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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

Screen Shot 2017-10-09 at 3.02.45 PM.png

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!

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November 17, 2016

Written by Lisa Jo (class of 2016-2017)

My first OREX day was Thursday, November 17. It was awesome! I saw a craniotomy, cataract removal, ankle draining, and a laparoscopic gallbladder removal.

I got to Kaiser Oakland for Grand Rounds, enjoyed a free breakfast burrito, and listened to a few residents give their presentations. The first presentation was “Does Surgery Stimulate Inflammation?” (apparently it does); he summarized the immune and endocrine response to surgery. One new term I learned is “third-spacing”, which is fluid shifting into interstitial spaces; surgery typically involves blood volume loss, so (as I will discover later) the amounts of IV going into the patient and the urine produced after are recorded to monitor fluids.

The next resident briefly talked about Ella Wheeler Wilcox, a poet who outlived her children and husband, and read her poem “Solitude”.

The final two presentations were the pros and cons of using statin and aspirin during surgery. Both presentations cited the Jupiter trial and Poise-2 paper, and mentioned Dr. Poldermans (a doctor that fabricated data for many papers). Overall, it seems that statins do not significantly harm patients during or after procedures, while aspirin marginally does.

Grand Rounds was over around 8 am.

At Highland, the first surgery I observed was a craniotomy! I walked in to see the patient already unconscious, on her side, and head in a clamp. It was unexpectedly fast; the surgeon, Dr. Patel, dictated the patient information before starting and predicted that it would take about an hour and a half (and it did). The patient had meningioma. He has able to pinpoint the tumor location by using a reflective tool to create a 3D model of the current head and compared it a recent MRI. He sliced through the iodined scalp, drilled and picked a small (~3 inch diameter) circle in the skull, removed it into a bucket, and used an ultrasound tool to cut through the brain matter. The white tumor he removed was about the size of a grape and probably benign. Dr. Patel filled with a white material then a blue liquid plug that mimics the cerebrospinal fluid. The skull flap was polished and had metal brackets attached to it so that the piece can be screwed to the rest of the skull. Then the scalp was sewn, stapled, and wrapped.

The patient’s urine was collected to measure the patient’s fluid loss during the procedure.

The cataract removal was performed by a resident. The patient was responsive and draped throughout the procedure and put under a microscope. The surgeon dropped in a liquid onto the eyeball to keep the eye dilated and injected anesthesia under the eye. He cut a few slits around the iris and injected a blue dye into the eye to stain the capsule surrounding the cloudy lens. He removed a part of the blue capsule, and the lens surfaced. He used an ultrasonic tool that also acts as a vacuum to break up the lens and suck it out; he also used another tool that filled the area with water. After he made sure the area was clean of cloudiness, the resident injected the lens implant and stitched slits in the cornea with the smallest thread and needle I’ve ever seen. The eye was covered with gauze and a hard patch. The procedure took about 2 hours.

An orthopedic surgeon and a resident did the ankle drain. The patient had a previous injury and had sutures. The resident cut the sutures, and the doctor stuck his finger into the open wound! He felt around the tissue, lifted the foot over a bucket, and washed the wound with saline solution. He injected and vacuumed the solution multiple times. He pointed out a visible nerve in the foot; it looked like an off-white, thin cord. The wound was closed with sutures and the whole leg was wrapped. The procedure took about 15 minutes.

I visited Dr. Krosin on the 7th floor. The orthopedic back office was really cramped and full of computers displaying x-rays. I shadowed him while he met and followed up with two patients, one who had hip replacement surgery a month prior and another with back pain. He was really amicable with the patients and their family, but also efficient. He addressed their concerns on the spot and explained away any confusion. The patients were visibly glad to be in his care. (Afterwards, I got another even bigger and better free burrito in their office!)

The laparoscopic gallbladder removal was performed by three doctors. They inverted the belly button and cut it into quadrants. The reason of going through the belly button is the skin there is relatively thin for all patients. This is where the camera went through. They filled the cavity with air so they had more room to see and work; with the light of the camera inside, the body looked like a red, glowing balloon. They made two other entry points near the gallbladder with their scalpels for their tools. The gallbladder was white-ish green and really distended. They cut and burned near the base of the organ to look for the cystic duct and blood vessel; the gall bladder popped during this process and black bile leaked out. They used the vacuum to suck out the bile. Once they found the vessel and duct, they clamped and cut them. After the gallbladder was free, they cut to detach it from the surrounding area, tossed it into net that passed through the belly button, and removed it from the body. The entry points were stitched. The procedure took about 2 hours.

At about 4pm, my feet were a bit sore and decided to get going. After all the excitement, I was glad I didn’t get kicked out once! Everyone was helpful and willing to answer my questions.