Written by Xiteng Yan (class of 2014-2015)
On Tuesday, November 25th, there was a guest lecturer (unfortunately, I forgot to write down his name) in the morning rather than Dr. Harkens. He gave a lecture on mass casualty preparedness and drew on his own experiences as a doctor in NYC during the 9/11 terrorist attacks. He began with a list of topics that he would cover and a few relevant photos. One of them was a photo of a fire-truck at ground zero – the lecturer pointed how doctors and nurses are usually not sent to ground zero because they are not equipped for the environmental dangers present. Another was of the empty receiving area of the lecturer’s hospital the morning of the attack. The point of that photo was to illustrate how there were relatively few injured people – the reason being that most of the people in the attack were immediately killed. In fact, the dead-to-injured ratio of the 9/11 attacks was an astounding 10:1. In comparison, the ratio for a war zone is 4:20, the ratio for a trauma center 1:20.
Next, the lecturer discussed the problems of over-triage, which is the incorrect assignment of patients to the trauma center. The issue of over-triaging is that it takes away the finite resources from those who are critically injured. The lecturer posted a slide displaying a graph from Dr. Frykbergs research, which showed a linear relationship between over-triage and critical mortality. For the last portion of the presentation, the lecturer gave advice on how to best handle a critical situation like 9/11. One was the importance of not letting “walking wounded”, basically anyone who is not critically injured, within the treatment areas dedicated for the critically injured. Another was the importance of “clipboard organization.” “Clipboard organization” is basically the jotting down of the hospital’s resources and statistics on a clipboard where one can easily see them; the organization it provides is critical to running a smooth disaster response. In the end, I really enjoyed this lecture because it was easy to grasp (no difficult scientific concepts) and immediately relevant given the current protests.
As for the operation I observed, I watched Dr. Park operate on patient with the assistance of resident D. Kendrick. The patient had been assaulted at a BART station a few weeks ago and sustained multiple fractures in the face (e.g. bilateral Lefort I, II and III fractures, naso-orbital-ethmoid [NOE] fractures, palatal fractures, frontal sinus and skull fractures). In addition, the patient suffered multiple lacerations to the face and scalp. There wasn’t a procedure name written on the whiteboard or on the photos indicating the injured areas; as a result, I was unsure of what exactly was going to happen. During the preparation stages, the residents shaved off a row of hair, approximately one inch wide, from ear-to-ear and going across the top of her head. During this period, I had the pleasure of speaking with Dr. Mock, the director of Highland’s dental clinic. He was kind enough to give me a brief overview of oral surgery education in the Bay Area. Soon after I spoke with Dr. Mock, the operation began.
The first few hours were dedicated to fixing metal braces around the upper and lower jaw. These braces were then held in place with wire loops. At this point, I was standing about five feet from the operating site and on top of two stepstools. From this vantage point, it appeared as if the residents were fastening the brace to each individual tooth with the wire loop. The loops were then tightened via twisting once everything was in place. A plastic-looking splint was also inserted into the top of the patient’s mouth; additional wires were inserted to secure this component in place. Once the braces and wires were secured, the residents brought out a pair of large pliers to work on the upper jaw. Unlike my first surgical observation, I did not have someone to guide me through the procedure, step by step. Luckily, the anesthesiologists and the vendor, M. Jaeger, were available to answer my questions when they weren’t busy. For instance, from Mr. Jaeger, I learned that the pliers were being used to mobilize the maxilla so that the splint is positioned properly.
Following the work done on the jaw, Dr. Park took over and the surgical team diverted their attention to the patient’s head, specifically the row that was shaved clean during the preparation steps. First, Dr. Park used a pen to draw a zig-zag line across the row. Next, he and the residents took turns making incisions along the drawn line. Once the incisions were made, the skin was then lifted to expose the skull. The membranes and muscles on the skull were scraped off using the scalpel as the surgical team lifted the skin. Mr. Jaeger explained to me that this procedure was called a “coronal flap,” and it is used to access the fractures in the forehead and the top of nose. The reason why this procedure is being used is that it sidesteps the scarring that would occur in the face should they access the fractures directly. The removal of the skin covering the head continued for a few hours until the team reached the patient’s brow. Once this point was reached, Dr. Park took care to verify that they have reached the fractures. As soon as this was confirmed, photos were taken. A tiny silver piece resembling a flattened chain was then placed between two fractured bones above the patient’s right eye and drilled into place. Once this chain was properly implanted, the team moved onto the next fracture, which was located on the other side of the face. It was at this point that I excused myself from the OR and ended my day.