October 28, 2015
Written by Sarah-Jane Parker (class of 2015-2016)
I woke up at 5am with some anxiety. I stretched, dressed in my outfit, laid out the night before, and considered breakfast. I generally am not an eater of breakfast, unless I’m running a road race that morning, but I am a follower-of-directions. I reasoned that standing for several hours was not unlike a marathon. Peanut butter toast in stomach and coffee in hand, I headed out the door at 5:30. Bus, BART, Shuttle and I was in the conference room just before the first resident at 6:42.
Today’s discussion was on colon cancer.The residents/med students went around the table and discussed what they had found surprising in their reading. Examples included:
- A behaviour trait study that indicated higher levels of aggressive behavior are associated with a greater risk of colon cancer.
- Taking COX-2 inhibitors reduces risk and aspirin actually reduces relative risk by 50%!
- It is important to screen patients for colon cancer after treating diverticulitis – not because it increases their risk, but to confirm that the diverticulitis diagnosis was not a misdiagnosis of colon cancer.
- Fiber reduces risk of colon cancer partially becauses it encourages quick passage of stool but also because it may absorb bile salts which contribute to colon cancer.
A med student was asked to draw a colon on the whiteboard as well as the main arteries that supply it. This ended up being very useful as I would be spending several hours that day viewing that region of a patient’s gut.
There was a quizzing discussion of:
- Intraperitoneal/retroperitoneal that was a bit over my head. But thanks to this handy diagram, I realize they were being quizzed on where an organ or an artery was in reference to the peritoneum.
- How to differentiate between the colon and the small bowel
houstra in the colon, microvilli in the small bowel and not the colon
3. Layers of the bowel wall:
Mucosa–>sub mucosa –>muscularis –>sub serosa –>serosa
- staging of colon cancer based on lesion level, node level and metastasis
- A discussion on what research has found to prevent or contribute to colon cancer followed and included:
I put away my notebook and intended to introduce myself to Dr Harkin, but I was seated next to Ingrid (a nurse practitioner that I know from Healthy Hearts) and he needed to talk with her. I sat down and waited a couple of minutes to see if he would come back and then decided it was best to head to the fifth floor. Before I exited, Dr Cushman who manages all the med students introduced himself and asked about me. I explained the OREX program and he jovially introduced me to Martha George who is the command center of the surgical program, as described by Dr Cushman. He then escorted me to the 5th floor and advised me to go into OR 4 or 5. I changed as quickly as I could, but when I got back to the board everyone was already in surgery and I was nervous to go in unescorted. I then panicked-emailed the three volunteers that had already had their first day and asked their advice on whether I should go in once a surgery had started – general consensus = NO (Thanks Carlos, Pooja and Jenn!).
I went to the family waiting room and had a chance to meet “Grandma L” whose grandson was scheduled for surgery that day. We talked about how she felt about his care (the best in the world) and frustrations of a long recovery from a car accident. She didn’t feel like she fully understood what was planned for today’s surgery, but she was glad he was having his care at Highland. I let her get back to napping and peered at the board to see if there had been any changes in the last 30 minutes.
I was spotted by a very helpful nurse, Nanny(sp?), who encouraged me into OR4 and introduced me to the circulator, Benny as well as the surgical team Dr Sadjadi, Dr Martens (5th year resident) as well as two 2nd years and a medical student. I was placed on top of a stool near the patient’s feet. Finally, having a chance to take in my surroundings I saw on the whiteboard that this was a distal gastrectomy, the patient was male in his early 60’s, they were about 45 minutes in, and HOLY LORD this man’s colon was out of his body! I did a quick scan of my own body to see if I felt ill, but no. I was steady and this experience is amazing! The team had already cut open the patient’s body from 3 inches below his belly button to sternum and they were placing retractors in to allow for a better view of the cavity. Based on their discussion I gathered that his partial gastrectomy was due to the patient’s cancerous giant ulcer (a medical term indicating that this ulcer was >3 cm), that they were removing a substantial section of the stomach, many lymph nodes and forming a new connection to the bowels. This was delicate work and the time flew by. I was allowed to go to the side of the patient for a close (but still safely distant view) several times. The surgeons were so generous. I was even allowed to participate in the quizzing that went on with the anaesthesiologist and as I got two answers right (thanks recent physio exam!), I was awarded an extra viewing opportunity from behind the curtain that allowed me to see the patient’s pancreas when the floppy colon and muscular, but now ragged stomach, were moved aside. Everything was actually very pretty: pulsating hues of lavender, soft pinks, crimson clots, and occasional bulges of rich, yellow fatty tissue. The caudal lobe of the liver was exactly the shade of “stone” I had been looking for in my wedding invitations – taupe/gray. Dr Martens allowed me to glove up and feel the portion of the stomach that had been removed. It was very cold already, the outside felt thick and ropey while the inside was soft until you reached the ulcer, which I agree with medical science was GIANT. It was very hard and angry looking. I was so elated and thankful for the entire experience. Watching the patient wake up after having seen his liver only a couple hours ago was humbling. I was also aware that although his surgery was over, this would be only the beginning of his treatment. Chemotherapy would be next- he had a hard road ahead of him. It was 12:30 and it felt like I had wiggled through a wormhole where time felt weirdly dense with experience yet sped up. I was hungry for my next OR.
The board only showed circles to indicate if a patient had been seen – no times were shown. I asked a nurse, who knew me at this point, and she suggested that OR 5 or 2 would be my best bet. By 13:13, my name was on the board and I was standing in position for a bilateral inguinal hernia. The patient was in his late 60’s and male. He had been suffering from abdominal pain from the hernia. This was a much shorter surgery performed by two residents, Dr Lee and Dr Huyler with Dr Cushman coming in to supervise, on occasion. Tytus the surgical tech was blasting 90’s hip hop jams, and it was a little surreal to watch mesh being placed with precision and care while Tytus gyrated to early Mariah Carey. I admired Dr Huylers beautiful suture work. Once they were done with one side, you could barely tell that there had been a 4 inch incision. Because of the comparatively small incision, I couldn’t see as much of this surgery, but this allowed me time to focus on the instruments and the way in which tools, needles, and pads are accounted for carefully by the team. I am curious about the cauterizing tool that is used. It allowed the surgeon to stop bleeds, cut minor tissue, but does not cut through the surgeon’s glove. Does it use microwaves? Once the fascia was closed, Dr Lee kindly allowed me to ask questions. I know very little about hernias, so I asked about risk factors (heavy lifting), non surgical treatments (very few, time until it gets worse). The patient was difficult to wake from anesthesia, but soon he was out of the room.
The next surgical tech informed me that the OR would have a quick turnaround for an appendectomy, so I stayed in the area and followed the next patient in. She was in her mid 40’s and spoke only spanish, so I didn’t have a chance to communicate with her. The anaesthesia tech (Christina) escorted me through her entire process, and I felt very lucky. She allowed me to visualize the rings of the trachea she used to direct her intubation. The patient’s ET-tube and eyes were taped, the drapes went up, and I had a great seat for the laparoscopic appendectomy. Dr Lee and Dr Huyser were again at the helm with Dr Cushman overseeing the operation. A large hole was made near the patient’s belly button. Once the camera was in, the abdomen was blown up with CO2 and they were able to visualize the placements of two smaller holes for instruments. There was pus in the abdomen which indicated that the appendix had already perforated. It took skillful maneuvering to isolate the appendix from the bowel and any important veins/arteries. The surgical team’s discussion indicated that the location of the perforation (at the base) made the operation more difficult. Within an hour the appendix was separated and placed in a baggie inside the cavity. Once all the instruments were out, the bag was neatly pulled through the central hole. Christina explained that once the fascia was closed she would begin the process of allowing the patient’s body to stimulate itself to breath (by allowing CO2 levels to rise). As the patient woke up from her surgery, I said my thanks to the surgical team and anesthesia team for an amazing day, I saw that it was 6:30PM and my legs were filled with lead.
On my way out the door I stopped by Grandma L’s couch in the family waiting room. She was still there 11 hours later waiting for her grandson. Her daughter was now there and had brought her dinner. They were worried but in good spirits. I felt overwhelmingly grateful for the dedication that the surgical team was showing this lovely family’s son/grandson and for the spirit of inclusiveness and education they had shown me today.