November 22, 2014
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!
Posted on January 6, 2015, in Uncategorized and tagged excisional biopsy left flank/axilla mass, in-situ melanoma, Kienbock's disease, left axillary mass excision, left ulnar nerve transportation, right inguinal hernia repair, umbilical hernia repair. Bookmark the permalink. Leave a comment.