Written by Jenny Luong (class of 2016-2017)
Being very optimistic about today’s OR session, I went ahead and arrived 15 minutes early to a completely empty room. I ate my apple and watched the clock tick. I started panicking a little when the clock hit 6:59 AM and no one had arrived still.
Luckily, a resident came in a minute later. People seemed to follow him in, and Dr. Harkin appeared. He noticed me and gave me a handshake! I was fangirling inside yet totally professional on the outside. I hope.
Today’s morning lecture consisted of some biochemistry and genetics. Dr. Harkin presented some cases and pictures of mucosa-associated lymphoid tissue (MALT) lymphoma and gastrointestinal stromal tumors (GISTs) and then talked about some papers that proposed the genetic pathways behind the formation of these tumors. He spoke about how GI sarcomas were treated with standard chemotherapy drugs in the past to no effect. It was in 1999 that Gleevec was used, bringing about a complete change in the approach towards GI sarcomas. One of the papers he mentioned showed that the use of Gleevec for several weeks prior to removal of a GI sarcoma increases the likelihood of a positive patient outcome. The general solution for many of these cases were surgical. And if they were recurrent, those would need to be excised as well.
I walked myself over to the OR and asked Nurse Julia very nicely for the vendor card again. I made sure to be very polite, as always. She was very nice to me in turn. I made some small talk with someone in scrubs in the changing room and went up to the board. Everything was crossed out again. Am I reading this wrong?
I decided to just walk down to the OR and look like I knew where I was going so at least I wouldn’t be stuck in the hall. The person I was talking to in the changing room was walking towards OR 2, so I walked up, introduced myself and she let me follow her in.
Turns out, she is Dr. Sarah! The patient was a female born in 1973, and today’s procedure was a left percutaneous nephrolithotomy, cystoscopy and laser lithotripsy, and ureteral stent placement.
Due to the muscle relaxants given to the patient, she was particularly floppy and required careful maneuvering and placement. The nature of the surgery meant that placement was crucial in making sure the surgeons could access the area of interest. First, Dr. Sarah and Dr. Yamaguchi placed the patient face-down. Dr. Linda, the nurse anesthesiologist, directed the moving and was very knowledgeable how to best protect the patient’s airway and breathing. I want to be her when I grow up.
Because the patient was so wide, they had to triangulate where the kidney was. There were black marker lines everywhere. Better safe than sorry. After making a small incision and inserting a tube to make a pathway into the kidney, they used contrast on threads and on their wireless camera to get a better view of the inside. There were at least 2 kidney stones and deposits lining the ureter all over the kidney.
There were saline bags that needed to be replaced all the time. Nurse Benny was running around frantically throughout the surgery. These saline bags needed to be put in little sleeves that could be pumped up to add pressure. This would allow more effective irrigation and allow better visibility inside. This was necessary because there was so much blood clotting that it was almost impossible to see. The deposits were not helping either, as they bled if removed by force.
After a while Dr. Yamaguchi closed up the hole and announced that they needed to reposition the patient and attempt a ureteroscopy now because the percutaneous nephrolithotomy did not work out. Wheeling in equipment to strap the patient’s legs apart so they could try from the bladder end. It took about an hour to finally locate the stone and get everything ready for the laser blasting. I had a lead jacket on with goggles and I felt equipped for anything that was going to fly my way. Nothing did, thankfully.
Dr. Yamaguchi spent the next hour or so blasting away the calcification. It was everywhere. There were so many deposits that even the doctors were amazed. I think the best part was when the laser machine would go “pew, pew, pew”. Compared to the rest of the surgery, the stent only took a few moments, and suddenly, we were done!
It was quite amazing to see how far technology has gone and how high definition that little camera way inside the body. This was another amazing day with OREX!
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!
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.