Written by Seungwhan Alex Roh (Class of 2012-2013)
The first OREX shift of 2013 started out as usual with me arriving early to the conference room and introducing myself to Dr. Harken. Dr. Harken, as usual, was lively as ever and seemed to be full of energy so early in the morning. Just like the last two times, the residents all poured in at once as soon as the clock struck 7:15am. The topic for today was hyperglycemia in regards to septic shock. Dr. Harken started out by briefly laying out the normal conditions of the body. He described how during clean stress, the body increases blood glucose level by emptying out the glucagon storage in the liver and converting it via gluconeogenesis. Then he laid out four different situations of stress: starvation, clean injury, a high intake of calories with high metabolism, and septic injury. According to reports, only septic injury seems to cause a different stress response than the previous three and it is what most surgeons encounter during their operation. After some discussion, he moved onto his next point which was whether hyperglycemic conditions were better for septic injuries. He shared various journals that had done studies upon the topic and saw that overall, people with chronic hyperglycemia did not fight against infections as well as normal patients. He then went unto further discussion on what we could do to get conclusive evidence. Finally, he ended the discussion by stating what the current status was, that during septic shock hyperglycemia is either a control mechanism to counter the shock or a result of endocrine homeostasis failure.
As the morning discussion ended, I quickly went up and changed into scrubs to see what the available surgeries were for the day. There were two that caught my eye immediately, but I ultimately went towards the ACL repair since, as a sports fanatic, I have frequently heard of athletes getting ACL repair. The official full name for the operation was right arthroscopic anterior cruciate ligament repair with meniscal repair and debridement. The patient was already put into unconsciousness when I arrived and the medical staff was getting ready for the operation. The setup for the operation took longer than usual since the tourniquet had to be put onto the right leg and also the foot had to be wrapped tight to have the rest of the blood from being pooled there. They covered the entire patient with the sterile blue sheets as usual and only left he knee joint exposed. At the start of the operation, I did not see Dr. Krosin, who was supposed to be the attending physician for the operation, but only Dr. Wang, the senior resident. He began by marking the incision spot (inferior and medial to the patella) and making the incision with the scalpel. Then he started harvesting two tendons, the gracilis and the semi tendonitis. He carefully scraped along the tendons, making sure no damage to the actual tendon occurred. As soon as the attachment points for the tendons near the incision was freed up, Dr. Wang sutured up the end of the tendons individually. Then he proceeded to pull the tendons while scrapping up the other attachment point with a metal rod with a loop to complete the harvesting. At that point, Dr. Shah entered to help Dr. Wang with the rest of the surgery. The two tendons were then allowed to soak in saline to prevent it from drying out. A few minutes later, two other physicians, one attending (I believe Dr. Krosin?) and one resident, entered the room. The team then decided to switch directions and decided to do the ACL repair with an autograft (using the nerve from the patient’s body) rather than the allograft (using a nerve from a donor). The only problem with the decision was that the box that contained the allograft was already opened so the team wasn’t sure if that allograft was returnable or not.
With that confirmed, the team split into two. Dr. Wang proceeded with the meniscal repair and debridement while Dr. Shah prepared one of the two tendons as an autograft. For the meniscal repair, Dr. Wang inserted a camera in the joint and used a rotating suction and a grappler to clear away the damaged tissue. The whole area was flooded for the camera and the suction. Interestingly, the images displayed on the screen looked similar to the images for an underwater flora as the damaged tissue waved back and forth like an anemone that was moving with the ocean current. The images displayed were also very crisp as the cameras were capable of high definition and registered no lag. The downside of the camera was that it had to be moved around manually and so it was hard to control. This meant that there were moments when it took time to position the camera so that the operation could be seen clearly. This also resulted in a longer period of debridement as the camera had to be moved around quite frequently to survey which tissues had to be removed.
While Dr. Wang went on with his work, Dr. Shah began preparing the autograft. He first scraped off any extra tissue stuck onto the nerve with the edge of a scissors and rinsed the nerve with the saline. Then, with the instruction of the other attending physician, he began making suture crosses at the end of the nerves. This was so that the team could have a firm grasp of the nerve. The nerve was tested at the end by applying tension to it and seeing if it could handle the tension.
As soon as both of the tasks were finished, Dr. Wang grabbed a drill and drilled a hole through the head of the fibula. Once inside the joint, the drill folded into a 90° angle and Dr. Wang partially drilled back to create an even bigger opening that spanned halfway. This was where one end of the nerve was going to go. This end was going to be held up with a pin that would clamp itself in the opening and would allow the nerve to stay. The other end was going to be attached with a screw and would determine how much tension the nerve was going to have. The screw itself was white and made with the latest technology, made with a biodegradable material that would be completely absorbed by the body in two years. When the graft was inserted, the pin stuck right away in the correct position. It was interesting to see with how much force both Dr. Wang and Dr. Shah pulled on the sutures to test the strength of the pin and the nerve. It really showed how strong the human body was. Next, Dr. Wang drilled a hole through the tibia so that the screw could be put in place. Once the nerve was set in place, the team took several photos of the result and the operation was deemed successful. The incisions were sutured up and a caste was put on the leg. Overall the entire operation took a little less than 4 hours to complete.
As the team was finishing off, the physician was writing up the total bill for the operation. It was shocking to see how much each equipment cost and made me realize why most people wanted to avoid surgeries. If not for insurance, I could see why most people could not receive surgeries even if they wanted to. To see that one screw alone cost upwards of $300 seemed a little preposterous to me.
The best thing about the shift, however, was not the surgery itself but rather the conversations I shared with the doctors (and even just the conversation between the doctors themselves). It was cool to see what kind of activities that doctors enjoyed (and even better to know that it was the same activities that anybody else enjoys). Just the vibe that doctors were not always the serious and grave but also were cheerful and fun for some reason surprised me. Throughout the whole operation, the various doctors including the anesthesiologists came up to me and gave me various tips on the med school process and on which area of medicine I should choose. Overall, no day of OREX disappoints.
Posted on July 16, 2014, in Entries and tagged ACL repair surgery, harvesting tendons, hyperglycemia, meniscal repair, right arthroscopic anterior cruciate ligament repair with meniscal repair and debridement, septic shock. Bookmark the permalink. Leave a comment.