March 2012 (Part 2)
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!