November 2013

Written by Weijia Chua (class of 2013-2014)

THE LECTURE

Dr. Harken’s Friday morning lecture began promptly at 7:15am. He spotted me, came over to introduce himself and warmly welcomed me for the day.

Dr. Harken opened the lecture with a question: which would heal faster, a cut in the toe of a diabetic or a cut in the scalp of one of our residents after we have spit into it? (Dr. Harken kept the lecture entertaining with his playful sense of humor) The residents all agreed, diabetes decreases blood flow, so injuries are slower to heal in diabetics than in people who do not have the disease. His follow up question, however, was trickier: is it the difference in blood flow or difference in exposure to oxygen that allows the resident’s wound to heal faster? If you could only increase blood flow without increasing oxygen exposure or only increase oxygen exposure without blood flow, which would you choose?

As I began to ponder in what real-life situations would a physician have to choose between one or the other, when the two seem so clearly linked, Dr. Harken started to make his point by presenting a retrospective case study: in 1993 a hospital encountered 300 patients who had gone into septic shock. Of the 300, 85 survived and 215 died. Aside from the ~75% mortality rate, what was striking about the data was that all the survivors were reported to have had a natural cardiac output of greater than 6L/min, while all those who did not, reported a natural cardiac output of less than 4L/min. “After seeing this data, are you convinced that you should treat septic patients by increasing their cardiac output? How would you design a study to test your hypothesis? Is it ethical to put patients in the control group (ie. no treatment/increase of cardiac output)?” he asked.

After some deliberation and teasing from Dr. Harken about the residents’ inability to come to a consensus—something surgeons will need to learn how to do as they make decisions about unclear cases as a team—Dr. Harken presented the follow-up study in which the control group was given standard treatment (no increase in cardiac output) with a resulting mortality rate, again, of 75% and the treatment group’s cardiac output was artificially increased with a resulting mortality rate of 40%, showing that stimulating cardiac output indeed improved the outcomes

of sepsis patients. I noticed that Dr. Harken did not explicitly provide “correct” answers to any of the questions he posed, which may have been his way of saying that medicine often does not provide us with black and white answers. However, I took his presentation of the follow- up study to mean that, in his opinion, it was okay to put patients in the control group in order to study and establish better treatment standards.Finally, Dr. Harken brought the lecture back to his original question by presenting two final studies. The first showed that artificially increasing oxygen delivery to normal physiological levels led to a mortality rate of only 15%, even lower than that from increasing cardiac output past normal levels. The second showed that artificially increasing oxygen delivery past normal physiological levels, however, did not improve patient outcomes as predicted by some physicians at the time.

While the day’s lecture seemed to be somewhat unrelated to surgery, I realized there were many universal lessons that Dr. Harken’s talk brought to life: 1) study design (and medicine in general) can be tricky and involves many variables, including ethical implications 2) you must be cautious of the conclusions you make from studies and know how to not over interpret data and 3) my personal favorite: more is not always better. These valuable lessons stayed with me as I observed the decisions that the physicians made throughout the day.

GETTING STARTED

After the lecture, a crowd of residents formed around Dr. Harken, each with questions or thoughts they wanted to discuss with him. Unsure of whether to wait or not, I decided to head up to the OR by myself.

Because I arrived alone, I rang the bell on the speaker, even though my badge was able to open all the doors. I introduced myself to Nurse Wendy and she buzzed me in, showed me the loaner scrub card and how to get scrubs out of the scrub vending machine right outside the women’s locker room. She explained that I would need the same card to return the scrubs at the end of the day, and to just ask for it at the front office. I got changed, threw on a pair of shoe covers and what looked like a non-waterproof shower cap (found next to the scrubs machine), and Wendy showed me to OR 5, at the order of Nurse Julie. Before entering the OR doors, I put on a mask with an attached eye guard (found above the sinks outside the ORs).

Wendy introduced me to the residents assigned to OR 5 for the day: Dr. Muriel Babey, a first year resident, and Dr. Jessica Williams, a second year resident. I also met Matt, a nurse who was the circulator also assigned to OR 5 for the day. Like Connie, I ended up sticking with the same team and OR 5 for the day and Matt really enhanced my experience by helping me to find a good position to watch from and providing explanations for what I was observing.

FIRST SURGERY

The patient, a 59 year old Filipina woman, was already lying sedated on the operating table when I entered the OR. She was very thin, petite, and had a delicate looking build that instantly reminded me of my grandmother. Dr. Williams showed me her chart and explained that this surgery would be a re-excision on a recent lumpectomy. She had been diagnosed with breast cancer and had a tumor removed (lumpectomy) about 2 months ago. A follow- up mammogram showed that the original surgery did not remove the outermost edges of the tumor, and thus today’s surgery was scheduled in order to remove what was missed last time. I was surprised to learn that the need for re-excision surgery is quite common, at a rate of about 50%. Dr. Williams explained that this type of surgery is considered an art since surgeons cannot visually identify tumors even when they open up a woman’s breast tissue. In this particular case, the surgeon would have to find the cancerous tissue by touch.

Dr. Sajadi was the attending presiding over the case, but he mostly observed and advised Dr. Williams as she performed the surgery. She began with a small horizontal slice above Ms. S’s right nipple and Dr. Sajadi held the cut open as Dr. Williams used a cauterizer to separate the tissue from the skin and to remove two 1inch by 1inch chunks. These tissue chunks’ orientations were labeled with sewn in threads by the surgeon and sent off to pathology. Although the patient has DCIS: Ductal carcinoma in situ, the earliest form of breast cancer, Dr. Williams explained that her case was not a straightforward one and a committee would have to take a look at the tissue pathology results and discuss whether a mastectomy would be needed as part of her future treatment.

But for the present, Dr. Williams cauterized back some tissue to help the closure sit evenly, sewed the patient up like an expert, and injected some type of clear fluid that seemed to inflate the hole that had been created by the tissue removal. The anesthesiologist then woke her up.  In total the surgery lasted only thirty minutes!

SECOND SURGERY

After my first surgery, there was an unusual lull in the surgery schedule. Every single OR was empty as each of the scheduled surgeries was somehow delayed due to unexpected circumstances or complications. Curious, I headed to the patient area, where I met a young man in his late twenties waiting to receive a skin graft on his recently operated on legs. He shared that he made his living as a caregiver and hoped to be able to walk again soon so he could return to work. I could tell that his profession suited him well as he spoke warmly and pleasantly and displayed a great deal of patience despite his difficult situation. His surgery had been delayed several hours as he had had an allergic reaction to the pre-surgery antibiotics his surgeon had given him. His team was now trying to find him a suitable antibiotic by testing small amounts of different ones on him and waiting to see if he would react. The poor guy had already reacted to three by the time I saw him.

In the bed next to the patient, a patient whose surgery I would be observing next. She was a 52 year old African American woman who would be receiving a lumpectomy to remove a region of possibly cancerous calcifications from her left breast. She was clearly concerned about the surgery and expressed adamantly that she did not want to be intubated. Dr. Williams’

first response was to kindly ask, “Why?” It was then that we discovered that the patient’s passion was singing in her church choir and she was worried that a breathing tube could even slightly damage her vocal chords. Dr. Williams gently outlined the pros and risks of each of her anesthetic options with specific attention given to the effect it could have on her vocal chords. She then gave her some time alone to make her decision. From what I gathered, she had little to be concerned about. However, I was touched by how serious Dr. Williams took her patient’s concerns and could see how far not only the conversation, but also her demeanor went in easing her mood and preparing her mentally and emotionally for surgery.

This second surgery was similar to the first, yet differed in that the mass to be removed could not be identified by touch. Instead, X-ray was used to visualize the tissue and insert a metal hook into her breast tissue that would act as a marker for the region containing the calcifications. Dr. Babey and Dr. Sajadi were then able to use the X-ray (aka. Mammogram) pictures and the hook to guide their cutting. I felt silly thinking this, but I was truly amazed at the beauty and effectiveness of such a simple low tech method.

This time, the removed mass was sent to X-ray. And after thirty long minutes of waiting, we received the good news: X-ray showed that the mass removed indeed contained all the expected calcifications. Success!

THIRD SURGERY

The third surgery I observed was an emergency one that bumped down the next case that was originally scheduled for OR 5. It was officially termed a “decompression of the corpus cavernosa” by Dr. Das, the attending who would be performing the procedure. However, none of the other staff in our OR had ever seen or knew of the procedure.

The patient was a 22 year old male who had arrived at the hospital with an erection that would not go down. (It was unfortunately also his birthday that day.) He displayed very little emotion as he described the pain and sensitivity he was feeling. The doctors were unsure of what had caused this, as the only suspecting substances he had had the day before was alcohol

and marijuana—not known to be related to prolonged erections. Dr. Das mentioned that they sometimes see this happen in patients that have sickle cell anemia, as the sickled blood cells can cluster and block the vessels leading out of the penis causing blood to collect there. However, he did not have sickled cells and none of the men in his family had ever experienced this before.

While the cause was a mystery, what needed to be done was not. The corpus cavernosum is one of a pair of sponge-like regions of erectile tissue which allows the penis to become erect when filled with blood. If the penis remains erect for too long, it means that blood has pooled there and is not circulating through the tissues. Without blood circulation, the tissues will eventually die.

Thus, the plan was to surgically drain the blood from his corpus cavernosa, though there was a possibility that he could still lose the ability to have an erection in the future.

Dr. Das began the procedure by inserting a needle into each side of the penis and squeezing it to force the blood out through the needles. Every five minutes he injected a small volume of phenylephrine, which was meant to constrict the blood vessels entering into the penis in order to hopefully stop blood from continuing to enter into the corpus cavernosa. Once blood was no longer flowing out from the needles, Dr. Das made a series of incisions along the length of the penis and suctioned out the blood. Once the penis was finally drained, he sewed up the incisions and then bandaged up the area, thoughtfully leaving some leeway room in the bandage for when Mr. N would have to urinate.

I unfortunately had to leave at this point, and did not get a chance to see the patient wake up from the surgery.

TIPS?

-Just wanted to second what Connie mentioned about the circulators, moving around the OR, and sticking with the same team/OR for the day.

-Residents Dr. Williams and Dr. Babey mentioned to me that the breast cancer cases are usually scheduled for Fridays and they even offered to let me shadow them in the breast clinic that afternoon. If you are interested in breast cancer, then maybe Fridays would be a good day for you to come in.

-I thought the OR board would have the start time for each surgery, but I realized that there weren’t any times listed because I am guessing that it can be difficult for the staff to predict how long surgeries will take and sometimes preparation complications arise, delaying the start of surgeries. I figured out that they erase the surgeries off the board once they’re finished, so whatever surgery is listed first under an OR is either currently going on or about to happen. I would say, if you see a surgery you are interested in, peak into the window of its OR. If it hasn’t started yet, head into the patient area and look for the patient. You’ll be able to find them because there’s a brightly colored card with their OR# displayed next to their bed. You can chat with them and observe the doctors prepping them for surgery. Then you can just follow the patient from the prep room into the OR so you’ll be sure to not miss a thing.

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