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December 22, 2016

Written by Himakar Nagam (class of 2016-2017)

Waking up at 5AM, ready for my usual commute, I woke up with a different feeling today– one full of excitement and anticipation. Today was my first day of OREX, and it was all that I thought it would be and more. I put on my scrub pants and my gray t-shirt, walking out of my house in Fremont wondering what I would be observing for the day.

However, my day did not start off as expected. I got to the hospital early, around 6:50A.M., and went to the conference room in OA2 where we had our orientation, only
to find nobody there. Confused, I asked a lady in the adjacent room why nobody was there. She said that on the last Wednesday of every month, they have a special conference with the ED department physicians as well to discuss trauma cases in Classroom A on the above floor. I made my way to classroom A, sat down, and looked around nervously as Dr. Harken had not yet arrived. Eventually, he did, and I introduced myself to him and introduced myself to an attending that I was sitting next to. In came our speaker, Dr.Jeffrey Deweese, Director of the Saint Francis Bothin Burn Center in San Francisco and his 120 slide powerpoint presentation.

He had a lengthy presentation on the largest burn center in Northern California (with 16 beds), specific patient cases, as well as how physicians at Highland could improve their treatment of burn patients before sending them over to the burn center. One thing that Dr. Deweese emphasized was the importance of their burn nurses and the level of collaboration in their burn center. I remember in one picture specifically seeing physicians of all different specialties meeting together to discuss cases as well as hearing him say that their patient bed numbers are limited because of the amount of nurses they have.

With regard to treating burns, he talked about conducting both a primary survey (with the pneumonic ABCDE—you can learn about this more in detail at https://www.americannursetoday.com/abcdes-emergency-burn-care) and a secondary survey to assess the patient. He talked about not immediately putting ice or cold water on the patient contrary to popular belief and wanted physicians to monitor fluids and not put on this common gel used to treat burns called silvadene.

He also discussed determining the TBSA (Total Body Surface Area) of the patient that was burned by using the Rule of Nine’s (which I learned about in my anatomy class this semester!) and using the Parkland’s Formula to estimate how much replacement fluid the patient needs after incurring a burn to remain hemodynamically stable.

Then, he discussed various cases. There was one case about a woman who was window shopping in San Francisco when a transformer blew up right above her and made her fly across four lanes (!) of traffic across the street. In another one, a lady was lighting candles for a religious celebration when her dress caught on fire. Normally for other cases they use pig skin grafts temporarily, but she was vegetarian, so they had to obtain skin grafts alternatively. One boy was working with his dad in the fields when some black powder exploded; for this case, he discussed the usage of a Q-Switch Laser to remove scar tissue and also remove tattoo ink in other patients. I was really impressed with the burn center by the end of the presentation, and it was time to go to the OR. By then, Dr. Harken had left the room with another colleague, and I did not see other residents leaving (I think there may have been another presentation going on afterwards), so I left to go upstairs by myself.

Everybody is right when they said you will know who the scary nurse is; she immediately asked me who I was and what I was doing there once I entered the department. I grabbed my scrubs from the vending machine after she showed me where to get the card from and wandered off in the hallway when Dr. Krosin, who I previously knew, told me to come watch the surgery he was performing—a total right knee replacement revision. I was super excited as I put on my mask and entered the operating room.

The patient originally had a right knee replacement done in February but was not satisfied with the job done—she was complaining of some midflexion instability. The resident, Dr. Nguyen, showed me this was the case because she could not hyperextend, but could flex a full 90 degrees, and then showed me the wobbliness when flexing around 45 degrees. So, in order to fix this, they had to lower the joint line by putting in different hardware in the knee joint. The ACL (Anterior Cruciate Ligament) was taken out in the previous surgery, but now they had to take out the PCL (Posterior Cruciate Ligament) but would keep the MCL and LCL intact (Medial and Lateral Collateral Ligaments).

The one thing I immediately noticed was a checklist on all of the walls of the operating rooms. I read about the importance of them, especially within medicine, with regard to preventing unnecessary infections and mishaps in a book called The Checklist Manifesto by Atul Gawande (which I would highly recommend), so that made me really happy. They made sure they injected the proper amount of anesthesia, antibiotics, made their marks, covered the rest of the body, etc., then got to work by making the first incision and moving all the fat out of the way.

They used a cauterizer (known as the Bovie) to remove excess scar tissue and cement from the last surgery as well. They had to make sure to cut around the Patellar tendon as well as the quadriceps tendon then moved the patella to the side. This was all very interesting to me because I had seen these muscles and bones on cadavers, but I had not seen them in an alive person. They used these tools called gelpies to pry open the cavity so that they wouldn’t have to hold it open themselves.

Screen Shot 2017-02-19 at 9.31.28 AM.pngAfter moving the patella as well as the tendons connected to it to the side, I saw the silver hardware that replaced the condyles within the prior surgery as well as the other hardware that covered the intercondylar eminence. Using various tools like a saw (apparently this is what it is literally called), Dr. Krosin took out the old hardware attached to the condyles of the femur, the plastic in between the tibia and the femurs meant to replace the menisci, as well as the metal stem that was inserted in the tibia through the intercondylar eminence.Screen Shot 2017-02-19 at 9.32.01 AM.png

In order to place in the new hardware, the surgeons had to re-shape the femur and the tibia to fit the new parts. Dr. Krosin increased the size of the reamer placed within the tibia one by one so that the actual stem that would be placed would eventually fit. For the femur, he used the saw again in combination with a broach to make lines on the femur that would fit within the grooves of the metal replacement. He used a reamer for the femur as well. This was a very lengthy and tedious process, and one of the residents accidentally chipped off part of the patellar surface of the femur, which Dr. Krosin said was fine because the metal would be covering that anyway. This showed me one thing: that even doctors can make mistakes. I should not be too hard on myself because although that may be in my nature, it is important to stay cool and collected in all situations as a leader.

Screen Shot 2017-02-19 at 9.32.13 AM.pngI noticed a few other things as well: the first was the importance of teamwork and communication. An operation will only go well if the team that is operating communicates properly and works together efficiently. Every member of the team is crucial to the success of the operation, from the nurse anesthetist, who anesthetizes the patient, to the surgical assistant, who hands the proper tools to the surgeon when he/she needs them. This is something that Highland instills in its volunteers—the importance of communication in a well-oiled machine, and is something that Dr. Deweese emphasized in his talk earlier in the day as well. The other thing I noticed is the authority that the surgeon possesses; despite recommendations on what knee hardware replacement would be best for the patient, he is the one who has the “trump card” as the assistant put it. He can overrule other peoples’ opinions and do what he thinks is best for the patient because of his position; this is part of what makes me want to be a physician. I want to be the leader who has the ability to call the shots, and I saw this first hand today. Lastly, I noticed the importance of an attending physician teaching his residents. Medicine is a profession in which people will constantly be learning and teaching other people, and seeing an attending physician mentor his residents today is something that I appreciated and something that motivates me to become a physician one day because of my passion for teaching.

Going back to the procedure, they put in temporary metal just to assess the fit, and took measurements of all the pieces they would need. I smiled as I heard the hardware “click” into place and saw the knee joint flex properly and fully hyperextend, which was a good sight. So, after taking all the temporary metal, they laid out all the actual metal they would place in the knee on the table. The resident, Dr. Nguyen, irrigated the joint cavity with fluids and cut off blood supply so that blood would not dry up once the new hardware was placed on the bones. Then, they put in all the new hardware (one component for the tibia, one for the femur, one for the cavity for everything to glide on). They also mixed some chemical powder and fluids to form the cement to hold everything together in the cavity.