February 5, 2013
Written by Jon Zaid (class of 2012-2013)
When I first arrived to the conference room the residents and the students were engaged in a conversation led by Dr. Palmer regarding different approaches to post-op antibiotic treatment and how the goal is to pick the right dose with an aggressive regiment. However, there are also damaging repercussions if the antibiotic therapy is either too potent or too long in duration. This made me think about how surgery is a very technical skill but that is not all there is to being a surgeon. Interviewing patients and getting to know them prior to surgery allows the doctors to determine how compliant may be with post-op therapy or the antibiotic regiment. Highland is unique in that the types of patients that are seen tend to be poorer and less educated, and with that is a correlation to be non-compliant with prescribed courses of action. This presents an interesting hurdle for doctors in these types of areas, as opposed to doctors and surgeons in more affluent areas in which patients can recall their medical and family medical histories with greater accuracy, and are also more likely to follow up in the proper manner. Speaking with Dr. Palmer afterwards, he told me that no two surgeries are ever exactly the same, not only because the patient’s anatomy is different, but their medical and social history is different which can sometimes add complicating factors during and after surgery.
The first surgery of the day was a right portal catheter placement by Dr. Stam. The patient was a 55 year-old female who was recently diagnosed with breast cancer, and the catheter was to be placed to make infusion therapy more tolerable. Working in an ER, I am able to see many patients that come in with the ports already embedded in the chest and I’ve never had the opportunity to see how the ports get there in the first place. I should first describe the reason for ports to be inserted in the first place. Cancer patients undergoing chemotherapy will have infusion therapy sessions each week in which they are stuck with an IV that continuously delivers the chemical cocktail into their veins over the duration of the session. When getting “stuck” in the same veins over the course of chemo treatment, veins can get hardened from the repeated traumatic poking and can become more and more difficult to be a viable route for chemo. A port cath is literally a plastic ring that is directly linked to a major vein that gets inserted beneath the skin. Now a nurse can initiate infusion therapy through the port to deliver the cocktail to the patient, rather than having to find veins in the arm. In this case the jugular vein is connected to the catheter so that the drugs can be most effectively distributed to the body once it reaches the heart and is distributed systemically after reaching the left ventricle. When the course of treatment has ended and the patient is cancer-free, the port is removed.
The procedure itself was interesting, as it was the only one that the staff (including myself) had to wear lead vests throughout the duration so that X-rays could be taken frequently to verify that the catheter is correctly positioned into the jugular vein (JV). First a small incision is made below the right clavicle and a wire is fed into the JV with the aid of ultrasound. Then a 2cm incision is made about 6cm below the initial incision where the port is inserted. Then beneath the skin a path is created between the first incision and the port where a catheter tube connected to the port is pushed through to where the first incision and the wire is situated. X-rays are used to verify that the wire is indeed going into the JV at this point. Then the wire is removed but replaced with a larger hollow tube using a gun-like device. The catheter connected to the port is then fed into the larger hollow tube, which is in the JV. The upper chest is then X-rayed again to verify the placement of the port cath as well as ensure that it does indeed connect to the JV. The port is then sutured to the subcutaneous layer and then is flushed with a heparin solution. The heparin solution is an anti-coagulant, which is used to make sure any blood that makes it into the catheter does not clog the newly placed cath. Once that is complete the skin over the port is stitched up and the entire procedure only took about 45 minutes. The patient’s life is now made easier after a simple outpatient operation that was facilitated by amazing technology that wasn’t around 20 years ago.
The next procedure was a wide local excisional biopsy of a large “melon-sized” liposarcoma on a 39 year-old male by Dr. Bullard and Dr. Rahbari. The tumor was so large that many other staff-members came in to see it, and even Dr. Palmer took several pictures of it from different angles because of its unusual size. Although the surgery seemed pretty straight forward, it was interesting because once the first incision was made (about 2cm surrounding the black necrotic skin), the only way to tell how deep into the leg the tumor penetrates is by feeling for hardened material below the surface. Therefore it is not straightforward and some difficult decisions needed to be made regarding how deep into the leg should be excised. Dr. Bullard and Dr. Rahbari had to be in constant communication because the tumor was so large that each cut needed the support of the other doctor to hold the weight of the tumor to ensure that no vital arteries are accidentally sliced. During the excision, I could see various leg muscles twitching, which I had never seen before. Almost the entirety of the anterior skin of the left thigh was removed so it looked as if I was in an anatomy lab. The doctors were pointing out various aspects of leg anatomy to myself and the students as it is not often that we are able to get the opportunity to view such a large portion of an exposed area on a living person. After the 3 hour surgery was complete a mass about 15x 25×13 (or the size of a football) was removed from the patient and placed in a bucket. The estimated weight was about 8lbs. To identify the proper orientation of the removed mass on the body once it was removed, the medical student made long stitches on the lateral aspect and short stitches on the superior aspect. The large exposed area of the thigh was then closed like a corset with some of the exposed muscles simply covered with damp dressing. The patient had much of one his thigh muscles completely removed, but would be able to walk again with physical therapy and he would now hopefully be cancer-free. Another aspect of serving in poorer areas is that patients can often come to see a physician well after they should have initially sought medical evaluation. This makes for more acute illness and perhaps more interesting (from a medical standpoint) cases such as the large liposarcoma. This goes back to what Dr. Palmer had told me earlier in the day about no two patients or surgeries being exactly alike. I was able to see two very different cancer patient’s lives hopefully improve a lot today in two very different ways.