June 2012 (Part 2)
Jimmy Lam, OREXer ’11-12
One of the symptoms of an OREX intern, I feel, is that you have a mild sense of insomnia the night before your observation. I guess it is because of the excitement and anticipation. I was actually up before my alarm went off at 6:30am. I got dressed and was out the door. I arrived at the 0A2 just in time. By 7:30AM the doctors and medical students begin to trickle in as they do. I was excited to see that Dr. Harken was lecturing today and I should be because the topic was about recovery and survival rates of patients with varying oxygen content in their blood. Dr. Harken started the lecture with the question, “what would heal faster, an incision on the head or the toe of a diabetic?” If you didn’t know anything about diabetics, you should know that a common and morbid effect of diabetics is the need to amputate limbs due to poor vascular circulation. Dr. Harken explained that the oxygen content in the blood makes a huge difference in the survival of the body or the organ it supplies. Dr. Harken then went in to describe a retrospective research that collected 75 patients that have been involved in an accident that caused the patient to drop to a blood pressure less than 90. The study then split the group into two, 35 patients were treated with standard levels of oxygen in their blood and the other 40 patients were treated with some chemical or hormone that increased their oxygen content to a hyper oxygenated state. The results of the studied showed that if you had your oxygen content increased either naturally or artificially, you had a 0% mortality rate in the operating room. Regardless if you were in either groups, if your oxygen content could not increase to the hyper oxygenated state, then you had a 30% chance of mortality. The researchers were not able to determine the underlying cause that permitted a treated or untreated patient with the chemical to reach hyper oxygenated states. The beauty and beast of science is that with every answered question paves the way to countless more unanswered questions. I left the lecture room a bit more confused than when I came in. But again, Dr. Harken’s objective of these lectures is to get you thinking and surely enough, he got me thinking.
The highlight surgery of my day goes to an incision and drainage of a right knee of a middle aged Filipino male. The patient’s knee had a large opening about a foot long that extend from his lower thigh, across his knee, and down to the middle of his lower leg. The doctors had the gash filled with a black absorbent sponge that was sutured in place. I have never seen this done before and was taken back at the site of the sponges as it appeared, from afar, as implants or ingrown black fungus patches on the surface of his skin. When I realized it was sponges, I breath a breathe of relief for the patient because for a moment I thought I was in some horror movie! What appeared as a wound from a freak accident actually had no collision based origin at all. Actually, the patient’s wound was caused by an initial bone infection I believed that ballooned up forcing the surgeons to cut open and operate on the leg. What complicated this injury even further was that the patient had diabetes that decreased the circulation in his legs which probably caused the patient to develop his end stage renal disease. End state renal disease is a condition where you kidneys are no longer function and you would need to have a kidney transplant or get kidney dialysis for the rest of your life. This would make recover and healing a difficult challenge for the patient and the doctors. The point of the surgery was to remove the sponges, drain the wound of blood and tissue debris, and then suture sponges back in. Thus they called this an incision and drainage operation. A big objective of the surgery was to acquire blood and tissue sample from various regions of the gash to test for infection. Even if all goes well, because of the patient condition, there is a great of amputation later down the road.
The surgeon for this operation was Dr. Billings who is the oldest and wises surgeon you will meet at highland hospital. Despite his age, Dr. Billings is very affable at heart, loves to travel, and will share his stories to those that have the pleasure of his company. The surgery initiated with the removal of the sutures that held the black sponge in place. Once the sutures were removed and the sponges were taken out, blood began to spill out. The blood was slowly mopped up after several towels, yet blood continued to drip out. There was so much blood lost that the patient needed a unit of blood. Once most of the blood has been wiped up, you can see the bones of the patient’s femur and the knee joint. The tissue that usually surrounds the knee was completely peeled of the bone through the entirety of the gash. Just from the sight of the opening itself instilled doubt in my mind of the patient’s ability to walk normally again in the future. It was pretty disturbing for me to watch Dr. Billings wipe down the bone and then suction off blood in between the bone and the flesh, flapping the flesh around. I remember cringing my eyes from the sight and sounds created by the undertaking. To my surprise, Dr. Billings was complimenting on how clean the wound was, once he removed all the thick coagulated blood wedged between the tissue and bone. Once I got desensitized to the sounds and sights of the surgery, I began to really see the beauty of it all.
Just when I thought things were wrapping up, Dr. Billings took out an instrument that looked like what I can best associate as an ACME ray gun from the cartoons I watched growing up. It had a round funnel like opening at the tip that appeared soft and functioned by both sprayed and suctioned fluids. The instrument was turned on and Dr. Billings was quick at work irrigating the gash and then sucking fluids right back up. After twenty minutes of cleaning the opening, the wound was considered clean enough for the samples of tissue and blood to be taken. Swabs were used to accomplish this feat, swabbing to extract tissue in between the bone and the tissue of the knee. Once everything was done, Dr. Billings began to suture the tissue up a little bit. He did not suture the entire opening closed but more to hold the tissues of the knee against the bone. The opening was still very much open and exposed to the air. More of the black sponge was cut into strips to stuff the opening. Some light suturing was done to keep the tissue and the sponge flush together. A giant clear tape cover was used to saran wrap, if you will, the top of the entire opening. A small hole was cut into the tape, a tube was inserted, and a compressed bulb was placed at the other end. The bulb at the other end function to create negative pressure and suck out any pooled blood and acting as an indicator of how much internal bleeding was occurring. I was astonished at the bulb because I have never seen it used in this manner before. In the end, the leg was wrapped up tightly and the swabs were sent out to pathology. I am crossing my fingers that pathology comes back clean so the patient can keep is leg.
This observational day was the longest time I spent at the OR, cranking in at monstrous 16 hours. Good practice for residency I thought. I had a very rewarding experience in the OR today. In my wake, I had the pleasure of observing a radial bone repair of the hand, a sentinel lymph node biopsy, a laparoscopic colonoscopy, a part of a total thyroidectomy, an inguinal hernia repair, and an emergency throat tumor removal. A shout out to Dr. Billings, Dr. McDonald, Dr. Boudreault, Dr. Lim, and the podiatric and medical students that is extremely helpful and approachable. I meet a lot of new and familiar faces today. Just another reason to be excited to be a part of OREX. Until next time, Jimmy out.