March 30, 2015

Written by Andrew Sondag (class of 2014-2015)

My OREX day began with a delay. I had planned to meet with the ophthalmic team to watch a cornea transplant that was scheduled to begin at 8:30am, but when I arrived in the OR the doctors were just standing around. The resident explained that the donor cornea had not arrived yet, and they had to wait for it to be transported from San Francisco. After some discussion about switching tissue transport companies and about 45 minutes of waiting, the cornea finally arrived and the preparation began.

Dr. Lim, the attending, showed me the donor cornea as well as the information slip that arrived with it. She pointed out the different things you look for to make sure it is a good tissue, such as the endothelial count (which you want to be around 3,000) and time from death of the donor to extraction of the tissue. It was a bit unnerving to be reminded that this tissue came from a person who had been alive just a week before, but it also helped me remember how much of a gift this cornea truly was.

As the patient went under anesthesia, the doctors began working. The biggest difference between ophthalmologists and many of the other surgeons that work at highland is scale. As one of the ophthalmic residents put it during clinic later in the day “everything we do is small.” These ophthalmologists didn’t have large retractors or forceps; they had stools to sit on and microscopes to work over. At first I wondered if I would miss most of the action with the two doctors hovering over the patient’s eye, but one of the OR techs flipped on a monitor in a room that showed the POV of the microscope over the eye.

Two things happened to begin the surgery. The doctors inspected the eye one last time for the scarring that had been present. Dr. Lim invited me to the microscope and I was able to see it. At first I had trouble locating it, because when I think scar, I think of a discolored streak of skin. However, on an eye scarring just looks like a slight cloudiness. It doesn’t take much to alter the passage of light on what should be a clear cornea! The second thing was the cornea was measured and marked for cutting. Calipers were used to get an exact marking, proving again the point that “everything we do is small.”

The doctor’s then explained that while they were ready and scheduled to perform a full cornea transplant, they were going to attempt a tricky partial cornea transplant first. They explained that in a partial cornea transplant, only the top half of the patient’s cornea is cut away and the donor tissue is placed on top of the remaining tissue on the patient’s eye. While this leads to better outcomes, it is very technically difficult. What often ends up happening is during the cutting and separation of the patient’s cornea, the remaining tissue gets punctured. When that happens there is no choice but to perform the full cornea transplant.

The resident began the partial transplant and skillfully separated most of the top half of the cornea from the bottom half. On the monitors I could see a clear circular bubble forming between the two layers. Just as he was about to finish the separation of the layers, the bubble quickly disappeared all at once. The cornea had been punctured. This meant they had to remove the entire cornea as originally planned.

After removal of the patient’s cornea, they moved over to the donor tissue which was set up on a side table in the OR. The donor tissue comes with a lot of extra sclera attached to it, and you only need the relatively small (about 6mm diameter) cornea in the center of the tissue. To get only the tissue they needed, the resident brought out a circular punch that corresponded to the exact size of the tissue they had removed from the patient. With an unsettling but oddly satisfying *crunch*, the donor cornea was separated from the donor sclera in a perfect circle.

Now that both tissues were ready to go, all that was left was to sew the new cornea into place. You read that right, even with the eye it always comes back to needle and thread. This part of the procedure took much longer than I thought it would. Almost half of the entire operation was dedicated to sewing the cornea into place. Part of the reason for this is making sure that the cornea isn’t stretched too tight or too loose. Either of which could cause problems down the road. After over an hour of stitching, the doctors showed me how they tested the seal. They mixed a dye and poured it over the eye. If any of the dye appeared on the other side of the cornea, they would know they had a bad seal. Amazingly, none of the dye made its way past the stitches that locked the new cornea into place!

With that test completed the surgery was done, and I had witnessed my first full cornea transplant. I had so much fun with the ophthalmic team that after lunch I stayed with them to shadow clinic hours, where they explained a lot of the more simple procedures they do in the office (again all with a microscope!). I would definitely recommend picking an eye surgery next time you are staring at that white board deciding what to watch. It is definitely an interesting contrast between some of the “large” surgeries that many of the other surgeons are performing.

March 24, 2015

Written by Vickie Nguyen (class of 2014-2015)

I had a FANTASTIC OREX day. I mean, it was phenomenal, spectacular, STUPENDOUS, simply amazing. Really though, I don’t think any word in the english dictionary could sum up exactly how I felt about my day. (when is an OREX day not great? I mean come on..)

To start off, during morning lecture, a resident invited me to come and sit next to him. I’m feeling a lot more comfortable with the residents now, and this kind gesture sent warm and fuzzy feelings right to my heart! In the middle of lecture, Dr. Harken asked about Thallium, what it was used for and why. The same resident who invited me over, answered the question with some hesitation. Dr. Harken said he was correct. Almost immediately, I see the resident fist pump under the table and hiss out a “yessssss.” He was clearly pleased with himself. This moment was definitely one for the books, especially as a pre-medical student, I look up to medical students and residents with so much respect and hold them at such high regards. Deep down, I fangirl when I’m in their presence, and sometimes I forget they’re human too. I loved that I could relate to this resident in that answering difficult questions correctly gives us that confidence boost we need to get on with our day, and why not fist pump while we’re at it?!

Today, Dr. Harken took me under his wing, again, and brought me into an OR with Dr. Maggie Brooks. I watched Dr. Brooks perform a portacath insertion surgery as well as an AV fistula, with Dr. Harken as her attending.

I’ve seen these surgeries once before, and a part of me was disappointed. However, I remembered what Lucy said about re-watching surgeries, and how they’re all different and many more new things could be learned. So, I stuck with it and quickly changed my attitude to a more positive and open one.

The patient was a spanish-speaking female. What was different about this surgery was that she was awake upon entering the OR, and everyone in the room made conversation with her and put their best foot forward in trying to make her feel at ease. Language was a slight barrier, but Dr. Brooks as well as the anesthesiologist were able to speak some spanish with her. It was a different change of pace for me, because I’ve never seen a physician-patient interaction inside the OR before.

Once the patient was put under anesthesia, Dr. Harken used an ultrasound to observe her internal jugular vein as well as the carotid artery. Dr. Harken asked me to come take a look at two dark circles on the ultrasound screen. He pointed out the jugular vein as well as the carotid artery, the jugular vein was a black circle resting just above another black circle, the carotid. He explained to me how there is a higher pressure in the carotid artery compared to the jugular vein, which is collapsible.

Dr. Brooks performed the surgery and finished within an hour. After checking to see if the portacath insertion was done correctly, I hear Dr. Harken exclaim “BEAUTIFUL!”

It was the first of many to follow!

The surgical technicians in the OR were also different from the one’s I met before. One was named Tim and the other Joe. They were a lot more talkative and a lot less serious than the last few I met. They asked if I was going to stay and watch the AV fistula, and I said of course I would! It was probably one of the best decisions I made. Ever.

I did watch an AV fistula surgery before, this one was so different from the last. Just a re-cap on what this surgery is, it’s done on patients with end stage renal disease. It is meant to surgically create a stronger vein so the patient can undergo dialysis without the vein collapsing from multiple dialysis treatments. To make a stronger vein, the surgeon will connect a vein in the forearm to the radial artery.

In comparison to the first AV fistula, this patient had significantly smaller veins and arteries compared to the last. It was a lot more difficult to find the radial artery. There was a lot of time spent using a “doppler,” a device to help listen to the pulse coming from the radial artery. Both Dr. Brooks and Dr. Harken were getting a bit frustrated after a while, since they knew where the radial artery was, they could feel the pulse with their hands, but the “doppler” wasn’t picking up the pulse.

Eventually, after delving in a little deeper they found the artery and were finally able to create the fistula. I got the best seat in the house, Tim brought over a stepping stool and placed it directly behind Dr. Brooks. I was literally standing inches away from her, and could see right over her shoulder! It was both a scary and exhilarating feeling to be standing so close to a surgeon while they do their work, but if I were to make one wrong move I’d topple over the entire operation! Luckily nothing of the sort happened, I stood very still keeping my hands crossed over my body and observed. Every time Dr. Brooks pulled a stitch through to connect the vein and artery , Dr. Harken bellowed “BEAUTIFUL!”..TWICE he gave Dr. Brooks a heavy tap on the hand she was operating with and said “BEAUTIFUL!”..Startling to watch, since Dr. Brooks is sewing together the tiniest blood pipes with even tinier needles and threads, very delicate! But of course, everything was beautiful and turned out to be very successful. Truly an operating-room-experience.

Dr. Harken removed his gown and gloves, I said thank you to everyone in the room, and he lead me into another OR. The first thing I saw was a patient with only one foot. Later on, Wendy, another surgical technician I met from a previous OR day, informed me of the patient’s story and why she was getting operated on.

The patient was a 17 year old gunshot victim. She was shot to the side of her shin bone, and her foot could not be saved. There was too much nerve damage and no blood circulated to her foot, it had to be amputated. This surgery was performed by Dr. Green, and the goal was to surgically treat the appendage so it would be a better fit for a prosthetic. I watched as Dr. Green attached staples around the appendage, then the attending surgeon explained how they would be using these yellow stretchy strings called “vessel loops” to tie the leg up as if it were a pair of shoe laces. The operation didn’t take all that long, before finishing up, they placed a piece of silver paper on the wound. The attending explained that silver has antimicrobial properties, and I assume that the paper would stay on the wound for a while to aid in healing.

This was the first real non-traditional surgery I encountered, and I noticed a few differences. First, there were a lot of people in this OR. I counted eight people not including myself or the patient. This surgery was a lot less standardized. Unlike a portacath surgery or an AV fistula, there was a lot more contemplation in how to go about this surgery, meaning they actually discussed how they would go about doing the surgery while in the OR. I heard the attending talk about how they will approach this surgery experimentally. Basically figuring out a way to shape the leg using a new tactic, the “shoe-string.” One last major difference was the patient’s age. Most other operations I observed were for middle-aged patient’s. This was a healthy teenager, and if it weren’t for getting shot in the leg, she probably wouldn’t be any where near this hospital.

It was a pretty awesome OREX day for me (did I mention that already). Now that I’ve been in the OR three times, I feel a lot more comfortable in this environment. I’m learning how to appreciate surgery holistically. As Tim described to me earlier, we treat these surgeries with the utmost respect. Imagine if it was us in the OR, or someone near and dear to us. Though some of these surgeries take place every day, more than once a day, it’s still a very fragile and traumatic experience for any person to go through. It takes the right combination of science and humanistic traits to be a part of this beautiful and literally life-changing art we call surgery.

March 27, 2015

Written by Adrienne Carter (class of 2014-2015)

I arrived at Highland a little past 7:00 am. When I entered the conference room, Dr. Harken and his students were not there, so I proceeded up to the OR.

When I got to the OR, I went into room 4.  The nurses were prepping for a patient undergoing a laparoscopic paraesophageal hernia.

Dr. Smith took the time to explain the procedure to me.  She explained that the patient came into the ER complaining of shoulder pain. Doctors performed a CT scan.  The CT scan showed that the patient had a hernia. Dr. Smith explained that there are several types of hernias. In this particular case, the patient’s entire stomach had moved all the way up past his diaphragm into his chest cavity. Dr. Smith showed me the patient’s CT scan. I was amazed to see how much the patient’s stomach had moved! The patient’s stomach was almost near his heart.

Dr. Smith explained that shoulder pain is characteristic of diaphragm irritation, which is called radiating pain.

After about 45 minutes of preparation, the patient was wheeled into the operating room. The patient was a 51 year old, Hispanic male. Dr. Schwarz who was the anesthesiologist, prepped the patient. Next, the doctors inserted the tools and a camera to perform the surgery laparoscopically. They used the tools to move his liver out of the way and to help to move the stomach down past his diaphragm. However, they had difficulty keeping his stomach in the proper place.  They eventually concluded that it would be best if they did an invasive procedure instead of laparoscopic, to help them visualize and gain better access.

They removed the cameras and made a large incision down the patient’s belly. They used large clamps to hold back the patient’s skin. I was amazed at how much I was able to observe, I saw the patient’s liver, spleen and stomach. I even saw the patient’s heart pumping! Seeing this definitely made me realize how unique this opportunity is. The OR is the only place where I will ever get to literally see inside someone’s body and see how all of their organs are connected.

The remainder of the surgery consisted of the surgeons pulling the stomach into the proper place and using mesh to ensure that it did not move back in the future. The entire surgery took about 5 hours.

Since the procedure was longer than expected, I did not have time to view any other surgeries, but I felt very fortunate that I was able to observe this one.

March 16, 2015

Written by Ayetzi Nunez (class of 2014-2015)

THE HOUDINI RADIUS

Monday, March 16, 2015, 7am-12:45pm; 5 hours and 45 minutes.

This was my first sitting in Dr. Harken’s lecture and observing in the OR.

Dr. Harken’s lecture was about aortic aneurysm, how to detect them and how to care for patients with them. He also gave a brief description of the different types of aortic aneurysms. The types of aortic aneurysms that he discussed were Fusiform, Saccular, Michaic, and Dissections aneurysms.

Fusiform – The aneurysm bulges in all directions and has no distinct neck. The fusiform aneurysm does not present any symptoms but there is a possible rupture if it’s not treated. (Definition was found on Mayfield clinic website)

Saccular – (most common, also called “berry”) the aneurysm bulges from one side of the artery and has a distinct neck at its base. With this type of aneurysm the larger the pocket the higher the tension is in the pocket. (Definition was found on Mayfield clinic website)

Michaic aneurysm– it is rare and is caused by viruses such as syphilis and salmonella.

An aortic dissection– the inner layer of the aorta tears. Blood surges through the tear, causing the inner and middle layers of the aorta to separate (dissect). If the blood-filled channel ruptures through the outside aortic wall, aortic dissection is often fatal. The aortic dissection aneurysm does present pain (irritation) and there is lots of pain when they are cut. (Definition was found on Mayo clinic website)

Operating Room Experience

This surgery was about fixing a fracture on the forearm of a male patient that had fallen and landed on his right arm. The patient is a male with a history of stroke (right side affected), and a history of drinking alcohol.

When I arrived to the OR, the patient’s right arm was being prepared. One of the nurses scrubbed the arm twice and then wiped it dry. During that time, the surgeons, a PA, and the other nurse where putting their sterile gown and gloves on. I did not scrub in for this surgery because I was not asked to do so but I wore the lead vest due to the x-ray machine that was used during the surgery. Right from the moment I walked inside this OR I felt welcomed and as if I was a part of the team. Everyone was professional and helpful. Elka Jacobsen PA-S was very informative about PA school and about the surgery. As the surgery was moving along she instructed me where and how close I could stand to the team doing the surgery. She was a great guide for me. Dr. Shah, the main surgeon who was teaching the other surgical student, was also great. As Dr. Shah taught, his students and I listened carefully to everything he said. Dr. Shah’s way of teaching is smooth and he also made it look easy. He created a relaxed environment that was conducive to learning. The nurses and the surgical techs where very nice too and did a good job in guiding me.

The surgery

After the arm is prepped, the surgeon drew a line down the arm where the incision is going to be made, then smaller lines were drawn across the main line. These smaller lines are done for the closing, to make sure the skin is matched perfectly. The incision is made and then he proceeds to find the artery and the nerves in the arm. Dr. Shah does not use the mechanical tourniquet because it is easier to find the artery without it also preventing cutting into it by accident. Dr. Shah stated that when a tourniquet is used it becomes more difficult to find the artery. They found the artery by looking and feeling for the pulsating movement. The original x-ray showed that there were 2 fractures present, one on the radius and one on the ulna. These fractures look like they were an oblique or spiral in the middle of the arm. Dr. Shah decided that they would fix the radius first and then fix the ulna.

Fixing the radius

After the section of the bone that was fractured was exposed the surgeon and the surgeon student cleaned it. They removed any bits of tissue that were attached to it, and they also smoothed the broken edges of the bone. Then the reduction was done, they inserted 2 screws, in an x shape, to hold the bones together. This is when they attached a small plate to secure the bone in place. After the plate was secured the surgeon bends the arm at the elbow and noticed that something was not right, so he tries the maneuver a few more times and then decides to check radius on the proximal end. He found another fracture that was not visible on the original x-ray. When I looked at the original x-ray it looked like nothing is wrong with the bone at that section. They took more x-rays right over there to make sure he did have another fracture, and it was confirmed. This was fixed the same way, with a difference that a larger plate was placed and the original small plate that was placed in the middle was also changed for something larger. Dr. Shah is thinking that this might have been a spiral fracture, so he decided to look at the distal end to make sure there were no fractures there and “viola” there was another fracture. This also got fixed the same way. At this moment they decided to put two plates at each site of the fractures on the radius, with a total of 6 plates.  

Fixing the ulna

For this section of the arm was a little tricky. They did another incision by the ulna and the forearm was put in an upright position, Elka was holding the arm by the hand for this. After the bone was cleaned they were having difficulty making that perfect bone to bone match and it looked like it was due to a small piece of the bone that was partially hanging. To fix it they removed the small piece of bone, cleaned it and plugged it back in with the rest. They finally made the perfect match, beautifully done, added some screws and a plate. More x-rays were taken to make sure that there were no more fractures present and to show the work done.

Closing

The arm was rinsed very well with normal saline, inside and out. They used dissolvable suture and then they added staples to close the incisions. Some dressing, bandage, and a splint were put on the arm to keep it immobilized.  

The procedure was amazing and left me wanting more.