Monthly Archives: February 2017
Some wonderful pictures from our meeting on 2/18/17! We had great student-led discussions on several issues including the rigors of surgical training and the imposter syndrome, over-reliance on EMR, therapeutic communications skills, strategies to ace the NCLEX and MCAT exams, and preparation for job interviews. Everyone participated and it was great learning exercise for all in attendance!
Written by Olincia White (class of 2016-2017)
My first day in the OR was very exciting. I woke up early and anxious to arrive on time. I showed up to AO2, nervous but excited. After reading all of the journals, I could only imagine what the topic of the discussion would be. I arrived at about 6:55am to find the light off and the room empty. This made me very nervous and tons of thoughts went through my mind. Was I too early? Surely everyone wouldn’t magically appear at 7am sharp. Luckily there was a nice lady sitting quietly in her office, across from the room. She informed me that there were no meeting on Thursday and that although she didn’t know much about the program I should probably head to the OR. More confusion set in. How would I find a resident? How will they know who I am? I made my way to the 5th floor and asked the first person I saw to help me. He was very kind and walked me over to the nurses station. I was greeted by a nice nurse, Wendy, who informed me that all surgeries started at 8:30am on Thursdays. She recommended that I go have breakfast and return. I returned at 8:15am, got changed and made my way to the board. I noticed that the board only had 3 surgeries. Hesitant to stare at the board for long, I picked an OR but I didn’t just want to walk. Luckily Wendy reappeared and helped me pick a surgery that hadn’t yet started. This allowed me to introduce myself to the female resident at bedside and the surgeon, Dr. Geoffrey. I introduced myself and we proceeded into the OR.
Procedure #1 Left Breast Abscess Excision
The staff explained that it was uncommon to see a lot of procedures scheduled at the end of the year and that it was superstitious for patients of Asian cultures to have surgeries before the new year. This patient was having a small abscess excised from her left breast. The patient reportedly works out at the gym 5 days a week. They suspect that the abscess is a result from sweating and daily wear of her constricting bra. After sedating the patient, the resident made a small incision, cut down to healthy tissue and excised the abscess. Dr. Geoffrey stood at bedside, giving minimum instructions on what to do next. After the abscess was removed, the empty space in the breast was “stuffed” with healthy tissue (tissues in the breast were rearrange to make sure there weren’t any empty pockets) and the incision was nicely sutured. During the procedure, Linda the Nurse Anesthetist, showed me how to insert an Esophageal Tracheal Stethoscope! I have never seen one of these used and Romello, teased her for only showing off her toys when guests were there. Either way I was excited and she complimented me for my enthusiasm. The ET stethoscope went direct into the patients airway and had a small earpiece connected to it that allowed Linda to listen to her lung sounds and heart rate. From a nursing standpoint I thought it was pretty cool.
The entire procedure took about 45 minutes. After the patient was sutured up, Linda, the Nurse Anesthetist, prepared her to be extubated.
The circulating RN, Romello, was very nice and immediately began asking about my career goals and interest in the medical field. I explained that I had recently graduated as an RN and word traveled fast! Linda was made aware and welcomed me with open arms. During the procedure she schooled me on her every move and explained why she was adjusting the ventilator, what numbers she was paying attention to and what to do if things didn’t go as planned. As soon as she extubated the patient she began quizzing me in front of all the MD’s (there were 3!). We begin discussing nasal cannulas vs. simple face mask. She asked how much oxygen would be delivered via face mask.. my mind said 40-60% but I was so intimidated that I uttered 40. SMH, always go with your first mind and be confident. We then talked about the Fio2 and what percent we all breathe on room air, 21% of course. Where was my mind. I kicked myself all morning for not being the sharp me that I know I can be. It was humbling to say the least. Once the patient woke up, we wheeled her to recovery and I thanked everyone for their time.
Romello recommended that I check out OR #2 so I headed that way.
Procedure #2 L5 Laminectomy
I entered OR 2 to find a patient lying supine with a cushion box over his face. He was being prepped for a Lumbar Laminectomy. The cushion was going to provide comfort for his face once he was turned over into the prone position. He had cancer in his spine and the surgeons figured if they removed L5 the tumor would have more room to expand and would not compress on the nerve endings as much, saving him from further complications down the road. Without this he could become incontinent and lose his ability to ambulate. This OR was much more crowded, Romello was there so I felt like I knew someone. I was immediately greeted by Larry, the PA, who I absolutely adore! He was a lot of fun, had a lot of jokes but just as much knowledge to offer. He explained the procedure and pulled up the patient’s X RAYS to help me get a better understanding. Larry explained that we were waiting on the surgeon, Dr. Castro-Murell, which he said in a funny tone. He prompted me on how to say it so that “He would be my best friend” and sure enough Dr. Castro-Murell and I hit it off well. He was also full of jokes and laughter. I also had the pleasure of meeting Dr. Thurman Hunt who is the anesthesiologist and supervised both procedures.This entire procedure was scheduled to take about 4 hours but I only had about 2 more to spare.
I spent a lot of my time with the representative from the company that offered a machine that would be used in surgery. The rep was super nice and really enjoyed talking with me. Every chance he got he was showing something else on the machine or making small talk about his previous experiences. He was there to ensure that the doctor could accurately align the prons on the device he was using (poor description but I can’t recall what it was called, and had never seen anything like it). The device had sensors that were facing a camera. Dr. Castro-Murell made 21 virtual markings on the patient that he would later be able to use as reference points. The rep had a machine that had a 3D image of the patient’s lumbar spine. The goal of the machine was to help the doctor find the proper trajectory. Without the device there would be lots of x rays needed. There were cameras on the end of each point and it was up to the doctor and the rep to ensure that it was aligned correctly. Dr. Castro-Murel had no problem with this and things continued smoothly. Unfortunately I had to leave shortly after.
Just watching the patient lie face down with his entire lumbar spine revealed was shocking and interesting. I wish I could have stayed longer but my toddler needed my attention. I felt so fulfilled by it all that I was beaming from ear to ear and signed up for the next earliest day available. I am looking forward to going back.
One thing that was really cool is that a lot of the staff noticed how many pins I have on my badge, (a total of 5) and thanked me for my service!! How nice is that? I absolutely love Highland for days like this! It started off rough but ended well. I am very grateful for the opportunity. Thank you!
Written by Bianca Salaverry (class of 2016-2017)
My second day of OREX turned out to be even better than the first! I’m still getting used to things, so when I first got up to the OR, I was a little confused because it seemed like the surgeries listed on the board weren’t all where they were supposed to be. I wanted to observe a total knee replacement (TKR), but there was a sign on the door to that OR that said not to go in because of the infection risk. I stepped into the room adjacent to it thinking I would observe a surgery in there, but it hadn’t quite begun and the nurse anesthetist urged me to go watch the TKR instead, but to go in through a side door. I went in and sure enough, everyone in the room said it was fine to observe, but just not to go in/out through the exterior door.
There were six main people in the room: a senior resident, a junior resident, a scrub tech, a circulating nurse, an anesthesiologist, and a sales rep. When I first arrived, I was instructed to get goggles because things get a little messy. I remembered Lucy saying this about Ortho surgeries at our orientation, but wasn’t sure quite what to expect. The man who helped me with that was the sales rep, someone I hadn’t encountered in the ED before. One of the most surprising things about this surgery for me was seeing how involved the sales rep was, how much instruction he gave the surgeons, the degree to which they deferred to him despite him having no medical training, and so on. Although all the surgeries I’ve witnessed so far have involved hundreds of tools, this one was at a whole other level. There were drills and saws, rulers, screws; generally just too many devices to count. The sales rep was incredibly knowledgable about every tool, frequently directing the surgeons to use a particular instrument, or instructing them about how something should fit (e.g. “That shouldn’t be so hard to remove,” or “Pinch there and then open it from the top.”). He navigated back and forth around the room between the OR tech and his tools and the surgeons doing the action.
This surgery played out much differently from my previous OREX day in a few ways. First of all, because there were only two doctors at the table, I was able to see what was going on much more easily.
For most of the surgery, I stood at the foot of the operating table, about three feet from the edge. My view was amazing! Secondly, I had heard this before, but this surgery was much more gruesome than ones I’d seen previously. There was a lot more blood (including some spurting arteries), the incisions were much deeper and generally done a lot more quickly than in abdominal surgery, and of course, there was a lot of sawing and drilling involved. After the initial incision, the surgeons flipped the patella out of the way to access the knee joint. Over the course of the next several hours, they proceeded to saw the ends off of the femur and then tibia.
The initial cut, off the end of the femur, was perpendicular to the axis of the bone, but then the doctors made several additional cuts at different angles forming a precise shape that I couldn’t quite capture in my drawings, but which looked roughly similar to this with a groove running down the middle of the femur end.
After each piece of bone was sawed off, a guide was screwed into place so that the next bit of bone would be removed at the proper angle. Obviously this stage involved a lot of sawing and at one point I got flicked with some blood/bone droplets, some of which got on my skin. I definitely wondered at that point about how the surgeons themselves are able to avoid getting splashed with a lot of bodily fluids since they’re right in the middle of the action. I’ll have to remember to ask someone about that sometime.
Once the cuts were all made, the scrub tech mixed some cement to attach the metal pieces that would form the artificial knee. One surprising thing about this step — the cement was really nauseating to me. I don’t have a very good sense of smell, which I think is a huge advantage working in a hospital. I’ve never had a problem before, even with the most pungent odors I’ve been exposed to in the ED, but I almost had to step away from the table because the cement smelled so strong. It was awful! Another surprise: the cement wasn’t mushy like the kind you see used in construction; the texture was more similar to fondant, a kind of sugar based “clay” that bakers use to cover cakes.
At this point, Dr. Krosin, the attending, came in and the surgeons showed him their work. They moved the patient’s leg around, bending and straightening it, and observing its rotation. At one point Dr. Krosin came and stood next to me, and I had the opportunity to ask him a bunch of questions about his experience in Orthopedics. He was very friendly and seemed happy to talk about his work. Dr. Krosin is the chief of Orthopedic Trauma at Highland, so he sees a lot of severe injuries. He talked a little about how orthopedic surgery has this reputation as being less cerebral than other fields of medicine, but that he doesn’t think that’s true. He also touched on how important it is to consider the psychological needs of patients who’ve experienced these major traumas. I was especially impressed by that, because there’s also a stereotype that surgeons don’t see the patient, they only see the part they’re working on, and that was obviously not true of Dr. Krosin or his residents.
After that, we talked a little about the patient at the table and he took me over to the computer and showed me some X-rays of patients he’s worked on recently. One was a young girl who had fallen from a tree, and another was a man who had been hit by a car. I asked about how the recovery would be for the man and he said very matter-of-factly that either the man would heal on his own, or his leg would have to be amputated. No wonder Dr. Krosin emphasized the psychological needs of these patients! I can’t even imagine how I would feel in that kind of situation. One piece of advice Dr. Krosin gave — if you ever get in an accident on the freeway, stay in your car! He said he sees a ton of people come in to the hospital after surviving a car accident only to get injured worse because they got out of their car and were hit again.
Once the artificial joint was put in place, the rest of the surgery consisted mainly of irrigating the area, soaking it in betadine, and stitching the patient up. Overall, this was easily the most interesting surgery I’ve seen to date. At this point, I took a short break, had a bite to eat, and then hurried back to the OR so I wouldn’t miss anything interesting.
It happens that the second orthopedic surgery I got to observe that day was with the exact same team. The patient in this case was an older woman who had suffered a fall and gotten a small fracture towards the end of her femur. The surgery started off roughly the same as the TKR, except that everyone in the room had to wear a lead jacket during the procedure because after the break was repaired, they would need to do multiple X-rays. The initial method for this surgery also involved cutting around and flipping the patella out of the way to expose the knee joint. I don’t know the anatomy of the femur very well, but I believe the break was through part of the medial condyle. It didn’t go all the way through the bone (i.e. there wasn’t a piece of bone that was floating completely separate from the rest of the femur) so the main aim of the surgery was to insert screws to hold the broken part in place until the bone could heal naturally.
As the doctors were working, it seemed like something wasn’t quite going right, and Dr. Krosin scrubbed in to help. Once he was done, he said it seemed like I had a question, so I told him I was a little confused and hadn’t been able to follow what the problem was. His answer was essentially that they were being perfectionists, and that they just needed to accept that their work wasn’t exactly a “textbook” job. I appreciated that piece of advice because it’s the kind of thing I struggle with. There’s a saying “Don’t let the perfect be the enemy of the good,” which essentially means the same thing — don’t get stalled because you want the thing you’re doing to be perfect instead of just good. Once the doctors had decided their repair job was good enough, they took several X-rays from different angles and saw that, in fact, they had done a great job and everything looked as it should.
At this point it had gotten late and was time for me to go, so I thanked the surgeons who had let me spend the entire day with them and said goodbye. All in all a great day!
Written by Himakar Nagam (class of 2016-2017)
Waking up at 5AM, ready for my usual commute, I woke up with a different feeling today– one full of excitement and anticipation. Today was my first day of OREX, and it was all that I thought it would be and more. I put on my scrub pants and my gray t-shirt, walking out of my house in Fremont wondering what I would be observing for the day.
However, my day did not start off as expected. I got to the hospital early, around 6:50A.M., and went to the conference room in OA2 where we had our orientation, only
to find nobody there. Confused, I asked a lady in the adjacent room why nobody was there. She said that on the last Wednesday of every month, they have a special conference with the ED department physicians as well to discuss trauma cases in Classroom A on the above floor. I made my way to classroom A, sat down, and looked around nervously as Dr. Harken had not yet arrived. Eventually, he did, and I introduced myself to him and introduced myself to an attending that I was sitting next to. In came our speaker, Dr.Jeffrey Deweese, Director of the Saint Francis Bothin Burn Center in San Francisco and his 120 slide powerpoint presentation.
He had a lengthy presentation on the largest burn center in Northern California (with 16 beds), specific patient cases, as well as how physicians at Highland could improve their treatment of burn patients before sending them over to the burn center. One thing that Dr. Deweese emphasized was the importance of their burn nurses and the level of collaboration in their burn center. I remember in one picture specifically seeing physicians of all different specialties meeting together to discuss cases as well as hearing him say that their patient bed numbers are limited because of the amount of nurses they have.
With regard to treating burns, he talked about conducting both a primary survey (with the pneumonic ABCDE—you can learn about this more in detail at https://www.americannursetoday.com/abcdes-emergency-burn-care) and a secondary survey to assess the patient. He talked about not immediately putting ice or cold water on the patient contrary to popular belief and wanted physicians to monitor fluids and not put on this common gel used to treat burns called silvadene.
He also discussed determining the TBSA (Total Body Surface Area) of the patient that was burned by using the Rule of Nine’s (which I learned about in my anatomy class this semester!) and using the Parkland’s Formula to estimate how much replacement fluid the patient needs after incurring a burn to remain hemodynamically stable.
Then, he discussed various cases. There was one case about a woman who was window shopping in San Francisco when a transformer blew up right above her and made her fly across four lanes (!) of traffic across the street. In another one, a lady was lighting candles for a religious celebration when her dress caught on fire. Normally for other cases they use pig skin grafts temporarily, but she was vegetarian, so they had to obtain skin grafts alternatively. One boy was working with his dad in the fields when some black powder exploded; for this case, he discussed the usage of a Q-Switch Laser to remove scar tissue and also remove tattoo ink in other patients. I was really impressed with the burn center by the end of the presentation, and it was time to go to the OR. By then, Dr. Harken had left the room with another colleague, and I did not see other residents leaving (I think there may have been another presentation going on afterwards), so I left to go upstairs by myself.
Everybody is right when they said you will know who the scary nurse is; she immediately asked me who I was and what I was doing there once I entered the department. I grabbed my scrubs from the vending machine after she showed me where to get the card from and wandered off in the hallway when Dr. Krosin, who I previously knew, told me to come watch the surgery he was performing—a total right knee replacement revision. I was super excited as I put on my mask and entered the operating room.
The patient originally had a right knee replacement done in February but was not satisfied with the job done—she was complaining of some midflexion instability. The resident, Dr. Nguyen, showed me this was the case because she could not hyperextend, but could flex a full 90 degrees, and then showed me the wobbliness when flexing around 45 degrees. So, in order to fix this, they had to lower the joint line by putting in different hardware in the knee joint. The ACL (Anterior Cruciate Ligament) was taken out in the previous surgery, but now they had to take out the PCL (Posterior Cruciate Ligament) but would keep the MCL and LCL intact (Medial and Lateral Collateral Ligaments).
The one thing I immediately noticed was a checklist on all of the walls of the operating rooms. I read about the importance of them, especially within medicine, with regard to preventing unnecessary infections and mishaps in a book called The Checklist Manifesto by Atul Gawande (which I would highly recommend), so that made me really happy. They made sure they injected the proper amount of anesthesia, antibiotics, made their marks, covered the rest of the body, etc., then got to work by making the first incision and moving all the fat out of the way.
They used a cauterizer (known as the Bovie) to remove excess scar tissue and cement from the last surgery as well. They had to make sure to cut around the Patellar tendon as well as the quadriceps tendon then moved the patella to the side. This was all very interesting to me because I had seen these muscles and bones on cadavers, but I had not seen them in an alive person. They used these tools called gelpies to pry open the cavity so that they wouldn’t have to hold it open themselves.
After moving the patella as well as the tendons connected to it to the side, I saw the silver hardware that replaced the condyles within the prior surgery as well as the other hardware that covered the intercondylar eminence. Using various tools like a saw (apparently this is what it is literally called), Dr. Krosin took out the old hardware attached to the condyles of the femur, the plastic in between the tibia and the femurs meant to replace the menisci, as well as the metal stem that was inserted in the tibia through the intercondylar eminence.
In order to place in the new hardware, the surgeons had to re-shape the femur and the tibia to fit the new parts. Dr. Krosin increased the size of the reamer placed within the tibia one by one so that the actual stem that would be placed would eventually fit. For the femur, he used the saw again in combination with a broach to make lines on the femur that would fit within the grooves of the metal replacement. He used a reamer for the femur as well. This was a very lengthy and tedious process, and one of the residents accidentally chipped off part of the patellar surface of the femur, which Dr. Krosin said was fine because the metal would be covering that anyway. This showed me one thing: that even doctors can make mistakes. I should not be too hard on myself because although that may be in my nature, it is important to stay cool and collected in all situations as a leader.
I noticed a few other things as well: the first was the importance of teamwork and communication. An operation will only go well if the team that is operating communicates properly and works together efficiently. Every member of the team is crucial to the success of the operation, from the nurse anesthetist, who anesthetizes the patient, to the surgical assistant, who hands the proper tools to the surgeon when he/she needs them. This is something that Highland instills in its volunteers—the importance of communication in a well-oiled machine, and is something that Dr. Deweese emphasized in his talk earlier in the day as well. The other thing I noticed is the authority that the surgeon possesses; despite recommendations on what knee hardware replacement would be best for the patient, he is the one who has the “trump card” as the assistant put it. He can overrule other peoples’ opinions and do what he thinks is best for the patient because of his position; this is part of what makes me want to be a physician. I want to be the leader who has the ability to call the shots, and I saw this first hand today. Lastly, I noticed the importance of an attending physician teaching his residents. Medicine is a profession in which people will constantly be learning and teaching other people, and seeing an attending physician mentor his residents today is something that I appreciated and something that motivates me to become a physician one day because of my passion for teaching.
Going back to the procedure, they put in temporary metal just to assess the fit, and took measurements of all the pieces they would need. I smiled as I heard the hardware “click” into place and saw the knee joint flex properly and fully hyperextend, which was a good sight. So, after taking all the temporary metal, they laid out all the actual metal they would place in the knee on the table. The resident, Dr. Nguyen, irrigated the joint cavity with fluids and cut off blood supply so that blood would not dry up once the new hardware was placed on the bones. Then, they put in all the new hardware (one component for the tibia, one for the femur, one for the cavity for everything to glide on). They also mixed some chemical powder and fluids to form the cement to hold everything together in the cavity.
Written by Courtney Pasco (class of 2016-2017)
Yesterday was my first day in the OR and it was easily the best day I have had in a long time. I got to the morning meeting a couple of minutes late and walked past the stares of twenty or so residents gathered around the table. I snagged an empty seat and settled in to the morning’s discussion on melanoma. I thought the give-and-take style of teaching was quite effective, with the attending presenting hypothetical cases with pictures and asking the residents how they would proceed and why. I was expecting the morning meeting to go way over my head, but I actually learned a lot and all of the talk about childhood sunburns, naturally freckly skin, and melanoma mortality statistics made me want to get to a dermatologist immediately.
After the meeting, I proceeded up to the 5th floor and went to get my scrubs. It was pretty obvious I was new because I made mistake after mistake just getting ready. Once I was, though, I was pretty timid about walking into an OR. All of the surgeries scheduled for 8am were crossed off and it was 8:10, so I didn’t want to walk into an ongoing surgery and disrupt anyone. Eventually, though, one of the ortho attendings (I think it was Dr. Krosin) told me if I “promise not to breathe or move” I could watch a total hip replacement.
The surgery took about two hours in total and the patient was an older arthritic Greek woman who had already had her other hip replaced. At first I was standing by the nurse anesthetist, Linda. She was very kind and explained the purpose of each of the medications she was giving the patient and what she was responsible for monitoring. From my vantage point, I couldn’t really see much past the incision, but I have anxiety and was feeling pretty apprehensive so I was grateful to just get the chance to get acclimated to the room and machines and instruments. However, when the residents who were performing the surgery (Jackie and Jeff I believe were their names), saw that I couldn’t really see into the incision, one of the nurses, Tim, brought over another stepping stool and moved me to the side of the patient. By this point I was over my initial nervousness and could focus on how cool it was to be seeing an actual hip joint! Once the joint was exposed, the attending stepped into assist the residents. Jackie grabbed the saw and within seconds, the entire ball-and-socket had been removed. The next steps of the procedure involved carving out a new socket in the pelvic bone and inserting the new metal joint. With all of the sawing, grinding, and pounding, it seemed more like construction work than surgery! Everyone in that room was really nice about chatting with me and making sure to answer my questions.
In the afternoon, I decided to observe an exploratory laparotomy on a young African American man who had been shot four times that morning. He had one bullet wound in each arm and another two in his abdomen. The surgeons, led by Dr. Palmer, opened him up and after observing the wound to his liver, began to run his bowel. That was easily one of the most amazing things I have seen in my life. I mean I’ve studied the anatomy of the digestive system on models and cadavers, but to see it all pink and alive was simply incredible. After they had determined there was no major injury to his intestines, they observed an injury to his right kidney and closed him up. They didn’t repair either the kidney or the liver and are just counting on the healing on their own. At the end of the surgery, ortho was supposed to come and splint his right arm, where the through-and-through bullet wound had completely shattered his humerus. Ortho is scheduled to fix it on Friday, but there was a lot of bleeding so Dr. Palmer wanted to see if the bullet had nicked an artery before having ortho come in. He widened the hole and he could actually stick his finger all the way inside and feel that it was bone marrow that was pouring out, not blood from an artery. So he proceeded to pack the wound with gauze and wrap him up before ortho did the splint. During this surgery, I talked a lot with the surgical tech, Ana Maria. She was absolutely lovely and taught me a lot about the different instruments and then walked me back to show me how they get sterilized.
Nine hours really flew by and I can’t believe how much I learned, not just about the medicine, but also about myself. For a while now I’ve had this pipe dream about becoming a surgeon, but I’ve never seriously considered it because my anxiety crops up in more intense situations and going into the OR I assumed I would have to excuse myself almost immediately to calm down. But I didn’t. I got nervous, sure, but only for the first hour and then my excitement and curiosity took over. I’m starting to think that this is something I could not only handle, but really love.