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November 22, 2016

Written by Terry McGovern (class of 2016-2017)

I arrived early for my first OREX shift  in order to get situated on time. A few residents arrived early then the rest poured in, just moments before Dr. Harken came in. He immediately began with (hypothetical?) case studies for the senior residents to discuss. Quite complex cases that they had to figure out how and what to treat on the fly. I grasped much of it, but plenty of it was beyond my learning. Only the senior residents partook while the others listened.

One 3rd year medical student sat next to me. She said. “Are you OREX?” Why yes.

“I was too” she said.      WHATTTTT!!!!!

Alexis Colley is a 3rd year medical student at UCSF, and is now doing a rotation at Highland. She had previously volunteered in the ED for 3 years and participated in the OREX program 5 years ago.

I politely asked if she could show me the ropes in the OR and she immediately said ‘Of course! Someone showed me the ropes on my first day and I’m happy to show you”.  I felt the first day jitters fading. Then she added, “If you want, you could come to the surgeries that I’m partaking in with Dr. Russell (3rd year resident) and Dr. Harken. I jumped on that as fast as I could. But before I could say “Yes Please!” she had introduced me to 2 other residents who had interesting surgeries planned as well.

I got into the OR for surgery #1, installation of a porta Cath. A porta Cath provides chemotherapy access directly into the aorta. Dr. Harken, who somehow already knew my name, told me that it is a preferred manner by which to deliver chemotherapy drugs as they can cause great damage to the tissues of the arm thru a peripheral IV.

I had some familiarity with the device going in to the surgery but was intrigued to see how it would be placed. Dr. Harken, who is truly an amazing teacher, insisted that I get up right next to the ultrasound screen and the patient, to watch.

Alexis tried a number of times to get the needle into the vein, but it kept collapsing. after a few minutes. Dr. Harken said “This is almost impossible. I don’t know if I can even get this one.  This is not fair for you Alexis”.

She had just about got it, but handed it over to Dr. Russell.

He then manipulated the needle into the sub-clavian vein.  Dr. Harken then slid a guide wire into the vein, then the expander.  They made a second incision point where the port would be implanted and the tube that would carry the chemo to the aorta.  

Once the bulk of the surgery was done, leaving the stitches to the resident and Medical student, he said “C’mon Terry, let’s go see what other surgeries are happening before our next one.” We went onto OR 1 and there was laparoscopic myomectomy going on. This patient had a broken T 12 vertebrae that they were trying to stabilize with pins and screws

Then we went to see a laser Lithotripsy (laser breakdown of a large Kidney stone). Dr. Harken told me watch either one of these for a while and come back to OR3 in 30 minutes.

I returned to the surgery in OR3 just as it was to begin. This was a AV fistula being placed. An AV fistula is the joining of the cephalic vein with the brachial artery in order to make a better access for Dialysis. It is a meticulous vascular surgery. An hour and a half later, it was stitch up time.

As the surgery was completed, Dr. Harken asked for a “sleeve” from the OR tech. I didn’t know what this surgical implement was or how it would installed. A moment later the OR tech Asked for my right hand, pulling a sleeve on me and gloving me up. “I want you feel the thrill” said Dr. Harken.  A thrill is a buzzing sensation felt under one’s finger upon palpation at the location of a AV Fistula. I had felt one in nursing clinicals previously, so I had some expectation of what to feel. I was amazed to have had the opportunity to feel it immediately post-surgery.

An AV fistula takes about 6 weeks to “mature”, or until it is ready to be used.

The third surgery I saw was truly sad and very intense. It has taken me some time to try to process it, and it is likely to have a very strong impact on me for quite some time.  The patient was a multiple gunshot victim who had been in ICU for about 10 days. In order to keep her alive, they had used many medications including Levophed/Norepinephrine to vasoconstrict her blood circulation in order to maintain cardiac output and blood perfusion to her brain, heart and organs. This drug is usually used after severe hypotension or shock. One very dangerous side effect of the drug is that there can be decreased perfusion to the extremities due to its vasoconstrictive action, ischemia results and necrosis can occur.

After the patient was brought in, everyone in the room was noticeably affected by the condition of this patient. This was described to me as a “life or death surgery”. The head resident, Dr. John Swanson, said to me “You are now seeing the horrible side of the marvels of modern medicine”. The tragedy of this person’s situation was felt by every single person in the room.   (2 surgeons, 4 residents, 1 third year med student, 2 CRNA’s, 1 OR tech, 1 OR nurse). Both hands and both feet needed to be amputated to give the patient any hope of survival, as necrosis had affected all of her limbs. I will not go into the details of the surgery, but it was not an easy thing for anyone in the room.

The head resident again spoke with me to warn and prepare me.  “Have you ever witnessed anything like this?” No, I responded. He said “Just be careful because we have had people faint in these procedures.” I took extra precautions and positioned myself at a distance and paid keen attention to my own reactions. Thankfully, I did not faint. It was intense but I did watch, and after the initial amputations, I did watch the bandaging and cauterization fairly closely. Afterwards, there was a somberness in the room I will never forget.

From my experience volunteering at Highland in the ED, I have seen many victims of senseless gun violence. Every single victim has some effect on me, but the impact that this patient had on me is profound.