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April 27, 2017

Written by Jennifer Tu (class of 2016-2017)

On Tuesday, April 25th, I went in for my fifth OREX session! During lecture, Dr. Harken talked about appendicitis. He asked the residents and medical students how they would diagnose and decide on the treatment. I thought it was interesting to learn that, in addition to conducting physical examination (to assess patients’ pain in right lower quadrant) and ordering labs like CT, ultrasound and blood tests, another way to diagnose appendicitis is to observe the patient overnight to see if the condition worsens with only pain medication (no antibiotic). Antibiotic and appendectomy are two ways to treat appendicitis. Dr. Harken shared a research article on randomized clinical trials conducted to examine the effectiveness of these two treatment methods. After the lecture, I am curious to learn more about the factors that encourage doctors to perform appendectomy for some patients versus to prescribe/prolong medications like Augmentin for others.

After changing into scrubs, I went to OR5 to observe a video-assisted thoracoscopic surgery (VATS), lobectomy and pleurodesis. I had the chance to observe several laparoscopic surgeries in previous OREX sessions. It was very interesting this time to observe another type of endoscopic procedure: thoracoscopy. The patient was a 36-year-old male with pneumothorax − air leaking from the lungs and into the pleural space. Talking with the two residents, Rebecca and Francisca, I found out that the patient was a smoker and was experiencing breathing issues such as shortness of breath. There were several parts to the surgery. In the first part, the anesthesiologist deflated the lung on the side where VATS was to be performed. Then, the surgeons made three incisions in the chest area, one for the camera/light and two for the instruments. The patient was placed on his side. The staffs then flexed the operating bed in order to open the intercostal space needed for inserting the thoracoscopic tools. Once the monitors were on and lights were off, I immediately noticed the black dots on the patient’s lungs which looked like moldy bread (similar to darkened lungs I used to see on “stop smoking” billboards). Using the instruments, the surgeons located and clipped off the part of the lung that was leaky using surgical staples. They performed lobectomy, in which a small portion of the lung was removed, probably taken to the lab to determine if it is cancerous. Finally, in the last part of the surgery, pleurodesis was performed. When speaking to the residents, I was told that chemical pleurodesis was to be done using doxycycline to irritate the chest cavity. However, during the procedure, mechanical pleurodesis was done instead. In the “scratch technique,” a rough brush was used to irritate the pleura. I noticed that the brush caused immediate bleeding. Pleurodesis is done to cause inflammation and, hence, adhesion of the two pleurae to prevent air or fluid from building up again in the pleural space. Aside from the regions of the body that they are performed, I thought laparoscopy and thoracoscopy looked pretty similar; they are both minimally invasive surgeries that only required making small incisions in the cavities (thoracic in between the ribs and abdominal near the belly button) and insert a viewing tube/camera and other tools.

Later on that day, in OR 5, I also observed a laparoscopic appendectomy. Since the morning lecture was about appendicitis, I decided to stay to see how the information learned applied to the actual surgery. The patient was a 21-year-old female who complained of tenderness in the right lower quadrant area the night before. Similar to the thoracoscopy, three incisions were made, but in the abdominal area near the naval. The appendix was immediately located and stapled. With Dr. Palmer’s guidance and approval, the resident “fired” the staple to remove the appendix. Before stitching up, they also checked the gallbladder to make sure that there was no infection. From this experience, I learned that it is not easy to work with laparoscopic tools. They are, in fact, very difficult to navigate and require a lot of practice to master.

In between the surgeries, I was also encouraged by one of the nurses to observe a L5-S1 case fusion procedure in OR1. I introduced myself to the nurse, Boam, and learned from him that the procedure was done on a patient with degenerative spine. Rods were put in to strengthen and straighten the spine so that it doesn’t affect the nerves, which cause immense pain. It was very difficult to see the actual incisions since the room was a bit crowded. However, I noticed that several staffs watched the overhead machine called BrainLab Navigation System. Upon doing more research at home, I found out that this system is very useful in spinal surgery because it visualizes the entire spine and helps the surgeons make accurate screw placement..

Overall, I had amazing day today at OREX! VATS was definitely the highlight; I learned so much about the respiratory system. I look forward to getting a closer look at another spinal surgery next time!

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March 2012 (Part 2)

By Elliot Chan, OREXer ’11-12

I arrived this morning and went to OA2, to find it completely empty. This is no longer a surprise to me, as for some reason I never seem to catch an OREX day with a normal morning meeting. I knew there was the potential for another trauma meeting, so I scoped out the Classroom and it did look like they were setting something up. After a little delay, as the projector was stuck in traffic, a trauma meeting was held to take note of an interesting case from earlier in the week. Patient was brought into the ED for severe dehyradation and disorientation. The presentation was very very interesting, as it detailed the thought process of an Emergent physician versus a General physician. The patient had to be treated ASAP for her deficiencies, or she would die – she was given a saline IV with dextrose to replenish her immediately, and many lab tests were ordered. This was a very interesting case that they used to call attention to the differences in how medicine works for the ED. As a general physician, you have time to order labs, analyze results, and call your patient a few days later; in ED, you have to treat immediately for the emergent situation, then get pieces of the puzzle back from labs as you are treating the patient. It’s much harder to get the big picture in ED, where you have to keep your patient alive as you learn what’s wrong with them. So they ordered all these tests, and she seemed indicative of sepsis. But, they could not find a source of the sepsis. Then, one of the doctors showed how he came up with the correct diagnosis, showing all the flowcharts that were going through his mind and why he was able to eliminate certain diseases. Very very interesting stuff.

The meeting did run late though, so I did not get into the OR until much after 9. However, the surgery I ended up observing was also running late, and did not start until close to 11. Dr. Victorino was overseeing a right lobectomy, with Dr. Lee operating. The prep required for the procedure was lengthy as the patient was pretty overweight, and hard to maneuver. The patient was a male of about 35 years of age, and had been a smoker for about 20 years. He had developed a lung cancer in his right upper lobe of his lung, and was to have the whole lobe removed. Prep also took a while because the patient would have to have 2 tubes put in for anesthiology – one for his left lung, which would remain untouched, and one for his right lung, which was actually going to be deflated during the whole operation. The surgery was open, and I was excited because I had not seen an open procedure in some time. Dr. Lee made the incision about 12 inches under his armpit, and crossed about 12 inches wide so he could have full access to the chest cavity. After some cauterizing, they had entered the fascia and were looking at ribs. Using the metal spacer, they dissected between the 5th and 6th rib and spaced an opening – before I knew it, I was looking into the chest cavity of the patient! This might have been the second coolest thing I’ve seen in OREX yet (first being the craniotomy).

Dr. Lee had a medical student also observing named Simon, and Dr. Victorino took some time quizzing him on anatomy. As the patient was a heavy smoker, you could already see many black discolorations on the lungs. According to Simon also, the lung felt quite dense and hard already, which is also indicative of years of smoking. Using imaging they had previously taken, they located the cancer on the lung, which did not look as I had expected. They identified a small, circular, puckered area on the upper lobe, almost looking like a cigarette burn. It was distinct, but not as much as I had thought. Removing the lobe required a lot of work though, as all bronchioles and blood vessels supplying the upper lobe had to be cut off, and carefully. Dr. Lee went very methodically through the upper lobe, tying off any vessels going to the lobe, before staple-cutting them. He had to make sure he was not accidentally snipping another artery, which would introduce a lot of bleeding. Once he had accomplished this, they just lifted the lobe right out of the lung! To test to make sure they had no leaks, they asked the anesthiologist to reinflate the right lung. At this point, I had forgotten the lung was deflated, but as soon as air was put into the lung you could see how big it normally is. Just like a balloon, the lung was reinflated and you could see it was holding air – no bronchioles were left untied.

The procedure was done, but closing took almost as long. The mediastinum was cleaned and irrigated heavily, before having to reclose the ribs and suture them together tightly. Closing of the ribs, fascia, and dermis took a very long time even with Dr. Lee and Dr. Victorino working both sides. Once the dermis was sutured (they let the medical student do this one) they stapled the incision and wrapped the patient up. This was a really great procedure, albeit a long one. I was only able to watch this surgery as it was 2pm by the time we left the OR, and I could not get out of work today. But it was a great one!