March 1, 2017

Written by Olincia White (class of 2016-2017)

TAHBSO

My third day in the OR was very exciting! There were many surgeries on the board and I was right on time to take my pick. I’ve become quite familiar with the staff and a few of the nurses recognized me on this particular Thursday. I was greeted by a male nurse (whose name I cannot recall), who was happy to help me choose a good case. Together we briefly scanned the board and selected the TAHBSO or Total abdominal hysterectomy bilateral salpingo oophorectomy. This is the removal of the uterus, both ovaries, fallopian tubes and the cervix. Our patient was a 48 year old F who had presented with pelvic pain. Upon assessment a pelvic mass was found and at this time it was unknown whether or not it was malignant or benign.

The initial procedure would be a laparotomy for the excision of the pelvic mass. The attending was Dr. Lerner who entered the room and began prepping the patient. I was extremely excited as I continued to introduce myself to those that entered the room. One of the nurses took me over to the patient’s bedside and showed me her technique for starting a peripheral IV. We examined the patient’s arm and selected a good vein. Upon insertion there was blood return but the nurse was unable to feed the catheter into the vein and she felt resistance when flushing. No good. We selected another vein, leaving the initial bevel/catheter in the arm. The theory was doing so would prevent a bruise. Learned something new before the surgery even started! We selected another vein just to hit the same problem, resistance and inability to fully thread the IV catheter. The nurses anesthetist had another line and was pleased with her efforts so it was time to begin.

Dr. Lerner was accompanied by Dr. Akilah-Sworen (I am sure that I am spelling this wrong, my apologies). The patient was prepped in the lithotomy position with her feet up in stirrups and thighs pulled back. The first incision was made and I took a good seat at the patient’s head. The doctors welcomed me and all of my question as I watched with wide open eyes. As the incision was made and widened, the pelvic mass came into view and was slowly excised. Initially, I had no idea what it was because of its exceptionally large size. It appeared to be a bit larger than a grapefruit, maybe two. Once it was removed, Dr. Lerner requested to have the pathologist come in to exam it. Shortly after, a nice lady appeared, took the mass out and returned later to inform us that it was indeed cancerous but she was unable to determine much else and would have to defer her diagnosis to someone else.

While we were waiting, Dr. Lerner and Dr. Akilah sutured the areas of the pelvic cavity and poured water in to ensure that all bleeding had stopped. The surg tech asked if normal saline was okay and he specifically said that he wanted water so I asked why. He explained that normal saline has sodium in it making the fluid appear cloudy. Water is clear and would make it easy to see any bleeders. I was amazed because at this point it seemed as if she had lost very little blood and had just been freed from this deadly mass. Once we received the report from the pathologist it was time to remove all of her reproductive organs to prevent metastasis. This also included removing all of the lymph nodes associated with the reproductive organs and the descending aorta. It was a bitter-sweet moment for me so I proceeded to ask a few questions. Turns out the patient came in knowing the possibility of cancer but also had a chance at it being benign, which would have allowed her to keep her organs. The good news is she will hopefully be able to avoid chemotherapy and all of its ailments.

The uterus and cervix was carefully removed first. “What a beautiful and amazing organ!” I explained to the Doctors. Dr. Akilah agreed and we discussed how it appeared so small but is capable of expanding to carry a full term baby. Just fascinating! After the uterus, the ovaries and fallopian tubes were removed and they too were also quite amazing to see. Leave it to me to think that the work was done. Little did I know removing all of the lymph nodes were next!

The surgeons worked well together and were happy to answer all of my amateur questions. Different times throughout the surgery, Dr. Akilah would offer me a seat right next to her… a stool rather. I was able to get a good look as they explained the need for various instruments and rationales. After removing the lymph nodes associated with the reproductive organs, it was time to pull out the LigaSure.

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The LigaSure. This was my first time seeing this and I had many questions. Dr. Lerner happily explained that it would be used to clamp the omentum, fuse it together and prevent bleeding. The omentum is a highly vascular field so this tool is perfect. In fact, she didn’t lose much blood at all. As the omentum was removed and the descending colon was revealed and the surgeons were able to access more lymph nodes. This is what I found on google.. to give you an idea of the omentum.
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Many of my questions focused on the patient’s recovery. I could remember a little about TAHBSO from nursing school. I asked if she would have to take hormones going forward and they explained that it all depends on her symptoms. She was at the menopause age and so a lot of other things may be available to her. They were also hopeful that she would avoid chemotherapy. I wanted to stay and see her in the recovery room but I had to leave. I thanked everyone for their willingness to help and politely excused myself. I was so grateful for the experience and will never forget it. I commend the surgeons for their long hours and dedication to save, change and improve the lives of others!

 

 

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February 19, 2017

Written by Bianca Salaverry (class of 2016-2017)

I finally feel like I’m getting into the groove of OREX; I’m feeling slightly less nervous about walking uninvited into an OR and slightly more confident with the daily routine. This was the first surgical resident meeting I’ve been to that was led by someone other than Dr. Harken. I didn’t catch the name of the doctor leading it, but he was definitely a good substitute. This meeting focused on guidelines for putting on and removing cervical collars. We discussed several protocols that doctors follow when making these decisions. The overall question asked was: are these protocols (some of which haven’t been updated in over 10 years) sufficient in terms of preventing injury from undetected spinal injuries? Some of the criteria the residents said should be considered before applying a c-collar were the mechanism of injury, the patient’s GCS (a measure of consciousness), any neurological deficits, and intoxication with drugs/alcohol. We also discussed the importance of removing c-collars as quickly as possible once it was determined that the patient’s spine was stable. I’d never realized that leaving a c-collar on could have risks of its own, so that was interesting to learn.

With the above considerations in mind, the doctor leading the meeting brought up a study that was done where trauma patients who’d had a c-collar were scanned for spinal injuries. All the patients in the study were asymptomatic, but despite this, a fair number had significant injuries that were detected by MRI. My takeaway from this discussion is that this is actually a really difficult question; how can/should doctors take into account all the risks and benefits of different treatments, especially in cases such as this where the probability of serious injury is low, but the risk of such an injury going undetected is so high?

I got to observe my first arthroscopic surgery today and was enthralled through the entire thing. I’m still in shock about both the precision of the surgeons but also the ingenuity of the technology and mechanics involved in the procedure. The patient was a man in his early 20s who had been in a car accident. His left leg was broken but had been set the day before. On my OREX day, the surgeons began with arthroscopy of the right knee, during which they removed damaged tissue, repaired the meniscus, and reconstructed the ACL, PCL, and MCL using Achilles tendon and bone allografts (donor tissue that comes from a bank rather than the patient).

A lot of what was done in this surgery went over my head. On the positive side, because it was arthroscopic, I had an amazing view of everything the surgeons were doing. On the negative side, because the camera magnified the field so much and was moving around constantly, I had a hard time identifying the anatomy and couldn’t always get clear on the spatial orientation of the camera, tools, etc.. All the surgeries I’ve seen during my OREX shifts have been enlightening in some ways, but this was the first where I felt like my jaw was on the floor the entire time. I couldn’t believe how precise and careful they had to be working in such a tiny space with instruments in both hands that they couldn’t directly see. I have yet to see a brain surgery (an opportunity I’m dying for!) but I’m sure the same thing is true to an even greater extent in those cases.

At the beginning of the surgery, the head surgeon asked me to set a timer to go off every ten minutes, explaining that they would need to keep a strict eye on the man’s lower leg to make sure it wasn’t swelling up too much. Because this was an arthroscopic surgery, the open areas in the man’s knee around the tissue needed to be constantly irrigated to give the surgeons a clear view with the camera, so swelling in the lower leg can be an issue. The surgeons made two small incisions on either side of the patient’s patella, one for the camera and one for other tools. The first step was to remove the damaged tissue using a tool that looked and worked similar to a nail clipper, biting off pieces of tissue that were still attached. Another instrument called an arthroscopic shaver was used for bone debridement and to cut up larger pieces of tissue that the clipper (sorry I don’t have the technical term) removed so they could be suctioned out of the knee.

As I previously mentioned, it was hard for me to follow all the steps of this procedure, so I’ll just list a few parts I thought were interesting.

 

  • The allografts came in sealed, sterile packaging. I’m not sure why this was surprising to me. I guess because they were specimens from a cadaver, I assumed they would come in on ice, like during an organ transplant.

 

  • The graft tissue was a long, thin rectangular shape, approximately 2-3 cm x 15 cm. The surgeons prepped the grafts by affixing loops of thin strings through each end. This was done in such a way that they could perfectly position and stabilize the graft once it was implanted. They drilled two holes, a femoral and tibial socket, diagonally through the bottom of the femur and the top of the tibia. The graft tissue was then fed through these holes and secured outside the bone with two thin “buttons” as shown below. This picture only shows replacement of the ACL, but this patient had his PCL and MCL replaced too

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The second surgery I saw was a cataract removal, which wasn’t laparoscopic, but used a microscope with a camera attached, so I still got a magnified view of the surgery. Unfortunately the surgeons were using a brand new camera system for the first time and the camera wasn’t focused very well before the procedure so it was hard to see much. One fascinating thing about this surgery was that the patient was awake the entire time. She’d had meds to sedate and anesthetize her, but could still talk and understand what was going on. I was pretty horrified at the thought of having to watch scalpels and needles come at my eye, but this elderly woman seemed incredibly serene. The surgery was pretty straightforward and took under an hour.

My feet were aching by that point so I decided to call it a day. Having reached the 1/3rd mark of the OREX program, I’m already starting to feel like before I know it I’ll be in my 12th month and having to say goodbye to this amazing experience. Given that, I’m going to start making an effort to stay later on my OREX days, maybe taking more breaks to give my feet a rest. I’m finding that the ortho cases have been my favorite so far. I still have yet to see any cardiothoracic or neuro cases, though, so hopefully something like that will crop up in my next shift!

February 16, 2017

Written by Sammi Truong (class of 2016-2017)

My fourth day in the operating room was February 13th, 2017. I arrived at the hospital at 6:30 AM. It was actually the first time I was able to hear Dr. Harkin’s lecture. Every other time there was either a special conference or Thursday grand rounds. Dr. Harkin discussed inflammation as a sign versus a cause of illness, and also aspirin in the context of preoperative and daily supplements. The roles of lactate, C-reactive protein, white blood cells, and interleukin-6 elevate inflammation through the COX 1 and 2 mechanisms, which are inhibited by common over-the-counter drugs used to treat fevers. I was surprised to learn the benefits of aspirin intake. Knowing little about the molecular mechanisms of aspirin, I had assumed the effects to be negative and quite harmful, like the effects of acetaminophen. Turns out, there is compelling data suggesting that regular intake of aspirin can reduce the risk of both heart disease and cochlear cancer.

Dr. Harkin’s lecture concluded around 7:45AM. I meant to introduce myself, but was unfortunately cut off by some residents, so I made my way to the OR. My first surgery of the day was a total hip replacement performed by Dr. P. Slabaugh and his resident Dr. S. Robinson. The patient was a 62 year old woman with heavily calcified left femoral head and deteriorated cartilage in the acetabulum. It was a very straight forward case; however, the patient was overweight making the process of prepping, positioning her on her left side correctly, more difficult. An approximately 6 inch incision was made on the patient’s right lateral side, slightly inferior to the iliac spine of the pelvic bone. After cauterizing through the adipose tissue and moving under the muscles, the doctors used a saw to remove the femoral head, which was surprisingly to me only slightly larger than a golf ball in reference to the patient’s weight. Next, acetabular reamers of different sizes sanded down the hip socket and removed deteriorated bone and cartilage. This portion of the surgery took a while because the patient had a large amount of tissue between the skin and the hip, making the incision quite deep and the bones more difficult to access. A acetabular cup, which is a metal cup that is fitted perfectly to the patient’s acetabulum, was then positioned before addressing the femoral component of the implant (left picture seen below). In order to hold the new femoral head in place, a femoral stem must be inserted through the femur for support. Femoral reamers slowly cleared out the center of the bone, then secured the femoral stem with cement and attached the femoral head and a plastic liner, which acted as cartilage. Inserting this component was more complex in that the measurements and angles of insertion determined the length and positioning of the patient’s leg. The doctors had to take the time to maneuver the patient’s right leg in a number of different ways to secure the new hip with minimal error. Dr. Slabaugh and Dr. Robinson then closed and we were finished slightly before noon.Screen Shot 2017-10-09 at 2.36.54 PM.png

 I grabbed a quick lunch and the next case was a left ankle ORIF (open reduction internal fixation) performed again by Dr. Slabaugh and Dr. Robinson at 12:30PM. The patient had a bimalleolar fracture on his left ankle (very similar to the picture on the right); he had both a medial malleolar fracture on his tibia and a lateral malleolar fracture on his fibula. The fracture occurred about three weeks before the surgery, but the patient also had burns and blisters on his ankle, forcing the procedure to be postponed. The first incision was made on the medial side of the ankle and two screws were inserted into the tibia to secure  the broken malleos. Next, the doctors made a second incision on the lateral side of the leg, before drilling in two much smaller screws and then a plate lateral to the fibula, secured with more screws. It was another simple case, and the doctors began closing very quickly. Stitches were used on both the medial and lateral incisions, but staples were only used on the medial side. Dr. Slabaugh explained that the lateral side is prone to problems because it has a greater blood supply and adduction of the ankle joint. The doctors discussed the recovery process of ankle fractures and Dr. Slabaugh suggested that though many doctors would tell their patients to not bear weight on the injured leg for a few weeks, he believes weight-bearing with support from a cast or brace on a rotational injury, such as this bimalleolar fracture, would prevent muscle atrophy and strengthen the injury, as opposed to restricting the healing process. This surgery concluded at 3:00PM and I thanked the doctors and staff for their accommodation before ending my day.

Overall, this was a really good day, as I have realized my unknown interest in orthopedic surgery. So far I have only observed colorectal, genitourinary, and oncology surgeries. Each area of surgery offers new perspectives and knowledge about the human body and medicine. However, there was something about orthopedics that separated itself from the rest of the specialties I have observed. Perhaps it was the sawing and drilling that reminded me again of how strong and hard the human body is. After spending so much time at Highland and studying the human body at school, I’ve grown to think of all the ways our bodies are flawed, what can go wrong, and all the illnesses we can get. We forget what the human body has to endure and what we put our bodies through. I am really happy with how much I have explored with OREX and can’t wait to see what is next.

January 23, 2017

Written by Terry McGovern (class of 2016-2017)

Rounds at 7am with the usual cast of residents, many who I recognized, none of whom I really knew. Dr. Harken discussed new sepsis prevention guidelines for 2017 and then discussed some of the studies cited and how the guidelines were decided on. The most interesting discussion was the relation of clinical guidelines and the sometimes very ‘thin’ or minimal studies that are the basis of these guidelines.

We headed up to the OR.

OR 2 was set for 3 ortho surgeries for the day and given that they hadn’t started yet and were interesting to me, I jumped in on the first one which was a breaking and resetting of a second metacarpal bone on a left hand of a patient. I walked in as they were getting the patient ready, and introduced myself. And the resident, Dr. Tennyson Lynch, said, “Oh I remember you from your day in ortho with us. Come on in”. I think all of us OREX’ers know how nice it is  to be warmly welcomed into the OR.

The patient had been seen after the break in October which occurred after an altercation. They had hoped it would set on its own but alignment changed and thus needed to be re-broken and reset. The most interesting thing about this was that the “re-breaking” was nothing of the sort. It was actually more of scraping away the newly formed bone tissue, which was relatively soft and able to be scraped away with repeated and moderately forceful scraping of the bone. The groove got deeper and deeper until the new bone material was removed and the two parts of the metacarpal were separated. They were then realigned, drilled and pinned together. The pin went out thru the knuckle joint and was cut and left in place. It would be removed in a couple of weeks to let the bone set, but not too long, so as to not leave the joint immobilized for too long.

Surgery 2 was a debridement of the left ankle bone. This patient had been seen previously and had some sort of ankle reconstruction surgery a few months. He had an ulcer over the area and was still in tremendous pain with any weight bearing. So they wanted to do a biopsy to determine if there was any infection to the tissue or bone. Samples were taken from the ulcer as well as 2 or 3 from the bone. The biopsies were taken as deep scrapings from the bone. The bone biopsy was to determine if it was  acute osteomyelitis

One of the residents asked if this would be a case where antibiotics beads might be placed. Dr. Slabough talked about how those beads were only used in cases where there were gaps in the bone. A way to fill the space and prevent infection.

Surgery 3   Total Left hip replacement

This was “The” surgery to see in the ortho room today. I was curious about it as I have a number of friends, family members and patients who have had this done, so I was interested in observing  to see what is involved.

Dr. Mahar and Dr. Slabough started the surgery.  The patient had a lot of adipose tissue so it took a larger than expected incision and spreading of the tissue for there to be enough room to access and work on the hip. They cut the head of the femur off and when they removed it from the acetabulum they found a cyst in the joint. Both of the surgeons repeatedly said “I have never seen this before”. The cyst was between the head of the femur and the acetabulum. It was difficult to see given the blood in the area and it seemed like they didn’t really see it until they started to enlarge and rout out the opening for the placement of the cup portion of the new joint. So the cyst material which looked like a combination of soft tissue with some calcified components were gradually removed.

This seemingly straight forward surgery was becoming a lot more challenging than anyone expected. A call was made to get some other opinions. The patient was originally Dr. Pinna’s (but switched due to surgical scheduling) so he was called, and Dr. Shah was also called. They both entered the OR and were soon scrubbed in, looking and offering their ideas which were pretty much the same as Dr.  Mahar and Dr. Slabough. It was just a slow and methodical process.

The main issue at this point was how much they could ream out to fit the cup in place properly without removing too much bone. There was a ridge on the inside of the acetabulum that was in a location that prevented a perfectly snug fit of the cup. After repeated tries, and some angle changing it was decided by all 4 that they should get as close as possible and then put 2 screws through the bottom of the cup into the bone to affix it. It was intriguing to see that a full set, of what is essentially a dry run of pieces, are placed then removed and the real hardware installed.

It was agreed that nothing could really have been done differently, but that it was the cyst and the ridge on the inside of the acetabulum that had been complicating factors for this surgery. It also became clear that the top of her femur below where it had been cut was a very dense bone. They had to work extra hard to get the wedge shaped piece that goes into the femur into place.

Finally, after 3.5 hours, the fussing and grinding and hammering were complete.

At the conclusion of this much longer than expected surgery I headed home. Another great day of observation in the OR.

 

February 7, 2017

Written by Jennifer Tu (class of 2016-2017)

 

        I woke up today feeling energized and excited for my 3rd OREX day. Last time, I got sick during the first observation and had to step out of the room. So I slept very early last night and prepared a big breakfast this morning. I was determined to make the best out of today and learn everything that I could. I got to the conference room at 6:55am and there were already a few residents at the table, so I just took a seat at the corner.

        At lecture today, Dr. Harken talked about a case involving a 55-year-old man with sigmoid colon cancer. His pre-op and surgery (I believe he was referring to a colectomy) went fairly well. Four hours post-op, he had BP of 130/80, HR of 110 beats/min and normal body temperature. However, the EKG showed sinus tachycardia (HR greater than 100 beats/min). A few more EKG’s were done afterward. 36 hours post-op, the EKG taken showed ectopic heartbeats (small changes in normal heartbeat that lead to extra/skipped heartbeats). Dr. Harken explained the 5 causes of ectopy, including regional hypoxia, electrolytes, effect of drugs, potassium levels (and one more that I didn’t catch). He also discussed action potentials (the difference between skeletal and cardiac AP) and drugs that affect them. Ultimately, it was diagnosed that the patient had a inferior myocardial infarction (I got lost along the way and wasn’t sure how he reached this conclusion). It seemed that this is a very common case for patients after surgery to encounter these condition, but careful observation can help with prevention. He also talked a lot about hormones. For example, Angiotensin II has multiple effects on the body including increase in ADH, vasoconstriction, and thirst. At the end of the lecture, Dr. Harken encouraged everyone in the room to take a shot of potassium. I tried to hide, but was unsuccessful. The potassium drink did not taste pleasant at all.

        I then followed two residents (Jenna and Britney) and a PA student to the OR. After changing, I joined them in OR#2 for a case of partial nephrectomy. Dr. Yamaguchi and Dr. Ito were the attendings for the procedure and they explained that the patient had a mass on top of her kidney, which needed to be removed. It was very interesting to learn from Dr. Ito the “objective” way for some physicians to determine the complexity of nephrectomy. R-E-N-A-L, each letter stands for a determining factor. R for radius, E for entophytic/exophytic, N for anterior/posterior, and L for laterality(didn’t catch what A stands for). Using these criteria and a point system, surgeons determine whether to use laparoscopic surgery (if less complex) or a more invasive procedure (more complex). If the case is more complex, laparoscopic surgery may not be appropriate because it will be difficult to flip the organ. Afterwards, I listened as the tech taught the PA student how to perform urinary catheterization, in which a catheter is inserted through the urethra into the bladder to drain all the urine.

        Throughout the procedure, it was slightly difficult to see what was going on. There were many staff surrounding the patient (2 attendings, 2 residents, PA student and tech), and most incisions were very deep. To avoid being in their way, I stood farther away. The process to get to the kidney took 2 hours. Dr. Ito then used ultrasound to precisely locate the mass. Again, the large surgical retractor system was used to hold the tissues in place prior to the long-awaited incision. I thought it was very interesting that prior to cutting out the tumor, they poured ice chips onto the kidney for 10 minutes in order to achieve renal hypothermia. This method is apparently used to minimize ischemic renal injury. After the removal of the mass, Dr. Ito made “hemostatic rolls.” He rolled up what looked like a small piece of gauze and then wrapped it with a piece of foam, tying it off at two ends (looked like a candy in a wrapper). He made 10-20 of these. They were used to stop bleeding by promoting blood clots.

        After the 5.5 hours of nephrectomy procedure, I spoke to Dr. Yamaguchi about the next surgery. It was going to be cytoscopy that involved the use of laser to remove renal stones. Dr. Yamaguchi explained the procedure and showed me exactly where the renal and urethral stones were using the CT scan, which looked really cool. She explained that apparently, urethral stone is described by some women as being more painful than childbirth!

        After taking a quick lunch break, I returned to OR2, feeling excited about the next surgery only to learn that it was cancelled last minute. It was already 3pm and I decided to call it a day. Although I only saw one surgery today, I am very thankful to be able to see it from start to finish and learn the small details from residents and techs. I can’t wait for the next OREX; hopefully I can see the cytoscopy next time!

February 4, 2017

Written by Himakar Nagam (class of 2016-2017)

I walked in just in time as the attending at the end of the table started asking all of the residents questions. For all of my OREX days, Dr. Harken has not spoken yet, which was a bit disappointing for me; I loved reading about his lectures in other peoples’ OREX journals. The attending here gave a scenario for the residents in which a twenty-two year old comes into the ED as a level one trauma; the patient was shot and had a small hole in the right gluteal crease. The attending asks one of the residents about what should be done.

The residents lists a bunch of diagnostic steps, including a pelvic x-ray, providing the patient with fluids, etc. The scenario gets really intense when the attending suddenly says that the patient flatlines; at this point the resident is scrambling to provide the patient with more blood, perform a thoracotomy, and check for pulse again. In the middle of this, there’s an announcement on the loud speakers asking all of the doctors to report to the Trauma OR for a level one trauma. The look I see on the doctors’ faces is one I won’t forget—one of surprise, but calmness at the same time. They look at each other and run out of the room. I stay to listen to the rest of the scenario, then make my way to the OR to watch surgery.

After changing, I went to OR 5 to observe a surgery, but the staff told me they were uncomfortable having me watch the surgery without permission of the patient; so, I left and went to watch a right knee arthroscopy with autograft hamstring ACL repair and medial meniscus repair. I was really excited to watch the arthroscopy because I would be able to see everything.

Dr. Distefano was the attending, and he said it was okay for me to watch the surgery; I used to volunteer in the orthopedics department, so he said he remembered me from back then. This patient was a Hispanic male in his forties that tore his ACL and damaged his medial meniscus in his right knee playing soccer; in order to fix his ACL and meniscus, instead of opening the joint completely, the doctor just wanted to do an arthroscopy, which is similar to a laparoscopy except it deals with joints.

There are two options for fixing the ACL; one could either use a graft from a human cadaver, or one could use an autograft, meaning one can take the tissue from another part of the body, ie. the hamstrings tendon, to replace the ACL. So, this is exactly what the doctors did: they made a small incision to the left of the knee and isolated the two tendons of the hamstrings muscles. Once isolated, the resident, Dr. Robinson, took one of the tendons from the hamstrings and put it to the side so the attending could prepare it for putting it back in the body.

Dr. Robinson then makes incisions and puts the arthroscope into the joint cavity. He assesses the meniscus, the torn ACL and scar tissue, and dictates everything to Dr. Distefano as he is taking pictures of what he is seeing. Once he takes pictures of everything, he starts to remove the scar tissue with a few of the tools including the cauterizer, and punchers. You could see a lot of the scar tissue on the medial condyle of the femur and you can see the small tears at the sides of the meniscus. Dr. Robinson told me that it was a radial tear of the meniscus which they had to fix.

After removing the scar tissue from the cavity, Dr. Robinson got to work on fixing the meniscus; you could see the intense concentration and focus in his eyes as Dr. Distefano was directing him throughout the procedure. It was amazing to see the doctors loving what they were doing, as they were so immersed in the procedure.

After fixing the meniscus, Dr. Robinson started to reshape the patellar surface because of the tissue that was surrounding it. Then, using a reemer, they made a hole from the lateral side of the femur going through a hole where the ACL used to connect. They also made a hole coming in from the medial side of the tibia coming at a slant so that they could feed the graft in place of where the ACL used to be. After putting in a string and attaching the graft to it, they pulled the graft through the holes they made in the femur and the tibia. They marked the edges of the tendons to see until which point they would stop pulling it through.

After screwing everything in place and checking the status the bones and other tendons in the joint, they bent the knee to check if it looked normal, then pulled out the tools and sewed up the holes. It was amazing to watch the surgery—after hearing about ACL repair surgeries all the time with sports and with my friends, seeing what happens behind the scenes was amazing. This surgery especially is one that stuck with me because of its relevance to my life and to the lives of my favorite basketball players.

After this, I had to go to class. The surgery lasted for a few hours, and I left around noon time. I am thankful for yet another amazing OREX day.

January 27, 2017

Written by Viet Le (class of 2016-2017)

Surprise surprise surprise, today’s entry is not about our illustrious Dr. Harken even though I was pretty tempted to rave on about his awesomeness. My day started out in typical fashion but actually got better and better. I arrived early in the morning to a lecture about treating a patient who had sinus rhythm developing into atrial fibrillation post opt. In addition, their heart rate was a lot higher than normal. They discussed the use of metoprolol vs amiodarone vs diltiazem. The drugs had their pros and cons, but Dr. Harken wanted to see whether the article they were discussing confirmed the way they practiced medicine. I think this part of the lecture would have been more beneficial if I had a lot more background knowledge but it mostly went over my head. He left it up to everyone to come to their own conclusions and dismissed the session. I took the opportunity to head up to the 5th floor at this point to change and jump right into a surgery.

Two things happened that really made this day special. First off, I saw my first craniotomy which was pretty gnarly. The surgery itself was vastly different than the vascular operation or the ortho hip replacement from prior. In addition to that, I met a neuro PA that spoke thoroughly about his journey to get to where he is today. As some of you know, I aspire to one day become a PA and so the opportunity to learn from one who has been through it all is quite humbling. I consider myself fortunate.

PA Craig Roberts

I entered OR 1 and noticed that the room was bustling with staff who were prepping the patient. The attending, Dr. Patel, was going over images of the patient’s brain to look over details prior to operation. I introduced myself and asked whether it was OK to observe, which Dr. Patel happily obliged.  During this time, a few nurses came up to ask me who I was and what my academic goals were. One really upbeat circulation nurse name Rommel said, “That’s Craig…he’s the PA you want to talk to. He will tell you all the secrets!” At the mention of PA, Craig turned around and introduced himself. I felt this was very opportune and took the time to learn about his pathway to medicine.

Craig didn’t waste any time diving into all the nitty gritty details of his physician assistant career. We spoke extensively about why he chose to do the PA route rather than medical school or even nursing. It is always interesting to me to find a person’s passions behind their careers, especially since it gives a perspective into why they do what they do. Beyond making a good salary and enjoying a respectable social status, what purpose does being a PA bring? Even more importantly, with 10 years of experience behind him, how would he have done things differently? Craig enthusiastically answered my thoughts and expanded it with recommendations on how I should approach this journey. He spoke about the importance of autonomous decision making, the medical model, and how PA schools look for individuals who think holistically. He talked about how at his PA school interview, they made the applicants go to a restaurant, showed them a roster of individuals, and made them choose 2 people to fire (due to business downsizing). Pretty ruthless if you ask me. He said he ultimately chose to fire a “pregnant woman and another person who didn’t have family and was working towards law school.” Obviously, if the decision came down to this, it must have been a very tough spot! He explained the reason objectively to me and it made sense, enough that we chuckled at the situation.

Throughout the operation, Rommel and Craig kept coming by to make me feel comfortable! I felt like I do owe it to them because they made it more enjoyable to see what was going on. Rommel cracked jokes and pointed out optimal spots to watch from. Craig stepped away from the operation at times to explain what was happening in anatomy terms which I appreciated. At one point, Dr. Patel mildly snapped at the OR tech which got me a little nervous. Craig later told me how important it was to understand each doctor’s personality and to learn to be flexible since it can ultimately make your life a lot easier. Thank you, Craig for all your advice. Now onto the operation itself.

Right Sided Craniotomy

The operation began at 8 with the staff sedating and intubating the patient. A fixation device, which oddly resembled a vice, was placed on the patient’s head and then stabilized to the table. Neuro-monitoring wirings were placed at the patient’s extremities to make sure there were no neuro damages that were done to the patient’s nerves during the operation. This made sense since cutting into a brain can severely damage the nerve cords branching out if one isn’t careful. After about an hour, the procedure finally started and Dr. Patel cut into the right posterior side of the head. Compared to operations (ortho and vascular) that I have seen prior, this procedure seem a lot slower and more precise in nature. He finally drilled into the skull and placed bone wax throughout the process. I had a hard time seeing this and no matter the position, there was nothing optimal. I was not going to be Curious George and poke my head into their sterile area though. If anything, I will wait for a better time to get a better view. Fortunately, this came to an end as a giant microscope instrument was brought in. Dr. Patel operated on a tiny area but projected the image out to a large screen for everyone in the room to see. Bless this machine! I wish I could have taken a picture since it was so graphic. The pulsating brain, cerebellum, brain stem, and various nerve cords were gigantic and highly visible.

At one point, Dr. Block (I think that was his name) who was a neurophysiologist, came over to explain what was happening and pointed to the various structures. I appreciated this because he gave an overview of the procedure in anatomy terms which made sense to me. He explained that surgery was basically a process of HEMOSTATIS, where the surgeon cuts, cauterizes, and then controls the bleeding and then rinsing and repeating. That was a beautiful way to put it because that explained why it was so slow and controlled (otherwise if too big of incisions were made then the bleeding would be uncontrolled). Plegets, which looked like regular gauze pads, were actually placed into the brain mass and had specific medicine to stop bleeding. Finally, he pointed out the tumor which was apparently of a lighter white mass. He explained that a surgeon and doctor who has done this long enough can tell the difference, which helps to prevent one from taking good brain tissue. I asked him, “How do you sew back up the brain tissues together? Because in other operations, once you are wrapping things up, you sew back the tissues…” He said that’s a good question and that you basically are left with a hole in the head. You glue back the skull and make sure the CSF (cerebral spinal fluid) doesn’t leak out, resulting in massive headaches for the patient. I thanked him for the thorough explanation and he went back to monitor the cranial nerves.

So there you have it, day 3 of OREX. I find it interesting how Ive been fortunate to see 3 different operations (1 hip replacement in ortho, 2 vascular, and 1 neuro) since I have been here. One thing that I would like to point out is that this experience reveals to you many different sides to the OR. For one, I didn’t realize that my stamina for standing up was so low! After standing for a few hours, my legs and mind start wandering and I find myself feeling the need to stretch. It astounds me how the surgeons go for countless hours on the cardiothoracic surgeries and not require a break. I remember speaking to Dr. Harken and he said the nervousness and pressure of the procedure can definitely help with one’s focus. Fear and pressure plays a big role here, I guess. Anyways, I hope you guys enjoyed the read.

January 20, 2017

Written by Katie Darfler (class of 2016-2017)

Hi everyone! Happy new year. I hope all your observations are going well.

Morning Lecture: was led by Dr. Harken and he discussed recent research findings about how to treat sepsis. First, he went over some research about the importance of measuring volume (MAV: mean arterial pressure) to treat sepsis patients. Essentially, he concluded that we shouldn’t provide too much extra fluid just because it is “standard procedure,” because the studies showed that doctors who used their own judgment fared about the same as those who followed the standard procedure. Additionally, he mentioned that there is a 4% increase in mortality for every hour that a sepsis patient is without antibiotics. He discussed how patients with septic shock should be given a combination of antibiotics: at least one broad-spectrum in combination with another; patients with sepsis should be given one antibiotic, and he mentioned that it would likely be a broad-spectrum. Next, he went on to discuss the use of various “pressers” (dopamine, norepinephrine, and vasopressin (ADH)) and then compared the delivery of albumin versus saline for traumatic brain injury. Studies show that saline is the best bet.

Surgery #1: Excision of fibroadenoma from left breast, Dr. Palmer

During this surgery, Dr. Palmer and his resident Christina worked to remove a 5cm long benign tumor from the patient’s left breast. I walked in as the anesthesiologist was intubating the patient, the doctors were palpating the breast and making marks for their incision. They made a rainbow-shaped pen mark above the nipple and mentioned that the lump was at “four-o-clock.” I watched as they lifted up the nipple carefully and exposed the tissue underneath. The resident hooked through the mass with a hook and thread device to pull it up and continue to cut it out of the breast tissue. I got a little nauseous at this point because part of the nipple ripped off. I don’t know what it was, but I took a step back and a few deep breaths. I stopped looking at the device that was holding the nipple and focused underneath. All good!

Dr. Palmer said the mass “looks like a brain,” and he was right. He mentioned that this patient had already had a biopsy earlier and the tumor was determined to be benign, but that she wanted to have it removed because of discomfort or possible growth. She has a family history of ovarian cancer, so they’re also extra aware. Apparently, though, fibroadenomas don’t make her more at risk for breast cancer, but ovarian cancer in the family is something to be aware of. Then, I overheard Dr. Palmer say “Let’s keep it out so the student can feel it.” I didn’t think much of it, but you guessed it! I got to put gloves on and feel the fibroadenoma. Super cool! It felt like 7-8 squishy bouncy balls inside a sack. Each ball within the sack was about one centimeter in diameter. That was neat. Dr. Palmer instructed the residents to sew up the skin above the nipple in a way that would prevent rippling.

Surgery #2: Cystoscopy and urethral biopsy, Dr. Ito

During this surgery, Dr. Ito inserted a laparoscopic tube into the patient’s urethra and checked out both the urethra and the bladder. The patient had complained of blood in the urine and his pathology results had come back “abnormal” without much more clarification. Dr. Ito’s job was to assess the bladder and urethra to see if samples needed to be taken. [Can I just say that laparoscopic surgeries are super cool because you get to see everything on screen? I always feel like I’m in that episode of Magic School Bus when the kids get to go on a field trip inside the body.]

The initial view looked like a pinkish tube. Then, Dr. Ito went through the area right before the sphincter into the bladder. The walls looked almost like sea anemones were on them. He said this could be normal or concerning. He ended up taking a biopsy of this portion of the urethra by grabbing onto the wiggling epithelial skin. He would pull out the clamp a few times to ensure that he got enough sample and ended up with enough. While he noted that the bladder was “angry” (haha), he said he did not think it warranted a biopsy. Once he was able to biopsy the urethra, he used a “bovie” to cauterize any bleeding portions.

Surgery #3: Trauma surgery (GSW), Dr. Miraflor

Apparently this patient had been in surgery three times in the last 24 hours and I get the sense that he wasn’t doing too well. He came in and was bleeding (bubbly) out of his tube in his side. I noticed he was very tachycardic. He had large stitches all across his body from left mid axillary about 5th or 6th intercostal space up to his sternum. He also had an open belly. Doctors mentioned that he had lost about 4 liters of blood and they were concerned about him. The doctors opened his chest sutures and used a rib spreader to open up his body. Oh my gosh! I got to see his heart beating, his lungs, intestines, everything. The patient’s spleen seemed to be in many pieces. As awful as the situation was, I was also so inspired by the team working. They were pulling blood clots out, searching for the bullet, trying to find the bleed and stop it. They eventually found the bleed and I believe it was subcostal. There were several doctors coming in and out to discuss ways to go about the surgery. The doctor who completed one of the earlier surgeries came in the room to check on him and another came in to discuss ways to stop the bleed. He asked if the “IJ” (intrajugular) was on the right or left side and the doctor said it was on the right so the fluid wasn’t dumping & causing him to bleed. That was a cool question as to why he would be bleeding so much, but it ended up not being so. (I like how the doctors here work together and don’t seem to have egos that prevent listening to new ideas.) At one point, they decided to clamp the lung (I think, but I have no idea why!) and they used quikclot cloths in the wound (which looked a lot like the cloths they sometimes leave in surgery patients that will return for future surgeries). It was truly a team effort and no one got flustered. One doctor said his pH was 7.36 and his lactate was 6.8, which seemed concerning to him.

More on lactate here: https://labtestsonline.org/understanding/analytes/lactate/tab/test/  

He wanted the patient to warm up and get back to the ICU for care. They couldn’t find the bullet, but had to close him up to prevent any further loss of body heat.

Wow. That was amazing to witness and I am praying for this gentleman to recover.

January 17, 2017

Written by Jenny Luong (class of 2016-2017)

Being very optimistic about today’s OR session, I went ahead and arrived 15 minutes early to a completely empty room. I ate my apple and watched the clock tick. I started panicking a little when the clock hit 6:59 AM and no one had arrived still.

Luckily, a resident came in a minute later. People seemed to follow him in, and Dr. Harkin appeared. He noticed me and gave me a handshake! I was fangirling inside yet totally professional on the outside. I hope.

Today’s morning lecture consisted of some biochemistry and genetics. Dr. Harkin presented some cases and pictures of mucosa-associated lymphoid tissue (MALT) lymphoma and gastrointestinal stromal tumors (GISTs) and then talked about some papers that proposed the genetic pathways behind the formation of these tumors. He spoke about how GI sarcomas were treated with standard chemotherapy drugs in the past to no effect. It was in 1999 that Gleevec was used, bringing about a complete change in the approach towards GI sarcomas. One of the papers he mentioned showed that the use of Gleevec for several weeks prior to removal of a GI sarcoma increases the likelihood of a positive patient outcome. The general solution for many of these cases were surgical. And if they were recurrent, those would need to be excised as well.

I walked myself over to the OR and asked Nurse Julia very nicely for the vendor card again. I made sure to be very polite, as always. She was very nice to me in turn. I made some small talk with someone in scrubs in the changing room and went up to the board. Everything was crossed out again. Am I reading this wrong?

I decided to just walk down to the OR and look like I knew where I was going so at least I wouldn’t be stuck in the hall. The person I was talking to in the changing room was walking towards OR 2, so I walked up, introduced myself and she let me follow her in.

Turns out, she is Dr. Sarah! The patient was a female born in 1973, and today’s procedure was a left percutaneous nephrolithotomy, cystoscopy and laser lithotripsy, and ureteral stent placement.

Due to the muscle relaxants given to the patient, she was particularly floppy and required careful maneuvering and placement. The nature of the surgery meant that placement was crucial in making sure the surgeons could access the area of interest. First, Dr. Sarah and Dr. Yamaguchi placed the patient face-down. Dr. Linda, the nurse anesthesiologist, directed the moving and was very knowledgeable how to best protect the patient’s airway and breathing. I want to be her when I grow up.

Because the patient was so wide, they had to triangulate where the kidney was. There were black marker lines everywhere. Better safe than sorry. After making a small incision and inserting a tube to make a pathway into the kidney, they used contrast on threads and on their wireless camera to get a better view of the inside. There were at least 2 kidney stones and deposits lining the ureter all over the kidney.

There were saline bags that needed to be replaced all the time. Nurse Benny was running around frantically throughout the surgery. These saline bags needed to be put in little sleeves that could be pumped up to add pressure. This would allow more effective irrigation and allow better visibility inside. This was necessary because there was so much blood clotting that it was almost impossible to see. The deposits were not helping either, as they bled if removed by force.

After a while Dr. Yamaguchi closed up the hole and announced that they needed to reposition the patient and attempt a ureteroscopy now because the percutaneous nephrolithotomy did not work out. Wheeling in equipment to strap the patient’s legs apart so they could try from the bladder end. It took about an hour to finally locate the stone and get everything ready for the laser blasting. I had a lead jacket on with goggles and I felt equipped for anything that was going to fly my way. Nothing did, thankfully.

Dr. Yamaguchi spent the next hour or so blasting away the calcification. It was everywhere. There were so many deposits that even the doctors were amazed. I think the best part was when the laser machine would go “pew, pew, pew”. Compared to the rest of the surgery, the stent only took a few moments, and suddenly, we were done!

It was quite amazing to see how far technology has gone and how high definition that little camera way inside the body. This was another amazing day with OREX!

Janurary 19, 2017

Written by Cicily Cooper (class of 2016-2017)

It was so nice to be back in the OR after over a month of not being there.

I made the mistake of forgetting that it was Thursday and showing up at Highland at 6:50 to find the room totally empty.  I asked a friendly person and she apologetically informed me that Grand rounds were at Kaiser today at which point I kicked myself for knowing and forgetting.  After too much oscillating, I decided that I’d better go to Grand Rounds and be a few minutes late than wait around Highland for 2 hours!  And I did, and it was GREAT!!!

The person talking was the head of surgery at SFGH.  Her talk was on surgery and disasters and she had a ton of experience and so much to say.  I am particularly interested in disaster relief work and found her input on triage and disaster preparedness very intriguing. There was also food and coffee so by the time I headed back to Highland at 8:30 I was in a really good mood in spite of my self-caused morning stress.

When I got to the floor it seemed that most of the surgeries had started already and so I walked into a room that looked like it was just getting going and met Dr Yamaguchi, a urology surgeon, who was very friendly and helpful.  She showed me the CT of the patient who had had multiple washouts and debridements of Fournier’s gangrene which had caused necrotizing fasciitis.  At the point where he was in front of us, he had a wound from his anus all the way up to near his umbilicus, making a B-line through his scrotum.  One of his testicles was completely exposed and enlarged.  The wound was about 4-5 inches deep.  The plan for this day in the OR was to give it another washout and to partially close it.  

The patient had presented with some pain and swelling but it turned out that he had uncontrolled diabetes which was why the gangrene had gotten so completely out of control.  He had been completely septic and had he not been operated on would have died very soon, according to Dr. Yamaguchi.  

In other surgeries I had been in there had been way more residents and medical students and I felt more worried asking too many questions, but in this OR there was only the patient, the anesthesiologist, her student, the tech, Steve and Tim the OR nurses, Dr Yamaguchi and myself.  I had a pretty great view and asked her many questions which she answered.

First she did a saline washout of the wound to get rid of the dead tissue and expose the live pink tissue underneath.  Next she very slowly and tediously began to close the huge gaping wound that had remained.  She explained that she wanted to avoid creating any pockets where infection could get trapped.  We discussed the different types of sutures and when they get used.  She explained to me that the braided ones are worse for infection but she had to use some of the braided ones that dissolve inside for the areas that would be impossible to access once healing occurred.  The nylon ones for the surface need to be removed.

After about two hours she packed the remainder of his wound with soaked betadyne kerlex.  She wrapped his single exposed testicle in saline gauze that did not have betadyne on it to protect the testicle from the betadyne and keep it moist.

After this I watched Dr Yamaguchi’s afternoon procedure which was a cysto-left ureteroscopy, laser lithotripsy and possible ureteral stent placement. In other words, laser blast removal of a kidney stone through the urethra.

For this procedure we all had to wear “leads”, the x-ray proof dresses because x-ray was in the room with live imaging.  We also had to wear laser glasses to protect our eyes from the laser that was used.  Needless to say, I felt pretty darn cool.

The procedure was super interesting and everything was visible real-time on the screen above her head.  I got to watch the camera go into the kidney and search around for the stone and then we saw it on the screen.  It looked kind of like icicles or crystals in a cave.  It took some time but Dr Yamaguchi blasted the crystals and then had to keep blasting them.  She also sent in this tiny tiny wire with an even tinier grabber on the end to grab a hold of the little pieces of stone and pull them out.  It reminded me of the game in an arcade where you try grab the stuffed animals with the claw that is really hard to control.  Anyway, the stone was blasted and removed.  Dr Yamaguchi mentioned to me that one complication of this procedure is that bacteria are stuck in the calcification and then the patient becomes septic after because of the bacteria being blasted all over the kidney.  She also told me that these patients usually don’t present with pain because the stones only cause pain if they are restricting the ureter and not just because they exist, which is why people can have massive calcifications before they feel anything.

So, another wonderful day in the OR!  I’m going to try to get to Grand Rounds again because that was so great, and I saw Terry there!