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June 2012 (Part 2)

Jimmy Lam, OREXer ’11-12

One of the symptoms of an OREX intern, I feel, is that you have a mild sense of insomnia the night before your observation. I guess it is because of the excitement and anticipation. I was actually up before my alarm went off at 6:30am. I got dressed and was out the door. I arrived at the 0A2 just in time. By 7:30AM the doctors and medical students begin to trickle in as they do. I was excited to see that Dr. Harken was lecturing today and I should be because the topic was about recovery and survival rates of patients with varying oxygen content in their blood. Dr. Harken started the lecture with the question, “what would heal faster, an incision on the head or the toe of a diabetic?” If you didn’t know anything about diabetics, you should know that a common and morbid effect of diabetics is the need to amputate limbs due to poor vascular circulation. Dr. Harken explained that the oxygen content in the blood makes a huge difference in the survival of the body or the organ it supplies. Dr. Harken then went in to describe a retrospective research that collected 75 patients that have been involved in an accident that caused the patient to drop to a blood pressure less than 90. The study then split the group into two, 35 patients were treated with standard levels of oxygen in their blood and the other 40 patients were treated with some chemical or hormone that increased their oxygen content to a hyper oxygenated state. The results of the studied showed that if you had your oxygen content increased either naturally or artificially, you had a 0% mortality rate in the operating room. Regardless if you were in either groups, if your oxygen content could not increase to the hyper oxygenated state, then you had a 30% chance of mortality. The researchers were not able to determine the underlying cause that permitted a treated or untreated patient with the chemical to reach hyper oxygenated states. The beauty and beast of science is that with every answered question paves the way to countless more unanswered questions. I left the lecture room a bit more confused than when I came in. But again, Dr. Harken’s objective of these lectures is to get you thinking and surely enough, he got me thinking.

 
The highlight surgery of my day goes to an incision and drainage of a right knee of a middle aged Filipino male. The patient’s knee had a large opening about a foot long that extend from his lower thigh, across his knee, and down to the middle of his lower leg. The doctors had the gash filled with a black absorbent sponge that was sutured in place. I have never seen this done before and was taken back at the site of the sponges as it appeared, from afar, as implants or ingrown black fungus patches on the surface of his skin. When I realized it was sponges, I breath a breathe of relief for the patient because for a moment I thought I was in some horror movie! What appeared as a wound from a freak accident actually had no collision based origin at all. Actually, the patient’s wound was caused by an initial bone infection I believed that ballooned up forcing the surgeons to cut open and operate on the leg. What complicated this injury even further was that the patient had diabetes that decreased the circulation in his legs which probably caused the patient to develop his end stage renal disease. End state renal disease is a condition where you kidneys are no longer function and you would need to have a kidney transplant or get kidney dialysis for the rest of your life. This would make recover and healing a difficult challenge for the patient and the doctors. The point of the surgery was to remove the sponges, drain the wound of blood and tissue debris, and then suture sponges back in. Thus they called this an incision and drainage operation. A big objective of the surgery was to acquire blood and tissue sample from various regions of the gash to test for infection. Even if all goes well, because of the patient condition, there is a great of amputation later down the road.

 
The surgeon for this operation was Dr. Billings who is the oldest and wises surgeon you will meet at highland hospital. Despite his age, Dr. Billings is very affable at heart, loves to travel, and will share his stories to those that have the pleasure of his company. The surgery initiated with the removal of the sutures that held the black sponge in place. Once the sutures were removed and the sponges were taken out, blood began to spill out. The blood was slowly mopped up after several towels, yet blood continued to drip out. There was so much blood lost that the patient needed a unit of blood. Once most of the blood has been wiped up, you can see the bones of the patient’s femur and the knee joint. The tissue that usually surrounds the knee was completely peeled of the bone through the entirety of the gash. Just from the sight of the opening itself instilled doubt in my mind of the patient’s ability to walk normally again in the future. It was pretty disturbing for me to watch Dr. Billings wipe down the bone and then suction off blood in between the bone and the flesh, flapping the flesh around. I remember cringing my eyes from the sight and sounds created by the undertaking. To my surprise, Dr. Billings was complimenting on how clean the wound was, once he removed all the thick coagulated blood wedged between the tissue and bone. Once I got desensitized to the sounds and sights of the surgery, I began to really see the beauty of it all.

Just when I thought things were wrapping up, Dr. Billings took out an instrument that looked like what I can best associate as an ACME ray gun from the cartoons I watched growing up. It had a round funnel like opening at the tip that appeared soft and functioned by both sprayed and suctioned fluids. The instrument was turned on and Dr. Billings was quick at work irrigating the gash and then sucking fluids right back up. After twenty minutes of cleaning the opening, the wound was considered clean enough for the samples of tissue and blood to be taken. Swabs were used to accomplish this feat, swabbing to extract tissue in between the bone and the tissue of the knee. Once everything was done, Dr. Billings began to suture the tissue up a little bit. He did not suture the entire opening closed but more to hold the tissues of the knee against the bone. The opening was still very much open and exposed to the air. More of the black sponge was cut into strips to stuff the opening. Some light suturing was done to keep the tissue and the sponge flush together. A giant clear tape cover was used to saran wrap, if you will, the top of the entire opening. A small hole was cut into the tape, a tube was inserted, and a compressed bulb was placed at the other end. The bulb at the other end function to create negative pressure and suck out any pooled blood and acting as an indicator of how much internal bleeding was occurring. I was astonished at the bulb because I have never seen it used in this manner before. In the end, the leg was wrapped up tightly and the swabs were sent out to pathology. I am crossing my fingers that pathology comes back clean so the patient can keep is leg.

This observational day was the longest time I spent at the OR, cranking in at monstrous 16 hours. Good practice for residency I thought. I had a very rewarding experience in the OR today. In my wake, I had the pleasure of observing a radial bone repair of the hand, a sentinel lymph node biopsy, a laparoscopic colonoscopy, a part of a total thyroidectomy, an inguinal hernia repair, and an emergency throat tumor removal. A shout out to Dr. Billings, Dr. McDonald, Dr. Boudreault, Dr. Lim, and the podiatric and medical students that is extremely helpful and approachable.  I meet a lot of new and familiar faces today. Just another reason to be excited to be a part of OREX. Until next time, Jimmy out.

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June 2012 (Part 1)

By Chris Villanueva, OREXer ’11-12

On my observation day, I was in general surgery with Dr. Chong and it was something else. During the meeting, Dr. Harken talked about how oxygen delivery is caused by cardiac output, which is the length and intensity of exercise. This factor helps increase our quality and quantity of life.

After this wonderful lecture, I went into the OR with Charlie, a UCSF medical student and Dr. Chong, who surprisingly was my doctor in Kaiser Hayward. He was going to take out my appendix, but that was ruled out. The first surgery that we saw was an umbilical hernia, where Dr. Chong had his whole finger in his belly. After watching this short surgery, the next patient came in with a right Colectomy. That patient had pre-cancer and they wanted to remove the risk of it growing into a tumor by taking that part of the colon out. I saw as they prepped the patient and most importantly go over the comprehensive surgical checklist. There was the “sign in,” which had a list of checkpoints before the patient transferred to the OR bed. The “time out,” which was another checklist before the patient is cut. Finally, the “sign out,” which was a list of checkpoints before the patient leaves the OR. For this surgery, they used a camera and microscopic instruments to cut and shear the colon without actually cutting her open.

The doctor cut part of the colon out until they finally removed part of the colon with the appendix through her belly button. Honestly, it was worth the six hour observation because it was huge, I thought it was going to be a small portion but it was huge and I got to see the appendix! After they took out the colon with the appendix, Dr. Chong finally came in and performed a reanastomosis. Charlie explained that a reanastomosis is when they connect two tubes together to help heal the colon and resume with proper bowel movement. He also explained that if there is too little colon, then they cannot perform a reanastomosis and as a result, a permanent colostomy bag is required. We would have a non- reanastomosis if there were too much cancer on the colon and we would not be able to connect it to another tube. This was one of my best observation surgeries.

May 2012 (Part 2)

By Tarik Afnoukh, OREXer ’11-12

I was late to the morning teaching; arrived around 8A.M to Highland and went directly to the OR. I saw Dr. Harken talking to Dr. Lim second year general surgery resident; so I joined the team for the rest of the day.

First patient was in her sixties complaining of chest pain. The patient had a Pacemaker 10 years ago because of third degree heart block and was stable until lately where the battery of the machine is no longer working which needed to be changed soon as possible. Let’s talk a bit about what is heart block? As the name says “Block” it means that the electrical drive pathway of the heart from Atriums to Ventricles is blocked somewhere (see picture 1). Usually the cause of this block is a fibrotic tissue came from either aging, side effects of medications, or diseases. We classify the block on three degrees. First degree there is slow electric conduction from atriums to ventricles, in the second degree there is an asynchronous between the atriums and the ventricles  sometimes ventricles contract after atriums sometimes not, and the third degree is when the ventricles contract independently from atriums. To regain the heart beat synchronization, we need to coordinate between atriums and ventricles by a Pace Maker (means it will speed the electric activity from atriums to ventricles). It has two wires one connected to the inside of ventricle and the second to the inside of atrium, from that the machine will know instantly when the heart is contracting and which cavity is delaying (see picture 2). The surgery was easy and fast, after injecting of anesthetic drugs Dr. Lim made an incision on the old surgical scare and took out the old pace maker after disconnecting it from the wires that had been introduced to the right heart cavities and fixed a new machine in the same place.

The second patient was 62-years-old, with a history of Coronary Artery Diseases -had three stents on 2010-  complaining of chronic and intermittent chest pain. A second degree heart block was diagnosed with a severe bradycardia 35 beats/min (it was a second degree type 2 or Mobitz II block). I talked to the patient in pre-op for awhile with her niece, a bit stressed but she was smiling at the end when the circulator came. After skin sterilization of the chest and neck, Dr. Lim made a small incision below the left clavicle guided by Dr. Harken. She stuck the left axillary vein and introduced a wire toward the right ventricle. X-ray with scope was used to make sure that we are in the vein toward the right heart not in the artery toward the left heart. First, Dr. Lim pushed a ventricular pace maker lead guided by the wire and the X-ray toward the right ventricle. A very funny technique; first we need  to push the lead -we saw in the screen that the lead was driven by the blood flow to the pulmonary artery- from that we need the retrain the lead few cm until it became straight (not curved) then push it again “but fast this time” in the way that it will be driven by the blood flow from the atrium to the bottom of the ventricle; the lead has a hook like shape which can stick easily into the trabiculated (not smooth) ventricle wall. Second, is the atrium lead guided by the atrium wire and the X-ray, this lead should be fixed perpendicular to the ventricle lead. Dr. Harken explained for as with looking to the scope screen how the two leads move with the heart beat, first the atrium lead then the ventricle lead, if one of them move abnormally or lately; a signal will be transmitted to the Pacemaker which can synchronize it. After making sure that all leads were placed and fixed in the correct place, Dr. Lim connected the leads to the Pacemaker and fixed it in subcutaneous bellow the left clavicle. A technician from the Pacemaker’s company was there with a special machine to program the Pacemaker in the safe way for the case (depending on the heart rate and the energy consumed by the heart in each beat).

Third patient was a 64-year-old diagnosed recently with Tonsillar cancer, in the need of chemotherapy. A port-vein catheter is necessary to deliver medicine safely. I also talked to him in the pre-op station. He was not stressed but he was a bit upset about the anesthesiologist who didn’t find a good vein for IV. The patient’s mother and sister were there, we laugh a lot when I asked the sister is the patient related to you? She said yes “I am his brother” and then the mother said so “I am the Daddy.”  After skin sterilization of neck and chest, Dr. Lim put a central line from the right jugular vein guided by ultrasounds and introduced a catheter through toward the right atrium, ideally into the superior vena-cava. She made an incision 2cm below the right clavicle where she fixed the chemo-chamber reservoir beneath the skin. It has a silicon septum where the nurse can stick needles easily and inject the chemo-drugs. To connect this chamber to the jugular vein catheter, the resident made a subcutaneous way, then passed and connected the catheter into it.

Fourth patient was a 70-years-old with End Stage Kidneys Failure who is in dialysis almost a year. He is a Mexican man, moved seven months ago to the USA to live with his son. I talked to him, he doesn’t speak English but the patient’s neighbor was translating to me and to the staff. He likes the US and he wants to stay here to the end of his life. He receives dialysis three times a week through a central line in the right subclavicular vein, which is at high risk of infection and sepsis. The surgery today is the arterio-venous fistula, where Dr. Lim and Dr. Harken made a fistula (a communication) between the Ulnar artery and the Ulnar superficial vein using surgical magnifying glasses. The Principal of the technique is that arteries are small, strong vessels with high resistance, and thick walls (for that we feel the pulses) but veins are large, weak vessels with thin and muscle-less wall (low resistance no pulse, for that veins can dilate easily and widely without rupture). So because arteries are  strong vessels, when we communicate an artery with a vein; the high artery pressure will be transferred to the vein, but because the vein is low resistant, the wall will dilate –after surgery it becomes bigger and easier to stick a needle in to- Try to palpate a vascular fistula when you have a chance (like in the ED, usually patient is in room 12) you will feel a thrill indicating a high blood flow transferring.  After making an incision in the lateral 1/3 lower left forearm, a superficial vein was readily under the skin but the Ulnar artery took some time to find, guided by its pulsation. Because of the patient’s age, Dr. Harken had pointed out for us a fibrotic tissue surrounding the patient’s blood vessels; we need to make sure that when we suture these vessels to keep the fibrotic tissue outside the lumen of the fistula (otherwise it can be a risk of fistula thrombosis).

The last patient was a 54-year-old patient hospitalized in the ICU; she had a third degree heart block in need of a pacemaker. The ICU staff brought the patient to the OR. The surgery had been in quick and safe conditions. Here the end of the Full day iVascular Surgery.                                            

            1/Picture from ekginterpretation.com                       2/Picture from icardiomg.com

May 2012 (Part 1)

By Tiffany Polar, OREXer ’11-12

Today I looked at the white board with great anticipation and excitement for seeing amazing surgeries.  I scanned the surgeries for the day and the C4-C5 decompression soon caught my eye.  I scrubbed in and prepared for the surgery.   I wasn’t too certain exactly what C4-C5 decompression is or how the surgery will be performed but I was thrilled to learn.  A cervical spine surgery seemed very risky.   And cervical decompression sounded like they would be reducing the C4-C5 disc.  I was immediately curious if they would be sawing the bone off to reduce some type of nerve pressure.  I sat and watched the surgery team prepare the patient for surgery.

I was able to discuss the patient’s history with one of the nurses before the surgery began.  I learned the patient had been having very devastating pain with the nerves in his hands and legs for several months now.  The patient was in his middle 50’s and had numbness, tingling, and severe pain due to his C4-C5 disc degeneration.  The nurse walked me to his X-ray to view the bone that had been putting pressure on the patient’s spine.  Looking at the x-ray it became very noticeable how the bone was pushing against the spine. There was also another problem the patient’s C4-C5 disc had degenerated over some time, which was another cause of his pain.  I could see the two bones almost sitting on top of each other with very little space in between, in comparison to the other bones which all had apparent space in between each one.  The nurse informed me that aging caused this and there was no exact cause of the degeneration or the growth of the bone that had been pushing against the spine.  She ensured that the surgeon would be able to cure both problems.

I learned the goal for the surgery was to first reduce the bone that had been putting pressure against the spine.  This was done by a sort of sawing off of the bone back to a safe size relieving and reducing the pressure against the spine.  It will no longer sit against the spine.  Next the surgeon will insert a device to open the space between the bones that had degenerated and had fallen on top of each other.  The device will be inserted and slowly opened to allow the necessary space between the bones.  The surgery took about 4-5 hours and went smoothly. I was happy to know the patient would be relieved from the horrible pain he was receiving.

The next surgery I witnessed was a left breast tumor re-incision.  It was a 37-year-old woman patient who had surgery several months prior to remove the cancerous cells.  The doctors found suspicious cells and wanted to go back into the breast and remove more cells to ensure the cancer would not return.  The patient was already prepped for surgery when I arrived into the Operation Room and the first incision into the breast was soon to happen.  Two senior residents were performing the surgery under the direction of a surgeon.  The residents seemed very skilled and it was clear they had performed this surgery before.  This was interesting to view because the cells were removed via laser and suspicious lymph nodes were cut out. The surgery went smoothly and hopefully the cancer will not return.

2011-2012 OREX T-shirts and Welcome to New Members

April 2012 (Part 2)

By Jennifer Devereaux, OREXer ’11-12

First Flora and I went to Grand Rounds, Dr. Krosin talked about Orthopedic Damage Control.  Ortho doctors use metal plates, pins, and screws to support bones that have been broken.  He also mentioned that multiple surgeries are sometimes needed to repair a broken pelvis for example.  So ortho will recreate the pelvic bone structure, then another set of surgeons will repair the vasculature but then ortho will have to modify their work and destroy all the vasculature work and this could go on several times.  I took away from Dr. Krosin’s presentation that if the surgery can be organised then the patient will be facing less risk.

My first surgery was the repair of a nose following the removal of a large squamous cell carcinoma.  The student did most of the repair and used incisions called “dog ear incisions.”  The look of the dog ear incision was much like a spiral to create a more spreadable and stretchable flap of skin.  The doctor stretched the skin over the nickel size area and stitched up the work.  The surgery was very short.

My second surgery was wonderful and I am glad I saw it.  Dr. Harken was the surgeon and he had a student with him as well.  The patient needed to have his right femoral epicondyle plus about 2 inches of proximal bone amputated.  The patient’s lower leg was already amputated.  The patient came in with a bandage around his existing wound, and the wound was weeping blood.  A pneumatic tourniquet was applied around the patient’s thigh, but despite the tourniquet the patient’s tissue weeped blood throughout the whole surgery.  The doctors cut away tissue using cauterization.  Then they cut off the portion of bone to be removed using a wire saw.  Then the remaining tissue was folded over the bony stump and sutured.  The student surgeon did a great job.  For such a dramatic surgery the whole undertaking took just a few hours.

April 2012 (Part 1)

By Jimmy Lam, OREXer ’11-12

Alarm went off at 6:30am and by 6:38am I was already out the door eager to embark on my seventh day at OREX. As usual, I arrived at the A2 wing just a few minutes early. Unusual today, Dr. Harken was not here yet. Medical students and medical residents begin to trickle in and the room began to fill with medical conversations about patients and new surgical techniques. We waited for Dr. Harken and to my dismay, he was absent today. I guess even doctor’s need a break here and there and can get sick. Despite Dr. Harken’s absence, I did happen to learn something new. I learned that the medical residences are quite nice to each other and try to help one another finish their rounds if they happen to finish their’s early. How nice of them I thought. As I was bummed out that we had no lecture today, I was quickly picked up by realization that would get the pleasure of observing surgery an extra hour. How can you be down from that?

Being more experienced now at OREX encounters, I know better now to grab breakfast first before entering the operating room. As I was checking out the scrub card, I had the pleasure of meeting Mark, one of the new administrative assistants. He was very nice and smiley and liked to crack a lot of jokes. My acquaintance with Mark reminded me how much fun and exciting it can be to meet new people. Within minutes I was all scrubbed down and geared up to enter the operating room. My highlight surgery of the day goes to an endoscopic sinus surgery with Dr. McDonald. The patient has developed some over grown sinus in his nose that now occluding his airway and made it very difficult to breathe. After talking to Dr. McDonald, I unraveled that the doctors tried to treat his sinuses with steroids first to stunt and reduce the sinus growth, however that did not work which prompted the necessity for surgery today. I was in for a treat today because the nasal camera feed live video to a screen overhead that would allow me to see every step done in this procedure today. Super awesome!

Light projected out of the ends of some fiber optic cable endoscopic camera permitted us to see into the nasal cavity. Fine and slender instruments were used to probe around the nasal cavity. Looking at the video feed, I would never have guessed I was looking through the nasal cavity as it looked very foreign. This ignorance I feel is naturally common as our daily encounters with the nose consist primarily on the outside (well at least for me). As I watch Dr. McDonald navigate through the nasal airway, I am astound at how dexterous he is. One hand held a suction tube and the other the fiber optic video instrument, all the while managing to probe about the nasal cavity which was a very small opening. It is incredible how these surgeons are highly specialized. I can’t even know what tissue is supposed to be there or not. I guess I need trained eyes of a nasal surgeon to distinguish that. As Dr. McDonald ventures deeper and deeper into nasal cavity, he maneuvers both instruments concertedly, being very gentle not to cause damage to the surrounding tissue. He uses one of the suction instruments and begins to suck what appears to be mucus and tissues that are preventing him from entering deeper into the nasal cavity. An hour of this goes by, slowly inching through the nasal cavity, cleaning and sucking what appeared to be stray tissue and drainage. I was beginning to think that this surgery was like a chimney cleaning just a very fine and miniature version with much more at stake.

Eventually Dr. McDonald reached deeper into the nasal cavity and there hung an abnormally large nasal turbinate. The best way to describe how the nasal turbinate looks like is to imagine an oversized uvula that was large at the base. Now the nasal cavity itself was made of very smooth tissue while the nasal turbinate looked quite tumorous from the growth. Dr. McDonald then switched to a different instrument that had, I thought, little chompers at the tip. I wish had asked what it was called but I am going to refer to it as the chomper. Dr. McDonald inserted the chomper into the cavity and directed it at the base of the nasal turbinate. Now describing it as nibble is most likely an understatement because man, can this make quick of the nasal turbinate. Sure enough, after a few minutes that nasal turbinate was gone and was replaced with a large pool of blood. In came the suction tube again to drain out the blood. The issue was more blood came out and still more came out. Dr. McDonald then inserted long strips of cotton into the nasal cavity in hopes of, for lack of better descriptive wording, plugging the nose bleed. I thought to myself, how is that going to work? There is so much blood coming out there is no way that is going to work! And indeed it wouldn’t work. But Dr. McDonald didn’t tell me that these cotton strips were soaked with epinephrine. Now I remembered from my course work at Cal that cocaine can be and is used as a topical vasoconstrictor to prevent bleeding. I am certain that epinephrine must work in a similar fashion. But in any case, it worked beautifully. You learn something everyday.

Once the cotton strips where removed, and we all got a better view of the nasal cavity, it was hard to believe how much different the nasal cavity looked. The nasal cavity appeared three times more spacious. All the blood was gone. It was as if a plumber came in and fixed a running clogged sink and now I can see the bottom again. This is just going great I thought. The patient is definitely going to enjoy being able to breathe through his nose again. As Dr. McDonald was wrapping up the surgery, I asked if any nasal function was compromised due to the removal of the nasal turbinate or just from the procedure alone. Luckily no glands or major tissue was removed so there would be no loss of functionality at all. Now I did not mention that throughout the surgery, Dr. McDonald was addressing both nasal cavities and performing the nasal turbinate removal in both nasal cavities of the nose; switching back and forth between the two nasal cavities. I explained it as such because it didn’t occur to me that he was doing that until I saw the other nasal turbinate. I thought it would be interesting to have you, the reader, experience that jump in realization as I did that day. I am certain that Dr. McDonald has been specializing in this for a very long time because he executed the surgery magnificently. I felt like I was watching a well-orchestrated performance and the punch line was, “and then there were two.”

In the end I had, as expected, an amazing time at OREX. Other surgeries I had the pleasure of seeing was tibula and fibula ankle clamping with a special wire technique, an anal fistula, and a broken ankle hardware removal. As usual, I am always disheartened at how much space I get to describe my amazing experiences here at OREX. Not to mention how I didn’t get to stay till my usual 7pm because all the surgeries were done. There is never enough time in the OR. However, I can always manage time to give a shout out to Mark who is super friendly, Dr. McDonald for a job expertly done, Dr. Farrell who has been very helpful, and easily one of my most favorite surgeons, Dr. Krosin, who I always wonder how he can be so rockin’ yet down to earth. These surgeons, two words: top notch. It has only been 24 hours since I left the OR and already am I excited for my next OREX encounter. Until next time, Jimmy out.

March 2012 (Part 2)

By Elliot Chan, OREXer ’11-12

I arrived this morning and went to OA2, to find it completely empty. This is no longer a surprise to me, as for some reason I never seem to catch an OREX day with a normal morning meeting. I knew there was the potential for another trauma meeting, so I scoped out the Classroom and it did look like they were setting something up. After a little delay, as the projector was stuck in traffic, a trauma meeting was held to take note of an interesting case from earlier in the week. Patient was brought into the ED for severe dehyradation and disorientation. The presentation was very very interesting, as it detailed the thought process of an Emergent physician versus a General physician. The patient had to be treated ASAP for her deficiencies, or she would die – she was given a saline IV with dextrose to replenish her immediately, and many lab tests were ordered. This was a very interesting case that they used to call attention to the differences in how medicine works for the ED. As a general physician, you have time to order labs, analyze results, and call your patient a few days later; in ED, you have to treat immediately for the emergent situation, then get pieces of the puzzle back from labs as you are treating the patient. It’s much harder to get the big picture in ED, where you have to keep your patient alive as you learn what’s wrong with them. So they ordered all these tests, and she seemed indicative of sepsis. But, they could not find a source of the sepsis. Then, one of the doctors showed how he came up with the correct diagnosis, showing all the flowcharts that were going through his mind and why he was able to eliminate certain diseases. Very very interesting stuff.

The meeting did run late though, so I did not get into the OR until much after 9. However, the surgery I ended up observing was also running late, and did not start until close to 11. Dr. Victorino was overseeing a right lobectomy, with Dr. Lee operating. The prep required for the procedure was lengthy as the patient was pretty overweight, and hard to maneuver. The patient was a male of about 35 years of age, and had been a smoker for about 20 years. He had developed a lung cancer in his right upper lobe of his lung, and was to have the whole lobe removed. Prep also took a while because the patient would have to have 2 tubes put in for anesthiology – one for his left lung, which would remain untouched, and one for his right lung, which was actually going to be deflated during the whole operation. The surgery was open, and I was excited because I had not seen an open procedure in some time. Dr. Lee made the incision about 12 inches under his armpit, and crossed about 12 inches wide so he could have full access to the chest cavity. After some cauterizing, they had entered the fascia and were looking at ribs. Using the metal spacer, they dissected between the 5th and 6th rib and spaced an opening – before I knew it, I was looking into the chest cavity of the patient! This might have been the second coolest thing I’ve seen in OREX yet (first being the craniotomy).

Dr. Lee had a medical student also observing named Simon, and Dr. Victorino took some time quizzing him on anatomy. As the patient was a heavy smoker, you could already see many black discolorations on the lungs. According to Simon also, the lung felt quite dense and hard already, which is also indicative of years of smoking. Using imaging they had previously taken, they located the cancer on the lung, which did not look as I had expected. They identified a small, circular, puckered area on the upper lobe, almost looking like a cigarette burn. It was distinct, but not as much as I had thought. Removing the lobe required a lot of work though, as all bronchioles and blood vessels supplying the upper lobe had to be cut off, and carefully. Dr. Lee went very methodically through the upper lobe, tying off any vessels going to the lobe, before staple-cutting them. He had to make sure he was not accidentally snipping another artery, which would introduce a lot of bleeding. Once he had accomplished this, they just lifted the lobe right out of the lung! To test to make sure they had no leaks, they asked the anesthiologist to reinflate the right lung. At this point, I had forgotten the lung was deflated, but as soon as air was put into the lung you could see how big it normally is. Just like a balloon, the lung was reinflated and you could see it was holding air – no bronchioles were left untied.

The procedure was done, but closing took almost as long. The mediastinum was cleaned and irrigated heavily, before having to reclose the ribs and suture them together tightly. Closing of the ribs, fascia, and dermis took a very long time even with Dr. Lee and Dr. Victorino working both sides. Once the dermis was sutured (they let the medical student do this one) they stapled the incision and wrapped the patient up. This was a really great procedure, albeit a long one. I was only able to watch this surgery as it was 2pm by the time we left the OR, and I could not get out of work today. But it was a great one!

March 2012 (Part 1)

By Flora Chang, OREXer ’11-12

On my OREX day, there was no morning meeting at 7AM.  I’m not sure if this is true of every Wednesday, but apparently the meeting was moved to noon?

The first procedure I witnessed was a closed reduction of a nasal fracture.  The patient was a young male who appeared to be in his twenties.  I later learned from one of the visiting medical students that the patient suffered his injury as a result of being punched by his brother.

Not surprisingly, most nasal fractures result from fist fights, impact from contact sports, or falls.  The nose is actually the third most commonly broken bone in the body and the most common broken facial bone.  Nasal fractures can affect both bone and cartilage, and they may affect breathing.  A septal hematoma, which is essentially a collection of blood, can sometimes form on the nasal septum.

Dr. Park was the main surgeon for this procedure; Dr. Williams and Dr. Isom assisted.  The doctors used nasal speculums, nasal pledgets, forceps and another tool called the elevator.  They basically realigned the nose, packed the inside with gauze and put a cast over the patient’s nose.

Next, I watched an umbilical hernia repair.  Dr. David Boudrealt was the surgeon.  Dr. Miller was the anesthesiologist, and a young lady named Lisa was on her anesthesia rotation.  She was responsible for manning the entire anesthesia aspect of the surgery.
This patient was a middle-aged Hispanic woman.  Umbilical hernias often occur in infants but can also occur in adults.  They can occur in patients who have health issues that create pressure in the belly, such as being overweight, pregnant, or having too much fluid in the belly.  Other health problems can also cause umbilical hernias, such as chronic cough, constipation, or problems urinating as a result of an oversized prostate gland.

After the patient was intubated and anesthetized, the surgery team began by cleaning the patient’s belly button area from in to out.  Dr. Boudrealt then injected a local anesthetic and drew the incision line with a black marker.  He drew a short, crescent shaped line about an inch below the patient’s navel.  Next, he cut along the line with the scalpel and pushed any bulging tissue back inside the belly.  Finally, Dr. Boudrealt closed the wound transversely with stitches.

The final procedure I watched was a colonoscopy with a possible biopsy.  Most colonoscopies are actually done in endoscopy rooms at Highland.  Every once in a while, however, these procedures are performed in the OR.  This particular procedure was done in the OR because the patient was difficult to anesthetize.  She was an elderly woman with perhaps some mental issues.
The physician inserted the colonoscope through the rectum and searched through the patient’s colon.  The view of the large intestine on the monitor reminded me of an endoscopy or a laproscopic surgery.  As he moved the scope around the intestine, he pointed some hemorrhoids and some polyps, a few of which he deemed as “definitely cancerous.”

February 2012 (Part 2)

By Hannah Kang, OREXer ’11-12

Today Dr. Harken gave a lecture about how standards dictate the quality of care that is given. He questioned the interns regarding whether hospitals should lower their standards in order to treat more patients, or maintain their high standard, but consequently only treat a smaller number of patients.  This lecture was thought provoking, and reminded me of the complexity in overcoming health disparities that are present, today.

After the lecture I observed a left tibia sqeuestrectomy operation conducted by Dr. Krosin, in Room #2.  I learned that the patient was suffering from an gram + bacterial infection in his tibia.  Due to the condition of the infection, Dr. Krosin told me that they had to remove the part of his tibia in hopes to help overcome the patient’s infection.  During the procedure, the assisting surgeon’s glove ripped, so there was an immediate call for hepatitis and HIV tests to be delivered.  Dr. Krosin encouraged the assisting surgeon to sit out for the remainder of the surgery.
Additionally I was able to observe a surgery conducted on a college student.  This appeared to be a mystery case, as the college student had no idea how he got injured—his skull was dented, and his dens was broken.  As a result, the surgeon drilled a circular region out of the patients skull, hammered the dented region to be more rotund, and then screwed it back onto the patient’s skull.  Next, the surgeon conducted a few x-rays to get shots of the broken dens on the patient’s spinal cord.  Once this was completed, they inserted screws to connect the dens back onto the second cervical vertebra.

Today’s experience reminded me of the things I had learned in Microbiology, and Anatomy.  I was amazed to see how drastically a bone can wear down due to a gram + bacterial infection, and I was fascinated to see how drills can replace such a fragile, and crucial, piece of the spinal cord.  I’m truly thankful for Dr. Krosin and the nursing staff that allowed me to gain such a memorable experience in the OR, today.