year resident with a sarcastically funny sense of humor. The first case was delayed so while we were waiting in the room I got to hear a conversation Dr. Palmar had with a first year resident student. He was correcting her and telling her that she didn’t have to give the impression that she knew everything – it was okay to say that you didn’t know the answer. I thought this was an interesting conversation. When medical students do go to residency, there is a culture in which new residents learn from the older ones, who show them the ropes of the hospital. It was interesting to see this culture played out before me and gave me a picture of what being a new resident might be like.
The first surgery I observed was a gynecological case. A nurse, named Sheena, was very nice and allowed me to observe this surgery. Some vendors were in the room as well because they were selling the physician a new product. I didn’t even know that such job opportunities were possible! It would be cool to have a job to sell products and observe surgeries at the same time! The patient was a 39 year old woman who had fibroids, located in her uterus, that were causing her pain. Dr. Lennox cut through the woman’s stomach and widened this cut using instruments to widen the cut. I was somewhat aghast to see two physicians pulling on a woman’s stomach to widen the opening. I had always imagined surgery to be delicate and refined, and this … was definitely not delicate! Dr. Lennox located a ball of tissue and cut the strands of tissue that suspended the ball of tissue in the cavity. He proceeded with this surgery with great precision and dexterity. I could see just how years of experience has made him an excellent and efficient surgeon. He would alternate between excising and sewing until the ball of tissue was finally taken out completely. It had the shape of a sphere and looked like the size of a softball. I thought: “Wow, that’s a huge fibroid!”
But when I looked at the patient’s charts and read abdominal hysterectomy, I realize that the physician had taken out not the fibroid but the woman’s uterus! I should definitely read the patient’s history first for each case – lesson learned! I couldn’t believe that this was what a uterus actually looked like! This was so different compared to what I saw in the anatomy books. After getting over my initial shock, I went to another operating room.
Next, I saw two portacath placement surgeries. A 58 yo male who was diagnosed with metastatic stage IV nonsmall lung cancer had to have a portacath placed in his body to allow easy injection of chemotherapy drugs. The portacath allows for another way of injecting chemotherapy drugs to reduce irritation and to reduce chance of clogging in veins. This patient has a very poor prognosis and will probably not live for more than a year, according to Dr. Palmar. This statement really made me pause. I wonder what it would be like to be this man – to know that he will not survive for more than a year and that his life will soon come to an end. I cannot even fathom what he must be going through. The next case was 57 yo woman who appeared healthy when I first met her. However, I later learn that she has an adenoma-carcinoma in her colon and will also need a portacath to inject chemo drugs. These cases made me contemplate the fragility of life and the life-giving power of medicine. You hear people say all the time that they want to be doctors to save lives, but it is not until you see patients who are battling and struggling to simply live that you see the depth of this cliche statement. It is truly a privilege to have the gift of health and to pursue a career in medicine.
The last case that I got to see was a total laproscopic hysterectomy. This patient wanted to have permanent sterilization. What was really cool is that the doctor used a camera to see the women’s reproductive organs. He located the fallopian tubes, ovaries, and uterus using this camera. Again, I was just so amazed to see what these reproductive organs actually looked like compared to the textbook images!
Today was a great experience as I got to shift from one OR to another and explore all the different types of surgeries medicine had to offer. It was awesome!
By Jimmy Dinh, OREXer ’11-12
I arrived to Highland Hospital around 8:30am after dealing with a bunch of traffic on the freeway. After I signed in, I went upstairs to the 7th floor to look for Dr. Krosin, the orthopedic surgeon. I had trouble finding which one was the orthopedic clinic, so I had to ask around. I went through the doors of the orthopedic clinic, but Dr. Krosin was no where to be found! Luckily, there were sound residents there who helped me: Dr. Molina, Dr. Enriquez, Dr. Rodriquez, and Dr. Kelly. Dr. Molina helped me page Dr. Krosin. Dr. Krosin told me to meet him in the surgical floor.
I met up with Dr. Krosin and he is very friendly and nice! Dr. Krosin and I walked to O.R. 1 and he asked me about myself. He then explained to me the patient’s situation. The patient, initials D.I, is a 20 year old female, had a broken ankle. Dr. Krosin explained to me that D.I and her friends were slightly intoxicated and drove to Jack in the Box for food, but got into a car accident. She had a broken femur, which was surgically treated earlier in the morning. However, they did not see the broken ankle and now Dr. Krosin was going to repair it. The patient was already put under anesthesia. Dr. Krosin elevated the foot first and the nurse cleaned the entire food area. He then marked about a 4 inch line with his marker.
The surgery started at 9:43 a.m and he used a 15 blade to make the incision. A little blood gushed out. He made the incision and exposed the broken ankle within a minute! He then showed me the broken ankle with the white bones. He used various tools to keep the broken ankle exposed as he started to drill screws into the ankle. There had to be a lot of suction because there was a good amount of blood. Dr. Krosin then took x-rays of the ankle to make sure the screws were placed carefully. At the end, he used two screws to repair the broken ankle. He made sure they were tight and placed correctly by using a screw driver to tighten the screws. I asked Dr. Krosin about what kind of stitch material he was using and he was using absorbable stitches. He then used a staple like tool to completely close the wound. He finished at 10:03 a.m! Dr. Krosin is so fast! He finished in about 20 minutes!
We left the O.R and went up back to the orthopedic clinic. Dr. Krosin told the residents to invite me with them when they see patients. Dr. Kelly invited me to help him speak Spanish with a patient. He knew a bit of Spanish, but he wanted me to see what the primary care setting was like. He first explained to me what the patient’s x-rays meant. The patient was around 50 year old and is female. She has a history of bad arthritis and needed a complete joint replacement in her right knee. The materials that were used were metal and plastic. Dr. Kelly and I entered into the exam room and he explained to the patient that I am a volunteer. Dr. Kelly examined her and said she was doing great after 6 weeks. Dr. Kelly prescribed her vicodin and antibiotics. I helped translate a lot and it felt good to be able to help out.
Next, Dr. Enriquez invited me to come see a gun shot wound patient with her. The patient was a 28 year old male. Two days ago, the patient was shot in his upper right arm (near the should area) and the bullet went through superficially to his scapula. The bullet did not exit. Dr. Enriquez examined the wound and tried to see his arms’ range of motions. We then went out to examine his x-ray. Dr. Enriquez said sometimes they do not need to surgically remove the bullet, unless it is compromising other organs. Sometimes, they even come to the surface of the skin where they can easily remove the bullet. We came back and Dr. Enriquez prescribed him vicodin and a referral to see a physical therapist. She explained to the patient and me that the nerves and tissues around the bullet wound were still repairing and that’s why he was still experiencing a lot of pain.
Lastly, Dr. Rodriquez invited me to see a 55 year old male patient. The patient was approved a knee surgery, but needed his primary care physician’s ‘okay’ to proceed with the surgery. The patient explained to Dr. Rodriquez that he wanted a knew surgery to help him with knee problems, which was preventing him from a lot of physical activities. The patient likes to hike, jog, play sports, and other things. Dr. Rodriquez told him to take the tests and paper work to his primary care physician to sign, because without it, the anesthesiologist would be uncomfortable with putting the patient to sleep given him health concerns. I thanked the doctors for allowing to be exposed to the primary care setting, as it was very exciting for me because I want to become a primary care physician.
I went back up to the surgery floor, observed a masectomy due to breast cancer, laparoscopic uterine fibroid removal, hysterectomy, and a permecath (performed by Dr. Harkin, a medical student, and two residents). I left at 5 p.m.
By Jessica Kao, OREXer ’11-12
When I arrived in the morning at 7am, Dr. Harken and the residents weren’t there, and so there was no morning meeting. Although I wasn’t sure if there were still surgeries going on that day, I headed up to the fifth floor to check and saw on the board that there were still a couple surgeries, though there were much fewer cases than normal. The first surgery listed immediately caught my eye—I had always dreamed of watching a brain surgery, so I was very excited to see “Bicoronal Craniotomy with resection of brain mass” listed on the board.
I headed over to the OR, where the nurses were prepping all the instruments and tools. I was told that the surgery wouldn’t start until 8:30am, and was advised to make sure to eat breakfast and to put on one of the scrub jackets, since the surgery would likely last 12-13 hours. After the patient was brought in around 8:30am, the anesthesiologist, Physician Assistant named Larry, and nurses worked on intubating the patient. Because the patient had a smaller mouth and shorter neck, it took quite awhile for them to position her appropriately and to intubate her. After finishing the intubation, the anesthesiologist inserted the IV’s and then called for the attending, Dr. Moure, to come in for the surgery. The entire process of prepping the patient had taken awhile, so by the time the surgery officially began, it was already 10am. During that prep time, Larry was kind enough to answer many of my questions and to point out the MRI/CT scans of the brain tumor. The meningioma was a huge mass in the patient’s brain, which was why the surgery was going to take so many hours. The patient had been experiencing vision problems, and thus the purpose of resecting the mass was to prevent blindness. Larry also explained how anesthesiology had revolutionized the field of surgery by enabling surgeries to last more than the prior limit of 15 minutes, understandably due to the fact that patients could feel every bit of the surgery since they weren’t anesthetized. He stated that anesthesiologists are the “most important people in the hospital,” which I had never thought about before. Even considering the craniotomy that day, which would take 12-13 hours, that surgery wouldn’t even be fathomable without the anesthesiologist and his careful monitoring of the patient throughout the entire procedure.
After securing the patient’s head in place with clamps, Dr. Moure and Larry partially shaved the patient’s head, and one of the nurses scrubbed the shaved area in order to sterilize it. Two towels were draped around the designated area and stapled onto the skin. After the incision line was marked, a cover with a clear plastic area for the designated area on the head was draped over the patient. At this point, Dr. Moure was preparing to make the first incision when they realized that the Neptune suction device wasn’t working and that they would have to use the ventilator attached to the ceiling in the room. Dr. Moure was insistent on proceeding with the surgery only if the Neptune was functioning, since the suction from the ventilator wasn’t strong enough. They all scrambled to try to fix the Neptune, and Dr. Moure became more insistent that he didn’t want to proceed without strong enough suction. He wanted to cancel the procedure, but eventually began the surgery after Julie came in and firmly told him that the ventilator suction would be sufficient. The nurses later mentioned that the equipment dysfunctions that day—such as the malfunctioning suction device, a slightly faulty Raney clip applier, etc.—were because it was a complicated and demanding surgery that required many instruments.
After Dr. Moure made the incision along the marked line, Dr. Patel joined the surgery. They inserted Raney clips along both sides of the incision and pulled the scalp flap back to reveal the designated area (see image). They used an instrument to push away the dura, and then smeared bone wax (to control bleeding) on the skull. They then drilled holes and removed a rectangular sized piece of the skull, exposing the brain. They simultaneously used numerous surgical patties/strips to mitigate the bleeding. I learned from Jackson, one of the nurses, that the strips are specialized absorbent ones that are gentle enough to use in the brain. Since so many strips are utilized, it is imperative to keep count of how many are used, so that strips aren’t accidentally left in the incision—as a precaution, the strips are marked with X-ray detectable stripes. The surgeons then bent and placed metal rods to locate and designate the tumor, which was located in between the hemispheres. At this point, they were ready to proceed with getting rid of the brain mass, and Dr. Patel was kind enough to beckon me closer to show me all the different parts of the brain and surrounding areas that were now visible, including the eye sockets/balls, temporalis muscle, and left and right hemispheres of the brain. It was also breathtaking to see the exposed brain pulsating gently, as the surgeons prepared to start resecting the tumor mass.
Dr. Patel left for a meeting at that time, so the nurses assisted Dr. Moure in positioning the microscope equipment and his seat adjacent to the patient’s head, where he used the microscope to visualize the tumor. Primarily using Bovie bipolar forceps and the CUSA ultrasonic aspirator, Dr. Moure methodically got rid of the tumor bit by bit. It was amazing to watch him working via the video monitor and to see him eliminating the white tumor mass.
I left at 3:30pm since Dr. Moure was still working on resecting the tumor, and Larry said that the entire process would take awhile since the mass was quite large—the entire surgery was projected to last approximately until midnight or later. I am truly grateful for the opportunity to witness such a complex and awe-inspiring procedure, and I am very thankful for the helpful and encouraging staff who answered my questions, made sure that I was always comfortable throughout the many hours, and taught me so much about the procedure.