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December 29, 2017

Written by Catherine Lee (class of 2017-2018)

 

I am not a morning person. Waking up at 5 wouldn’t be something I would ever have conceived of doing on a voluntary basis even two years ago, but with how excited I was about my first OREX day I actually ended up getting only two hours of sleep. I learned this day that this excitement was probably an underestimation, if anything – the OREX experience was even more magical, fun and educational than ever expected.

After wandering the halls of the second floor lost like a puppy at ungodly early-o’clock on friday trying to find the conference room, I found myself following some doctors to a room way down the hall closer to Hallway A. There, Dr. Swanson, the chief resident of the elective surgery team, greeted me with a smile and talked about his cases for the day – a neck mass excision for recurring papillary thyroid cancer, a complete thyroidectomy, and a diverting ostomy for a patient who had advanced rectal cancer and had sinuses through his gluteus oozing fecal matter and pus to the outside. That is not a mental image that you expect at 7 in the morning, and I could only feel terrible empathy for the patient – who apparently walked into the clinic after recently becoming transient, living in his car in a trash bag.

After the conference wrapped up – the case was a GSW from that previous night with an entry wound in the right shoulder presenting with an absent distal radial pulse, which prompted a discussion on CT Angio or CT with IV contrast, whether or not the extra detail provided by the CTA would be necessary given that the cause of the hemostasis needed to only be located. The attending then went over the anatomy of the axillary and subclavian arteries. I learned that internal arterial injuries can actually spasm and clot by themselves, and the clotting proceeds proximally until it reaches the nearest branch – which is what the CTA showed, the subclavian artery abruptly cutting off posterior to the pec minor. After a discussion of the various surgical approaches, we learned that the bullet had severed the artery; the patient was expected to be fine after arterial repair.

After the conference, I found myself in OR 4 with Dr. Palmer, Dr. Swanson, Dr. Fer and the last doctor whose name I forget. Together they made up the elective surgery team – apparently there are three surgery teams in the day and only one at night. The patient had metastatic papillary thyroid cancer, and multiple nodules had recurred even after complete thyroidectomy and lymphectomy – but since the risks of removing them outweighed the benefits (apparently papillary thyroid cancer is slow growing and relatively benign) she was there only to remove the one midline to her neck that was causing her pain. With Queen playing on the portable speakers Dr. Fer brought in, the surgery began at 0842 and ended at 0906 – incredibly fast! The team was really nice to me, answered all of my questions, and invited me to come closer and watch with a stepstool. The excised lump was 3.5cm across and 1.5cm in height, and I was surprised by how much subcutaneous depth there was to that tracheal area inferior to the larynx. 

After that surgery, the team and I gathered to the board to find out that an emergency case had come in, and since the anesthesia team was short-staffed for the holidays, the elective surgery team was put on hold along with a fair bit of confusion and consternation from everyone involved.

The emergency case was a patient with Fournier’s Gangrene (necrotizing fasciitis, sometimes called flesh-eating bacteria, of the perineal region) who had come into the clinic earlier that day, and a surgeon who specialized in these cases was sent for. Apparently, he was about to get on a flight for his vacation but abandoned that to come treat this patient; his dedication left a strong impression on me. I then followed the new surgeon, because who doesn’t want to see something like this? Fournier’s is something you see on House, not something you imagine happening in real life!

Fournier’s is a rare disease – 1.6 cases per 100,000 – that occurs commonly in older men, often obese, EtOH, and diabetic with poor blood sugar control; mainly facultative anaerobes such as streptococci and staphylococcus infect the patient often through trauma to the skin and into the fascia, travelling rapidly along the fascial plane and killing the tissue. The treatment is aggressive surgical excision of the skin down to the fascia until bleeding, living tissue is encountered. Sadly, the surgeon said, he had seen way too many of these cases during his career; with more progressed cases he had had to excise even dead organs like the rectum and bladder and not just skin and fascia. His empathy and regret for the patient’s situation was palpable.

After a very long delay in getting the room prepped – I was slightly worried about how long it took even, knowing that necrotizing fasciitis can progress very rapidly – the patient was rolled in and anesthesia induced. The standard procedure is to pre-oxygenate the patient with 100% O2 for 5 minutes before anesthesia to fill the patient’s lung residual volume with O2 for the transition between paralyzing the patient and intubating them under mechanical ventilation. In spite of that precaution, his O2 sat crashed to the 60s within seconds, causing a slight panic and active bagging to stabilize before intubation. I learned that such events can happen, especially with obese patients not in the best of health. With the patient’s legs in stirrups, two distinct black lesions, one ~2cm and the other ~1cm, oozing with pus were visible on his right scrotum, which had swollen significantly. A circle was drawn with about 2cm of distance from the visible lesions to mark the initial excision area.

Surgery began at 1112, and while it wasn’t quite the swamps of Dagobah that I had thought of as a worst case scenario, it was still … alarming. The incision revealed tissue that was distinctly grey – like meat that had gone very bad. Instead of blood, what came out when the surgeon pried into the fascia with his finger was dark grey goo. The initial excision area – probably about 6x4cm – was clearly nowhere near the extent of the infection. Further excisions continued superior to the initial incision, with the surgeons alternately shoving into the fascia with fingers to feel by texture and relying on the fact that dead tissue doesn’t bleed to determine where to stop – eventually, most of the skin and fascia around the base of the penis was excised. Next came nearly the entirety of his right scrotum and a little past it, and the bucket of dead tissue was starting to pile up. Ultimately, about 85% of his scrotum and the skin and fascia around the base of the penis ended up excised. The surgeons’ gloves were very much more grey than red.

They then used a neat tool for debridement that looked very much like an immersion blender but with a suction cup and a rotating brush at the end – when pressed against the skin and activated, suction pressed the cup to the skin, the brush spun to debride the tissue and water was circulated through and suctioned out. The wound was packed with betadine gauze and the remaining part of his left scrotum was stretched and stapled to close over. He would be back tomorrow for a followup debridement and evaluation of whether or not the patient’s remaining organs were viable; he would be in a great deal of pain but at least he’s alive, the surgeon said. That was really heartbreaking to hear, and together with the abject reality of the giant mass of flesh missing from him made it overall an incredibly neat experience, but also incredibly terrifying.

My final case for the day was also the longest – Dr. Palmer’s elective surgery team had apparently found an anesthetist and begun surgery on the patient who needed complete thyroidectomy by 1132. When I walked in there at around 1230 immediately after the end of the Fournier’s case, they had apparently conducted a midline slice through the thyroid and were very slowly and carefully separating the right half of the thyroid from the larynx. I learned that great care had to be taken for thyroidectomies because the recurrent laryngeal nerves lie right underneath the thyroid. The recurrent laryngeal nerves are a branch of the Vagus (CN X) nerve that splits off and loops underneath the right subclavian artery and aortic arch respectively on the right and left, before coming back up to innervate the larynx. Damage to these nerves would render the patient’s laryngeal folds paralyzed, resulting in a permanent hoarse voice or worse. I also learned that the thyroid is really well vascularized – every time they isolated a string of tissue and snipped it with electrocauterizing forceps, I was seeing a blood vessel being cut.

Another thing I learned was that anatomy in real life looks nothing like that in books. The thyroid just looked like another red lump of flesh lying on top of other red lumps, and was nowhere near the discrete organ that you would have expected from drawings in a book. In fact, the surgeons had difficulty locating the parathyroids, and sent off several biopsied pieces to the lab from various parts of the thyroid to confirm histologically with frozen slices if they were parathyroid or thyroid. By the time the entire thyroid was taken out, it was around 1500 or so.

Because parathyroid hormone deficiency would be much more severe than thyroid because of its critical role in regulating calcium, they did what I thought was the neatest thing about this surgery. They chopped up the piece of parathyroid they had confirmed by the lab into small 1x1mm pieces and implanted each one separately along the sternocleidomastoid muscle with small incisions, as if they were planting seeds along a furrow. Apparently the body will just keep these bits of parathyroid alive and they will happily secrete parathyroid hormone for the rest of their lives; the body is truly an amazing thing!

It is remarkable how much I feel like I learned from just this 9 hours spent in the OR courtesy of this amazing program. It is truly like immersive language learning, the quickest and most effective method of second language acquisition. I took in so much interacting with everyone in this environment, seeing all the little things and the teamwork that goes into what makes a surgery work and be successful, building pedagogical relationships with all the members of the team who are generous enough to teach me – like having the anesthetist grill an intern (and myself!) about anatomy and how anesthetic drugs work, and noticing the empathy you notice in other members of the team for patients who sometimes have the most awful of situations and diseases. I learned the sheer dedication of these surgeons who work 80 hours a week and have 4 days off a month, that cancel their vacation flights so they can come in to save someone’s life; I learned how much my feet hurt after 9 hours of standing with almost no walking and that I should really exercise more to be in better shape; I learned that despite all the horrible and amazing things I saw today, I remain so excited and humbled by the chance to experience and learn all of this, and I cannot wait until my next OREX date.  

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October 30, 2015

Written by Amari Washington (class of 2015-2016)

 

My first day with OREX was interesting to say the least!

I arrived in the OA-2 room at 6:30am. I signed in and walked towards the table. I paused and looked at the chair in the corner across from the table, next to the door. I laughed a bit remembering what Lucy said about hiding behind the wall, I was tempted, but decided to sit at the table, in the same seat I took during our orientation. I did some reading as I waited for the rest of the group to arrive. When 6:50am came around I began to wonder if I was in the right room. At 6:55 I thought maybe it was Saturday and I had gotten my days mixed up and  missed my OREX day due to extreme exhaustion (ridiculous, I know haha).

At about 7:01am three people walked in. I greeted them. The women said hello and took their seats on the opposite side of the table. The man that walked in with them remained silent and sat in the back corner of the room (I’m guessing he was tired). The rest of the group began to trickle in, exchanging stories about things they had seen on previous shifts and preparation for the day’s cases. One of the residents told his colleagues about a case he had regarding an elderly woman who had been in a car accident. I am not completely clear on the details, but it sounded like some “young reckless driver” ran into her and her seat belt sliced her neck. I believe about two weeks later she was still having pain, and they determined that surgery was required. They found her earring inside of her neck. The resident passed around his phone so everyone could see the earring he removed (it was pretty big). He mentioned that she was unaware that it was in there, and that she just knew she was in pain. Crazy, right?!

I introduced myself to Dr. Harkin. He was very kind and told me he was happy to have me there (Yay for OREX student!!). He then introduced me to a fourth year resident by the name of Dr. Jessica Williams. He asked her what she had on her schedule for the day. She explained that she was with ENT for the day. Dr. Harkin asked if she minded if I tagged along and explained that I could hang out with Jessica for the first part of the day, and that we would link up later on so that he could take me around the OR. She agreed. She was very warm and welcoming. We discussed her journey through medicine and she inquired about mine. We also discussed her schedule for the day. She explained that ENT was Ear, Nose and Throat, and that the surgeon she was going to be assisting was Dr. M. McDonald. Jessica took me to the 5th floor and helped me work the machine to get my scrubs. That machine was awesome! Pretty cool how the scrubs were neatly folded in a little section of the machine. After changing into my scrubs, Jessica allowed me to place my belongings into her locker. I put my cap and shoe covers on before completely exiting the locker room.

We then walked over to the pre-op area and approached her first patient. She greeted her warmly, introduced herself, then me and asked if it was okay that I was present during her procedure. The patient agreed. The patient was a young woman, perhaps late teens, no more than twenty years of age. The first procedure was a tonsillectomy. Jessica explained the case as we put on our masks and entered OR 4. I watched as everyone set up the OR; the surgical tech, Joe, set up his station with the RN, Glenda, assisting him. The anesthesiologist, Becca, was instructing the resident, Justin, on how to help set up their station, position the patient, and how the medication would affect the patient. Jessica was paired with Dr. McDonald and the PA, Ingrid. I enjoyed watching them work as a team, each component coming together in order to ensure that the procedure ran smoothly for the patient.

Once the team was ready to start, after Dr. McDonald, Jessica, and Joe were scrubbed in (Ingrid exited the OR to attend to something else), they read off the start time, procedure and information about the patient. They began by placing some sort of instrument (I didn’t catch the name) into the patient’s mouth in order to keep it open during the procedure. I wanted to make sure I was not in the way, so I tried not to get too close to the table. Justin grabbed a stool and placed it directly behind Dr. McDonald so he could get a better look. Since everything was done inside of her mouth I couldn’t see much. When the tonsil was removed, Jessica told me to take a closer look. It was huge! Maybe around the size of the circle you can make with your thumb and index finger. Once the procedure was finished, they asked me to come stand on the stool and look at the stitch they made. Once they removed the instruments from the patient’s mouth Dr. McDonald left the OR. Jessica, Justin, Becca, Glenda and Joe all began prepping the patient for recovery. She began waking up, and as she became more alert she began to twitch, and push away from the OR staff. She was disoriented and pretty aggressive. She tried talking but couldn’t since her throat was sore. She started crying and kept pulling her oxygen mask off of her face. The OR staff  did their best to comfort her and keep her calm. Jessica explained that this reaction usually happens with pediatric patients when they first wake up, and that for some reason, the adult patients don’t normally react that way. Once they were able to calm the patient a bit and transfer her to the other bed, they rolled her over to recovery. There, we sat and waited for the next procedure.

During the wait, I overheard the staff discussing a few issues with the day’s schedule. The next two surgeries were delayed due to issues with paperwork and insurance. The staff expressed their frustrations with the issues that caused the delay. While we waited, Jessica took me over to the OR board. It was set up much different than the board I was used to reading for the OR on the 9th floor. She helped me to better understand how to read the board and walked me over to two of the ORs. One was performing a mastectomy and the other was dealing with a hernia. The hernia had just finished and the mastectomy was extremely difficult to see, so we hung out in the pre-op area until it was time for the next procedure.

The second procedure was a Thyroidectomy vs. Right-hemi. This patient was a woman in her late twenties/ early thirties. This procedure was much easier to see. Jessica told me that the best position would be next to the anesthesiologist, so I positioned myself right next to them. Justin brought me a stool so that I would be able to see a bit better. Before they opened her up, she instructed me to feel my own neck and then feel the patient’s neck so that I could get a better idea of the size, position and feel of the mass. They started by making a small, horizontal incision across her throat, in the middle of the area they marked for the mass. They then used instruments to cut and burn through the fat and muscle in order to get past the many layers that covered up her thyroid. Dr. McDonald allowed Jessica to do the majority of the procedure as he guided her along. Ingrid assisted with the positioning and Joe provided all of the necessary instruments. One in particular was the harmonic, which they used quite a bit in order to make it easier to cut and burn through the fat and flesh. During the procedure, Jessica was sure to explain every step as she proceeded, moving certain muscles rather than cutting through them, identifying major arteries and nerves and explaining the severe consequences of damaging them. They eventually removed the right side of her thyroid and then flushed out the area. Once finished, they began to stitch up each layer, thicker sutures (surgical thread) were used for the more inward layers. Jessica explained that they did not want to make the stitches tight in order to allow for oozing. If the patient began to bleed, the build up of blood would result in the formation of a large lump in her throat that would press on her airway and eventually stopping her from breathing. Once they got to the outer layer, they used smaller sutures (surgical thread) and made them tighter in order to reduce the visibility of the scar that would eventually form.

As with the first patient, when the procedure was finished, Dr. McDonald left the OR (he actually left before the suturing was finished – Jessica completed the suturing and Ingrid assisted). When the patient woke up, she too was disoriented, but as Jessica explained, she did not react the same way the first patient did. She was a lot more calm and less aggressive. She quickly relaxed and was rolled over to recovery.

The final procedure I saw was called a Functional Endoscopic Sinus Surgery. This patient looked to be in her mid to late fifties. Before the procedure, Jessica showed me some of the images from her chart to help explain the issues the patient was having. The right side of her nasal cavity looked normal, but the left side looked like she had a huge blockage. Once we arrived in the OR, everything was already set up. This procedure was going to be viewed on a huge screen. Dr. McDonald began by sticking white strips with blue strings into the patient’s nostrils. Jessica explained that the medication on the strips would help reduce bleeding and also help open up the cavity. After a few minutes, the strips were removed and they began inserting the camera (which was actually a long rod with a small camera at the tip). They used the camera to navigate and identify the different structures in the cavity. First they viewed the normal nostril (on the right), then moved to the left side and pointed out the huge differences between the two. I was able to see where the mucus was dripping and where the polyps were located. Dr. McDonald started by using an instrument (I cannot recall the name) to break the maxilla bone. He then broke into a mass that caused a bit of mucus to leak out. He began removing the pieces of bone and the polyps. Dr. McDonald allowed Jessica to navigate around the cavity to make sure everything was removed. Once the cavity was cleared, they flushed it out. They made sure that there were no polyps, left over bone fragments or liquid left in the cavity. Once the procedure was complete, they placed what they referred to as a “mustache” (a large bandage with tape) under the patient’s nose in order to catch any blood, mucus and additional leakage.

I was sure to thank Dr. McDonald for allowing me to watch his procedures for the day. He was very kind. After he said his goodbyes and thanked the team, he exited the OR. After thanking the rest of the OR staff, Jessica and I exited the OR as the rest of the staff prepared the patient for recovery. Jessica explained that they were essentially done for the day and asked if I was planning to stick around to catch a few more procedures. It was actually time for me to leave, so I went back to the locker room to return my scrubs. The machine is pretty cool, I didn’t know that it accepted “deposits” as well. Once I turned in my scrubs, I said my final goodbyes and expressed my gratitude to Jessica, who said that hopefully next time they can get me in to see some other procedures that I will be able to view a bit better. I did not get a chance to meet up with Dr. Harkin before I left, but I am hoping I can catch him next time!

Woohoo for day one!