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December 31, 2017

Written by Man Kim Phan (class of 2017-2018)

I got to Highland super early today and got myself situated in room 230 half an hour before the morning meeting. At about 7:10 am, residents started trickling in, but the attending was still not here. Everyone decided to wait 5 more minutes but the attending still hadn’t shown up. And so the meeting was cancelled as people dispersed to grab early breakfast. I gotta admit I was really disappointed as I was curious as to what the Wednesday’s lecture could be about. I went to the cafeteria and waited until the first surgery.

Once in the OR, as I was checking out the schedule of surgeries on the whiteboard, an intern, whose name I recalled was David Liu (?), was also there wondering which surgeries he should observe for the morning. He gave me a brief overview of each type of surgery listed on the board and gave me advice on which one I should watch. He said if I’m interested in seeing surgery, then a laparoscopic cholecystectomy would be ideal as there will be a camera; on the other hand, if I’m interested in learning about surgical procedures then any of the orthopedic surgeries would be extremely informative. He was personally interested in a case on unclogging the arteries of an elderly patient that might involve complications (I couldn’t catch the names of the procedures) but the patient wasn’t there yet. Since this is only my second surgery day and I hadn’t seen a lot of surgeries yet, I took his advice to catch the cholecystectomy.

The surgery already started when I got into the room. The circulation nurse kindly got me up to speed with what was going on. On the screen, I could see the gallbladder, a dark red mass of tissue covered with fat and layers of connective tissues, and the liver in the back. The surgeon was delicately “peeling” away the peritoneum (I think…) with heat! At the same time, I overheard them looking for the cystic duct and artery. After some time had passed, the surgeon encountered a thin pale white duct slightly inferior to the gallbladder as the gallbladder was flipped over. Upon close examination, I think they determined that it was the cystic artery, and the surgeon ligated it with a clip. Furthermore into the dissection, as more layers of tissues were peeled off, the surgeon located the cystic duct, slightly larger in diameter than the artery. The cystic duct was also ligated. Then, both ducts were cut. At this point, he finished up dissecting the gallbladder from its attachment to the liver. I think the tool he used was also heated as it left the surface of the liver with shiny, metallic-looking traces everywhere it touched. As the surgeon moved away, I started paying attention to the three port insertions on the patient’s abdomen and realized how incredible it was to be able to operate on the internal anatomical structures of the human body through only three small incisions. I witnessed the gallbladder completely detached from the liver and safely placed in a specimen bag- this process was still going on inside the abdomen. I couldn’t see how the specimen was sucked out, I assumed through one of those three “holes”. Then, I noticed the patient’s abdomen was unusually inflated and flaccid but did not give it more thought as to why. Later on, as I looked up written explanation of this procedure, I found that the surgeon must inflate the patient’s abdominal cavity with carbon dioxide after initial incisions to create easier access. This was the preparation step that I missed but I was in awe that a seemingly insignificant detail that the eye of an amateur, aka me, did not catch does matter in the course of the surgery. Everything all made more sense to me.

As the first surgery was over, the nurse recommended me to watch some orthopedic surgeries so I went to OR 1 where Dr. Liu was. Before entering the room, I made a quick observation of what everyone was wearing from outside the room and noticed the CT machine. I went to grab a lead vest and was told that the purple vests are the lighter ones (“small” people take note!).

This time, an Open Reduction and Internal Fixation of Distal Femur (ORIF) was in progress. This room had a completely different atmosphere than the room I was in earlier- more vibrant and almost hectic as surgeons shouted out instructions and, every now and then, words of motivation. And unlike in the previous surgery, the surgeons and med students were all operating with large tools such as long needle-looking nails, screw, metal graft, etc. I could see quite an amount of blood on the patient’s lower leg which got onto the CT machine and all over the floor. At the moment, a surgeon was pulling from the patients’ leg as others adjusting the positions of the nails and metal plate. I could see the CT scans taken at every step although I could not tell at all what the changes in positions of the bones or the instruments were. I could, however, make out the fractures around the medial epicondyle of the femur. I couldn’t tell what was going on during most of the procedure but some quick Google searches helped me understand the overall steps involved in an ORIF. Basically, this procedure is used to treat bone fractures. The broken pieces will be aligned and secured with screws, metal plates, wires, or pins. The surgeons were incredibly meticulous, making sure every pieces of metal was in the exact position. Countless CT scans were taken until the surgeons were satisfied with their work. This process took about four hours. Toward the final stretch, the patient started regaining some sensation so the nurse and Dr. Liu gave the patient some injections through the IV. I actually did not realize the patient was awake until half-way through the procedure. The patient was only given local anesthesia. The nurse and Dr. Liu continued comforting and checking in with the patient over the blue shield. I could not imagine what the patient must have felt throughout the surgery but I’m glad the staffs were really supportive and professional. Someone shouted out, “Final stretch,” as the head surgeon secured the last walkers (like some sort of screw that secures the metal plate in a position laterally along the femur). Other surgeons quickly sewed up the patient’s skin and cleaned up the blood. The surgery was being wrapped up as the head surgeon asked the CT tech to take a couple final shots of the femur where the metal plates were. At that point, the room was getting rather crowded as the staffs were working on transitioning to the next surgery so I just excused myself and headed out. There weren’t any more surgeries besides a couple of cataract removals so I decided to call it off, amused and inspired by what I have observed and learned today.

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.

November 13, 2015

Written by Sarah-Jane Parker (class of 2015-2016)

The night before I decided to put my new doughnut pan to good use and bring apple cider baked doughnuts to the morning meeting. I had forgotten it was Friday the 13th the next day, and I ended up baking a failure instead of the dreamy autumnal doughnuts from Molly Yeh’s Blog (yes I’m blaming bad luck). See side by side comparison:Screen Shot 2016-01-09 at 4.52.20 PMI internally debated whether to bring the hideous creatures that still tasted pretty good and ended up throwing them in my bag and delaying the decision. I arrived in the conference room at 6:30 on the dot and did work until 7:00 when I started to worry because I was still alone in the dimly lit room. A couple minutes later the chief resident and a couple 2nd years came in and wondered the same thing and then saw the baked doughnuts on the table. It was later explained that Dr Harkin was out today,and that I had brought food. Everyone was super appreciative, and I realized this was a genius baked failure idea. A 5th year joked that he would be happy to make all my surgery dreams come true.

The focus of the morning meeting was practicing Oral Boards. It was explained by the board certified surgeons that the point of boards was not to discern your history/physical exam skills – these should be well-honed at this point- but rather to talk about management of the patient, clear knowledge of contraindications and diagnostics, and that the scenarios will change quickly. It was impressive to see how much knowledge needed to be at their fingertips: from stratifying patients with appendicitis to rare adrenal cancers.

The meeting wrapped up, and I was resigned to the fact that I would be finding my way again by myself. At least I knew how to work the scrub machine this time! I hurried along with the students, changed quickly and was in front of the board before all but one of the surgeries started. I noted the Laparoscopic cholecystectomy patient was rolling towards OR7 and headed that way.

Dr Lee (5R) and Dr Huyser (2R) were performing the surgery with Dr Victoriano attending. I was familiar with this duo from two surgeries on my last OREX. They work quietly and efficiently and Dr Lee tends to invite questions in quiet moments or after the surgery is done. The Patient was a 27 year old male who had been complaining of pain due to gall bladder stones. Dr Victoriano later explained that although diet and medication can help manage gall bladder stones there are few long term risks to removing it (diarrhea) and gall bladder pain (due to stretch receptors) can be truly debilitating. The patient was joking with the anesthesiologist about getting the good stuff and he was quickly put to sleep and the surgery was under way. Once the camera wand was in, the gall bladder was visualized as a purplish looking gland wrapped around the intestine. The peritoneum was slowly pulled away from the surface of the gall bladder, so that the surgeons could visualize the anatomy. Dr Victoriano explained that the complication of this surgery is in being sure that you are not cutting the hepatic duct connecting the liver to your digestive system. The surgeons therefore need to isolate the cystic duct (connecting gall bladder to common duct), the cystic artery, and then the right hepatic duct to be sure they are in the right place and because not everyone’s anatomy is text book. In my hand drawn picture the lines across the duct / artery are where staples were placed and before sectioning off the gall bladder.Screen Shot 2016-01-09 at 4.52.47 PM

Once removed, the surgeons noted the gall bladder was full of stones. I hoped I could glove up and touch it, but I didn’t want to interrupt. Next time!

The next surgery was a left breast excisional biopsy with Dr Bullard and Dr Hernandez (intern). The patient was a 47 year old female whose X-rays were up showing where radiology had marked some unusual calcifications. Dr Bullard explained that calcifications themselves are not dangerous but they indicate something (potentially cancerous cells) may be blocking a duct. He also explained that they would be going in to collect a biopsy sample, following the wire that poked through the patient’s skin and looped around the area where the unusual calcifications were located. The surgeons would need to be careful not to move the wire (or it would need to be replaced by radiology) and to be sure to section out enough tissue for the biopsy while being as conservative as can for aesthetics sake. Finally, he explained that about 40% of these biopsies indicated cancerous tissue that would require further treatment. As the surgery got underway, Dr Bullard complained about the placement of the wire which apparently ran parallel to the skin surface for too long rather than going straight. This meant that the surgeons needed to cut more into the tissue and also be careful to not move the wire for a longer distance. The surgery went longer than expected for this reason, but the biopsy was eventually gathered and bagged up. Dr Bullard went directly to pathology to confirm that they were able to get at least 1 mm around the calcifications – otherwise they would need to go back in to gather more. While we waited for results, Dr Hernandez closed up and we discussed med school and challenges of the intern year. Dr Bullard quickly confirmed that enough tissue had been taken (barely) and the patient was woken up. I thanked everyone and headed to the board.

I hoped to watch an orthopedic surgery in OR 1 or 2 and waited over there for 30 min, but something changed or was rescheduled and I went back to the board to see which surgeries had already begun or were not scheduled till much later. I decided to wrap it up for the day and headed to go change out. The chief resident stopped me to thank me for bringing donuts again and I resolved to bring food more often. Excited for next time!

November 4, 2015

Written by Antony Gout (class of 2015-2016)

The name of the day was laparoscopic Cholecystectomy, or in common parlance, gallbladder removal. I saw three such procedures, and one hernia repair with a mesh. But let me start at the beginning.

I got to the conference room early, and sat nervously in the dark because I didn’t want to turn on the light and draw any attention to myself. Residents started filling in at around 6:55, and I exchanged pleasantries with one of them, Jessica, while waiting for the lecture to start. It was a discussion on lower GI bleeds, which mostly involved the discussion leader (whose name I forgot to note), quizzing the residents about their reading. Evidently lower GI bleeds are rarely surgical and have many possible causes (including hemorrhoids, ulcerative colitis, bacterial infections, etc…). As the discussion wound to a close, I paid less and less attention, as I got more and more nervous. Not wanting to have the same experience as Sarah-Jane, as soon as the discussion ended, I got up my courage and rushed to introduce myself to Dr. Harkin. He immediately paired me up with a Chief Resident, Abhishek Parmar (who I will call AP, in case I misspelled his name), who I followed around for the rest of the day.

I followed him up to the surgery floor, although I didn’t really get a chance to talk to him, because 3 other residents were crowding around him most of the way talking about plans for specific patients, which I couldn’t really follow. He showed me to the dressing room where I fumbled into my scrubs. A few minutes later, I follow AP into the surgery room.

Surgery #1: Laparoscopic gallbladder removal

The patient, a middle aged female, was already sleeping and the abdomen had been cleaned when I entered. I picked a spot that seemed out of the way, and crossed my arms so as to not touch anything. Dr. Cushman, the attending, must have thought I was cold, and draped a warm blanket around me. He also offered me a seat near where I could see one of the two screens, which I thought was very sweet. The resident performing every surgery I saw was a second year resident, Michelle (M). The patient was covered with seemingly unending layers of blue surgery sheet things, and the surgery started.

First, AP or M punched a hole in the abdomen, I believe the navel (I’m not entirely sure, because I couldn’t see very well), inflated it with CO2, and placed the camera. Then M illuminated from the inside the other spots where they want the other holes to go. AP injected some lidocaine at each site, scored the skin with a scalpel, and jammed in a laparoscopic channel (And when I say jam, I mean it. When I saw it on the screen I was shocked by how physical and almost crude the process was). Once all the tools were inside, they looked for the gallbladder (which apparently looked so generic it could have been from an anatomy textbook). Once found, they have to free it from the tough peritoneum around it by using the cauterized tool (Figure A). I looked up how that tool works, and it uses a small electric current to heat itself up and burn the tissue you place it on. M started out by hooking the cauterizing tool in between the peritoneum and the gallbladder and twisting the tool to free up some space. AP told her that it is instead preferable to move it up and down (Figure B), after which you can pull away from important tissue and

cauterize. Then she dissected out the artery and the duct, by using the Maryland tool (Figure C) with which she was told to columnize the fascia (Figure D). She also used the “peanut” to twist away some fascia. She then clipped three times the duct and artery and cut in between the second and third clip (Figure E). After this, they carefully cauterized the gallbladder out, plopped it in a plastic bag, and popped the bag out of the body. They popped in some gauze to sop clean up the area, and then deflated the patient (it sounded like letting the air out of ball, it was weird). Finally, they cauterized the wounds (also sometimes touching the cauterizing tool to the tweezers, which I assume heated those up and allowed AP to cauterize with more precision, which was very cool), and sewed her up layer by layer. Phew! What a trip. We grabbed a small bite to eat, and got back down to business.

Surgery #2: Laparoscopic gallbladder removal

The second surgery was extremely similar to the one before it, so I won’t bore you with another long-winded description. There were some differences though! First, the artery seemed to branch, so Dr. Cushman asked M to dissect it out to make sure one branch didn’t go to the liver, which it turns out it didn’t. The first clipping tool was faulty and M accidentally launched a clip into the abdominal cavity, which AP quickly grabbed. After another few more close calls, they switched out the tool. Once the surgery was done, I followed M who had to get a consent form filled by a patient to have her gallbladder removed later that day. Then, we went back to the OR for the next operation.

Surgery #3: Inguinal hernia repair with mesh placement

This patient was a 29 year old male. I didn’t get to see nearly as much as the previous two surgeries, because it was not laparoscopic and thus there was no screen to watch. Nevertheless, I gave my calves a really good workout in order to make myself as tall as possible. AP made one slice into the lower abdomen and they went at it. They dug in with their fingers (again, it seems so crude), pulled out a slightly white tube out of the way which I thought was a portion of intestine, but actually I later learned was a spermatic cord (I was quite shocked that those things went up so high! They also mentioned the “vas” a lot during the surgery, which again, I didn’t think was the vas deferens because I didn’t know it went up so high). They pulled out some stuff (like I said, I couldn’t see that well), cut out the ilioinguinal nerve (which apparently can get tangled up in the mesh which caused a lot of pain. Sacrificing it means losing some sensation on the skin if the thigh, a relatively low price to pay for not being in pain), pushed the mesh cone in, then sutured the flat part of the mesh in around the spermatic tube. They shoved everything back to where it belonged, and sutured the patient up layer by layer. I make it sound like it all happened in five minutes, but it really took quite some time to find the hernia, isolate it, cut it out, and suture the mesh in place. M’s final suturing was quite beautiful, because you couldn’t see the stitches when she was done. She then applied pressure to the wound for a while. I had time to quickly eat before coming back to the OR.

Surgery #4: Laparoscopic gallbladder removal

My last surgery was on the 26 year-old woman from which we had just obtained consent. Again, I won’t bore you, but instead I will highlight differences I saw in this surgery. Her gallbladder

was again, normal looking, even though it was supposed to look inflamed (AP joked that I was their lucky charm, as my presence clearly caused these wonderful gallbladders and smooth operations, and that I should maybe come again next week. I think so too, AP. I think so too.) This gallbladder was a little less eager to leave the abdominal cavity, because it ruptured while they were cauterizing it out. M had to quickly cauterize it to stem the flow of bile, and then quickly cut it out. They had to irrigate the area (with saline I believe) to wash away the bile. Lastly, there was some bleeding that they had to stop so they cauterized a whole big area until they were satisfied. Once they closed her up, I followed AP out of the room, and thanked him and said goodbye.

I think it was because I was so tired, but I forgot to thank M and the rest of the surgical team for letting me watch them before I took off my scrubs, and once I had changed, I couldn’t go back in to the OR and speak to them, so I’m really annoyed at myself because of that. I hope I see them again to tell them so! Thus ended my first OREX day, at 4:05 PM.

For those of you who have followed me this far, I have a few remaining comments. I was incredibly thankful for being able to see three of the same procedures by the same surgery team. I saw M learn throughout the day and integrate her learning. As AP said, it is a rare thing to have three of the same procedures lined up like that, which really will help her get comfortable with the operation. I spent the rest of the day in awe of the skill and care the entire surgery team displayed.

The images of the surgeries have kept playing in my head; as I fell asleep that night, my mind was filled with images of Maryland tools, spreading fascia, again, and again, and again.

Thanks for reading! I have the figures below (some of them from the stryker website source: Stryker website, and some of them drawn with my great artistic skills).Screen Shot 2016-01-09 at 3.38.22 PM

Figure A: Some cauterizing tools from Stryker. I’m not sure if AP and M used any of these, because they don’t look all that familiar.

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November 17, 2014

Written by Anna Grace (class of 2014-2015)

Hi OREXers, I just completed day two and it was full of memorable moments. I first wanted to say how much I enjoy reading everyone’s journals and incredible experiences, holy cow! Also, I just finished writing this journal entry and it’s pretty long, so I apologize for being so wordy. If anyone actually has the time to read this, I commend you. Haha. Ok, here we go…

I arrived at 6:45 this morning (yikes, too early) and by about 7:10, everyone had filed in and Dr. Harken began his lecture with an exercise; “55 year old patient walks into the ER complaining of maroon colored stool. What do you do?” He jotted notes down as the residents all offered thoughts and ideas, and continued to offer “results” if they ordered diagnostic tests or asked for vitals in order to keep the exercise going. It seemed like everyone did pretty well, even after he moved onto patient two, a 24 year old male with a pickaxe sticking out of his chest. Each avenue they would suggest would turn up no helpful results, and the idea was so Dr. Harken could see how they were thinking through the problem and how they would proceed further. (It reminded me of the Kobayashi Maru Simulation, for any Star Trek fans out there.) The lecture covered the topic of hypovolemia, or low blood pressure, and tamponade, which is the accumulation of fluid in the pericardium that alters normal compression of the heart. An interesting tidbit I THINK I gleaned correctly was on the relationship between volume and pressure in the pericardial sac, and how it changes depending on age or circumstance. Younger patients have less of a “stretching” ability in the sac, and will experience higher pressure within a very narrow tolerance, whereas an older patient who has had more of a chronic problem (and more fluid buildup over time) may experience much more of a stretching capability and need more fluids to alter her blood pressure past that point of elasticity.

The lecture ended and I made my way up to the OR (let me take this moment to say how amazing it is that the surgeon it is named after is Claude ORGAN) and checked out the board. I saw that Dr. Harken was scheduled with Dr. Candell, my kind savior from my first day. I noticed that the operation had to do with the pericardium (I am blanking on the medical name of the surgery) and was interested to see it as a family member of mine had similar sounding heart issues in the past (endocarditis, pericardial swelling). Dr. Candell said hi as soon as she saw me and I hung in the room until I saw Dr. Harken and a transporter wheeling in the patient. Dr. Harken immediately introduced himself and I can confidently tick a check mark off in the Dr. Harken Is the Greatest category after watching him guiding the surgery. It turns out everyone else knows he rules because three medical students came in as well as the residents that were participating. It was a full house. Dr. Candell was trying to figure out who of us observers would scrub in given the large number of people in the room but then Dr. Harken invited everyone (in true Oprah fashion) to scrub in. You scrub in, and you scrub in! Everybody scrubs in!

So one of the very kind medical students gave me a refresher and showed me how to grab a gown and gloves and the special way to unwrap them to get them ready for the surgical tech. Every tiny rule in the OR continues to amaze and impress me. As the med student said, “Everything in the OR has a reason.” and it’s so cool and so true.

So we are all watching Dr. Harken lead Dr. Candell through the surgery, and as soon as skin, fascia, and muscle were cut through, he is guiding her on excavating the rib from its surrounding tissues. All I could think about was my cadaver lab and how this is the same thing but a living person and was busy marvelling at the reverence of it all. It was really special to see Dr. Harken coaching Dr. Candell through the excavation. “That’s it! You’ve got it!” Things like that. She works through a couple of different scrapers and finally gets it isolated enough to be handed the biggest wire cutter I have ever seen, which obviously is not a wire cutter but a bone cutter. Craziness. Dr. Harken asks if Dr. Candell can feel a certain “noddle” on the rib as a landmark. “The noddle?” She and the other resident giggle. “Yeah! What is that noddle?” he prods with as much enthusiasm and delight as Levar Burton on Reading Rainbow. It was some part of the costal cartilage/sternocostal ligament/sternum connection, if my memory of their response and a quick glance at my Netter Atlas serve me correct. “Can we call it Harken’s Noddle?” The other resident doc asks with a laugh. So Dr. Candell positions the cutters at Harken’s Noddle and snap! The medial cut is done. She then positions the cutters lateral to the first cut so that a section about 3 or 4 inches long of rib #5 is removed. Dr. Harken remarked that the bone was probably full of cancer, and it was only then that I found out the patient had cancer.

It was around this point I saw a pink and black speckled fleshy thing emerging and disappearing into the open space. I soon realized it was going in time with a breathing rhythm and that was indeed a piece of lung. Wow. Dr. Harken explained that the black speckles were pollution (although it turns out the patient’s cancer was of the lung so pollution probably includes cigarette smoke).

Next Dr. Harken asked the group what color cancerous pericardial fluid is, and one of the residents correctly answered “bloody.” He explained that piercing the pericardial sac in this patient would be quite a sight, as it will gush red fluid that looks suspiciously like blood. Which is exactly what happened when Dr. Candell pierced the sac. A red gusher poured out and the other resident dutifully suctioned it up. “I shouldn’t have warned you,” teased Dr. Harken. “You would have thought you’d cut the heart!” Everybody chuckled like, “that would be really mean,” and probably no one was more relieved he DID warn them than Dr. Candell. In total, I think about 900 mLs of fluid were drained from the patient’s pericardial sac, although that number seems impossibly large, but I remember the surgical tech making a point of telling the anesthesiologist she hadn’t sent any irrigating fluids into the cavity and that was all from his body. At this point Dr. Candell remarked on how the cancer was all over the heart tissue, and how abnormal it made the tissue appear. She invited everyone to come look and made sure I got a chance, too. Sure enough, in all the glory of a heart that hasn’t stopped beating once in all the decades of this patient’s life, it was plainly covered in white bumps and nodules. The cancer had metastasized to his heart.

The next part of the procedure was installing a large chest tube drain in the space left by the patient’s resected rib. The medical student explained that the tube had several drainage holes in the business end, in case some of them clotted up, the others would still render the tube functional. I asked her when the tube would be removed, because it looked large and uncomfortable, I’d guess about a quarter inch in diameter. She explained that the patient’s prognosis was such that it would likely remain until he passed, and that the entire surgery was a palliative measure.

Soon after that, the procedure was done and the residents began suturing everything up. Dr. Harken left them to it, said his goodbyes and we all thanked him. The medical student performed the final and most superficial set of sutures. Suturing is pretty mesmerizing to watch. The surgery only took a little over an hour, which seems so short for all that happened.

After that, it took me a while to find another open surgery, most of the other ones were already underway. One of the nurses had me enter OR 7, where a laparoscopic cholecystectomy was underway performed by chief resident Dr. Bell and guided by attending Dr. Bullard. Although they were no longer laparoscopic, and there never was a gallbladder to begin with! For part of the procedure I stood by the anesthesiologist, although there were no blocks free for me to stand on so I couldn’t see much, other than the very interesting giant bicycle gear-looking apparatus used to hold tools that isolated the area for them. (Dr. Bell is quite tall so most of the blocks were in use by Dr. Bullard and the resident and med students at the table with him.) At one point I walked over to another wall where another med student was standing and she filled me in on some of the details of what was happening. The patient had a cholecystectomy procedure previously but presented with upper right quadrant pain. A scan showed gallstones present in the remaining portion of her cystic duct, and what had started as a laparoscopic procedure had turned into a traditional procedure at some point during the first hour or so of the surgery. Drs. Bell and Bullard spent an extensive amount of time cauterizing and cutting and prodding. At one point, one of the scrubbed in med students showed us the specimen bucket of gallstones. Two of them looked like smooth fake gold nuggets that were props from some kind of pirate costume. The non-scrubbed in med student next to me explained that black stones are from bile, and those gold-looking ones are cholesterol.

One interesting thing I noticed as I looked at the board to try and figure out what was going on was a phrase written in dry erase marker, “Laps over liver!!!! 2 ⅓ .” I was puzzled by this until, toward the end of the procedure, Dr. Bullard pulled a gauze towel out of the open cavity and called out, “Lap over liver!” and cautioned the tech to take extra time counting the laps because in this type of procedure it isn’t too hard to lose track of one of them when they are all tucked behind organs. It seems like the laps are the little gauze towels with the blue stitching and that a total of 3 of them were stuffed on top of the liver. They were each called out and carefully counted before the end of the procedure. I also thought the counting system used is pretty interesting. Maybe this is obvious to everyone else but I was confused by all the fractions I’d seen on the boards in each surgery so far (anyone else with me?) and it finally made sense. A lap count of 2 ⅓ means that they started with 2, and then added 1 for a total of 3. Eureka.