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November 21, 2017

Written by Tanya Joseph (class of 2017-2018)

I was standing in the lonely hallway on OA-2 at 6:30 am unable to decide which door to badge in when I bumped into Dr. Victorino. I kindly introduced myself, and he directed me to the glassed door in front of the department of surgery. My badge did not work there, so I went to OA-3 and had enough time for a coffee at the vending machine in OA-3 to kick-start my day. I came back down to OA-2 and an internal medicine physician saw me stand confused and unable to badge in, and she was so kind to let me into the Resident City with her badge. While making myself slowly familiar with the resident faces, I realized they were all very alert and attentive for an early morning class. The vibe was a very enthusiastic one, and it was more like a case discussion rather than a class. Slowly the room was full with 13-14 people inside sitting around the conference table, including medical students and attending, Dr. Victorino. I was amazed how friendly he was to the team of residents and students. The flow of topics from him totally convinced me that he was a very experienced surgeon. I became more eager of the topics that he came up with.

The class began with discussion of a case that came in the Emergency department the previous night. A middle-aged man was brought in with loss of consciousness, and fixed pupils after a head injury. His distal pulses were feeble and he was intubated because of signs of aspiration. His chest X ray showed an abnormality in right upper lung lobe. The questions followed after one of the resident presented this case. Dr. Victorino made sure that he asked each and every resident a question regarding the case. The first question was, “What do you think the problem was, what are the differential diagnoses, what will you do next- EKG, Blood labs?’’ All the residents were prompt with their answers regarding the pathology, diagnosis and treatment. They discussed how this could be from a previous medical condition and not purely a result of the traumatic event. From their discussion, I figured that it is good to have a perspective opinion from an internal medicine physician in such cases. They discussed what the ER team did, in order to resuscitate the patient and then went on to start discussing about the treatment for hyperkalemia since the patient’s potassium levels were very high (7 mEq/liter). Hyperkalemia occurs when serum potassium levels are more than 5- 7 mEq/Liter and it could precipitate cardiac arrhythmias. If serum potassium levels are high, your aim is to stabilize the heart, treat with insulin to drive the potassium back into the cells, kayexalate, calcium gluconate, and ringer lactate. Normal saline should be avoided because of risk of metabolic acidosis.

They later went on to discuss another case of an 82 year old lady with duodenal rupture that caused the contrast agent (gastrograffin) to leak. She was previously brought into the ER for bilious vomiting and constipation for 4-5 days. She had a previous history of stroke according to her daughter. The surgeons were concerned about mesenteric ischemia (lack of blood supply to the intestines making the perforation difficult to heal) due to past history of stroke and her age. She was scheduled yesterday for an exploratory laparotomy and repair of the duodenal perforation. They would repair it with the patient’s omentum. They discussed briefly the CT scan of her abdomen. The first picture is of the CT abdomen showing duodenum.Screen Shot 2018-03-08 at 6.10.16 PM

I tried to find a picture  similar to the contrast leak that was shown in class in picture 2.

I hardly got any time to talk to a resident as everyone dispersed immediately after the class, and I walked to the OR. I had read Lucy’s recap of orientation many times and this helped me get to exactly where the vendor card was. There was no one at the station, so one of nurses (Mark) helped me get the card and he understood that it was my first day. He walked me out to the changing room and showed me exactly how I could get my scrubs and gave me instructions about the hair cover cap. The red line to the OR can be crossed only if your head is covered and you have a mask on. I also covered my shoes with the shoe cover.

Later I found myself staring at the board to decide which surgery to go and observe. I wanted to tail Dr. Victorino and I stepped into OR # 3 for Right heart catheter implant. I stepped into the room and introduced myself to the nurse (Monica) and I wrote my name on the board. She was so sweet that she personally took me out to get the X-ray shield and said to have it on all the time that I was there. There were totally 6 of us in that room and Dr. Victor said, “Whoever is in OR 3 should stick to OR 3.” All the time I was very careful not to touch the sterile blue area. The X ray tech asked me to get a thyroid protection shield but they were all in use, so he was very kind enough that he offered me his shield. The surgery was performed by a resident under the guidance of Dr. Victorino. The atmosphere in the OR was calm and everything went smooth. The procedure was short and finished sooner than I thought.

Overall, my day was very good and I was happy that I learned a lot. Later I stepped out and thanked Dr. Victorino and he mentioned that we are welcome to attend lectures on Wednesday mornings in the Old Building. They teach different topics on Wednesdays. I did not come across Nurse Julie the whole time, so I think she must be off for the Holidays. Everyone whom I came across was very helpful and kind.  The only times I fumbled were to get hold of the Vendor card and I did not know where to put away my used scrubs, so I placed them in the blue cover in the changing room that I assume is for used scrubs.