Written by Chuck Chan (class of 2014-2015)
After a two month hiatus, I was excited to be back in the OR. I arrived at Highland at 7:15AM and listened in on a medical ethics talk by Dr. Harken. Though I had heard a similar talk by Dr. Harken a few months back, something really stood out to me this time around. Dr. Harken took out a pocketbook of the U.S. Bill of Rights from the inside of his coat and read the first amendment aloud. He made a point that people have the right to practice religion, but some beliefs can compromise the ability to deliver healthcare. The residents had some great input in this discussion. At what point can we breach the first amendment to ensure the safety of others? This is a topic that deserves thorough elaboration especially when it comes to vaccination. Doctors are trained for medical intervention, but the extent of intervention that doctors are entitled to is seldom clearly defined. It was great food for thought before getting my day started. Dr. Francesca Maertens was my resident guide for the day and I was happy to follow her into the OR.
CASE 1 – Fistula
Dr. Harken & Dr. Maertens
Entered OR @ 8:10AM
I asked Dr. Maertens about how she decided between surgery and medicine because I had heard that it was a major fork in the road before becoming a doctor. Dr. Maertens described how surgeons have a distinctive personality and an innate ability to be calm under even the worst circumstances. She compared the competitive personality of a surgeon to that of an athlete. The live surgery was essentially a performance, similar to a game for an athlete. My experiences so far in the OR were absolutely consistent with what Dr. Maertens had to say.
The first case of the day was a cimino fistula. I had heard the term fistula before, but I really didn’t know what its purpose was. Dr. Maertens told me to look up the procedure a few minutes before the surgery started, which was really helpful in getting myself to ask the right questions when the procedure actually began. For the large majority of cases, a fistula is a surgical manipulation to connect an artery to a vein for access to the bloodstream for dialysis patients. An ultrasound was used along the patients left arm to locate nerve for anesthetic injection. A large needle with an electrode was used to determine where the nerve was. When a voltage was applied near the nerve, the entire arm would twitch in a pulsatile, rhythmic fashion. Dr. Harken pointed out the deep veins and arteries that looked like large circles on the ultrasound screen. Veins collapsed much more easily upon applied pressure than arteries so it was easy to differentiate veins and arteries. Once the anesthesia was in place, it was time to start cutting.
Dr. Maertens made a cut parallel to the length of the arm that was about 4 ½ inches long. The cut exposed a large artery, a large vein, and a nerve. A yellow loop was tied around each tissue type. Dr. Maertens used a black marker to mark the vein in black. The vein was cut and injected with a clear, anti-clotting agent. A separate incision was made parallel to the first cut to locate an artery to attach the vein to. Once the artery was identified, a yellow loop was tied around it. The artery was carefully cut and suspended so that the vein can be threaded into the artery. Dr. Maertens knotted the artery-vein attachment and felt around the attachment to ensure that there was proper blood flow. The skin was sutured and the procedure was finished in a little over two and half hours. The patient was awake for the entire procedure and I only noticed once the surgery was completed.
CASE 2 – AV Graft
Dr. Harken and Dr. Maertens
Entered OR 10:31AM
The subsequent case was an AV graft. Despite the lack of similarity in name between an AV graft and fistula, the procedures are nearly identical. The one major difference between the two procedures was that in an AV graft, the artery and vein are joined by a white tube. The major advantage in using another material to join the artery and vein is that the white tube has a large diameter, which ensures great blood flow between the artery and the vein. This makes complete sense according to Poiseuille’s Law on blood flow. Who knew physics was important in medicine after all.
Dr. Maertens started by making two parallel incisions along the elbow bend. The median nerve was exposed and it looked like a flat elastic band. Prongs were used to hold the medial incision open. Plastic yellow ropes were tied around the nerve, artery, and vein just as had been done for the fistula case. A third perpendicular incision was made distal to the first two incisions. The vein was marked and cut. Anti-clotting agent was added to the vein and the white tube was attached to the vein. Dr. Harken explained that the white tube was made of the same material used in North Face outerwear jackets. Once the white tube was attached to the vein, it was pulled through the perpendicular incision and back inside to reach the second parallel incision. The artery was carefully cut and knotted to prevent bleeding. Dr. Maertens used a syringe to inject saline through to make sure that the passageway was not obstructed. The artery was then attached to the white tube.
The three incisions were promptly sutured and the procedure was finished by 1pm. I thanked Dr. Harken and Dr. Maertens for the great opportunity and I was on my way out of the OR just in time for my afternoon class. It was an awesome day of surgery to say the least.
Written by Vickie Nguyen (class of 2014-2015)
My first OREX day was an absolutely terrific and most magnificent experience I have yet to experience at Highland Hospital. Though the surgeries themselves were a great spectacle, I couldn’t help but note down a lot of things that may be trivial to all those who work in the OR, but to me they were really quite interesting. In comparison to 5E and SDU, the department I have been volunteering for the past couple of months, I couldn’t help but notice how CLEAN everything was. And I mean CLEAN. Hospitals are normally thought to be clean places, there are so many sick people entering and leaving, and I know that it’s very hard to maintain a sterile environment. The operating room however, is seriously no joke. Everything was pre-packaged, everything sterile was blue, everything was systematic, and everything was carefully and preemptively thought out. I admired the environment and the precautions taken to ensure prevention of contaminations and infections that could jeopardize not just the hospital’s reputation, but human lives! The thought process that goes into designing an OR and what goes in the OR is absolutely magical to me; it takes a lot of brilliant and practical minds to prepare an environment as such. To the say the least, I’m really happy to finally know what the inside of an OR looked like.
Upon entering my first surgery observation, I reminded myself to remain very calm. Standing in the middle at least five feet away from everything, I analyzed the room and carefully made my way to an area as far away from blue so that I could get a good view of the patient without contaminating anything. Dr. Lee introduced himself to me and told me the patient had large masses developing at the site of where he received dialysis, his left forearm. This is also called a renal fistula. Dr. Lee said the masses growing maybe due to an infection and that him and Dr. Harken would be able to figure out the source of growth with this surgery. I watched Dr. Lee as he felt the masses, slightly pushing on the masses and methodically moving his way up and down the arm, even in areas where there was no lump. He told me that the vein in which the patient received dialysis felt hard. Both Dr. Harken, Dr. Lee, and Nurse Ruthie made their way to the operating table. With just an arm exposed in a sea of blue sheets placed atop the patient, they began.
Dr. Harken drew lines such that the end product looked similar to that of standing waves. Dr. Lee then used a scalpel to cut the patients skin, carefully following the lines Dr. Harken’s lines. Next, Dr. Lee used a device to separate the skin surrounding the mass, revealing an enlarged vein. I now realize the device is called a cauterizer, I thought it was kind of cool and weird to see how easily it separated skin and let off smoke… In the middle of all this, another person joined us, he turned out to be a medical student, it was his first time seeing a vein removal too!
The first piece of the vein was removed, and Dr. Harken pointed out the graft that was placed INSIDE of the vein to prevent the clot. Unfortunately for the patient, the graft did not help with that, because when the medical student squeezed the second piece of vein, a large, squishy, dark, and thick clot of blood came out. AND THAT, my fellow Orexers, was the cause of the huge growths. Prior to the removal, I should note that there were four noticeable masses lined up on the patient’s inner forearm. The largest of the masses were the middle two, the size of the masses…imagine cutting a decent size boiled egg in half, hot dog style, then placing that half on your arm. That big.
In total, three pieces of the vein were removed from the mans arm, each end of the remaining ends of the vein were stitched closed by Dr. Lee. And for those of you wondering, what happens when you remove a vein? Don’t we need it? (At least those were the thoughts running through my mind) We actually don’t need it, there are other veins in our arms, and instead of the blood running through the severed vein, they’ll just find another vein to flow through!
I attended five other surgeries afterwards, all are definitely worth talking about, but there was one particular surgery that I felt was truly unforgettable.
I was on my way to the cafeteria to grab a quick bite before heading back to one last surgery, and Dr. Krosin actually stopped me and asked if I wanted to join him on his hip replacement surgery! Of course I said I would love to! I rushed back to the OR, and tried finding my way to OR #1. Instead I found myself walking into Dr. MacDonald’s nasal polyp removal surgery. He allowed me to watch him in two other surgeries that day, and I decided that I would stay because I thoroughly enjoyed the way he talked through the surgery and gave his resident pretty helpful tips. (It still would have been awesome to see the hip replacement surgery, hopefully I have a chance to watch another time.)
The patient had severe polyp growth in his nasal cavity, to the point where he had chronic headaches and could not breath out of his nose. Before the surgery took place, a resident, Dr. Zerhouni showed me an MRI of the patient’s head. She pointed out how the nasal cavity of the patient was grey in color, and it shouldn’t be. It should instead be black in color, which represents air. The grey color denoted liquid that filled up the patient’s nasal cavity, very abnormal and is the precise reason why he was in the OR that day.
Dr. MacDonald used an endoscope,a device with a camera and light on the end, so I got to enjoy most of the surgery on a big screen. First impression was that it would be a short surgery, because Dr. MacDonald’s previous surgeries were much shorter than the other ones I experienced. The surgery ended up being over two hours long. One by one, Dr. MacDonald began removing these milky colored polyps from the patient’s right nostril, and it seemed as if these polyps were just attached via mucus-like strings. Each polyp removed was taken by Nurse Nina, and she placed them in jars to be taken down to pathology. While performing the procedure, Dr. Macdonald carefully talked through it to Dr. Zerhouni, and eventually she took a turn at removing the polyps in the left nostril. This procedure was drastically different from the vein removal, it was very microscopic and it required a lot more technological instruments. It reminds me how blessed we are to live in an era where we have so much access and knowledge to such useful instruments that are used to save and/or better human lives.
Nearing the end of the surgery, I remembered both the assisting nurse, Wendy, as well as Dr. MacDonald acknowledging how much this surgery is going to change this young man’s life. Though this was not a typical life-saving surgery, it was a one to enhance this person’s quality of life. I felt that the first surgery I attended was a lot less humanistic in comparison to the polyp removal. I’m not saying that Dr. Lee and Dr. Harken are robots, but I think the way Dr. MacDonald kept mentioning how much better off this man is going to be after this surgery is what really opened my eyes to what surgery can do aside from saving a life. Certainly anyone or anything can live, but I think that the emphasis on the quality of life is sometimes forgotten.
Overall, I find that my first day of surgery was successful, inspiring, and it’s left me craving more time in the OR.