Monthly Archives: January 2016
Written by Carlos Yang (class of 2015-2016)
I arrived at Highland around 6:45am and raced to the meeting room. Due to the hour change the sky seemed a lot brighter than I remembered from my first OREX day so I had a small fear that I was already late to the meeting. When I arrived in the room I was the only person there, further feeding my fears. After a few minutes more people trickled in so I realized that I was on time and got ready for the lecture. This time instead of going over an article Dr. Harken played a game of medical Dungeons and Dragons with the residents. He would describe a situation and they would have to tell him what they would do. First he presented them with a sixty year old man with acute epigastric pain, BP or 90/60, and a temperature of 38 degrees. First the group wanted to check his breathing, which they were told was fine. Next they checked his pulse which was 120 bpm. At this point Dr. Harken explained a little bit about the exercise saying that as surgeons sometimes they have to start therapy before they fully know what is wrong with the patient. With this information the residents opted to give the patient crystalloids and gave Ringer’s lactate. Then someone said to do an EKG which did not lead to much, but the patient did say he had an inferior myocardial infarction three months ago. Then someone suggested doing a fast exam to look for bleeding, but the test came back negative. Then they decided to have an X-ray taken to look for air in the diaphragm. Next they checked the lab results and I do not remember where that lead and my notes are illegible. At this point Dr. Harken had the patient reveal that he drinks a liter of vodka a day and that his abdomen was still very tender. The residents then gave him some morphine for the pain and checked his echocardiogram, his ejection fraction being 40%. All his stats were the same so they put a central line in and saw his central venous pressure was 4 mm Hg which was on the low side so they gave him more Ringer’s which bumped it up to 6 mm Hg. This example sort of ended there and Dr. Harken revealed that the true purpose of the exercise was to see the thought process of the residents. He would rather them guide him through what they are thinking than to just say the right answer. There was another example, but it was almost exactly the same as the first and then it was time to go to the operating room.
I walked up to the 5th floor by myself since there were no residents available to take me. As I went to get the vendor card to get scrubs I noticed that the OREX pictures still did not show me in them so I hoped that the woman at the front would remember me from last time. I do not think she did, but she let me take the vendor card in exchange for my phone. I got into the scrubs and checked the board. The first procedure that leapt out at me was a Left Thyroid Lobectomy. So I went to OR 4 and waited for the procedure. There was a man already inside putting things on the white board so I went and put my name up as well. We waited for a bit and talked about OREX and other things until a doctor came in and said that the procedure was postponed due to the patient not having insurance. This was an interesting development that left me without a surgery to watch, but all was not lost since my new friend directed me to an ortho surgery that had not yet started. I slipped into OR 1 and introduced myself to the first person I saw. The procedure they were doing was a “Left Ankle Open Reduction and Internal Fixation” which is a really fancy way of saying they were fixing the patient’s ankle. Apparently this patient had broken their ankle in Austria while practicing for the winter Olympics. What was just as interesting as the procedure was the environment it was being done in. There was 90’s alternative rock music playing and the doctors were kind of talking to each other like bros. One of the surgeons was the most junior of the three so he was the target of most of the banter. The other doctors kept reminding him not to cut a nerve, pointing it out whenever they told him to do something. At one point he reached for an instrument and the most senior surgeon took it from him and said that good surgeons do not use that tool.
I positioned myself to get a good view of the surgical field and I could see the ankle. This was the first time I had seen exposed bone in person other than teeth. The doctor noticed me and pointed out the fracture which was a very noticeable line. They also took some X-rays to look at the way it moved and you could see the joint sort of open up when moved.
What is really interesting about orthopedic surgery was the inelegance of it. While still very technical surgery they employ a lot of drills and tools that use brute force. After setting up some guides the junior surgeon started drilling them into place. After skillfully avoiding the nerve and drilling all the plates into place they began sewing up the ankle. At the end, instead of using sutures, they stapled the skin together which was the first time I had seen surgical staples. They also applied a cast which was fun to watch. I have never broken any bones so I have never seen a cast being put on. It was a little like papier-mache.
The next procedure I saw was a “Laparoscopic Left Pelvic Mass Removal and Potential Removal of Left Ovary”. I went into OR 3 and introduced myself to who I thought was the doctor. It turns out it was a third year medical student named Ben who was very friendly. I talked to him about applying to medical school and he said he does not miss the application process. He was worried about applying for a residency, but I am pretty sure he will be fine. When the doctors came in they asked who I was and I told them I was with OREX. Both of the doctors did not know what OREX was so I explained it and one said that she remembered Dr. Harken sending her an e-mail about it two years ago. They did not kick me out so I think it all went okay. The procedure was very similar to the colecystectomy I saw during my first OREX day. Since both procedures are laparoscopic the set up was the same. They made a hole into the woman’s pelvic region and put the camera inside. The patient had previously had a hysterectomy so there was not much to see inside except for the left ovary and a fibroid that was the target of the operation. The doctors used the grabbing arm of the laparoscopic tool to simultaneously grab the fibroid and cut it off. The mass was too big to just yank out so they spent a long time cutting it into small pieces. This work seemed to be very routine for the doctors because they began to talk about all sorts of things. What I remembered most of the conversation was that one doctor was going to get her Thanksgiving food from Market Hall, which is something that my grandmother was thinking about doing too. The cutting took a long time so they had someone put on some music to “set the mood”. Instead of 90’s alt rock the music for these doctors was more contemporary. I recognized one Muse song, but that was it. After taking the mass out, they sutured up the holes using the smallest needle I had ever seen. Ben got to do some of the sutures and I think he did a good job. After the procedure was over I had to go home to check on my sick cat, but I had spent a good six hours from 7:00am to 1:00pm watching surgeries that I had not seen before and also seeing the surgeon’s personalities come through in the music they were playing.
Written by Arisa Mototake (class of 2015-2016)
I got to OA-2 at 6:50 and there were already 5 residents seated at the table. I politely said good morning but all I got in return was a stare. I sat at the table but felt very out of place. I now understood the urge to sit behind the wall. Dr. Harken walks in and starts his mini-lecture. Today he spoke about acute blood loss in trauma/surgery. He then posed a question, is this blood loss the same as anemia found in cancer, chemotherapy, critical illnesses or other chronic diseases. The residents remained silent. He then poses another question, “Does the number of hemoglobin make a difference or how you got there?” Dr. Harken then answers “We simply do not know”. He then continues to go through different experiments and statistical data and explains that many different patients respond better on the SF-36 when they have higher hemoglobin counts. SF-36 is a group of 36 questions to assess how happy/healthy you are. To wrap things up the goal of this lecture was to press that the goal of a physician was to make the patient feel better.
He quickly wrapped up lecture and I hurried over to him as he was about to leave. I introduced myself to him and he happily introduced me to Dr. Kara Rothenburg, a second year resident.
She looked a bit hesitant at first and told me that she had elsewhere to go afterwards. She quickly explained to me which OR she would be in and told me to meet her there. First time in the OR and now I had to find my way without sticking out like a sore thumb. I asked a cleaning lady where the front office was to get the vendor card for the futuristic scrub dispensing machine. I finally got to the office and asked for the vendor card. “Who are you?” the woman asked coldly. I quickly explained and she told me I had to leave a collateral for the card. Boy, was she intimidating. I quickly changed into my scrubs and headed on over to OR4. (After asking someone of course; I wasn’t going to risk becoming lost on the first day of my OREX)
The first procedure being done was an ICD placement for a 57 year old male suffering from Atrial Fibrillation and CHF (Congestive Heart Failure) with an ejection fraction (EF) less than 20%. EF is the percentage of blood that is pumped out from the heart with one contraction and is one of of the clinical indications of heart failure. A healthy individual will have an EF over 55 percent. This was a great surgery to start my OREX experience as I volunteer in the healthy hearts clinic with CHF patients. Many of our patients have pacemakers so being able to watch one being installed was incredible; I felt my volunteer experiences coming to a whole circle. I walked in and the patient was getting prepped for anesthesia. As fluoroscopy was going to be used I was instructed to wear a lead apron for protection. Dr. Harken walks in and explained the procedure to Kara. They were to insert a catheter through the superior vena cava and insert an electrode into the right ventricle to shock and pace. Kara showed me how to scrub in just in case I ever needed to but I reassured her I was only there to observe. Afterwards we re-entered the OR and the nurse taught me how to assist in gowning. At 8:29AM the patient was completely ready for the procedure and the first incision was made. Kara started cutting away and inserted her fingers to clear the connective tissue. I later saw that this was a pocket for the pacemaker. Kara then continued and inserted a needle below the clavicle for catheter insertion. This was rather a difficult task as she kept hitting the bone and was unable to get into the SVC. It took her many attempts but she was able to get it in successfully after putting in some contrast dye and visualizing it via fluoroscopy. The next couple steps for getting the electrode in was a tad confusing but involved multiple tubings and some pushing and pulling (excuse my crude explanation). But the electrode was placed and a technician was present to check on the signal. The numbers from the signal were stable, and the electrode was fastened and tightened and hooked up to the pacemaker. It was then tucked into the pocket made previously and sutured shut. After the surgery, Kara needed to go to the ICU and so she introduced me to a different resident, Dr. Francisca Maertens.
The next procedure being done was an arteriovenous fistula. This procedure is normally done for patients with end stage renal disease to make an easier access point for dialysis. The procedure first starts with searching for the venous target. It normally is done on the wrist but this time Francisca and Dr. Harken decided to use the area right above the elbow as the vein was easier to find there. As the incision was made and the target was found, the vein was surrounded by large amounts of fat droplets. Francisca isolated the vein and tied it to cut it off. It was then colored with a marking pen to indicate and prevent twisting. She also closed off and removed smaller veins that branched from the larger vein and cauterized them to prevent excessive bleeding.
Once the vein was isolated they flushed it out with a heparin/saline solution (weak heparin). Since the inside of the vein is very thrombogenic, it must be coated with weak heparin to counter these effects to prevent blood clots. There was another incision made medial to the first incision to find the arterial target. After isolating the artery and making a small incision on the artery the vein was looped under the skin to act like a bridge onto the arterial side. Francisca quickly sewed the vein into the artery. There was a discernible pulse within the vein and since veins do not normally hold pulses, this signified that the surgery had been completed successfully.
The turnover time for each surgery seemed to be 20 minutes for the same OR room so I decided to use this time to quickly eat my lunch and went back to OR4 for the next scheduled surgery.
This next procedure was a port-a-cath. It was a 54 year old male with metastatic rectal cancer. Once again this procedure required fluoroscopy and so wearing a lead apron was required. Kara came back to the OR and they (Kara and Dr. Harken) used an ultrasound to search for the carotid artery and jugular vein. This patient was not fully knocked out from the anesthesia, as they used a different form compared to the other cases I saw that day. The anesthesiologist nicely explained that they were using Ketamine and Propofol which induces a dissociative state. Initially it was a little difficult to see but they were successfully able to get the catheter in the vein. The anesthesiologist kindly allowed me to stand in her area where I propped up two stools on top of each other to be able to see more clearly.
Francisca then injected some lidocaine to where she was making an incision, right below the right clavicle. She then continued to insert a rod connected to a white tube. A small device was inserted where the incision was made (below clavicle). They removed the thin, long metallic catheter and inserted a valve like device simultaneously and inserted a tube into the valve. The procedure was a little confusing as I did not understand what was occurring or what it was for. I later asked Dr. Harken and he explained to me that the purple device being put in was a port for chemotherapy patients as the arteries starts to deteriorate when being used for chemo for so long. The white tube connected to the device goes straight into the right atrium and allows the drugs to flow directly into the heart.
I was so grateful for Dr. Harken allowing me to see so much during surgery. I feel like this opportunity was very rare and everyone on the surgery team in OR4 were all so nice, my first day of OREX was truly an incredible one. I finished my day at 5pm totaling to an 8 hour day and boy was I pooped. I thanked everyone for allowing me to observe their work and I happily went home. If you read all of my rambling, thank you! and yay to a great first day in OREX (: I cannot wait for my next day!
Written by Shannon O’Brien (class of 2015-2016)
I woke up this morning with mixed emotions. I was nervous, but also really excited. The idea that I was going to be able to observe my first surgery had finally hit me and I was really looking forward to it. When I arrived at the hospital my nerves had peaked but I remembered what we had talked about at our meeting. I told myself to be confident and comfortable. I went up to the fifth floor and entered the main door, I glanced at the board on my way to the office and saw the charge nurse standing in front of the office. I asked her if I get the key for the scrubs in the office and she asked who I was. At this time I realized that my badge was flipped over and she couldn’t see my name and picture. I turned over my badge and introduced myself as one of Dr. Harken’s students from the OREX program. She told me I could go into the office and ask one of the people in there for the card to get scrubs. I entered the office and introduced myself. One of the women in the office gave me the card and told me to exit the way I came in and to go through the door and into the changing area.
I got my scrubs and went to change. After changing into my scrubs I found a spot for my stuff on the shoe rack and exited the locker room. I put on my hair cover and shoe covers and made my way to the OR board. I looked at all the names of the surgeries that were occurring and the one that caught my eye was a breast reduction. I saw the charge nurse again and she told me that that would be a good one for me to go in on because they were going to be starting in the next few minutes, I thanked her and made my way to OR 7. When I looked through the window to the OR I saw that the patient had already been sedated and intubated. The surgeon was scrubbing in at the sink next to the OR so I waited for him to finish so I could grab a mask without getting in his way. He introduced himself, Dr. Allen, and asked who I was. I explained and he told me it would be great if I joined them. I grabbed my mask, put it on, and entered the OR behind Dr. Allen. He introduced me to everyone in the OR and then he started talking to the nurse to make sure everything was in order to get started.
I was given a stool to stand on so that I could see well. This was amazing, I never expected to be this close but it was incredible. Dr. Allen explained that the patient was a woman in her early 60’s who was having this procedure done to help alleviate some of the back pain and discomfort she was experiencing from the size of her breasts. He explained that the patient was HIV positive and that extra precautions would need to be in place to ensure everyone’s safety. I was given a face shield because I was standing so close to the table. I started to wonder how the surgeon feels about operating with the risk of having a patient with HIV. The first thing Dr. Allen did was inject epinephrine mixed with saline into multiple areas of the patient’s breast to reduce bleeding. Dr. Allen explained that the patient areola were relatively small so he would not need to reduce them to match the change in breast size. He discussed that often the areola have to be reduced during a breast reduction so that they match the new reduced size of the breast.
Dr. Allen began making his incisions, he explained the need to isolate and maintain the pedicle, where the nerve and blood supply are, so that proper healing can occur and nerve sensation is not compromised. He began de-epithelializing the breast by slowly cutting and removing the skin. Dr. Allen explained that the patient has desired to be a C cup by the end of surgery, but explained that that might not happen because removing that much tissue might be damaging. The patient had been an E cup and was likely to end up with breasts about the size of a D cup. Dr. Allen explained that breast surgery is unique, because unlike other surgeries, the breast does not contain the same anatomical and vascular land marks.
Dr. Allen removed the tissue from the first breast and weighed it, he mentioned that he expected to remove slightly more from the other breast because it was a little larger to begin with. When Dr. Allen finished with the first breast (right), the nurse practitioner, Beazley, began stapling the breast closed. After finishing with the staples he made his way along the staple line with sutures, removing the staples as he went. Dr. Allen continued on the left breast with one of the residents assisting him. When he finished he applied the staples and the resident did the suturing. Dr. Allen then went to the phone and did his charting while the nurse practitioner and resident continued to suture. The surgery was 4.5 hours long with at least 2 of those hours being just suturing, I could imagine that their hands must have been pretty tired after that. I left the OR and thanked Dr. Allen for allowing me to watch.
Reflecting on the surgery I thought about the fact that I was really glad that the first case I got to observe was a plastic surgery case. What I like about plastic surgery is the fact that the results are so apparent. You are able to see perfectly clear what was done and the end result the patient will see. I was unable to see anymore surgeries that day because all the others were in progress when I got out of my surgery, but it was an amazing day and I am really looking forward to my next OREX experience.
Written by Sarah-Jane Parker (class of 2015-2016)
The night before I decided to put my new doughnut pan to good use and bring apple cider baked doughnuts to the morning meeting. I had forgotten it was Friday the 13th the next day, and I ended up baking a failure instead of the dreamy autumnal doughnuts from Molly Yeh’s Blog (yes I’m blaming bad luck). See side by side comparison:I internally debated whether to bring the hideous creatures that still tasted pretty good and ended up throwing them in my bag and delaying the decision. I arrived in the conference room at 6:30 on the dot and did work until 7:00 when I started to worry because I was still alone in the dimly lit room. A couple minutes later the chief resident and a couple 2nd years came in and wondered the same thing and then saw the baked doughnuts on the table. It was later explained that Dr Harkin was out today,and that I had brought food. Everyone was super appreciative, and I realized this was a genius baked failure idea. A 5th year joked that he would be happy to make all my surgery dreams come true.
The focus of the morning meeting was practicing Oral Boards. It was explained by the board certified surgeons that the point of boards was not to discern your history/physical exam skills – these should be well-honed at this point- but rather to talk about management of the patient, clear knowledge of contraindications and diagnostics, and that the scenarios will change quickly. It was impressive to see how much knowledge needed to be at their fingertips: from stratifying patients with appendicitis to rare adrenal cancers.
The meeting wrapped up, and I was resigned to the fact that I would be finding my way again by myself. At least I knew how to work the scrub machine this time! I hurried along with the students, changed quickly and was in front of the board before all but one of the surgeries started. I noted the Laparoscopic cholecystectomy patient was rolling towards OR7 and headed that way.
Dr Lee (5R) and Dr Huyser (2R) were performing the surgery with Dr Victoriano attending. I was familiar with this duo from two surgeries on my last OREX. They work quietly and efficiently and Dr Lee tends to invite questions in quiet moments or after the surgery is done. The Patient was a 27 year old male who had been complaining of pain due to gall bladder stones. Dr Victoriano later explained that although diet and medication can help manage gall bladder stones there are few long term risks to removing it (diarrhea) and gall bladder pain (due to stretch receptors) can be truly debilitating. The patient was joking with the anesthesiologist about getting the good stuff and he was quickly put to sleep and the surgery was under way. Once the camera wand was in, the gall bladder was visualized as a purplish looking gland wrapped around the intestine. The peritoneum was slowly pulled away from the surface of the gall bladder, so that the surgeons could visualize the anatomy. Dr Victoriano explained that the complication of this surgery is in being sure that you are not cutting the hepatic duct connecting the liver to your digestive system. The surgeons therefore need to isolate the cystic duct (connecting gall bladder to common duct), the cystic artery, and then the right hepatic duct to be sure they are in the right place and because not everyone’s anatomy is text book. In my hand drawn picture the lines across the duct / artery are where staples were placed and before sectioning off the gall bladder.
Once removed, the surgeons noted the gall bladder was full of stones. I hoped I could glove up and touch it, but I didn’t want to interrupt. Next time!
The next surgery was a left breast excisional biopsy with Dr Bullard and Dr Hernandez (intern). The patient was a 47 year old female whose X-rays were up showing where radiology had marked some unusual calcifications. Dr Bullard explained that calcifications themselves are not dangerous but they indicate something (potentially cancerous cells) may be blocking a duct. He also explained that they would be going in to collect a biopsy sample, following the wire that poked through the patient’s skin and looped around the area where the unusual calcifications were located. The surgeons would need to be careful not to move the wire (or it would need to be replaced by radiology) and to be sure to section out enough tissue for the biopsy while being as conservative as can for aesthetics sake. Finally, he explained that about 40% of these biopsies indicated cancerous tissue that would require further treatment. As the surgery got underway, Dr Bullard complained about the placement of the wire which apparently ran parallel to the skin surface for too long rather than going straight. This meant that the surgeons needed to cut more into the tissue and also be careful to not move the wire for a longer distance. The surgery went longer than expected for this reason, but the biopsy was eventually gathered and bagged up. Dr Bullard went directly to pathology to confirm that they were able to get at least 1 mm around the calcifications – otherwise they would need to go back in to gather more. While we waited for results, Dr Hernandez closed up and we discussed med school and challenges of the intern year. Dr Bullard quickly confirmed that enough tissue had been taken (barely) and the patient was woken up. I thanked everyone and headed to the board.
I hoped to watch an orthopedic surgery in OR 1 or 2 and waited over there for 30 min, but something changed or was rescheduled and I went back to the board to see which surgeries had already begun or were not scheduled till much later. I decided to wrap it up for the day and headed to go change out. The chief resident stopped me to thank me for bringing donuts again and I resolved to bring food more often. Excited for next time!
Written by Andrew Hartman (class 0f 2015-2016)
As I was one of the students who missed the orientation, I was very grateful for all of the excellent write-ups from those who had already gone before to help me know what to expect. That was super helpful, and I had much less anxiety, and it helped me to have a really great first day!
I arrived in the OA-2 conference room at 0645 and took a seat along the back wall. The residents and medical students started arriving just before 0700, and Dr. Harken walked in wearing a suit right at the stroke of 0700. He had some NG tubes in his hand and joked about how, when he was in medical school, students would have to intubate each other while conscious. He then went on to lecture about lung function and how it is particularly relevant to surgeons.
Dr. Harken explained that the Department of Surgery was trying to establish a “surgical hub,” which was a group to handle pre-op logistics that the surgeons didn’t have the time to deal with. He further explained that, three years ago, approximately 44% of procedures were cancelled due to administrative reasons after the patient was already in the operating theatre, and this surgical hub was intended to mitigate that. One of the things the surgical hub would be responsible for would be addressing the four things that an anesthesiologist would want to know about a patient:
- Are the patient’s lungs okay?
- Is the patient’s heart okay?
- Is the patient particularly likely to bleed (for non-surgical reasons)?
- Is the patient particularly susceptible to infection?
Dr. Harken then went on to lecture about lung function. There was lots of interesting physiology and pathophysiology, which I won’t bore you with here, but there were some interesting take-aways for surgery.
- If a patient is taking beta blockers for their heart, it increases their work of breathing.
- Hypoxia leads to an increase in anxiety but not a change in minute ventilation. If a patient is unusually anxious post-op, that patient should always be considered hypoxic until proven otherwise.
- Many physicians and clinical staff think that extubating a patient will reduce their work of breathing (assuming they are off the ventilator and breathing on their own). In fact, this is not so, and the effort of breathing when intubated is about the same as extubated.
We then broke up the lecture. I rushed to introduce myself to Dr. Harken. He was very welcoming and gracious, as others have mentioned, and introduced me to Jessica Williams, a fourth-year resident who is working with him this month. He asked her to show me around and get me settled, which was a huge help. We went upstairs and Jessica showed me where to get the vendor card and where the men’s locker room was. I got my scrubs and got changed and met her outside the board. Her first surgery of the day was to install a porta-cath and suggested that I start with that.
Catheter port installation in 51 y.o. female.
When we arrived in the operating theatre, the patient was already on the table and sedated. I was introduced to the rest of the operating room staff, notably Lindsay who was the circulating RN that day. Lindsay and Jessica taped the patient’s breast out of the way and put a rolled blanket under her so that the neck was curved, making access to the veins easier. Jessica then used a portable ultrasound machine to visualize the vein and marked it with a pen. After that they scrubbed up and prepared the sterile field over the patient. The plan was to use x-ray to confirm placement of the catheter, so we were all wearing lead aprons and neck coverings.
Dr. Harken arrived at 0816 and conducted the time out, where they confirmed the patient’s identification and went over what the surgery was to entail. Jessica then made a small incision, cauterizing the skin with the cauterizing tool, over the vein so that she could pull the skin back and stuck her needle into the vein, sliding a wire all the way down into the patient’s heart. They then took an x-ray to confirm that the wire was in the right place. For my benefit, Dr. Harken asked them to take a continuous x-ray for a few seconds so that we could see the heart beating and the lungs moving with her breaths. That was pretty cool.
Next, Jessica made a larger incision in the patient’s chest, cauterizing the skin as she went, to serve as the pocket for the port itself. She slipped the port under the skin and threaded the catheter under the skin up to where the first incision was. Like others have commented, I was surprised at how rough it seemed. The catheter was threaded along the wire all the way down into the heart, and the wire was removed. The catheter was now entirely under the patient’s skin with nothing showing. Another x-ray was taken to confirm correct placement and that there were no kinks.
Lots of local anesthetic was injected at both incisional sites. Jessica explained that it was novacaine with a little epinephrine in it. The epi is a vasoconstrictor, which minimized the weeping and oozing at the injection site, making it easier for her to close it cleanly and reducing bleeding. Dr. Harken then closed the neck incision while Jessica closed the port incision. Both were beautiful – you could barely see the line. Bandages were placed over both sites and the procedure was over at 0842. The patient was roused and seemed calm but a little groggy. Jessica’s next surgery wasn’t for a while, so she took me over to another operating room where an interesting surgery was about to begin and introduced me to the staff there.
The second surgery was for a 47 yo female who was having a cholecystomy (gall bladder removal) and a partial hepatoectomy (removing part of her liver). Apparently, she had cancer of the gall bladder that had spread to her liver, so some of that needed to be removed as well. Even though that surgery was scheduled for 0800 also, when I got there at 0850 they were still prepping the patient. She was sedated, but as this was very major surgery with lots of bleeding expected, they had established several access points, including an arterial line. They had also tried to give the patient an epidural, but that had not been successful.
The surgery was to be done by Dr. Victorino (attending physician) and Dr. Panmer (chief resident). After they finished prepping the patient, they scrubbed up and established their sterile field. Dr. Panmer then made a HUGE incision (about 30 cm) across her belly above her liver, and used the cauterizing tool to burn through the belly fat (the patient was fairly overweight, so there was a lot of that to get through). They then placed a frame over the incisional site. It looked like a giant erector set with a hoop to which they attached the retractors and pulled the skin, fat, and layers of muscle back to expose the peritoneal cavity. After moving around at the foot of the bed trying to stay out of everyone’s way (and being told by the scrub tech to NEVER turn my back to a sterile field!), the anesthesiologist kindly brought me up to the patient’s head, where she put a stool so I could stand out of the way and watch the procedure over the sterile drape. I was able to see the patient’s liver right in front of me. It was pale pink, not the deep red I normally associate with liver in the supermarket. The surgeons worked for a couple of hours to excise the cancer and remove the gall bladder. They were cauterizing up the blood vessels and bile ducts that they were severing. I couldn’t see very well, but I gathered that not everything was exactly where they thought it should be. At one point, Dr. Victorino asked Dr. Panmer, “What’s your plan?” Dr. Panmer responded, “Well, this doesn’t look anything like the Youtube video I watched.” Everyone got a good chuckle. Unfortunately, I had to leave at that point. My afternoon class had been moved up to a noon start and I wasn’t able to stay as many hours as I had hoped. However, I felt very fortunate that I got to observe two very interesting and exciting procedures being performed and I’m looking forward to coming back in December on a day when I have no conflicts and can stay the entire day!
Written by Antony Gout (class of 2015-2016)
The name of the day was laparoscopic Cholecystectomy, or in common parlance, gallbladder removal. I saw three such procedures, and one hernia repair with a mesh. But let me start at the beginning.
I got to the conference room early, and sat nervously in the dark because I didn’t want to turn on the light and draw any attention to myself. Residents started filling in at around 6:55, and I exchanged pleasantries with one of them, Jessica, while waiting for the lecture to start. It was a discussion on lower GI bleeds, which mostly involved the discussion leader (whose name I forgot to note), quizzing the residents about their reading. Evidently lower GI bleeds are rarely surgical and have many possible causes (including hemorrhoids, ulcerative colitis, bacterial infections, etc…). As the discussion wound to a close, I paid less and less attention, as I got more and more nervous. Not wanting to have the same experience as Sarah-Jane, as soon as the discussion ended, I got up my courage and rushed to introduce myself to Dr. Harkin. He immediately paired me up with a Chief Resident, Abhishek Parmar (who I will call AP, in case I misspelled his name), who I followed around for the rest of the day.
I followed him up to the surgery floor, although I didn’t really get a chance to talk to him, because 3 other residents were crowding around him most of the way talking about plans for specific patients, which I couldn’t really follow. He showed me to the dressing room where I fumbled into my scrubs. A few minutes later, I follow AP into the surgery room.
Surgery #1: Laparoscopic gallbladder removal
The patient, a middle aged female, was already sleeping and the abdomen had been cleaned when I entered. I picked a spot that seemed out of the way, and crossed my arms so as to not touch anything. Dr. Cushman, the attending, must have thought I was cold, and draped a warm blanket around me. He also offered me a seat near where I could see one of the two screens, which I thought was very sweet. The resident performing every surgery I saw was a second year resident, Michelle (M). The patient was covered with seemingly unending layers of blue surgery sheet things, and the surgery started.
First, AP or M punched a hole in the abdomen, I believe the navel (I’m not entirely sure, because I couldn’t see very well), inflated it with CO2, and placed the camera. Then M illuminated from the inside the other spots where they want the other holes to go. AP injected some lidocaine at each site, scored the skin with a scalpel, and jammed in a laparoscopic channel (And when I say jam, I mean it. When I saw it on the screen I was shocked by how physical and almost crude the process was). Once all the tools were inside, they looked for the gallbladder (which apparently looked so generic it could have been from an anatomy textbook). Once found, they have to free it from the tough peritoneum around it by using the cauterized tool (Figure A). I looked up how that tool works, and it uses a small electric current to heat itself up and burn the tissue you place it on. M started out by hooking the cauterizing tool in between the peritoneum and the gallbladder and twisting the tool to free up some space. AP told her that it is instead preferable to move it up and down (Figure B), after which you can pull away from important tissue and
cauterize. Then she dissected out the artery and the duct, by using the Maryland tool (Figure C) with which she was told to columnize the fascia (Figure D). She also used the “peanut” to twist away some fascia. She then clipped three times the duct and artery and cut in between the second and third clip (Figure E). After this, they carefully cauterized the gallbladder out, plopped it in a plastic bag, and popped the bag out of the body. They popped in some gauze to sop clean up the area, and then deflated the patient (it sounded like letting the air out of ball, it was weird). Finally, they cauterized the wounds (also sometimes touching the cauterizing tool to the tweezers, which I assume heated those up and allowed AP to cauterize with more precision, which was very cool), and sewed her up layer by layer. Phew! What a trip. We grabbed a small bite to eat, and got back down to business.
Surgery #2: Laparoscopic gallbladder removal
The second surgery was extremely similar to the one before it, so I won’t bore you with another long-winded description. There were some differences though! First, the artery seemed to branch, so Dr. Cushman asked M to dissect it out to make sure one branch didn’t go to the liver, which it turns out it didn’t. The first clipping tool was faulty and M accidentally launched a clip into the abdominal cavity, which AP quickly grabbed. After another few more close calls, they switched out the tool. Once the surgery was done, I followed M who had to get a consent form filled by a patient to have her gallbladder removed later that day. Then, we went back to the OR for the next operation.
Surgery #3: Inguinal hernia repair with mesh placement
This patient was a 29 year old male. I didn’t get to see nearly as much as the previous two surgeries, because it was not laparoscopic and thus there was no screen to watch. Nevertheless, I gave my calves a really good workout in order to make myself as tall as possible. AP made one slice into the lower abdomen and they went at it. They dug in with their fingers (again, it seems so crude), pulled out a slightly white tube out of the way which I thought was a portion of intestine, but actually I later learned was a spermatic cord (I was quite shocked that those things went up so high! They also mentioned the “vas” a lot during the surgery, which again, I didn’t think was the vas deferens because I didn’t know it went up so high). They pulled out some stuff (like I said, I couldn’t see that well), cut out the ilioinguinal nerve (which apparently can get tangled up in the mesh which caused a lot of pain. Sacrificing it means losing some sensation on the skin if the thigh, a relatively low price to pay for not being in pain), pushed the mesh cone in, then sutured the flat part of the mesh in around the spermatic tube. They shoved everything back to where it belonged, and sutured the patient up layer by layer. I make it sound like it all happened in five minutes, but it really took quite some time to find the hernia, isolate it, cut it out, and suture the mesh in place. M’s final suturing was quite beautiful, because you couldn’t see the stitches when she was done. She then applied pressure to the wound for a while. I had time to quickly eat before coming back to the OR.
Surgery #4: Laparoscopic gallbladder removal
My last surgery was on the 26 year-old woman from which we had just obtained consent. Again, I won’t bore you, but instead I will highlight differences I saw in this surgery. Her gallbladder
was again, normal looking, even though it was supposed to look inflamed (AP joked that I was their lucky charm, as my presence clearly caused these wonderful gallbladders and smooth operations, and that I should maybe come again next week. I think so too, AP. I think so too.) This gallbladder was a little less eager to leave the abdominal cavity, because it ruptured while they were cauterizing it out. M had to quickly cauterize it to stem the flow of bile, and then quickly cut it out. They had to irrigate the area (with saline I believe) to wash away the bile. Lastly, there was some bleeding that they had to stop so they cauterized a whole big area until they were satisfied. Once they closed her up, I followed AP out of the room, and thanked him and said goodbye.
I think it was because I was so tired, but I forgot to thank M and the rest of the surgical team for letting me watch them before I took off my scrubs, and once I had changed, I couldn’t go back in to the OR and speak to them, so I’m really annoyed at myself because of that. I hope I see them again to tell them so! Thus ended my first OREX day, at 4:05 PM.
For those of you who have followed me this far, I have a few remaining comments. I was incredibly thankful for being able to see three of the same procedures by the same surgery team. I saw M learn throughout the day and integrate her learning. As AP said, it is a rare thing to have three of the same procedures lined up like that, which really will help her get comfortable with the operation. I spent the rest of the day in awe of the skill and care the entire surgery team displayed.
The images of the surgeries have kept playing in my head; as I fell asleep that night, my mind was filled with images of Maryland tools, spreading fascia, again, and again, and again.
Thanks for reading! I have the figures below (some of them from the stryker website source: Stryker website, and some of them drawn with my great artistic skills).
Figure A: Some cauterizing tools from Stryker. I’m not sure if AP and M used any of these, because they don’t look all that familiar.
Written by Amari Washington (class of 2015-2016)
My first day with OREX was interesting to say the least!
I arrived in the OA-2 room at 6:30am. I signed in and walked towards the table. I paused and looked at the chair in the corner across from the table, next to the door. I laughed a bit remembering what Lucy said about hiding behind the wall, I was tempted, but decided to sit at the table, in the same seat I took during our orientation. I did some reading as I waited for the rest of the group to arrive. When 6:50am came around I began to wonder if I was in the right room. At 6:55 I thought maybe it was Saturday and I had gotten my days mixed up and missed my OREX day due to extreme exhaustion (ridiculous, I know haha).
At about 7:01am three people walked in. I greeted them. The women said hello and took their seats on the opposite side of the table. The man that walked in with them remained silent and sat in the back corner of the room (I’m guessing he was tired). The rest of the group began to trickle in, exchanging stories about things they had seen on previous shifts and preparation for the day’s cases. One of the residents told his colleagues about a case he had regarding an elderly woman who had been in a car accident. I am not completely clear on the details, but it sounded like some “young reckless driver” ran into her and her seat belt sliced her neck. I believe about two weeks later she was still having pain, and they determined that surgery was required. They found her earring inside of her neck. The resident passed around his phone so everyone could see the earring he removed (it was pretty big). He mentioned that she was unaware that it was in there, and that she just knew she was in pain. Crazy, right?!
I introduced myself to Dr. Harkin. He was very kind and told me he was happy to have me there (Yay for OREX student!!). He then introduced me to a fourth year resident by the name of Dr. Jessica Williams. He asked her what she had on her schedule for the day. She explained that she was with ENT for the day. Dr. Harkin asked if she minded if I tagged along and explained that I could hang out with Jessica for the first part of the day, and that we would link up later on so that he could take me around the OR. She agreed. She was very warm and welcoming. We discussed her journey through medicine and she inquired about mine. We also discussed her schedule for the day. She explained that ENT was Ear, Nose and Throat, and that the surgeon she was going to be assisting was Dr. M. McDonald. Jessica took me to the 5th floor and helped me work the machine to get my scrubs. That machine was awesome! Pretty cool how the scrubs were neatly folded in a little section of the machine. After changing into my scrubs, Jessica allowed me to place my belongings into her locker. I put my cap and shoe covers on before completely exiting the locker room.
We then walked over to the pre-op area and approached her first patient. She greeted her warmly, introduced herself, then me and asked if it was okay that I was present during her procedure. The patient agreed. The patient was a young woman, perhaps late teens, no more than twenty years of age. The first procedure was a tonsillectomy. Jessica explained the case as we put on our masks and entered OR 4. I watched as everyone set up the OR; the surgical tech, Joe, set up his station with the RN, Glenda, assisting him. The anesthesiologist, Becca, was instructing the resident, Justin, on how to help set up their station, position the patient, and how the medication would affect the patient. Jessica was paired with Dr. McDonald and the PA, Ingrid. I enjoyed watching them work as a team, each component coming together in order to ensure that the procedure ran smoothly for the patient.
Once the team was ready to start, after Dr. McDonald, Jessica, and Joe were scrubbed in (Ingrid exited the OR to attend to something else), they read off the start time, procedure and information about the patient. They began by placing some sort of instrument (I didn’t catch the name) into the patient’s mouth in order to keep it open during the procedure. I wanted to make sure I was not in the way, so I tried not to get too close to the table. Justin grabbed a stool and placed it directly behind Dr. McDonald so he could get a better look. Since everything was done inside of her mouth I couldn’t see much. When the tonsil was removed, Jessica told me to take a closer look. It was huge! Maybe around the size of the circle you can make with your thumb and index finger. Once the procedure was finished, they asked me to come stand on the stool and look at the stitch they made. Once they removed the instruments from the patient’s mouth Dr. McDonald left the OR. Jessica, Justin, Becca, Glenda and Joe all began prepping the patient for recovery. She began waking up, and as she became more alert she began to twitch, and push away from the OR staff. She was disoriented and pretty aggressive. She tried talking but couldn’t since her throat was sore. She started crying and kept pulling her oxygen mask off of her face. The OR staff did their best to comfort her and keep her calm. Jessica explained that this reaction usually happens with pediatric patients when they first wake up, and that for some reason, the adult patients don’t normally react that way. Once they were able to calm the patient a bit and transfer her to the other bed, they rolled her over to recovery. There, we sat and waited for the next procedure.
During the wait, I overheard the staff discussing a few issues with the day’s schedule. The next two surgeries were delayed due to issues with paperwork and insurance. The staff expressed their frustrations with the issues that caused the delay. While we waited, Jessica took me over to the OR board. It was set up much different than the board I was used to reading for the OR on the 9th floor. She helped me to better understand how to read the board and walked me over to two of the ORs. One was performing a mastectomy and the other was dealing with a hernia. The hernia had just finished and the mastectomy was extremely difficult to see, so we hung out in the pre-op area until it was time for the next procedure.
The second procedure was a Thyroidectomy vs. Right-hemi. This patient was a woman in her late twenties/ early thirties. This procedure was much easier to see. Jessica told me that the best position would be next to the anesthesiologist, so I positioned myself right next to them. Justin brought me a stool so that I would be able to see a bit better. Before they opened her up, she instructed me to feel my own neck and then feel the patient’s neck so that I could get a better idea of the size, position and feel of the mass. They started by making a small, horizontal incision across her throat, in the middle of the area they marked for the mass. They then used instruments to cut and burn through the fat and muscle in order to get past the many layers that covered up her thyroid. Dr. McDonald allowed Jessica to do the majority of the procedure as he guided her along. Ingrid assisted with the positioning and Joe provided all of the necessary instruments. One in particular was the harmonic, which they used quite a bit in order to make it easier to cut and burn through the fat and flesh. During the procedure, Jessica was sure to explain every step as she proceeded, moving certain muscles rather than cutting through them, identifying major arteries and nerves and explaining the severe consequences of damaging them. They eventually removed the right side of her thyroid and then flushed out the area. Once finished, they began to stitch up each layer, thicker sutures (surgical thread) were used for the more inward layers. Jessica explained that they did not want to make the stitches tight in order to allow for oozing. If the patient began to bleed, the build up of blood would result in the formation of a large lump in her throat that would press on her airway and eventually stopping her from breathing. Once they got to the outer layer, they used smaller sutures (surgical thread) and made them tighter in order to reduce the visibility of the scar that would eventually form.
As with the first patient, when the procedure was finished, Dr. McDonald left the OR (he actually left before the suturing was finished – Jessica completed the suturing and Ingrid assisted). When the patient woke up, she too was disoriented, but as Jessica explained, she did not react the same way the first patient did. She was a lot more calm and less aggressive. She quickly relaxed and was rolled over to recovery.
The final procedure I saw was called a Functional Endoscopic Sinus Surgery. This patient looked to be in her mid to late fifties. Before the procedure, Jessica showed me some of the images from her chart to help explain the issues the patient was having. The right side of her nasal cavity looked normal, but the left side looked like she had a huge blockage. Once we arrived in the OR, everything was already set up. This procedure was going to be viewed on a huge screen. Dr. McDonald began by sticking white strips with blue strings into the patient’s nostrils. Jessica explained that the medication on the strips would help reduce bleeding and also help open up the cavity. After a few minutes, the strips were removed and they began inserting the camera (which was actually a long rod with a small camera at the tip). They used the camera to navigate and identify the different structures in the cavity. First they viewed the normal nostril (on the right), then moved to the left side and pointed out the huge differences between the two. I was able to see where the mucus was dripping and where the polyps were located. Dr. McDonald started by using an instrument (I cannot recall the name) to break the maxilla bone. He then broke into a mass that caused a bit of mucus to leak out. He began removing the pieces of bone and the polyps. Dr. McDonald allowed Jessica to navigate around the cavity to make sure everything was removed. Once the cavity was cleared, they flushed it out. They made sure that there were no polyps, left over bone fragments or liquid left in the cavity. Once the procedure was complete, they placed what they referred to as a “mustache” (a large bandage with tape) under the patient’s nose in order to catch any blood, mucus and additional leakage.
I was sure to thank Dr. McDonald for allowing me to watch his procedures for the day. He was very kind. After he said his goodbyes and thanked the team, he exited the OR. After thanking the rest of the OR staff, Jessica and I exited the OR as the rest of the staff prepared the patient for recovery. Jessica explained that they were essentially done for the day and asked if I was planning to stick around to catch a few more procedures. It was actually time for me to leave, so I went back to the locker room to return my scrubs. The machine is pretty cool, I didn’t know that it accepted “deposits” as well. Once I turned in my scrubs, I said my final goodbyes and expressed my gratitude to Jessica, who said that hopefully next time they can get me in to see some other procedures that I will be able to view a bit better. I did not get a chance to meet up with Dr. Harkin before I left, but I am hoping I can catch him next time!
Woohoo for day one!