Written by Sammi Truong (class of 2016-2017)
My fourth day in the operating room was February 13th, 2017. I arrived at the hospital at 6:30 AM. It was actually the first time I was able to hear Dr. Harkin’s lecture. Every other time there was either a special conference or Thursday grand rounds. Dr. Harkin discussed inflammation as a sign versus a cause of illness, and also aspirin in the context of preoperative and daily supplements. The roles of lactate, C-reactive protein, white blood cells, and interleukin-6 elevate inflammation through the COX 1 and 2 mechanisms, which are inhibited by common over-the-counter drugs used to treat fevers. I was surprised to learn the benefits of aspirin intake. Knowing little about the molecular mechanisms of aspirin, I had assumed the effects to be negative and quite harmful, like the effects of acetaminophen. Turns out, there is compelling data suggesting that regular intake of aspirin can reduce the risk of both heart disease and cochlear cancer.
Dr. Harkin’s lecture concluded around 7:45AM. I meant to introduce myself, but was unfortunately cut off by some residents, so I made my way to the OR. My first surgery of the day was a total hip replacement performed by Dr. P. Slabaugh and his resident Dr. S. Robinson. The patient was a 62 year old woman with heavily calcified left femoral head and deteriorated cartilage in the acetabulum. It was a very straight forward case; however, the patient was overweight making the process of prepping, positioning her on her left side correctly, more difficult. An approximately 6 inch incision was made on the patient’s right lateral side, slightly inferior to the iliac spine of the pelvic bone. After cauterizing through the adipose tissue and moving under the muscles, the doctors used a saw to remove the femoral head, which was surprisingly to me only slightly larger than a golf ball in reference to the patient’s weight. Next, acetabular reamers of different sizes sanded down the hip socket and removed deteriorated bone and cartilage. This portion of the surgery took a while because the patient had a large amount of tissue between the skin and the hip, making the incision quite deep and the bones more difficult to access. A acetabular cup, which is a metal cup that is fitted perfectly to the patient’s acetabulum, was then positioned before addressing the femoral component of the implant (left picture seen below). In order to hold the new femoral head in place, a femoral stem must be inserted through the femur for support. Femoral reamers slowly cleared out the center of the bone, then secured the femoral stem with cement and attached the femoral head and a plastic liner, which acted as cartilage. Inserting this component was more complex in that the measurements and angles of insertion determined the length and positioning of the patient’s leg. The doctors had to take the time to maneuver the patient’s right leg in a number of different ways to secure the new hip with minimal error. Dr. Slabaugh and Dr. Robinson then closed and we were finished slightly before noon.
I grabbed a quick lunch and the next case was a left ankle ORIF (open reduction internal fixation) performed again by Dr. Slabaugh and Dr. Robinson at 12:30PM. The patient had a bimalleolar fracture on his left ankle (very similar to the picture on the right); he had both a medial malleolar fracture on his tibia and a lateral malleolar fracture on his fibula. The fracture occurred about three weeks before the surgery, but the patient also had burns and blisters on his ankle, forcing the procedure to be postponed. The first incision was made on the medial side of the ankle and two screws were inserted into the tibia to secure the broken malleos. Next, the doctors made a second incision on the lateral side of the leg, before drilling in two much smaller screws and then a plate lateral to the fibula, secured with more screws. It was another simple case, and the doctors began closing very quickly. Stitches were used on both the medial and lateral incisions, but staples were only used on the medial side. Dr. Slabaugh explained that the lateral side is prone to problems because it has a greater blood supply and adduction of the ankle joint. The doctors discussed the recovery process of ankle fractures and Dr. Slabaugh suggested that though many doctors would tell their patients to not bear weight on the injured leg for a few weeks, he believes weight-bearing with support from a cast or brace on a rotational injury, such as this bimalleolar fracture, would prevent muscle atrophy and strengthen the injury, as opposed to restricting the healing process. This surgery concluded at 3:00PM and I thanked the doctors and staff for their accommodation before ending my day.
Overall, this was a really good day, as I have realized my unknown interest in orthopedic surgery. So far I have only observed colorectal, genitourinary, and oncology surgeries. Each area of surgery offers new perspectives and knowledge about the human body and medicine. However, there was something about orthopedics that separated itself from the rest of the specialties I have observed. Perhaps it was the sawing and drilling that reminded me again of how strong and hard the human body is. After spending so much time at Highland and studying the human body at school, I’ve grown to think of all the ways our bodies are flawed, what can go wrong, and all the illnesses we can get. We forget what the human body has to endure and what we put our bodies through. I am really happy with how much I have explored with OREX and can’t wait to see what is next.
Written by Terry McGovern (class of 2016-2017)
Rounds at 7am with the usual cast of residents, many who I recognized, none of whom I really knew. Dr. Harken discussed new sepsis prevention guidelines for 2017 and then discussed some of the studies cited and how the guidelines were decided on. The most interesting discussion was the relation of clinical guidelines and the sometimes very ‘thin’ or minimal studies that are the basis of these guidelines.
We headed up to the OR.
OR 2 was set for 3 ortho surgeries for the day and given that they hadn’t started yet and were interesting to me, I jumped in on the first one which was a breaking and resetting of a second metacarpal bone on a left hand of a patient. I walked in as they were getting the patient ready, and introduced myself. And the resident, Dr. Tennyson Lynch, said, “Oh I remember you from your day in ortho with us. Come on in”. I think all of us OREX’ers know how nice it is to be warmly welcomed into the OR.
The patient had been seen after the break in October which occurred after an altercation. They had hoped it would set on its own but alignment changed and thus needed to be re-broken and reset. The most interesting thing about this was that the “re-breaking” was nothing of the sort. It was actually more of scraping away the newly formed bone tissue, which was relatively soft and able to be scraped away with repeated and moderately forceful scraping of the bone. The groove got deeper and deeper until the new bone material was removed and the two parts of the metacarpal were separated. They were then realigned, drilled and pinned together. The pin went out thru the knuckle joint and was cut and left in place. It would be removed in a couple of weeks to let the bone set, but not too long, so as to not leave the joint immobilized for too long.
Surgery 2 was a debridement of the left ankle bone. This patient had been seen previously and had some sort of ankle reconstruction surgery a few months. He had an ulcer over the area and was still in tremendous pain with any weight bearing. So they wanted to do a biopsy to determine if there was any infection to the tissue or bone. Samples were taken from the ulcer as well as 2 or 3 from the bone. The biopsies were taken as deep scrapings from the bone. The bone biopsy was to determine if it was acute osteomyelitis
One of the residents asked if this would be a case where antibiotics beads might be placed. Dr. Slabough talked about how those beads were only used in cases where there were gaps in the bone. A way to fill the space and prevent infection.
Surgery 3 Total Left hip replacement
This was “The” surgery to see in the ortho room today. I was curious about it as I have a number of friends, family members and patients who have had this done, so I was interested in observing to see what is involved.
Dr. Mahar and Dr. Slabough started the surgery. The patient had a lot of adipose tissue so it took a larger than expected incision and spreading of the tissue for there to be enough room to access and work on the hip. They cut the head of the femur off and when they removed it from the acetabulum they found a cyst in the joint. Both of the surgeons repeatedly said “I have never seen this before”. The cyst was between the head of the femur and the acetabulum. It was difficult to see given the blood in the area and it seemed like they didn’t really see it until they started to enlarge and rout out the opening for the placement of the cup portion of the new joint. So the cyst material which looked like a combination of soft tissue with some calcified components were gradually removed.
This seemingly straight forward surgery was becoming a lot more challenging than anyone expected. A call was made to get some other opinions. The patient was originally Dr. Pinna’s (but switched due to surgical scheduling) so he was called, and Dr. Shah was also called. They both entered the OR and were soon scrubbed in, looking and offering their ideas which were pretty much the same as Dr. Mahar and Dr. Slabough. It was just a slow and methodical process.
The main issue at this point was how much they could ream out to fit the cup in place properly without removing too much bone. There was a ridge on the inside of the acetabulum that was in a location that prevented a perfectly snug fit of the cup. After repeated tries, and some angle changing it was decided by all 4 that they should get as close as possible and then put 2 screws through the bottom of the cup into the bone to affix it. It was intriguing to see that a full set, of what is essentially a dry run of pieces, are placed then removed and the real hardware installed.
It was agreed that nothing could really have been done differently, but that it was the cyst and the ridge on the inside of the acetabulum that had been complicating factors for this surgery. It also became clear that the top of her femur below where it had been cut was a very dense bone. They had to work extra hard to get the wedge shaped piece that goes into the femur into place.
Finally, after 3.5 hours, the fussing and grinding and hammering were complete.
At the conclusion of this much longer than expected surgery I headed home. Another great day of observation in the OR.
Written by Courtney Pasco (class of 2016-2017)
Yesterday was my first day in the OR and it was easily the best day I have had in a long time. I got to the morning meeting a couple of minutes late and walked past the stares of twenty or so residents gathered around the table. I snagged an empty seat and settled in to the morning’s discussion on melanoma. I thought the give-and-take style of teaching was quite effective, with the attending presenting hypothetical cases with pictures and asking the residents how they would proceed and why. I was expecting the morning meeting to go way over my head, but I actually learned a lot and all of the talk about childhood sunburns, naturally freckly skin, and melanoma mortality statistics made me want to get to a dermatologist immediately.
After the meeting, I proceeded up to the 5th floor and went to get my scrubs. It was pretty obvious I was new because I made mistake after mistake just getting ready. Once I was, though, I was pretty timid about walking into an OR. All of the surgeries scheduled for 8am were crossed off and it was 8:10, so I didn’t want to walk into an ongoing surgery and disrupt anyone. Eventually, though, one of the ortho attendings (I think it was Dr. Krosin) told me if I “promise not to breathe or move” I could watch a total hip replacement.
The surgery took about two hours in total and the patient was an older arthritic Greek woman who had already had her other hip replaced. At first I was standing by the nurse anesthetist, Linda. She was very kind and explained the purpose of each of the medications she was giving the patient and what she was responsible for monitoring. From my vantage point, I couldn’t really see much past the incision, but I have anxiety and was feeling pretty apprehensive so I was grateful to just get the chance to get acclimated to the room and machines and instruments. However, when the residents who were performing the surgery (Jackie and Jeff I believe were their names), saw that I couldn’t really see into the incision, one of the nurses, Tim, brought over another stepping stool and moved me to the side of the patient. By this point I was over my initial nervousness and could focus on how cool it was to be seeing an actual hip joint! Once the joint was exposed, the attending stepped into assist the residents. Jackie grabbed the saw and within seconds, the entire ball-and-socket had been removed. The next steps of the procedure involved carving out a new socket in the pelvic bone and inserting the new metal joint. With all of the sawing, grinding, and pounding, it seemed more like construction work than surgery! Everyone in that room was really nice about chatting with me and making sure to answer my questions.
In the afternoon, I decided to observe an exploratory laparotomy on a young African American man who had been shot four times that morning. He had one bullet wound in each arm and another two in his abdomen. The surgeons, led by Dr. Palmer, opened him up and after observing the wound to his liver, began to run his bowel. That was easily one of the most amazing things I have seen in my life. I mean I’ve studied the anatomy of the digestive system on models and cadavers, but to see it all pink and alive was simply incredible. After they had determined there was no major injury to his intestines, they observed an injury to his right kidney and closed him up. They didn’t repair either the kidney or the liver and are just counting on the healing on their own. At the end of the surgery, ortho was supposed to come and splint his right arm, where the through-and-through bullet wound had completely shattered his humerus. Ortho is scheduled to fix it on Friday, but there was a lot of bleeding so Dr. Palmer wanted to see if the bullet had nicked an artery before having ortho come in. He widened the hole and he could actually stick his finger all the way inside and feel that it was bone marrow that was pouring out, not blood from an artery. So he proceeded to pack the wound with gauze and wrap him up before ortho did the splint. During this surgery, I talked a lot with the surgical tech, Ana Maria. She was absolutely lovely and taught me a lot about the different instruments and then walked me back to show me how they get sterilized.
Nine hours really flew by and I can’t believe how much I learned, not just about the medicine, but also about myself. For a while now I’ve had this pipe dream about becoming a surgeon, but I’ve never seriously considered it because my anxiety crops up in more intense situations and going into the OR I assumed I would have to excuse myself almost immediately to calm down. But I didn’t. I got nervous, sure, but only for the first hour and then my excitement and curiosity took over. I’m starting to think that this is something I could not only handle, but really love.