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November 23, 2015

Written by Carlos Yang (class of 2015-2016)

I arrived at Highland around 6:45am and raced to the meeting room. Due to the hour change the sky seemed a lot brighter than I remembered from my first OREX day so I had a small fear that I was already late to the meeting. When I arrived in the room I was the only person there, further feeding my fears. After a few minutes more people trickled in so I realized that I was on time and got ready for the lecture. This time instead of going over an article Dr. Harken played a game of medical Dungeons and Dragons with the residents. He would describe a situation and they would have to tell him what they would do. First he presented them with a sixty year old man with acute epigastric pain, BP or 90/60, and a temperature of 38 degrees. First the group wanted to check his breathing, which they were told was fine. Next they checked his pulse which was 120 bpm. At this point Dr. Harken explained a little bit about the exercise saying that as surgeons sometimes they have to start therapy before they fully know what is wrong with the patient. With this information the residents opted to give the patient crystalloids and gave Ringer’s lactate. Then someone said to do an EKG which did not lead to much, but the patient did say he had an inferior myocardial infarction three months ago. Then someone suggested doing a fast exam to look for bleeding, but the test came back negative. Then they decided to have an X-ray taken to look for air in the diaphragm. Next they checked the lab results and I do not remember where that lead and my notes are illegible. At this point Dr. Harken had the patient reveal that he drinks a liter of vodka a day and that his abdomen was still very tender. The residents then gave him some morphine for the pain and checked his echocardiogram, his ejection fraction being 40%. All his stats were the same so they put a central line in and saw his central venous pressure was 4 mm Hg which was on the low side so they gave him more Ringer’s which bumped it up to 6 mm Hg. This example sort of ended there and Dr. Harken revealed that the true purpose of the exercise was to see the thought process of the residents. He would rather them guide him through what they are thinking than to just say the right answer. There was another example, but it was almost exactly the same as the first and then it was time to go to the operating room.

I walked up to the 5th floor by myself since there were no residents available to take me. As I went to get the vendor card to get scrubs I noticed that the OREX pictures still did not show me in them so I hoped that the woman at the front would remember me from last time. I do not think she did, but she let me take the vendor card in exchange for my phone. I got into the scrubs and checked the board. The first procedure that leapt out at me was a Left Thyroid Lobectomy. So I went to OR 4 and waited for the procedure. There was a man already inside putting things on the white board so I went and put my name up as well. We waited for a bit and talked about OREX and other things until a doctor came in and said that the procedure was postponed due to the patient not having insurance. This was an interesting development that left me without a surgery to watch, but all was not lost since my new friend directed me to an ortho surgery that had not yet started. I slipped into OR 1 and introduced myself to the first person I saw. The procedure they were doing was a “Left Ankle Open Reduction and Internal Fixation” which is a really fancy way of saying they were fixing the patient’s ankle. Apparently this patient had broken their ankle in Austria while practicing for the winter Olympics. What was just as interesting as the procedure was the environment it was being done in. There was 90’s alternative rock music playing and the doctors were kind of talking to each other like bros. One of the surgeons was the most junior of the three so he was the target of most of the banter. The other doctors kept reminding him not to cut a nerve, pointing it out whenever they told him to do something. At one point he reached for an instrument and the most senior surgeon took it from him and said that good surgeons do not use that tool.

Screen Shot 2016-01-09 at 6.32.20 PMI positioned myself to get a good view of the surgical field and I could see the ankle. This was the first time I had seen exposed bone in person other than teeth. The doctor noticed me and pointed out the fracture which was a very noticeable line. They also took some X-rays to look at the way it moved and you could see the joint sort of open up when moved.

What is really interesting about orthopedic surgery was the inelegance of it. While still very technical surgery they employ a lot of drills and tools that use brute force. After setting up some guides the junior surgeon started drilling them into place. After skillfully avoiding the nerve and drilling all the plates into place they began sewing up the ankle. At the end, instead of using sutures, they stapled the skin together which was the first time I had seen surgical staples. They also applied a cast which was fun to watch. I have never broken any bones so I have never seen a cast being put on. It was a little like papier-mache.

The next procedure I saw was a “Laparoscopic Left Pelvic Mass Removal and Potential Removal of Left Ovary”. I went into OR 3 and introduced myself to who I thought was the doctor. It turns out it was a third year medical student named Ben who was very friendly. I talked to him about applying to medical school and he said he does not miss the application process. He was worried about applying for a residency, but I am pretty sure he will be fine. Screen Shot 2016-01-09 at 6.32.33 PM When the doctors came in they asked who I was and I told them I was with OREX. Both of the doctors did not know what OREX was so I explained it and one said that she remembered Dr. Harken sending her an e-mail about it two years ago. They did not kick me out so I think it all went okay. The procedure was very similar to the colecystectomy I saw during my first OREX day. Since both procedures are laparoscopic the set up was the same. They made a hole into the woman’s pelvic region and put the camera inside. The patient had previously had a hysterectomy so there was not much to see inside except for the left ovary and a fibroid that was the target of the operation. The doctors used the grabbing arm of the laparoscopic tool to simultaneously grab the fibroid and cut it off. The mass was too big to just yank out so they spent a long time cutting it into small pieces. This work seemed to be very routine for the doctors because they began to talk about all sorts of things. What I remembered most of the conversation was that one doctor was going to get her Thanksgiving food from Market Hall, which is something that my grandmother was thinking about doing too. The cutting took a long time so they had someone put on some music to “set the mood”. Instead of 90’s alt rock the music for these doctors was more contemporary. I recognized one Muse song, but that was it. After taking the mass out, they sutured up the holes using the smallest needle I had ever seen. Ben got to do some of the sutures and I think he did a good job. After the procedure was over I had to go home to check on my sick cat, but I had spent a good six hours from 7:00am to 1:00pm watching surgeries that I had not seen before and also seeing the surgeon’s personalities come through in the music they were playing.

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FEBRUARY 2013

Written by Manika Talati (2012-2013 Class)

There are some days you look back on and just know you will remember forever. You know the people, emotions, and environments you encountered will never escape your mind.  My third OREX experience was exactly this type of day. Here is a recount of my experience.

 

It was 10:45 AM. I was scrubbed-in and all-ready for my first surgery observation. I went to the surgery board schedule, where I encountered Dr. Krosin, who I knew very well. He immediately exclaimed, “Manika Talati! How are you today? Check out the surgery on the trauma patient that just came in! You’ll probably see some brain.” He also recommended I watch the foot reconstruction he was performing that afternoon. I was so glad I ran into him! His advice gave me a direction to jump-start my day.

I proceeded to the trauma patient’s room. The environment was intense. The neurosurgeon and general surgeon were debating on performing a craniotomy versus craniectomy, technicians were diligently preparing the patient for surgery, and PA students were quietly standing to the side. I could tell this was a serious operation. The patient was a construction employee who suffered an extremely unfortunate injury that morning. A sledgehammer fell on him at work, creating a 4-inch wide opening exactly on top of his head. About a half-cup of internal tissue had escaped from the opening, which appeared bloody, chunky, and soft in texture. His cranium was also fractured from the impact. At this point I was curious to find out what the escaped tissue was. Blood vessels? Blood clots? Brain? I had no idea. The PA told me that it was in fact, his brain. She also explained to me that it was better the impact caused the skull fracture and escape of internal tissue. Apparently, if the cranium were completely intact, the internal pressure would be so high that there would be greater complications. Finally, the neurosurgeon decided to perform a craniectomy, or remove of part of the skull bones to access the brain. I have learned before that the human brain is very well protected. It was not until this experience, however, that this idea became clear to me. The skin on the head was strong and sturdy, about a half-inch in thickness. It was the opposite of the thin, easily pinch-able skin on our hands and feet. Underneath was the cranium. I could see the four distinct parts it had broken into that were completely detached from each other. I wondered, how are they going to fix this? What they did took me by surprise. The surgeons simply removed the bone pieces and continued incising deeper into the patient’s head. Apparently, in situations like this, it is more important to optimize the functions of what can be repaired, which involves sacrificing other structures. I now could see a translucent material, the dura mater, which was encapsulating soft brain tissue. Wow, I thought, I am actually looking at the brain! Yes, in front of my eyes was the structure that runs the human mind – every emotion, every thought, every part of human intelligence. It was so real, so alive, and so intact! As I looked closer, I noticed it was moving at a constant lub-dub pace, similar to a heartbeat. This was surreal to me. I appreciated the intricacy, potential, and vibrancy of the human body more than ever before at that moment.  It is very rare one gets to experience situations like this, and I was utmost honored to be there.

Ultimately, the goal of the operation was rather simple. The first was to mesh escaped brain tissue into place. The second was to block internal bleeding. This involved using a “Doppler” machine to identify damaged blood vessels. After locating the veins, the neurosurgeon viewed them through a microscope to more precisely suture them. Next, he performed a ventriculostomy by inserting a catheter through the head to drain excess fluid. Lastly, he sutured the skin with strong stitching fibers. This marked the end of the operation. I did not even realize four hours had passed! I had been so captivated by the procedure! I felt like I could have kept learning, absorbing, and taking in everything from my surroundings. I felt so stimulated by all that was around me!

I knew exactly where to go next. I darted to Dr. Krosin’s surgery. I was welcomed with a lighthearted, casual atmosphere I knew to expect. With an iPod playing rock n’ roll, residents talking about “The Bachelor”, and Dr. Krosin’s friendly  “Hey Manika! How’s it going?” greeting, I knew this was going to be quite different from the previous surgery. Dr. Krosin was performing a flat foot reconstruction to create an arch in the patient’s foot. The surgery was a lot more intricate than I expected! It involved manipulating tendons in the ankle to bend the toes, physically shifting the heel bone to the side to realign the foot, and drilling through the navicular bone to form a curved shape. It was like watching an artist who was dedicating immense knowledge, skill, and mental focus to create a masterpiece. At the end of the three-hour procedure, I noticed a clear difference in the patient’s foot, which now had the signature arch-shape. This observation experience, although not a life-threatening procedure, was as memorable and special to me as the previous. It was uplifting to see a noticeable improvement in the patient’s condition. Even more, Dr. Krosin showed me anatomical structures and answered my questions throughout the procedure. The surgery team even included me in their “Can you guess what song is playing?” trivia, which made me feel more comfortable. The environment was a mix of productivity, good-natured talk, and hard work. I felt a part of the medical team and also learned a great deal!

It was now 5:30 pm. My day was so stimulating that I was tempted to stay longer! Yet, I did have plans for that Friday evening. I decided to call it a day.

In retrospect, it is interesting to compare my two surgery experiences. While they seemed starkly different from each other, they were actually quite similar. Of course, the type of operation, medical specialties involved, and operating room atmosphere were complete opposites. The informal conversations and music jamming in Dr. Krosin’s room set a far more casual tone than the neurosurgeon’s. The surgeons’ contrasting styles reminded me of how people study in college. One student might prefer the academic library setting while another enjoys a casual coffee shop. The study style doesn’t really matter as long as they can both put forth their best effort. The same applies to surgery. Each may have their own style, and what matters is that they ultimately help the patient to the best of their abilities. This idea is well-captured by something each surgeon happened to mention that day. I remember the neurosurgeon saying, “At any moment, this man’s life can turn around”. Very true, I thought. He was literally dealing with life and death. Dr. Krosin, on the contrary, told me that as an orthopedic surgeon, he admits he is not necessarily saving lives. What he loves, however, is being able to “improve lives”. Both statements were simply stated, yet so true. They illustrate how all medical specialties are important in helping the human condition. I was honored to experience the two worlds in the same day!