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.
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.
Written by Carlos Yang (class of 2015-2016)
I arrived at Highland around 6:45am and raced to the meeting room. Due to the hour change the sky seemed a lot brighter than I remembered from my first OREX day so I had a small fear that I was already late to the meeting. When I arrived in the room I was the only person there, further feeding my fears. After a few minutes more people trickled in so I realized that I was on time and got ready for the lecture. This time instead of going over an article Dr. Harken played a game of medical Dungeons and Dragons with the residents. He would describe a situation and they would have to tell him what they would do. First he presented them with a sixty year old man with acute epigastric pain, BP or 90/60, and a temperature of 38 degrees. First the group wanted to check his breathing, which they were told was fine. Next they checked his pulse which was 120 bpm. At this point Dr. Harken explained a little bit about the exercise saying that as surgeons sometimes they have to start therapy before they fully know what is wrong with the patient. With this information the residents opted to give the patient crystalloids and gave Ringer’s lactate. Then someone said to do an EKG which did not lead to much, but the patient did say he had an inferior myocardial infarction three months ago. Then someone suggested doing a fast exam to look for bleeding, but the test came back negative. Then they decided to have an X-ray taken to look for air in the diaphragm. Next they checked the lab results and I do not remember where that lead and my notes are illegible. At this point Dr. Harken had the patient reveal that he drinks a liter of vodka a day and that his abdomen was still very tender. The residents then gave him some morphine for the pain and checked his echocardiogram, his ejection fraction being 40%. All his stats were the same so they put a central line in and saw his central venous pressure was 4 mm Hg which was on the low side so they gave him more Ringer’s which bumped it up to 6 mm Hg. This example sort of ended there and Dr. Harken revealed that the true purpose of the exercise was to see the thought process of the residents. He would rather them guide him through what they are thinking than to just say the right answer. There was another example, but it was almost exactly the same as the first and then it was time to go to the operating room.
I walked up to the 5th floor by myself since there were no residents available to take me. As I went to get the vendor card to get scrubs I noticed that the OREX pictures still did not show me in them so I hoped that the woman at the front would remember me from last time. I do not think she did, but she let me take the vendor card in exchange for my phone. I got into the scrubs and checked the board. The first procedure that leapt out at me was a Left Thyroid Lobectomy. So I went to OR 4 and waited for the procedure. There was a man already inside putting things on the white board so I went and put my name up as well. We waited for a bit and talked about OREX and other things until a doctor came in and said that the procedure was postponed due to the patient not having insurance. This was an interesting development that left me without a surgery to watch, but all was not lost since my new friend directed me to an ortho surgery that had not yet started. I slipped into OR 1 and introduced myself to the first person I saw. The procedure they were doing was a “Left Ankle Open Reduction and Internal Fixation” which is a really fancy way of saying they were fixing the patient’s ankle. Apparently this patient had broken their ankle in Austria while practicing for the winter Olympics. What was just as interesting as the procedure was the environment it was being done in. There was 90’s alternative rock music playing and the doctors were kind of talking to each other like bros. One of the surgeons was the most junior of the three so he was the target of most of the banter. The other doctors kept reminding him not to cut a nerve, pointing it out whenever they told him to do something. At one point he reached for an instrument and the most senior surgeon took it from him and said that good surgeons do not use that tool.
I positioned myself to get a good view of the surgical field and I could see the ankle. This was the first time I had seen exposed bone in person other than teeth. The doctor noticed me and pointed out the fracture which was a very noticeable line. They also took some X-rays to look at the way it moved and you could see the joint sort of open up when moved.
What is really interesting about orthopedic surgery was the inelegance of it. While still very technical surgery they employ a lot of drills and tools that use brute force. After setting up some guides the junior surgeon started drilling them into place. After skillfully avoiding the nerve and drilling all the plates into place they began sewing up the ankle. At the end, instead of using sutures, they stapled the skin together which was the first time I had seen surgical staples. They also applied a cast which was fun to watch. I have never broken any bones so I have never seen a cast being put on. It was a little like papier-mache.
The next procedure I saw was a “Laparoscopic Left Pelvic Mass Removal and Potential Removal of Left Ovary”. I went into OR 3 and introduced myself to who I thought was the doctor. It turns out it was a third year medical student named Ben who was very friendly. I talked to him about applying to medical school and he said he does not miss the application process. He was worried about applying for a residency, but I am pretty sure he will be fine. When the doctors came in they asked who I was and I told them I was with OREX. Both of the doctors did not know what OREX was so I explained it and one said that she remembered Dr. Harken sending her an e-mail about it two years ago. They did not kick me out so I think it all went okay. The procedure was very similar to the colecystectomy I saw during my first OREX day. Since both procedures are laparoscopic the set up was the same. They made a hole into the woman’s pelvic region and put the camera inside. The patient had previously had a hysterectomy so there was not much to see inside except for the left ovary and a fibroid that was the target of the operation. The doctors used the grabbing arm of the laparoscopic tool to simultaneously grab the fibroid and cut it off. The mass was too big to just yank out so they spent a long time cutting it into small pieces. This work seemed to be very routine for the doctors because they began to talk about all sorts of things. What I remembered most of the conversation was that one doctor was going to get her Thanksgiving food from Market Hall, which is something that my grandmother was thinking about doing too. The cutting took a long time so they had someone put on some music to “set the mood”. Instead of 90’s alt rock the music for these doctors was more contemporary. I recognized one Muse song, but that was it. After taking the mass out, they sutured up the holes using the smallest needle I had ever seen. Ben got to do some of the sutures and I think he did a good job. After the procedure was over I had to go home to check on my sick cat, but I had spent a good six hours from 7:00am to 1:00pm watching surgeries that I had not seen before and also seeing the surgeon’s personalities come through in the music they were playing.