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December 29, 2017

Written by Catherine Lee (class of 2017-2018)

 

I am not a morning person. Waking up at 5 wouldn’t be something I would ever have conceived of doing on a voluntary basis even two years ago, but with how excited I was about my first OREX day I actually ended up getting only two hours of sleep. I learned this day that this excitement was probably an underestimation, if anything – the OREX experience was even more magical, fun and educational than ever expected.

After wandering the halls of the second floor lost like a puppy at ungodly early-o’clock on friday trying to find the conference room, I found myself following some doctors to a room way down the hall closer to Hallway A. There, Dr. Swanson, the chief resident of the elective surgery team, greeted me with a smile and talked about his cases for the day – a neck mass excision for recurring papillary thyroid cancer, a complete thyroidectomy, and a diverting ostomy for a patient who had advanced rectal cancer and had sinuses through his gluteus oozing fecal matter and pus to the outside. That is not a mental image that you expect at 7 in the morning, and I could only feel terrible empathy for the patient – who apparently walked into the clinic after recently becoming transient, living in his car in a trash bag.

After the conference wrapped up – the case was a GSW from that previous night with an entry wound in the right shoulder presenting with an absent distal radial pulse, which prompted a discussion on CT Angio or CT with IV contrast, whether or not the extra detail provided by the CTA would be necessary given that the cause of the hemostasis needed to only be located. The attending then went over the anatomy of the axillary and subclavian arteries. I learned that internal arterial injuries can actually spasm and clot by themselves, and the clotting proceeds proximally until it reaches the nearest branch – which is what the CTA showed, the subclavian artery abruptly cutting off posterior to the pec minor. After a discussion of the various surgical approaches, we learned that the bullet had severed the artery; the patient was expected to be fine after arterial repair.

After the conference, I found myself in OR 4 with Dr. Palmer, Dr. Swanson, Dr. Fer and the last doctor whose name I forget. Together they made up the elective surgery team – apparently there are three surgery teams in the day and only one at night. The patient had metastatic papillary thyroid cancer, and multiple nodules had recurred even after complete thyroidectomy and lymphectomy – but since the risks of removing them outweighed the benefits (apparently papillary thyroid cancer is slow growing and relatively benign) she was there only to remove the one midline to her neck that was causing her pain. With Queen playing on the portable speakers Dr. Fer brought in, the surgery began at 0842 and ended at 0906 – incredibly fast! The team was really nice to me, answered all of my questions, and invited me to come closer and watch with a stepstool. The excised lump was 3.5cm across and 1.5cm in height, and I was surprised by how much subcutaneous depth there was to that tracheal area inferior to the larynx. 

After that surgery, the team and I gathered to the board to find out that an emergency case had come in, and since the anesthesia team was short-staffed for the holidays, the elective surgery team was put on hold along with a fair bit of confusion and consternation from everyone involved.

The emergency case was a patient with Fournier’s Gangrene (necrotizing fasciitis, sometimes called flesh-eating bacteria, of the perineal region) who had come into the clinic earlier that day, and a surgeon who specialized in these cases was sent for. Apparently, he was about to get on a flight for his vacation but abandoned that to come treat this patient; his dedication left a strong impression on me. I then followed the new surgeon, because who doesn’t want to see something like this? Fournier’s is something you see on House, not something you imagine happening in real life!

Fournier’s is a rare disease – 1.6 cases per 100,000 – that occurs commonly in older men, often obese, EtOH, and diabetic with poor blood sugar control; mainly facultative anaerobes such as streptococci and staphylococcus infect the patient often through trauma to the skin and into the fascia, travelling rapidly along the fascial plane and killing the tissue. The treatment is aggressive surgical excision of the skin down to the fascia until bleeding, living tissue is encountered. Sadly, the surgeon said, he had seen way too many of these cases during his career; with more progressed cases he had had to excise even dead organs like the rectum and bladder and not just skin and fascia. His empathy and regret for the patient’s situation was palpable.

After a very long delay in getting the room prepped – I was slightly worried about how long it took even, knowing that necrotizing fasciitis can progress very rapidly – the patient was rolled in and anesthesia induced. The standard procedure is to pre-oxygenate the patient with 100% O2 for 5 minutes before anesthesia to fill the patient’s lung residual volume with O2 for the transition between paralyzing the patient and intubating them under mechanical ventilation. In spite of that precaution, his O2 sat crashed to the 60s within seconds, causing a slight panic and active bagging to stabilize before intubation. I learned that such events can happen, especially with obese patients not in the best of health. With the patient’s legs in stirrups, two distinct black lesions, one ~2cm and the other ~1cm, oozing with pus were visible on his right scrotum, which had swollen significantly. A circle was drawn with about 2cm of distance from the visible lesions to mark the initial excision area.

Surgery began at 1112, and while it wasn’t quite the swamps of Dagobah that I had thought of as a worst case scenario, it was still … alarming. The incision revealed tissue that was distinctly grey – like meat that had gone very bad. Instead of blood, what came out when the surgeon pried into the fascia with his finger was dark grey goo. The initial excision area – probably about 6x4cm – was clearly nowhere near the extent of the infection. Further excisions continued superior to the initial incision, with the surgeons alternately shoving into the fascia with fingers to feel by texture and relying on the fact that dead tissue doesn’t bleed to determine where to stop – eventually, most of the skin and fascia around the base of the penis was excised. Next came nearly the entirety of his right scrotum and a little past it, and the bucket of dead tissue was starting to pile up. Ultimately, about 85% of his scrotum and the skin and fascia around the base of the penis ended up excised. The surgeons’ gloves were very much more grey than red.

They then used a neat tool for debridement that looked very much like an immersion blender but with a suction cup and a rotating brush at the end – when pressed against the skin and activated, suction pressed the cup to the skin, the brush spun to debride the tissue and water was circulated through and suctioned out. The wound was packed with betadine gauze and the remaining part of his left scrotum was stretched and stapled to close over. He would be back tomorrow for a followup debridement and evaluation of whether or not the patient’s remaining organs were viable; he would be in a great deal of pain but at least he’s alive, the surgeon said. That was really heartbreaking to hear, and together with the abject reality of the giant mass of flesh missing from him made it overall an incredibly neat experience, but also incredibly terrifying.

My final case for the day was also the longest – Dr. Palmer’s elective surgery team had apparently found an anesthetist and begun surgery on the patient who needed complete thyroidectomy by 1132. When I walked in there at around 1230 immediately after the end of the Fournier’s case, they had apparently conducted a midline slice through the thyroid and were very slowly and carefully separating the right half of the thyroid from the larynx. I learned that great care had to be taken for thyroidectomies because the recurrent laryngeal nerves lie right underneath the thyroid. The recurrent laryngeal nerves are a branch of the Vagus (CN X) nerve that splits off and loops underneath the right subclavian artery and aortic arch respectively on the right and left, before coming back up to innervate the larynx. Damage to these nerves would render the patient’s laryngeal folds paralyzed, resulting in a permanent hoarse voice or worse. I also learned that the thyroid is really well vascularized – every time they isolated a string of tissue and snipped it with electrocauterizing forceps, I was seeing a blood vessel being cut.

Another thing I learned was that anatomy in real life looks nothing like that in books. The thyroid just looked like another red lump of flesh lying on top of other red lumps, and was nowhere near the discrete organ that you would have expected from drawings in a book. In fact, the surgeons had difficulty locating the parathyroids, and sent off several biopsied pieces to the lab from various parts of the thyroid to confirm histologically with frozen slices if they were parathyroid or thyroid. By the time the entire thyroid was taken out, it was around 1500 or so.

Because parathyroid hormone deficiency would be much more severe than thyroid because of its critical role in regulating calcium, they did what I thought was the neatest thing about this surgery. They chopped up the piece of parathyroid they had confirmed by the lab into small 1x1mm pieces and implanted each one separately along the sternocleidomastoid muscle with small incisions, as if they were planting seeds along a furrow. Apparently the body will just keep these bits of parathyroid alive and they will happily secrete parathyroid hormone for the rest of their lives; the body is truly an amazing thing!

It is remarkable how much I feel like I learned from just this 9 hours spent in the OR courtesy of this amazing program. It is truly like immersive language learning, the quickest and most effective method of second language acquisition. I took in so much interacting with everyone in this environment, seeing all the little things and the teamwork that goes into what makes a surgery work and be successful, building pedagogical relationships with all the members of the team who are generous enough to teach me – like having the anesthetist grill an intern (and myself!) about anatomy and how anesthetic drugs work, and noticing the empathy you notice in other members of the team for patients who sometimes have the most awful of situations and diseases. I learned the sheer dedication of these surgeons who work 80 hours a week and have 4 days off a month, that cancel their vacation flights so they can come in to save someone’s life; I learned how much my feet hurt after 9 hours of standing with almost no walking and that I should really exercise more to be in better shape; I learned that despite all the horrible and amazing things I saw today, I remain so excited and humbled by the chance to experience and learn all of this, and I cannot wait until my next OREX date.  

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Janurary 19, 2017

Written by Cicily Cooper (class of 2016-2017)

It was so nice to be back in the OR after over a month of not being there.

I made the mistake of forgetting that it was Thursday and showing up at Highland at 6:50 to find the room totally empty.  I asked a friendly person and she apologetically informed me that Grand rounds were at Kaiser today at which point I kicked myself for knowing and forgetting.  After too much oscillating, I decided that I’d better go to Grand Rounds and be a few minutes late than wait around Highland for 2 hours!  And I did, and it was GREAT!!!

The person talking was the head of surgery at SFGH.  Her talk was on surgery and disasters and she had a ton of experience and so much to say.  I am particularly interested in disaster relief work and found her input on triage and disaster preparedness very intriguing. There was also food and coffee so by the time I headed back to Highland at 8:30 I was in a really good mood in spite of my self-caused morning stress.

When I got to the floor it seemed that most of the surgeries had started already and so I walked into a room that looked like it was just getting going and met Dr Yamaguchi, a urology surgeon, who was very friendly and helpful.  She showed me the CT of the patient who had had multiple washouts and debridements of Fournier’s gangrene which had caused necrotizing fasciitis.  At the point where he was in front of us, he had a wound from his anus all the way up to near his umbilicus, making a B-line through his scrotum.  One of his testicles was completely exposed and enlarged.  The wound was about 4-5 inches deep.  The plan for this day in the OR was to give it another washout and to partially close it.  

The patient had presented with some pain and swelling but it turned out that he had uncontrolled diabetes which was why the gangrene had gotten so completely out of control.  He had been completely septic and had he not been operated on would have died very soon, according to Dr. Yamaguchi.  

In other surgeries I had been in there had been way more residents and medical students and I felt more worried asking too many questions, but in this OR there was only the patient, the anesthesiologist, her student, the tech, Steve and Tim the OR nurses, Dr Yamaguchi and myself.  I had a pretty great view and asked her many questions which she answered.

First she did a saline washout of the wound to get rid of the dead tissue and expose the live pink tissue underneath.  Next she very slowly and tediously began to close the huge gaping wound that had remained.  She explained that she wanted to avoid creating any pockets where infection could get trapped.  We discussed the different types of sutures and when they get used.  She explained to me that the braided ones are worse for infection but she had to use some of the braided ones that dissolve inside for the areas that would be impossible to access once healing occurred.  The nylon ones for the surface need to be removed.

After about two hours she packed the remainder of his wound with soaked betadyne kerlex.  She wrapped his single exposed testicle in saline gauze that did not have betadyne on it to protect the testicle from the betadyne and keep it moist.

After this I watched Dr Yamaguchi’s afternoon procedure which was a cysto-left ureteroscopy, laser lithotripsy and possible ureteral stent placement. In other words, laser blast removal of a kidney stone through the urethra.

For this procedure we all had to wear “leads”, the x-ray proof dresses because x-ray was in the room with live imaging.  We also had to wear laser glasses to protect our eyes from the laser that was used.  Needless to say, I felt pretty darn cool.

The procedure was super interesting and everything was visible real-time on the screen above her head.  I got to watch the camera go into the kidney and search around for the stone and then we saw it on the screen.  It looked kind of like icicles or crystals in a cave.  It took some time but Dr Yamaguchi blasted the crystals and then had to keep blasting them.  She also sent in this tiny tiny wire with an even tinier grabber on the end to grab a hold of the little pieces of stone and pull them out.  It reminded me of the game in an arcade where you try grab the stuffed animals with the claw that is really hard to control.  Anyway, the stone was blasted and removed.  Dr Yamaguchi mentioned to me that one complication of this procedure is that bacteria are stuck in the calcification and then the patient becomes septic after because of the bacteria being blasted all over the kidney.  She also told me that these patients usually don’t present with pain because the stones only cause pain if they are restricting the ureter and not just because they exist, which is why people can have massive calcifications before they feel anything.

So, another wonderful day in the OR!  I’m going to try to get to Grand Rounds again because that was so great, and I saw Terry there!