November 13, 2015
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!