December 12, 2014
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.