November 23, 2014
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.
Posted on January 6, 2015, in Uncategorized and tagged 3-D brain mapping, craniotomy and brain debulk, glioblastoma multiforme, replacement of pacemaker and defibrillator battery. Bookmark the permalink. Leave a comment.