Monthly Archives: January 2015
Written by Martin Susskind (class of 2014-2015)
ACL + Meniscus Repair
Well, I can now say from experience that there is just about nothing in life as “full-circle,” and quite frankly as eerie, as watching a surgery being done on someone else that was just recently done on you. That was my experience during my most recent OREX day; watching an ACL and medial meniscus repair as my own fully rehabbed ACL tingled with something akin to physiological PTSD…
The patient was a 30 year old male who had torn his right ACL and then frayed his medial meniscus because he continued to walk and work on it for 8 months after sustaining the injury. The patient elected to go with an autograft from his patellar ligament (autograft: from his own body instead of a cadaver) which was different from my own surgery in that I had harvested tissue from my hamstring for the ACL reconstruction.
To begin the surgery, the right knee was pumped full of saline to allow for some freedom of movement for the surgeons’ tools. This first step was very interesting to me as I had always wondered how surgeons operated in such a tightly packed part of the body as the knee. The next step was to make a long incision from the top of the patella all the way down to the head of the tibia. The knee opened right up like a zipper pocket to expose the tight white tissue of the patellar ligament which covered the entire surface of the patella. A strip was then cut out of the central third of the ligament that was roughly 10cm in length and 10mm in width. The surgeon literally measured these specs with a mini ruler and marked off his cut parameters with a marker! Sometimes orthopedic surgery is so very like carpentry. A chisel and hammer were then used to excise two “bone plugs” at the top and bottom of the graft (one from the low head of the femur, the other from the top head of the tibia). Once excised, the graft was stretched and tied to a metal apparatus like a clothes line with a wet saline wrap around it to keep it from drying. Finally, the Patellar ligament was stitched back together from the femur-end down to close up the graft excision site… now onto the actual surgical repair…
Three ports are needed for the arthroscopic portion of this surgery and the light on the scope turned the inside of the knee an amazing glowing red. A clipper tool was used to trim the edge of the frayed meniscus (which by the way was VERY frayed). Any fat in the knee was also cut out and sucked up with an amazing tool to increase work space and field of view for the scopes. The Medial side of the meniscus is not vascular tissue so it was excised but the lateral side is vascular and so it was left alone in hopes that it would repair. The frayed edge was meticulously stiched back to the PCL from which it had torn with an awesome “blind-stitch” technique.
The last step of the surgery was to insert the graft into the knee. It’s his new ACL! A small tunnel was drilled into the head of the femur and the head of the tibia and the bone plugs at either end of the graft were hammered into the resulting holes. A tapered plastic drill bit was then screwed into both ends of the graft and left perpendicular to the bone plugs to lock the graft in place. Dr. Guido finished by physically tugging the knee a couple of different directions and was very pleased with the stability fo the graft. The patient can expect a 6-8 month rehab period before he is back to 100% believe me… I would know!
This was such an awesome experience. Once again, I’m a proud OREXer.
Written by Xiteng Yan (class of 2014-2015)
On Tuesday, November 25th, there was a guest lecturer (unfortunately, I forgot to write down his name) in the morning rather than Dr. Harkens. He gave a lecture on mass casualty preparedness and drew on his own experiences as a doctor in NYC during the 9/11 terrorist attacks. He began with a list of topics that he would cover and a few relevant photos. One of them was a photo of a fire-truck at ground zero – the lecturer pointed how doctors and nurses are usually not sent to ground zero because they are not equipped for the environmental dangers present. Another was of the empty receiving area of the lecturer’s hospital the morning of the attack. The point of that photo was to illustrate how there were relatively few injured people – the reason being that most of the people in the attack were immediately killed. In fact, the dead-to-injured ratio of the 9/11 attacks was an astounding 10:1. In comparison, the ratio for a war zone is 4:20, the ratio for a trauma center 1:20.
Next, the lecturer discussed the problems of over-triage, which is the incorrect assignment of patients to the trauma center. The issue of over-triaging is that it takes away the finite resources from those who are critically injured. The lecturer posted a slide displaying a graph from Dr. Frykbergs research, which showed a linear relationship between over-triage and critical mortality. For the last portion of the presentation, the lecturer gave advice on how to best handle a critical situation like 9/11. One was the importance of not letting “walking wounded”, basically anyone who is not critically injured, within the treatment areas dedicated for the critically injured. Another was the importance of “clipboard organization.” “Clipboard organization” is basically the jotting down of the hospital’s resources and statistics on a clipboard where one can easily see them; the organization it provides is critical to running a smooth disaster response. In the end, I really enjoyed this lecture because it was easy to grasp (no difficult scientific concepts) and immediately relevant given the current protests.
As for the operation I observed, I watched Dr. Park operate on patient with the assistance of resident D. Kendrick. The patient had been assaulted at a BART station a few weeks ago and sustained multiple fractures in the face (e.g. bilateral Lefort I, II and III fractures, naso-orbital-ethmoid [NOE] fractures, palatal fractures, frontal sinus and skull fractures). In addition, the patient suffered multiple lacerations to the face and scalp. There wasn’t a procedure name written on the whiteboard or on the photos indicating the injured areas; as a result, I was unsure of what exactly was going to happen. During the preparation stages, the residents shaved off a row of hair, approximately one inch wide, from ear-to-ear and going across the top of her head. During this period, I had the pleasure of speaking with Dr. Mock, the director of Highland’s dental clinic. He was kind enough to give me a brief overview of oral surgery education in the Bay Area. Soon after I spoke with Dr. Mock, the operation began.
The first few hours were dedicated to fixing metal braces around the upper and lower jaw. These braces were then held in place with wire loops. At this point, I was standing about five feet from the operating site and on top of two stepstools. From this vantage point, it appeared as if the residents were fastening the brace to each individual tooth with the wire loop. The loops were then tightened via twisting once everything was in place. A plastic-looking splint was also inserted into the top of the patient’s mouth; additional wires were inserted to secure this component in place. Once the braces and wires were secured, the residents brought out a pair of large pliers to work on the upper jaw. Unlike my first surgical observation, I did not have someone to guide me through the procedure, step by step. Luckily, the anesthesiologists and the vendor, M. Jaeger, were available to answer my questions when they weren’t busy. For instance, from Mr. Jaeger, I learned that the pliers were being used to mobilize the maxilla so that the splint is positioned properly.
Following the work done on the jaw, Dr. Park took over and the surgical team diverted their attention to the patient’s head, specifically the row that was shaved clean during the preparation steps. First, Dr. Park used a pen to draw a zig-zag line across the row. Next, he and the residents took turns making incisions along the drawn line. Once the incisions were made, the skin was then lifted to expose the skull. The membranes and muscles on the skull were scraped off using the scalpel as the surgical team lifted the skin. Mr. Jaeger explained to me that this procedure was called a “coronal flap,” and it is used to access the fractures in the forehead and the top of nose. The reason why this procedure is being used is that it sidesteps the scarring that would occur in the face should they access the fractures directly. The removal of the skin covering the head continued for a few hours until the team reached the patient’s brow. Once this point was reached, Dr. Park took care to verify that they have reached the fractures. As soon as this was confirmed, photos were taken. A tiny silver piece resembling a flattened chain was then placed between two fractured bones above the patient’s right eye and drilled into place. Once this chain was properly implanted, the team moved onto the next fracture, which was located on the other side of the face. It was at this point that I excused myself from the OR and ended my day.
Written by Stephanie Nguyen (class of 2014-2015)
Dr. Harken was wearing a very nice suit in the morning—I should have asked him what he was dressed up for, but it definitely put a smile on my face to see him dressed in formal clothing as opposed to the usual surgery garb. The morning topic was about the respiratory system, a subject that he explored in my first OREX shift, but from a completely different take—it amazes me how one body system is composed of so many functioning parts that each come with their own issues. I had a few flashbacks to sophomore year physiology class, but the terminology and drawings were of course beyond the scope of my elementary understanding. At one point in the lecture, he requests a few students to demo a situation that happens in the OR, handing them thin tubes and asking them if breathing through them was any different based on the tube size. There was a lot of discussion and laughter when Dr. Harken reveals that the feeling of not being able to breathe was all in their heads. Occasionally a student gets up to use the phone when his or her pager beeps, but surprising to me was to see Dr. Harken look down at his pager in the middle of his lecture as well. It helps me realize that the suit he wears and his position in front of the class makes him no different as a surgeon from his students.
Extremely fortunately for me, I had planned my shift to overlap with that of a mentor I had as a freshman at Berkeley, who is now a UCSF medical student finishing his last week of surgery rotations at Highland Hospital. I caught Ryan at the tail-end of his rotations, when he was set to do his orthopaedic procedures. Thus, I followed him into two lengthy OR procedures that confirmed my love for surgery and possibly my interest in the specialty of orthopaedics.
The first procedure was a left below knee amputation of a heroin user with MRSA. Her leg had already been amputated to mid-calf, but she was coming in again because the infection that had plagued the bones in her foot (brought on by sharing needles) persisted through her previous surgery and spread up toward her knee. I was told to put on a yellow cape and gloves to avoid contracting MRSA. I stood alongside Ryan and the attending, Dr. Krosin, while the main surgeon, Dr. Brooks, and another surgeon (forgot his name) prepared the patient. Dr. Krosin pulls up a picture on his phone of the patient’s foot before it was amputated, and it looked mummified and extremely infected. When the surgeons unwrap the patient’s leg, it looks fairly similar to the picture: wrinkled, a little bloody. The skin is folded over and some parts are stitched, although there are gaping holes where I can see the inner tissue. One of the surgeons at this point calls out to me, “Don’t do heroin, this is what it looks like”. The nurse then begins to slab on the iodine solution from the patient’s stub up to her knee. Meanwhile, the anesthesiologist prepares a tourniquet for when they begin the heavy-duty surgery .The surgeons seal the patient’s stub in plastic and wrap the rest of her leg in blue wrapping. They mark and measure the leg to determine how far to cut and how they will sew up her leg.
The 2-hour procedure then begins. The surgeons cut into her leg, sucking up blood and looking in to see where the tissue is good enough to keep. They cut and pull up the skin, wiggling their fingers through the skin into the tissue. They also tug at arteries and veins, later suturing them to prevent too much blood flow. Ryan assists along the way, later informing me that this is one of the few surgeries where medical students are allowed to cut through structures. By the 30-minute mark, the surgeons have opened and exposed her leg to the bones, and fit a lever between the tibia and the fibula. Once they determine where they want to cut on the tibia, the surgery tech hands over a saw to one of the surgeons. What’s remarkable about what happens next is that the surgeon whose job it is now to cut through the patient’s bone, is a first-timer and… PREGNANT. She had never cut through bone before and although she knows how to handle the tools, they make sure she understands the recoil of the saw and how exactly they want her to cut. All the while, she stands a little ways away from the patient to prevent her bulging stomach from pressing up against the patient. I was extremely impressed by the whole situation. Not to mention, she does a phenomenal job and was praised by Dr. Brooks, who finishes the rest of the amputation by cutting through the fibula. The rest of the removal involves scraping off tissue from the bone, cutting through the leg muscle, and tying off nerves. By the hour-mark, her stump is completely off!
Side note: the stump looks very foreign to me. It’s possible that the procedure on this patient has been completely reduced to this one leg, uncovered only from the knee and below, which helps me to forget that what has just been sawed off is really part of someone’s leg. Or that it really does look alien: two bones in a sea of tissue, wrapped in skin and completely detached from a body. Either way, I am in awe as I look at this crazy-looking chunk of leg now sitting in a tray to be shipped off to Pathology. This surgery was way beyond what I expected.
The next hour consists of figuring out how to sew up her leg. The surgeons use scary tools that make holes in her bones and pierce through the marrow of her tibia. The surgeons discuss at length how they plan on using the extended piece of skin on the backside of her leg to cover the open tissue. They call in Dr. Krosin for a consultation, as he has done such a procedure before but the other surgeons have not. They sew the skin through the holes they make in the bone and they add a tube for drainage. It takes another hour or so to meticulously sew up her leg so it is sealed well and looks fairly presentable. It becomes routine enough that the surgeons encourage me to move onto the next orthopaedic procedure that they later stand in on.
So, the next OR over is a tibia fracture repair, with Dr. Krosin as the attending and Dr. Robinson as the resident. Ryan again stands by and assists by pulling up tissue and using a tube to suck up any blood. The fracture is apparently a very complicated one, as shown on the computer next to the table. It shows an X-ray of the base of the patient’s tibia at the heel, broken into many, many pieces. A tourniquet is set up and a pronged bar is already placed through the heel of the patient’s foot. Dr. Krosin this time is the main surgeon who is working on the patient, making surprisingly small incisions and working from an equally small gap in his foot. He beckons me to look inside this hole, but not only do I not want to get too close in fear of contamination, the hole is really too small for me to see anything very well. I’m amazed by how this surgery will work in such a tiny space. Dr. Krosin goes in, not gently, and wiggles his tools around to show me that this area should really be a place for bone and not emptiness. He begins to pull out an “explosion of bones” as he puts it, working to reduce the fracture. Once he is satisfied, he drills in a wire to mark the place for a plate and inserts the plate. He drills some more, adding screws with what looks like a normal screwdriver. This process takes about an hour and when he has prepared a rough placement of the plate in the patient’s foot, we go to the X-ray to examine his handiwork. That’s when Dr. Krosin finds out that he fixed the wrong thing. He had put in the plate at the wrong location, at another spot where the fracture needed to be repaired but later on. He says to no one in particular that it’s “not uncommon to take out hardware”. I believe him because he promptly begins to undo his work.
At this point, I have to run to my Healthy Hearts shift. I thank Ryan, Dr. Robinson, and Dr. Krosin. Both Ryan and Dr. Krosin were especially accommodating and I am so grateful to have spent half of my day with them. I keep repeating myself in each journal, but my love for surgery grows with each OREX day and I cannot wait for what my next shift has in store for me.
Written by Stephanie Nguyen (class of 2014-2015)
Yet another interesting day in the OR, but one that was very different from my first. Dr. Harken began the morning meeting by introducing the topic—ethics. Apparently, once a month he hosts a lesson on “professionalism”, which most likely means other OREX volunteers will be able to experience similar issues and discussions that Dr. Harken holds with his students. Interestingly enough, I was fairly prepared for this lesson, having studied ethics for my medical school interviews. But, I didn’t expect the kinds of scenarios that Dr. Harken presented—they were much more conflicted than I thought possible, and somehow these were real cases. There were never any straightforward answers, and I’m not sure Dr. Harken had any either. It was a very thought-provoking morning, especially at 7AM.
In the OR, I am standing in front of the board when a resident comes up and decides for me which procedures would be interesting and not interesting for me to watch: the knee procedure I couldn’t stand in on anyway, anything that had to do with the face would be too difficult to see, a removal of the gall bladder was “boring”, but the excision stuff would be cool. I took his advice and entered the Excisional Biopsy Left Flank/Axilla Mass.
The procedure was to be a 15-30 minute procedure in which the patient is heavily sedated, but not completely comatose. He had in-situ melanoma in his upper arm, which meant that the surgery would not go too far beyond the dermis. I had to ask the anesthesiologist later about why this patient couldn’t have had this removed in the Procedures Clinic, where such tissue is also removed but the patient is only anesthesized at the point of the excision. In this case, the surgeons didn’t know how far the patient’s melanoma went into his skin, so they had to put him under just in case it went deep. The procedure itself was very simple and worthy of the 15-30 minute expected operation time.
I realize that some surgeries share many of the same steps, namely the beginning and end of certain simple procedures. The excision process includes feeling and measuring the tissue to be removed, drawing an outline to follow with a knife or a bovie (the current-running flesh burner), cutting as deep as is needed to remove the target tissue, extracting and handling of the tissue to be sent to Pathology, closing up the gap with dissolvable sutures inside the body and un-dissolvable ones on the skin, and patching up the spot with gauze and wrapping. This melanoma excision followed this exact process, although Dr. Bradford took a little extra time at the end to tidy up her sutures. Thirty minutes and the anesthesiologist was speaking loudly to the patient to tell him the procedure was over. No sweat.
The second procedure I stood in on, however, was nothing like the excision and did not involve many of the steps I listed above. Dr. Hoffman and Dr. Brooks were working on a Left Ulnar Nerve Transposition on a patient who Dr. Brooks later mentions has a fairly rare disease called Kienbock’s. The disease creates pressure in the radius and poor blood supply to the wrist, resulting in pain that can be relived by leveling the radius and the ulna, as the two doctors were doing in this procedure. I entered at the time the wrist had already been cut and clamped open, exposing a metal plate placed directly on top of the bone. Light rock music is playing but is periodically drowned out by the sound of the drill Dr. Hoffman uses to bolt down the metal plate into the patient’s arm. The technician plays an extremely important role in this procedure, as is emphasized when he accidently mixes-up the screw for cortical bone with the screw for spongy bone—Dr. Brooks goes through with him how the shapes and sizes are specific for the kind of bone and the placement of the screw. With each screw, Dr. Brooks (not gently) flops the patient’s hand on a small X-ray machine to check that the screws are in the right place and are the right size for her bone. He then flops her hand back onto the board for further work. At this point in time, I realize how white and rubbery her hand looks, almost like a fake hand that one puts out on Halloween. Once the six or so screws are put in, they irrigate the spot, suture around the metal plate, and suture the skin. Unlike the excision, her arm is wrapped loosely to allow for swelling and then plastered up. It was a fairly long procedure, made light with talk of computer programming, the rad car that Dr. Brooks owns, and the interesting other operations that were going to happen after this one.
After a quick pastry break, I sat in on another excision: Left Axillary Mass Excision. The patient had a soft lump in her underarm, not thought to be cancerous, that she claimed causes pain. A 5th year resident, a 2nd year dental resident, and a 3rd year medical student participated while I stood off to the side with Dr. Bradford, a 2nd year resident, who gave me the run-down of the procedure and answered all the questions that popped into my head. Similar to the melanoma excision, the spot was circled and cut into—however, it took a lot of time and exploration to determine this spot. Unlike the melanoma, they were unsure where exactly her fatty lump was, so they probed and even felt around through the hole they cut into her. It’s not obvious when you find the lump, it doesn’t look unusual or anything, but it feels different so everything is based on touch and relativity. Again, once the tissue was removed, the spot was cleaned, dried, and patched up just like the melanoma excision.
Dr. Bradford was hosting the last operation I attended: Right Inguinal Hernia Repair with Mesh and Umbilical Hernia Repair. She and the other residents on the case met with the patient as I mulled around with another resident who was telling me stories about some of the surgeons and a little about himself. Once in the operating room, the patient asks outright: “So, who’s gonna see my junk?”, to which the nurse answers, “Everyone.” It becomes an ongoing joke in the operating room as the medical student shaves him down and his groin region is sterilized. I guess seeing and dealing with penises never gets less funny even as much as you work with them. I stood at the head of the gurney with the anesthesiologist as the surgeons marked, cut, and clamped open his belly area for the umbilical hernia repair. It is a slow process as they pull up tissue and cut each layer in his abdomen to get to the hernia. Previously, upon intubation, the patient was given a nerve blocker but the area in which the surgeons were working was still fairly tense. The anesthesiologist uses a nerve twitcher that sends a current into his forehead and sets his eyebrow twitching; clearly not enough of the nerve blocker but it is easily fixed. The last 15 minutes of my shift involves a long and tedious process of putting the suture through the area of the hernia and tying it… Six times with six different strings. I knew it was my cue to leave when she put in the fourth string to be tied just like the other three before and like the next two after. If I could have stayed, I’m sure I would have seen suturing of the skin back into place, and possibly the same with the right inguinal hernia repair (except this time next to the patient’s beloved man-parts).
Overall, a very thought-provoking, interesting, procedure-filled day in the OR. I can already picture myself drawing those ellipses on patients’ arms and handling the bovie and tying that damned suture knot 100 times over. Until next time!
Written by Lisa Zhang (class of 2014-2015)
Dr. Harken began his lecture at 7 a.m., where he put up an example of a 55-year-old patient with a 6 cm abdominal aortic aneurysm and another condition. He then proceeded to ask the room which of the conditions they would treat first and what the best treatment option was. Dr. Harken repeated the exercise by changing the second condition to different medical issues (ex. carotid lesions, occluded arteries, etc.) and ultimately presented two research studies about how the current medical literature recommends treatment.
After his lecture, I introduced myself to Dr. Harken, and he assigned Jessica (a third-year resident) to guide me up to the OR. Along the way, she talked to me about her unconventional route into ultimately deciding to go into the medical field and her experiences working as a resident at Highland. She told me to join her and Dr. Harken in OR 2 as soon as I had finished changing.
Surgery 1: (Dr. Harken) Replacement of AICD (pacemaker and defibrillator) battery
I joined Jess and Dr. Harken in OR 2 when the patient was already sedated and the surgery was ready to start. One of the medical students I met last month, Ryan, was there as well to help with the surgery and helped explain some of the procedures they were doing throughout. The patient was 56 years old and needed a replacement battery for his AICD.
The patient was not fully asleep for the surgery and he was instead in a state similar to napping or light sedation. Ryan later told me this was because there were some risks for general anesthesia, such as respiratory failure, that they didn’t want to take for a more minor surgery like this one. As a result, they needed to inject local anesthesia at the incision site before they began. The patient grunted quite a bit throughout the surgery, but Jess assured me that that was pretty normal for this procedure.
Jess did most of the surgery and she started by making an incision along a previous scar from the original placement of the AICD device. Dr. Harken was guiding her through the procedure and assisted with suctioning. After they were able to cauterize the area, all three together pried the opening apart to try to remove the battery. The battery looked like a flat cylinder-like object with four wires attached, and Dr. Harken and Jess detached the four wires to remove the battery. They then opened a new battery and reattached the wires in the correct locations. Another technician came in to test two of the wires (the ones that regulated the atria and ventricles) to ensure they were working properly. Ryan pointed out on the EKG rhythms what each of the patterns looked like when they stimulated the atria and when they stimulated the ventricles. Finally, when they were sure it was all working, Jess placed the battery back into the patient and closed the incision.
After the surgery, Jess took me to the boards and explained what other surgeries were going on that day. After I picked a neurosurgery, she introduced me to Dr. Patel and his two PAs, Jen and Larry. Jen told me that the surgery didn’t start for another hour and that they would be rounding in the ICU and invited me to join, so I followed along.
There were three patients in the ICU that Dr. Patel focused on:
- The first one was a patient who had been changing his tire on his car when a car towing a trailer had come by and hit his head. As a result, he was missing a chunk of his frontal lobe and at the scene, there had been reported that there was visible brain matter. He had been in the ICU for almost a week now and was pretty unresponsive to any stimulation, so they were just closely monitoring his vitals and his intracranial pressure.
- I wasn’t too sure what happened to the second patient, but the discussion the medical students had with Dr. Patel about this one was centered around what to do about his pain (he was apparently on a lot of morphine) and how to balance keeping his triglyceride levels stable while giving him a some other medications.
- For the last patient, the family of the patient was there so Dr. Patel just introduced himself and discussed the patient’s condition with the family.
After the rounding process, I followed Dr. Patel to the OR again and we entered in OR room for his next surgery.
Surgery 2: (Dr. Patel) Craniotomy and brain debulk
Larry showed me imagining pictures of the patient’s head as other people in the room were setting up for the surgery. The patient was 44 years old and they suspected he had Glioblastoma multiforme (GBM), an aggressive cancer in the brain where glial cells replicated rapidly and caused tumors. Larry told me that without surgery the man might hope to survive three months. With the surgery, his expected lifespan increased to 6 months to a year.
A decent amount of time was spent just securing the patient in a specific position to make sure nothing moved during the surgery. The patient needed to be on his side, so Dr. Patel and the nurses used bean polymer bags to keep the body on its side and then used metal bars around the head to secure that in the right position. Technicians from BrainLAB were also there with their = equipment that allowed for real-time precise location of the tumor area by using 3-D mapping of the patient’s brain combined with the previous imaging taken.
Dr. Patel began the surgery by making an incision at the side of the patient’s face and pulling the skin back, securing the skin in place with a stable-gun-looking device that attached a plastic clamp-like object at the end of the skin flap. One of the technicians from BrainLAB explained that Dr. Patel was drilling into the skull in a fashion similar to how someone might carve a jack-o-lantern top (like an upside-down circular pyramid) in order to attach the skull portion back later. Dr. Patel was also using a bipolar cauterizing device (instead of the normal one that shocks across the body) to avoid messing with the electrical signaling in the brain.
After Dr. Patel drilled through the skull and removed a portion of it, he peeled away the thin layer of the dura mater to expose the brain (which was white and pulsing). He then used the probe attached to the BrainLAB equipment to locate the area of tissue they believed was tumor tissue and removed a little bit manually and gave it to a pathologist who was on call to analyze. The pathologist came back a few minutes later to tell us the tissue was definitely a malignant tumor of at least level 3 (categorized by its proliferation rate) with no current visible necrosis (when the tumor is dividing so rapidly that the blood can’t supply enough nutrients so some cells die). Larry explained that the maximum was a level 4 tumor, and the pathologist needed to monitor and stain the tissue overnight in order to come up with more details about the tissue. However, because the tissue was for sure malignant, Dr. Patel would then be less aggressive in removing the tumor because the cells would just grow back very rapidly anyways.
For the removal of the actual tumor cells, Dr. Patel used a suctioning device that did three things: it would secrete chemicals to dissolve the tumor tissue, it would irrigate the area, and lastly it would suck the liquids out of the area into a disposal place. He would then use the probe to check the location to make sure he was removing tumor tissue. This process then repeated through the surgery.
I had to leave at around 2, when there was still about an hour or so left. Larry said most of the interesting things had already happened, and now it was just a process of removing the tissues bit by bit. As a result, I left at 2 before the surgery could finish.
This month, now that I wasn’t as nervous as I was the first time around, I really felt like I got to learn a lot more during the surgeries and had more questions for the PAs, residents, and doctors. I was also really excited to meet Dr. Harken and listen to his lecture (since he wasn’t here last time I came). In addition, getting the chance to round the ICU with Dr. Patel instead of just watching surgeries all day was an interesting change from last week. As a result, I think I got a more holistic picture of what working in the OR would be like this time, and I hope to get more chances to tag along for more of the daily fun stuff surgeons do next time.
Written by Anna Grace (class of 2014-2015)
Hi OREXers, I just completed day two and it was full of memorable moments. I first wanted to say how much I enjoy reading everyone’s journals and incredible experiences, holy cow! Also, I just finished writing this journal entry and it’s pretty long, so I apologize for being so wordy. If anyone actually has the time to read this, I commend you. Haha. Ok, here we go…
I arrived at 6:45 this morning (yikes, too early) and by about 7:10, everyone had filed in and Dr. Harken began his lecture with an exercise; “55 year old patient walks into the ER complaining of maroon colored stool. What do you do?” He jotted notes down as the residents all offered thoughts and ideas, and continued to offer “results” if they ordered diagnostic tests or asked for vitals in order to keep the exercise going. It seemed like everyone did pretty well, even after he moved onto patient two, a 24 year old male with a pickaxe sticking out of his chest. Each avenue they would suggest would turn up no helpful results, and the idea was so Dr. Harken could see how they were thinking through the problem and how they would proceed further. (It reminded me of the Kobayashi Maru Simulation, for any Star Trek fans out there.) The lecture covered the topic of hypovolemia, or low blood pressure, and tamponade, which is the accumulation of fluid in the pericardium that alters normal compression of the heart. An interesting tidbit I THINK I gleaned correctly was on the relationship between volume and pressure in the pericardial sac, and how it changes depending on age or circumstance. Younger patients have less of a “stretching” ability in the sac, and will experience higher pressure within a very narrow tolerance, whereas an older patient who has had more of a chronic problem (and more fluid buildup over time) may experience much more of a stretching capability and need more fluids to alter her blood pressure past that point of elasticity.
The lecture ended and I made my way up to the OR (let me take this moment to say how amazing it is that the surgeon it is named after is Claude ORGAN) and checked out the board. I saw that Dr. Harken was scheduled with Dr. Candell, my kind savior from my first day. I noticed that the operation had to do with the pericardium (I am blanking on the medical name of the surgery) and was interested to see it as a family member of mine had similar sounding heart issues in the past (endocarditis, pericardial swelling). Dr. Candell said hi as soon as she saw me and I hung in the room until I saw Dr. Harken and a transporter wheeling in the patient. Dr. Harken immediately introduced himself and I can confidently tick a check mark off in the Dr. Harken Is the Greatest category after watching him guiding the surgery. It turns out everyone else knows he rules because three medical students came in as well as the residents that were participating. It was a full house. Dr. Candell was trying to figure out who of us observers would scrub in given the large number of people in the room but then Dr. Harken invited everyone (in true Oprah fashion) to scrub in. You scrub in, and you scrub in! Everybody scrubs in!
So one of the very kind medical students gave me a refresher and showed me how to grab a gown and gloves and the special way to unwrap them to get them ready for the surgical tech. Every tiny rule in the OR continues to amaze and impress me. As the med student said, “Everything in the OR has a reason.” and it’s so cool and so true.
So we are all watching Dr. Harken lead Dr. Candell through the surgery, and as soon as skin, fascia, and muscle were cut through, he is guiding her on excavating the rib from its surrounding tissues. All I could think about was my cadaver lab and how this is the same thing but a living person and was busy marvelling at the reverence of it all. It was really special to see Dr. Harken coaching Dr. Candell through the excavation. “That’s it! You’ve got it!” Things like that. She works through a couple of different scrapers and finally gets it isolated enough to be handed the biggest wire cutter I have ever seen, which obviously is not a wire cutter but a bone cutter. Craziness. Dr. Harken asks if Dr. Candell can feel a certain “noddle” on the rib as a landmark. “The noddle?” She and the other resident giggle. “Yeah! What is that noddle?” he prods with as much enthusiasm and delight as Levar Burton on Reading Rainbow. It was some part of the costal cartilage/sternocostal ligament/sternum connection, if my memory of their response and a quick glance at my Netter Atlas serve me correct. “Can we call it Harken’s Noddle?” The other resident doc asks with a laugh. So Dr. Candell positions the cutters at Harken’s Noddle and snap! The medial cut is done. She then positions the cutters lateral to the first cut so that a section about 3 or 4 inches long of rib #5 is removed. Dr. Harken remarked that the bone was probably full of cancer, and it was only then that I found out the patient had cancer.
It was around this point I saw a pink and black speckled fleshy thing emerging and disappearing into the open space. I soon realized it was going in time with a breathing rhythm and that was indeed a piece of lung. Wow. Dr. Harken explained that the black speckles were pollution (although it turns out the patient’s cancer was of the lung so pollution probably includes cigarette smoke).
Next Dr. Harken asked the group what color cancerous pericardial fluid is, and one of the residents correctly answered “bloody.” He explained that piercing the pericardial sac in this patient would be quite a sight, as it will gush red fluid that looks suspiciously like blood. Which is exactly what happened when Dr. Candell pierced the sac. A red gusher poured out and the other resident dutifully suctioned it up. “I shouldn’t have warned you,” teased Dr. Harken. “You would have thought you’d cut the heart!” Everybody chuckled like, “that would be really mean,” and probably no one was more relieved he DID warn them than Dr. Candell. In total, I think about 900 mLs of fluid were drained from the patient’s pericardial sac, although that number seems impossibly large, but I remember the surgical tech making a point of telling the anesthesiologist she hadn’t sent any irrigating fluids into the cavity and that was all from his body. At this point Dr. Candell remarked on how the cancer was all over the heart tissue, and how abnormal it made the tissue appear. She invited everyone to come look and made sure I got a chance, too. Sure enough, in all the glory of a heart that hasn’t stopped beating once in all the decades of this patient’s life, it was plainly covered in white bumps and nodules. The cancer had metastasized to his heart.
The next part of the procedure was installing a large chest tube drain in the space left by the patient’s resected rib. The medical student explained that the tube had several drainage holes in the business end, in case some of them clotted up, the others would still render the tube functional. I asked her when the tube would be removed, because it looked large and uncomfortable, I’d guess about a quarter inch in diameter. She explained that the patient’s prognosis was such that it would likely remain until he passed, and that the entire surgery was a palliative measure.
Soon after that, the procedure was done and the residents began suturing everything up. Dr. Harken left them to it, said his goodbyes and we all thanked him. The medical student performed the final and most superficial set of sutures. Suturing is pretty mesmerizing to watch. The surgery only took a little over an hour, which seems so short for all that happened.
After that, it took me a while to find another open surgery, most of the other ones were already underway. One of the nurses had me enter OR 7, where a laparoscopic cholecystectomy was underway performed by chief resident Dr. Bell and guided by attending Dr. Bullard. Although they were no longer laparoscopic, and there never was a gallbladder to begin with! For part of the procedure I stood by the anesthesiologist, although there were no blocks free for me to stand on so I couldn’t see much, other than the very interesting giant bicycle gear-looking apparatus used to hold tools that isolated the area for them. (Dr. Bell is quite tall so most of the blocks were in use by Dr. Bullard and the resident and med students at the table with him.) At one point I walked over to another wall where another med student was standing and she filled me in on some of the details of what was happening. The patient had a cholecystectomy procedure previously but presented with upper right quadrant pain. A scan showed gallstones present in the remaining portion of her cystic duct, and what had started as a laparoscopic procedure had turned into a traditional procedure at some point during the first hour or so of the surgery. Drs. Bell and Bullard spent an extensive amount of time cauterizing and cutting and prodding. At one point, one of the scrubbed in med students showed us the specimen bucket of gallstones. Two of them looked like smooth fake gold nuggets that were props from some kind of pirate costume. The non-scrubbed in med student next to me explained that black stones are from bile, and those gold-looking ones are cholesterol.
One interesting thing I noticed as I looked at the board to try and figure out what was going on was a phrase written in dry erase marker, “Laps over liver!!!! 2 ⅓ .” I was puzzled by this until, toward the end of the procedure, Dr. Bullard pulled a gauze towel out of the open cavity and called out, “Lap over liver!” and cautioned the tech to take extra time counting the laps because in this type of procedure it isn’t too hard to lose track of one of them when they are all tucked behind organs. It seems like the laps are the little gauze towels with the blue stitching and that a total of 3 of them were stuffed on top of the liver. They were each called out and carefully counted before the end of the procedure. I also thought the counting system used is pretty interesting. Maybe this is obvious to everyone else but I was confused by all the fractions I’d seen on the boards in each surgery so far (anyone else with me?) and it finally made sense. A lap count of 2 ⅓ means that they started with 2, and then added 1 for a total of 3. Eureka.
Written by Martin Susskind (class of 2014-2015)
Wow what a fine day to be an OREXer! I was early to rise in order to make it to Grand Rounds where I was learned up real good (insert cowboy accent) on the correlations between patient lung capacity and surgical success. I also got to load up on muffins, fruit, oatmeal and cups o’ joe… breakfast of champions… or surgeons…or both…
The conference ended at 8:30 so I squeezed in a quick sit with the cat at home before heading off to Highland for surgery at 11:30. Then I was told to wait until general surgeries started at 12:30. Anti-climax. But not really because when I came back I was blown away! Resident MD Robert Tessler took me right under his wing and prepped me on everything I could ever want to know about gallbladders with his tablet and then he invited me into his Laparoscopic cholecystectomy. I learned way more than I will write here but the general procedural steps are as follows…
- “Fish around” in the patients mouth and intubate the throat
- Iodine wash the exposed abdominal region for surgery. Never before had I seen a human so reduced to just an abdomen.
- Used the “Hasan Technique” (1st incision into the abdomen through the mid line right at the naval. 4 incisions total)
- Stick space shuttle-like “ports” into each incision for the scopes and tools to enter.
- Inflate the abdomen like a balloon with CO2.
- Using scopes and scalpels pull all fat and extra tissue off of the gall bladder.
- Cut/laser burn the tissue joining the gallbladder and the liver.
- Clip/tie off the 2 arteries connected to the gallbladder before cutting them.
- Use teamwork to excise the freed gall bladder.
After the surgery Dr. Tessler invited me to shadow him around for a bit as he checked in with post-op patients and prepared for his next surgery. I finally ended up going into one more surgery and it was probably the most ridiculous thing I have ever seen! Shotgun bullet right to a grown man’s tibia… this was some real ol’ fashioned slice and pull surgery here. Dr Allen and Swanson invited me over their shoulders to see literally everything. They excised a huge chunk of muscle as well as about 25 shards of loose bone. Metal scaffolding that was bolted into the bone surrounded the entire leg and the doctors used it as a handle when they moved the leg around. And now I’m just ranting but this leg was entirely open and ENTRIRLY excavated. It was truly incredible. The last step was to slice a foot long strip of skin off of the patient’s quadricep to use for a skin graft on the tibia. The surgeons fed the skin strip through a flattening device and poked holes through it like an aerator so that the skin graft resembled a strip of jersey mesh. They then stapled and sewed the skin graft onto the lower leg and dressed the wound. That is one more incredible instance of human ingenuity in the books folks! What a day! Cant wait for next month.
Written by Chuck Chan (class of 2014-2015)
My first day in the OR was on a Thursday so I went straight up to the 5th floor. I didn’t have a resident to guide me so I asked a clinical nurse, Patty, if she could help me out with getting scrubs from the vendor. Another nurse named Jose took over to give me a quick tour of the OR. I met the charge nurse, Julie, and she was very acomodating to me. I can’t deny that I was a bit nervous going to the OR without any one person to show me the ropes, but the staff members were incredibly welcoming.
CASE 1 – Skin Graft
I entered the surgery room early and was able to talk to the anesthesiologist Dr. Reddy. He talked to me about the sedation procedure. 2 mg of anxiolytic medication were given to the patient pre-op to relax the patient in anticipation for the surgery. Usually an EKG is done beforehand to note of any heart complications. Dr. Reddy used propofol to sedate the patient intravenously. Next, Dr. Reddy inserted a laryngeal mask airway in the patient to channel oxygen to the patient. Dr. Reddy likes to touch the eyelids of the patient as a technique to see if the patient has been properly sedated.
After sedation, the clinical nurses prepped the patient for surgery. One of the nurses, Tim, talked about using a compression pad for lower extremity procedures to ensure proper blood flow. The patient was getting a skin graft from her left thigh to cover a region in her lower left leg, so the compression pad was placed on her right leg. Dr. Reddy placed an inflatable synthetic sheet called the “bear hugger” to keep the patient warm during the surgery. The left leg was elevated and hung by the toes so that the nurse could soak the leg in iodide solution for sterility. Shortly after, Dr. Shah entered the room.
Dr. Shah is an orthopedic surgeon. He gave me a quick spiel on the orchestration of the OR. His point was that communication and organization were key to great health care. Dr. Shah helped with the final steps of the prep by stapling a glove with iodide in it onto the patient’s foot so that the toes don’t get in the way of the sterility of the procedure. Dr. Shah started by suturing the edges of the wound and cleaning loose matter from the gash. He used a ruler to measure the wound and it was 4.5cm x 2.5cm. He used a tool called the Dermatome to get a skin graft from the flattest side of the left thigh. The physician assistant, Ingrid, used forceps to pull the graft from the Dermatome. The graft was flattened and put through a mesher. The meshing of the skin graft allows for penetration of vascular tissue. Dr. Shah explained it as the process of imbibition in plants which helps the intake of water. The graft was placed over the wound and stapled along the edges. A spongy material was stapled on top and and taped down. Dr. Shah used a vacuum to remove the air from the sponge. Ingrid wrapped the left thigh in gauze followed by ACE wrap for the entire left leg. At this point, I had been in the room for 2 hours but the procedure itself lasted about 1.5 hours.
CASE 2 – Craniotomy
Soon after the first procedure, I got to chat with Glen – the surgical technician for the skin graft I had just observed. He told me that neurosurgeon, Dr. Patel, was half an hour into a craniotomy. Glen brought me through the core doors and asked the circulating nurse if it was alright that I come in to observe the craniotomy. She gave me permission and I was in immediate awe with an exposed cranium 3 feet away from me. I talked to Mike, who worked for an outside vender called BioLabs. He introduced me to Image Guidance, an MRI technology used for a lot of neurosurgeries. Essentially, an MRI of the patient is taken before the procedure and mapped out for the surgeon. This allows for the calibration of the probe used during the surgery. The probe can then be used to scan over the patient’s head and accurately locate the tumor non invasively. Whenever Dr. Patel scanned over the exposed cranium, I could see a small mass embedded in the dura mater on the MRI screen.
Dr. Patel drilled entry holes into the cranium around in a circle. Then he used an L shaped saw that would hook inside the holes and and saw through the holes in a circle. Once a section of the cranium was removed, Dr. Patel used a dural knife to carefully cut through the dura mater and access the tumor. Underneath the dura mater was squid colored mass which Dr. Patel quickly removed using the dural knife and cauterizing forceps. The mass was about half the size of a packet of gum. At this point, the dura mater was lifted and through the clear arachnoid layer I could see the exposed brain. The blood vessels were pulsating and all the superficial blood vessels were intact. Dr. Patel brought four corners of the remaining dura mater together in the center and held them together with sutures. He placed a thin membranous dura substitute on top. Dr. Patel had a physician assistant student drill four flower shaped screw plates into the removed cranium. The piece was placed on top of the dural substitute and twelve screws were put in to hold the removed cranium in place. Dr. Patel proceeded to remove the clips that were holding up the scalp and used a cauterizing tool to clot the blood from the edges of the scalp. The scalp was sutured and stapled and gauze was stapled on top to soak up any other remnant blood. The patient’s hair was washed and the procedure was all done in a matter of 3 hours. I did not get to meet Dr. Patel because I had come in during the middle of the procedure, but I would love to see another procedure of his for my next surgery day.
Written by Lisa Zhang (class of 2014-2015)
I read Anna’s journal a little late and didn’t get the memo that this week all the attendings would be out of the hospital for a conference. I showed up for the (nonexistent!) lecture at around 7:00 a.m. and sat in the room with a second-year resident (John Swanson) who was just there in case other people accidently walked in. He chilled with me until around 7:10 a.m., when four new UCSF third years walked in and told us they were here for their first day and were told to come to the lecture. After John explained that we weren’t having lectures this week, the students said they’d be okay with just waiting in the room until 8, when they were supposed to be meeting someone in charge of their orientation. John told me that he had a bunch of administrative stuff to take care of in the morning so it’d be more fun if I just followed the medical students around, so I stayed with them in the conference room and got to chat with them about their lives for an hour. (Thanks for keeping me entertained, John, Kacey, Joy, and Ryan!)
At 8, someone came to give them an orientation, and when she passed out the schedule, I noticed they were not going to the OR until 1 pm. The lady was really nice and let me page John to ask if he’d be okay if I just went to the OR by myself instead of following a resident around. He said he was fine with that, so I made my way to the OR and asked the front desk for scrubs. He gave me the vendor card and showed me the changing rooms. After I changed into scrubs, another nurse showed me where to get hair-nets and shoe-covers (hint: right next to the scrubs machine). I then followed her to her first room to watch the removal of an umbilical hernia. The nurse told me that there were a couple more surgeries going on if I wanted to check them out since she said there wasn’t much happening in that room at the moment and she said I could back later if I wanted.
Surgery 1: (Dr. Patel) Spacing open C2-C6 because of spinal cord contusions
I wandered out of the room and walked into the next room that had people in it. It turns out I was in one of Dr. Patel’s rooms where he was in the process of putting in spacers in a man’s cervical vertebrae (C2-C6). The nurse told me that the man they were operating on had been in a bike accident and ran into a pole. Because there wasn’t a lot of space and cushioning for the spinal cord in the man’s cervical vertebrae, his spinal cord actually ended up hitting his bone and getting bruised around C3, causing partial paralysis (known as a spinal cord contusion). They were then going to go in surgically and force open his C2-C6 and place in spacers in order to increase the space/cushioning the spinal cord had and prevent this from happening during future trauma accidents. I actually walked in at a good time — they had were in the process of drilling open each of the bones. The doctor let me watch from the head of the bed, where the anesthesiologist was, and one of the nurses found two step stools for me to stand on to see.
Dr. Patel was drilling open each vertebrae on the left side and loosening the right side in order to forcibly shift the the top of the vertebrae a little to the right and insert spacers (little chunks of plastic connected to screws). During this time, the nurse was on the other side, constantly irrigating and suctioning the area in order to remove all the bone dust that had accumulated. He was just finishing up the drilling when I started watching and was beginning to measure spacers that were needed to be placed. They used these things that looked like screwdrivers with the sharp end replaced with a rectangular piece of metal in the shape of a spacer. It only took Dr. Patel a few tries to measure out the three spacers he was inserting. He asked his tech to pass over the actual plastic spacers (which each had small metal rings of different sizes on the side) as well as screws of certain sizes and then began drilling the screws into the man’s bones. I was standing there for about an hour (from 9 to around 10) when a resident walked in to watch and told Dr. Patel he was apparently making very good time with this surgery since it usually took a lot longer.
Once the screwing in was finished, Dr. Patel prepared to suture the man back up. The nurse told me that they first used interrupted suture to stitch up the innermost layer, and then used a continuous suture on top of that. They then used another layer of interrupted suture on the very top and used surgical staples on top of that to keep the wound closed. After they finished padding the area, they began to move him to another bed and I left the room when they began to prepare for the next surgery (which was a man who had a part of his thoracic vertebrae completely thrown off to the side because of a motorcycle accident that I kind of wanted to watch too).
Surgery 2: (Dr. Valentine and Dr. Lee) Total laparoscopic hysterectomy and bilateral salpingectomy (laparoscopic removal of the uterus and fallopian tubes) due to fibroids
I actually chose this room because it looked like they had just put the patient to sleep and not much had happened yet. I entered the room before either of the doctors had gotten there and the nurses (Tiffany and Tim) said it was fine if I watched (and that it’d be easier to watch because it was laparoscopic).
The surgery was actually listed under Dr. Lee’s name, but I remember from shadowing Dr. Valentine previously that he often worked together with Dr. Lee for surgeries. I was pleasantly surprised when I saw him walk in and got to catch up with him briefly (especially since the last time I saw him was almost half a year ago). Dr. Lee and Dr. Valentine were both more than happy to let me watch. Dr. Lee went over the purpose of the surgery and their main goals with everyone in the room to make sure they were all on the same page, including logistics such as how long it was supposed to take and who would be doing what. Then, they began.
They first made four small incisions: one in the belly button (which was a bit larger and would be where they would end up inserting the camera) and one on each side. The last one was a bit anterior to the left one. They then inserted tubes in each of the incisions to keep the holes open during the surgery. They inserted a camera through the tube at the belly button and something similar to a pincer with teeth attached to a very long stick into the other three (Dr. Valentine held onto one and Dr. Lee held onto the other two). Before they even began the surgery, Dr. Lee and Dr. Valentine showed me a couple of anatomical features inside, including the uterus, ovaries, fallopian tubes, bladder, and peritoneum. Dr. Lee then began the slow process of using one of the heated tweezer pincers to cut around the uterus. They told me they were removing the fallopian tubes because they may ultimately result in complications in the future and were of no use to the patient if she didn’t have a uterus. They were, however, keeping the ovaries in because they provided important hormonal balance functions.
During the time she was cutting, Dr. Lee showed me how close she was to the uterine artery, which was a potential source of complications, especially given how much more blood flow was entering the uterus due to fibroids. She also showed me how close they were cutting to the ureters and bladder, where were both other sources of potential complications (and they would test this later to make sure this wasn’t an issue). The whole cutting process took over an hour, and Dr. Lee finished by cutting the connection of the uterus to the vagina. She then explained that they had to temporarily plug the vagina during this process with a raytex because once the uterus was detached, the cavity would no longer be airtight and would deflate, limiting their vision. Dr. Valentine then explained that one way they could tell if their cutting was successful was that the uterus was turning white because a lack of blood flow to the area.
After Dr. Lee successfully detached the uterus from everything inside the body, they removed the organ by pulling it through the vagina and plugging the vagina shortly afterwards with a bulb used for newborn CPR (points for creativity here!). Dr. Lee actually held up the uterus for me to glance at — it was a lot smaller than the screen made it seem! — before she handed to a nurse who placed it in a bucket for Pathology to look at it.
Dr. Valentine then explained that, while Dr. Lee made laparoscopic suturing look like the easiest thing in the world, it was actually extremely difficult as she tried to stitch the vaginal opening closed from the inside. He also explained that the string they used contained very small barbs in order to make sure it didn’t come loose during the process and would prevent the need to tie a knot at the end.
After they finished suturing, Dr. Valentine and Dr. Lee performed a cystoscopy (where they visualize inside your ureters and bladder) in order to make sure they didn’t puncture anything during surgery. During the surgery, they had asked for methylene blue to be injected. At this time, they had placed another camera into the bladder to look at the two intersections where the bladder met the ureters for a squirt of the methylene blue (meaning they were intact and undamaged). Dr. Valentine spotted the first one on the right quickly, but we waited for almost two minutes, staring at a very small dot on the screen, to see the second one (when we finally did, people cheered).
I unfortunately had to leave at that time — this was around 1:30 PM — but both the doctors assured me that most of the surgery was finished and they were just going to finish with the suturing. My legs were also killing me, and Dr. Valentine told me that if I ever wanted to be a surgeon, I’d need to be on my feet for hours at a time. I guess I’ll start building my tolerance now.
Overall, the day was super interesting since I got to see a lot of different types of surgeries. I was really excited to see Dr. Valentine actually operating, especially since all of my experience working with him as a chaperone had involved just clinical visits and I only got to hear about the surgical process through numerous pre-op/post-op appointments he had with patients. All the rooms I entered had nurses and doctors who were super welcoming, and all of them were inviting me to get closer to get a better view of what they were actually doing. I was also really grateful for their explanations (and all the answers to my questions) they gave and just how willing they were to teach me about what they did. I look forward to the next month!
Written by Anna Grace (class of 2014-2015)
Hi fellow OREXers! I just came back from my first day, and it was a really exciting experience. I arrived at 7:00AM to OA-2 and took a seat in the back corner of a room full of what looked like residents and some interns. After several minutes it became clear that there would be no lecture (bummer) and everyone began to disperse in search of breakfast. Luckily, a couple of residents took pity on me and let me tag along to the cafeteria with them. Sitting near the table they were at with several other residents, I felt like an awkward lurker! But they asked if I wanted to stick with them in elective surgery. I said I would love to, and the most senior resident, Dr. Leah Candell, shephard-ed me up to the OR and showed me how to get the scrubs and where to put my things. She warned me that her cases that day were mostly hernias and not that exciting. I replied that everything is pretty exciting to me at this point! The first surgery was a hemorrhoid with possible anal fistulotomy.
Dr. Candell asked if I wanted to scrub in. She showed me how to wash my hands and arms, and I learned how tough it is to get used to keeping a sterile environment. I tapped my arm against the edge of the sink! This would normally require starting over, but given the nature of the surgery and its location on the terminus of the GI tract, it is not considered a 100% sterile environment anyway (and of course the fact that I wouldn’t be doing anything!). So, she said it was ok not to. We proceeded into the room where the patient was being put under by the very focused nurse anesthetist, Amy. The other two residents with Dr. Candell (they introduced themselves as Rob and Alicia, and I can’t remember their last names) introduced me to the surgical tech, Gilbert, and showed me how to dry off with a sterile towel and slip into the gown and two layers of gloves that he held out. I’m not gonna lie, it was pretty fun. The rules and order of the OR are quite a sight to behold, and I felt really lucky to not only be in the room, but get to experience the preparations.
The patient’s legs were hoisted into stirrups and he was maneuvered a bit on the table to expose the area. He was obese, and I was about to get a firsthand look at one of the complications and dangers that can befall patients carrying excessive amounts of weight…
Dr. Candell got the ok from Amy to begin, and she palpated the perineum, opened the anus with a speculum, and located the external opening of the fistula. Dr. Candell explained that fistulas are tracts that run from inside, near the anal sphincter, opening up outside the anus. The can fill up internally as an abscess, and need time to drain before they can be closed up. The objective of this surgery was to install a sort of rubber band that would run the length of the tract and be tied up outside to allow for open drainage of the abscess. Here’s a link for an image search that clarifies the fistulotomy mechanism, don’t click unless you want to see some sphincters: (http://bit.ly/1wCfPNP).
It took some effort to position the speculum in such a way that would open the area for Dr. Candell to see what was going on. The patient’s perineal area was crowded due to his excessive weight. As she and Dr. Rob angled for some workspace, we began to hear groans and noise from the patient. Woah. Amy (the nurse anesthetist) explained that she didn’t want to give him any more anesthetic (I think it was Propofol), but due to his size, it was hard to keep him knocked out enough.
That’s when he started moving his legs. Dr. Alicia and a nurse known as the circulator (because she did not scrub in so she was free to make notes and get items needed by the surgical tech and surgeons) held his legs steady as Amy decided that he needed to be intubated to keep his oxygen levels up high enough to sustain the amount of anesthesia he was being given. She requested that the procedure be paused while she worked to stabilize him. She attempted intubation unsuccessfully, and had to alternate her attempts with holding an oxygen mask over his mouth, clamping it tightly with her hands. I watched the patient’s heart rate and blood oxygen saturation level fluctuate as she worked. His heart rate was up in the 110s as he “bucked,” and back down in the 90s when stabilized. Amy paged the anesthesiologist on duty, it was his first day at Highland and I didn’t catch his name amidst the intensity of the moment. He was a tall, very kind man, and came in and conferred with Amy about the best course of action. He suggested administering a muscle relaxer, but Amy was concerned that that would make intubation more difficult. I couldn’t tell if they ended up administering it or not. It seemed that the anesthesiologist was trying to respect Amy’s work and only act as an oversight, but it soon became clear that the patient needed a quick intervention. The two worked together, trying various types and sizes of instruments to intubate, always alternating with administering oxygen by a mask. The physicality of surgery really was a sight to see. Amy’s knuckles were white as she formed a seal over the patient’s nose and mouth with the mask, holding it against his jaw. They hoisted his head and shoulders to try and open his airway as best they could. They paged a man that brought in some type of endoscopy machine to aid intubation. Still no luck. Each unsuccessful tube they pulled out was covered with red sputum on the far end. As Dr. Rob explained after the surgery, the airway was so small and compressed due to the man’s weight. Things were getting tense and the patient was still making occasional noises and moving his limbs a bit, but I was so impressed with the calm focus that they had. Finally the anesthesiologist successfully intubated, and relief filled the room. By my count they were trying to intubate for around half an hour. “Thanks to whomever said the prayer,” he said aloud. He thanked the surgeons for their patience and the procedure continued. (He later mentioned that was the hardest intubation he can remember doing in recent history.)
Dr. Candell irrigated the external opening of the fistula with hydrogen peroxide to locate the internal opening. She then placed the rubber piece along the tract and looped it through. It was quickly trimmed to size (so as to not dangle out so far) and stitched closed in a loop. At that point, the procedure was over, the area wiped clean, and soon the patient was wheeled out of the room.
I stayed with Dr. Candell and the other residents for the next surgery, and this meant staying in the same OR with the same team. This patient was a smaller woman that had an epigastric hernia and an umbilical hernia. She was a little nervous before surgery, but everyone reassured her that she was in great hands. This time I got to see more of what Amy does to bring the patient under, and it involved two different syringes stuck into a line of some kind. She would squeeze out part of one, then the other, then pause, look at some readouts, give more of each. It was all really interesting, mysterious, and it made me very curious as to how anesthesia works. And then just like that, the patient was out. It felt like she went from alert to anesthetized in a minute.
Dr. Candell let me scrub in again and stand next to her on one side of the patient, with Drs. Rob and Alicia on the other side. Dr. Rob performed most of the surgery under Dr. Candell’s guidance. He made the initial slices to open the skin, and then they began to open up the subdermal/fatty layer. Dr. Candell would stab some forceps under a piece and spread them out. Dr. Rob would run a cauterizing wand over the area and so on. The umbilical hernia was quite small and required a couple sutures to seal. The epigastric hernia was on the border between something that can be sutured up, or something needing some mesh to hold it together. The patient’s CT scan was brought up and measured and they palpated around the incision, thinking it over. They also checked digitally for any surrounding fascial irregularities. Dr. Candell’s attending physician, Dr. Burell (I think I am getting her name wrong…) came in and offered advice. She asked if she could scrub in and feel around. She looked at the CT carefully and measured the hernia with the on screen size reference. She felt a mesh would be more successful, even though the patient had subpar fascia. I wanted to ask what that means, to have poor fascia, but I forgot to ask after the surgery. The mesh was measured, cut, and stitched in. I didn’t see a ton of details at this point because I preemptively moved further away when the attending scrubbed in.
When they were done, Drs. Rob and Alicia sutured up the external openings. Dr. Rob had to start over at one point, I guess something wasn’t sitting well. It was a privilege to see someone in the learning process of a very complex skill. He was very patient and careful and pulled out the stitches and began again, finishing successfully. I ended the day at 12:30. I wanted to stay for the last two patients of the day for the residents but I had a midterm I was dreading and needed to go study. All in all, it was a great day in the OR. 🙂