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December 25, 2016

Written by Bianca Salaverry (class of 2016-2017)

My second day of OREX turned out to be even better than the first! I’m still getting used to things, so when I first got up to the OR, I was a little confused because it seemed like the surgeries listed on the board weren’t all where they were supposed to be. I wanted to observe a total knee replacement (TKR), but there was a sign on the door to that OR that said not to go in because of the infection risk. I stepped into the room adjacent to it thinking I would observe a surgery in there, but it hadn’t quite begun and the nurse anesthetist urged me to go watch the TKR instead, but to go in through a side door. I went in and sure enough, everyone in the room said it was fine to observe, but just not to go in/out through the exterior door.

There were six main people in the room: a senior resident, a junior resident, a scrub tech, a circulating nurse, an anesthesiologist, and a sales rep. When I first arrived, I was instructed to get goggles because things get a little messy. I remembered Lucy saying this about Ortho surgeries at our orientation, but wasn’t sure quite what to expect. The man who helped me with that was the sales rep, someone I hadn’t encountered in the ED before. One of the most surprising things about this surgery for me was seeing how involved the sales rep was, how much instruction he gave the surgeons, the degree to which they deferred to him despite him having no medical training, and so on. Although all the surgeries I’ve witnessed so far have involved hundreds of tools, this one was at a whole other level. There were drills and saws, rulers, screws; generally just too many devices to count. The sales rep was incredibly knowledgable about every tool, frequently directing the surgeons to use a particular instrument, or instructing them about how something should fit (e.g. “That shouldn’t be so hard to remove,” or “Pinch there and then open it from the top.”). He navigated back and forth around the room between the OR tech and his tools and the surgeons doing the action.

This surgery played out much differently from my previous OREX day in a few ways. First of all, because there were only two doctors at the table, I was able to see what was going on much more easily.

For most of the surgery, I stood at the foot of the operating table, about three feet from the edge. My view was amazing! Secondly, I had heard this before, but this surgery was much more gruesome than ones I’d seen previously. There was a lot more blood (including some spurting arteries), the incisions were much deeper and generally done a lot more quickly than in abdominal surgery, and of course, there was a lot of sawing and drilling involved. After the initial incision, the surgeons flipped the patella out of the way to access the knee joint. Over the course of the next several hours, they proceeded to saw the ends off of the femur and then tibia.

The initial cut, off the end of the femur, was perpendicular to the axis of the bone, but then the doctors made several additional cuts at different angles forming a precise shape that I couldn’t quite capture in my drawings, but which looked roughly similar to this with a groove running down the middle of the femur end.

Screen Shot 2017-02-19 at 10.15.42 AM.pngAfter each piece of bone was sawed off, a guide was screwed into place so that the next bit of bone would be removed at the proper angle. Obviously this stage involved a lot of sawing and at one point I got flicked with some blood/bone droplets, some of which got on my skin. I definitely wondered at that point about how the surgeons themselves are able to avoid getting splashed with a lot of bodily fluids since they’re right in the middle of the action. I’ll have to remember to ask someone about that sometime.

Once the cuts were all made, the scrub tech mixed some cement to attach the metal pieces that would form the artificial knee. One surprising thing about this step — the cement was really nauseating to me. I don’t have a very good sense of smell, which I think is a huge advantage working in a hospital. I’ve never had a problem before, even with the most pungent odors I’ve been exposed to in the ED, but I almost had to step away from the table because the cement smelled so strong. It was awful! Another surprise: the cement wasn’t mushy like the kind you see used in construction; the texture was more similar to fondant, a kind of sugar based “clay” that bakers use to cover cakes.

At this point, Dr. Krosin, the attending, came in and the surgeons showed him their work. They moved the patient’s leg around, bending and straightening it, and observing its rotation. At one point Dr. Krosin came and stood next to me, and I had the opportunity to ask him a bunch of questions about his experience in Orthopedics. He was very friendly and seemed happy to talk about his work. Dr. Krosin is the chief of Orthopedic Trauma at Highland, so he sees a lot of severe injuries. He talked a little about how orthopedic surgery has this reputation as being less cerebral than other fields of medicine, but that he doesn’t think that’s true. He also touched on how important it is to consider the psychological needs of patients who’ve experienced these major traumas. I was especially impressed by that, because there’s also a stereotype that surgeons don’t see the patient, they only see the part they’re working on, and that was obviously not true of Dr. Krosin or his residents.

After that, we talked a little about the patient at the table and he took me over to the computer and showed me some X-rays of patients he’s worked on recently. One was a young girl who had fallen from a tree, and another was a man who had been hit by a car. I asked about how the recovery would be for the man and he said very matter-of-factly that either the man would heal on his own, or his leg would have to be amputated. No wonder Dr. Krosin emphasized the psychological needs of these patients! I can’t even imagine how I would feel in that kind of situation. One piece of advice Dr. Krosin gave — if you ever get in an accident on the freeway, stay in your car! He said he sees a ton of people come in to the hospital after surviving a car accident only to get injured worse because they got out of their car and were hit again.

Once the artificial joint was put in place, the rest of the surgery consisted mainly of irrigating the area, soaking it in betadine, and stitching the patient up. Overall, this was easily the most interesting surgery I’ve seen to date. At this point, I took a short break, had a bite to eat, and then hurried back to the OR so I wouldn’t miss anything interesting.

It happens that the second orthopedic surgery I got to observe that day was with the exact same team. The patient in this case was an older woman who had suffered a fall and gotten a small fracture towards the end of her femur. The surgery started off roughly the same as the TKR, except that everyone in the room had to wear a lead jacket during the procedure because after the break was repaired, they would need to do multiple X-rays. The initial method for this surgery also involved cutting around and flipping the patella out of the way to expose the knee joint. I don’t know the anatomy of the femur very well, but I believe the break was through part of the medial condyle. It didn’t go all the way through the bone (i.e. there wasn’t a piece of bone that was floating completely separate from the rest of the femur) so the main aim of the surgery was to insert screws to hold the broken part in place until the bone could heal naturally.

As the doctors were working, it seemed like something wasn’t quite going right, and Dr. Krosin scrubbed in to help. Once he was done, he said it seemed like I had a question, so I told him I was a little confused and hadn’t been able to follow what the problem was. His answer was essentially that they were being perfectionists, and that they just needed to accept that their work wasn’t exactly a “textbook” job. I appreciated that piece of advice because it’s the kind of thing I struggle with. There’s a saying “Don’t let the perfect be the enemy of the good,” which essentially means the same thing — don’t get stalled because you want the thing you’re doing to be perfect instead of just good. Once the doctors had decided their repair job was good enough, they took several X-rays from different angles and saw that, in fact, they had done a great job and everything looked as it should.

At this point it had gotten late and was time for me to go, so I thanked the surgeons who had let me spend the entire day with them and said goodbye. All in all a great day!

February 20, 2015

Written by Xiteng Yan (Class of 2014-2015)

When I arrived in the surgery wing last Friday for the 7AM lecture, I saw only the residents sitting at the table. They mentioned how Dr. Harken would not be in this morning, so after signing in, I went straight to the 5th floor. I was able to get some homework done before the first surgery, which was a tonsillectomy. The surgeon for this case was Dr. McDonald. The patient was in his late twenties or early thirties. The procedure began with a student inserting a ventilator tube into the patient under the guidance of a senior doctor. They used a laparoscopic camera in order to ensure the proper positioning of the tube. After this, the staff did a few more preparatory procedures (e.g. repositioning the patient) before the operation began. First, the tonsils appeared to be clipped in place before being removed by a pair of surgical scissors. A sickle-shaped instrument was also inserted into the patient’s mouth and may have been used to excise the tonsils. Finally, after the left and right tonsils were removed, the surgeon inserted a heating tool into the patient’s mouth, possibly to seal the cut blood vessels. Overall, the procedure was difficult to observe because it was entirely in the patient’s mouth and was not projected onto any screen like a laparoscopic operation. The operation was also brief, lasting only an hour. After it was completed, I went to the break room for a few minutes before heading to my next surgery.

The next operation I watched was on a left tibia plateau fracture. The surgeon on this case was Dr. Robert Hoffman. The operation was well underway when I entered the OR, but the staff brought me up to speed. The circulating nurse, Wendy, told me that the patient had been in a “pedestrian versus automobile” incident. The patient had his left leg propped up; there was a rectangular opening that started on the left side of his knee and went down to his upper shin. The team had already inserted several K-wires into the patient’s knee, which was visualized via X-ray. The K-wires were adjusted until they crossed in the left side of the left knee. A perforated, rectangular metal plate was then inserted into the leg, covering the left side of the knee down to the upper part of the shin. According to the circulator, the cartilage was damaged and the goal of the operation was to bring the upper and lower parts of the leg back together. The metal plate was needed to set the tibia back in place since it had been shattered into many small pieces by the incident. To conclude the operation, multiple screws were inserted into the knee (there were four horizontally placed screws and two that formed a cross at the knee). The placement of the screws were then checked with X-ray. Dr. Hoffman rinsed the opening with saline before asking the residents to close the wound. As I watched them suture the wound shut, another doctor came up from behind me and took my notebook. I was caught by surprise as he read through my notes out loud and slightly embarrassed by my simplistic observations. However, I quickly realized that the doctor was being tongue-in-cheek, but he nevertheless quizzed me on what had happened during the operation. After failing to give a satisfactory answer to a question on cartilage, the doctor invited me over to the OR next door, where a total knee replacement surgery was about to begin.

I found out that the doctor who invited me into his OR was Dr. Krosin. He was personable, had a good sense of humor and he was very inclusive during the operation. He told me that the patient coming in had arthritis in her left knee, which damaged the cartilage to point where she needed a total knee replacement. As a result of the operation being a total joint replacement, a sign saying “total joint no entry” was placed on the OR doors. Dr. Krosin explained this as an extra precaution; while all operations needed to be safeguarded against possible infection, the consequences of a joint being infected were considerably more dire than other cases. Nevertheless, Dr. Krosin said that I was free to leave whenever I needed to. The operation itself was incredibly dramatic. The speed and forcefulness with which the surgeons operated (e.g. their use of the power saw) was slightly terrifying but all the more admirable for it (I was asking myself how much training one had to go through in order to saw off slabs of bone with such speed and confidence). First, a slice of bone from the left side of the femur was sawed off and replaced with a metal disk. After this, portions of the cartilage connecting the femur to the tibia were systemically sawed away. Throughout all of this, the surgeons continuously checked the alignment of the knee to the rest of the leg. Finally, after the damaged cartilage was removed, metal replacements for the femur and tibia’s cartilage were inserted (the doctors went through several different sizes before finding the proper ones) and held in place with bone cement. The opening was then washed with a dark fluid (I forgot to ask for its name). Overall, the procedure was surprisingly quick, lasting no more than three hours. I thanked Dr. Krosin for inviting me to watch and left the OR.