Immersion Term - Week 1 - Winning in the OR

10 June 2014

Under the mentorship of Dr. Jason Spector, we (Ben and I) started off our summer immersion early with 6 AM rounds. Here, we followed Dr. Spector’s team of residents and med students to patients’ rooms for check-up. I’ll outline the ones I note:

• Two patients had part of their tibia taken out for use in reconstruction of their mandible
• Skin flaps and skin grafts translocation were used in multiple patients (note: flaps have major vessels while grafts are avascular)
• One patient was instructed to start moving around to start the recovery process, but she vehemently refused on the basis that she knew her body and did not want to start walking today, and I paraphrase, “I don’t want to do this. I THOUGHT THIS WAS AMERICA! I KNOW MY OWN BODY!”. I thought it was hilarious. The senior resident told her off, I think, but we didn’t stick around for the aftermath.

The highlight of the day was the intense surgery. 10 hours of madness (but not really). It was a large case consisting of three surgical teams—plastic and reconstruction (skin flap removal and transfer), oral and maxillofacial (opening of the mandible), and ENT (ear, nose, and throat) for tumor removal. The plastics team prepped the skin flap by excising the surrounding tissue while leaving the vascular in place while the other two teams opened up her lower mandible and removed tumors at the same time. When the ENT and oral teams were finished, the plastics transferred the flap and performed a microvascular anastomosis and connected the artery and veins from the skin flap to vessels near the jugular vein. It was interesting that they used clamps to attach the veins but small stiches for the artery. Despite the long procedure, each team was fairly laid-back, which was completely opposite of what is portrayed on TV shows (e.g. House).

11 June 2014

We saw two quick surgeries today in the morning:

1.  Removal of keloid in a child. A keloid is a benign fibrous tumor that is mainly composed of collagen type I and III. It can be caused by impurities of metals used in a procedure, such as piercings, but I don’t think this young child had any prior procedure.
2. Skin graft transfer of a diabetic patient to cover a hole in his foot. Diabetes patients are immunocompromised and have a loss of feeling—which is not well understood, but one theory states that the increased glucose in the blood stream increases protein glycosylation, which leads to cell death somehow. A combination of these events could cause the large hole on the bottom of his food. 
   The procedure was simple and relatively fast. First, a machine was used to cut (or rather slice) a thin piece of skin from his upper thigh (I couldn’t remember the thickness because they used imperial units [aka “Freedom units”]). The graft passed through a meshing machine so the graft is meshed to allow for fluid to escape and to increase the surface area of the graft coming in contact with the affected area.

There was a major case that day involving reconstruction of a child’s skull due to a birth defect. I can’t remember what it was called (maybe brachylcephaly?) but the child’s skull was irregularly shaped that resembled a tower. The procedure was delayed because the neurosurgery team had to fix a problem around the foramen magnum.

12 June 2014

Dr. Spector was out of town, but we decided to go on rounds again. Nothing special here—most of the patients were the same as before, some were discharged, and some were new.

We followed one of the residents into the OR and we were allowed to watch Dr. David Otterburn and Dr. Rache Simmons perform some surgeries.

1. The patient had a nipple reconstruction after double mastectomy with deep inferior epigastric perforator (DIEP) flap reconstruction. Basically the breast tissue was removed and reconstructed using fatty tissue from the abdomen. The procedure here was performed because the nipple came back positive for cancer cells, so they had to remove it.
2.  This patient had her implants removed and replaced for aesthetics. She also had a double mastectomy but instead of choosing the DIEP flap, she opted for implants. Unfortunately, the procedure took a little longer because one of the implants ruptured, which doesn’t occur often, but the silicone had to be cleaned up.

13 June 2014

We shadowed Dr. Otterburn and Dr. Spector’s team again, but we saw the full DIEP flap and double mastectomy procedures—a 10-ish hour process. While Dr. Simmons and team were removing the breast tissues, Dr. Otterburn and his team prepped up the flap by cutting away the tissue while leaving the perforators intact. When the breasts were ready, they transferred the flaps over and performed the grueling task of microvascular anastomosis. One interesting instrument used was the SPY system, which was a near-infrared imaging instrument to observe vasculature approximately 1-2 mm deep. Indocyanine green (ICG)—a dye that binds to blood plasma protein with a half-life of 2-3 minutes—was injected into the patient via IV for visualization of the intact flaps and breast tissue. Parts of the flap that didn’t have blood flow were excised.

So far, we have met the following people (who also know us!—I hope), and unless specifically noted, they are all MD’s:

• Jason Spector
• David Otterburn
• Rache Simmons
• Kevin Small (chief resident)
• Peter (resident)
• John (resident)
• Natalia (resident)
• Andrew (resident)
• Maria (med student)
• Adam (3^rd year med student)

Okay, I’m not going to write more than this for next week.