November 17, 2014
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.