Week #2: Tying not to drop the ball

The week began in rheumatology where I shadowed Dr. Kasturi in the arthritis clinic. I was not expecting a hands-on experience examining patients, but I learned how to identify inflammation via touch, feeling for warmth in the knee or other inflamed areas. One of our patients had been diagnosed with juvenile idiopathic arthritis (RIA) when she was 3 years old. Now 38 years old, she has numerous surgeries under her belt (spinal fusion, wrist fusions, etc) and continues to live in a great deal of pain (especially in her hip). I got to examine her “telescoping digits” -- soft, swollen fingers resulting from joint destruction and bone loss. The patient opted not to get a steroid injection to relieve the pain before going on vacation due to time constraints. While much of the patient's life was confined to a wheel chair, I was inspired by her reliance and positive outlook.

I also attended the “comprehensive arthritis clinic” where a special case is examined in detail by a room full of doctor and students. This week’s patient was a young Chinese girl diagnosed with multicentral carpotarsal osteolysis (aka “vanishing bone syndrome”). This mysterious condition was unknown to the majority of the room. Turns out, it is caused by a mutation in the MAFB gene (codes for a transcription factor/regulatory protein responsible for osteoclast maintenance and renal function). While the patient had many skeletal deformities and considerable wasting in the right hip, there was some reluctance to treat her (e.g. with a hip replacement, etc.) because of her lack of pain and the possibility of infection and further complications. Risk assessment appears to be a HUGE component of medical decision-making and this is one area where biomedical engineers may help design tools/techniques/quantitative methodologies for deciding the best way to intervene and WHEN.

After spending another day with my mentor, Dr. Ebben, meeting with patients in the Sleep Lab, I finally had my opportunity to explore the OR. For those looking to observe surgeries, the best way I have found is to check the schedule for the following day at 4pm at the OR desk (it is not out in the open so you have to ask). Pick a surgery that looks cool and visit the surgeon’s office and speak with his/her assistant (or directly with the surgeon). You might have to get paperwork signed, but you will then be good to go for the following day. Urologist Dr. Douglas Scherr is very willing to have students shadow and he was the first surgeon who I observed.

I watched a robotic prostatectomy which utilized the Da Vinci surgical robot to remove a cancerous prostate. This was one of the craziest things I’ve ever seen. As I quietly rocked out to Adele’s “Set Fire to the Rain” which the OR nurse had put on, I had the eerie feeling of being in a SciFi movie where a large alien octopus was hovering over the body, ready to operate. A dual consul setup enabled a fellow to operate the machine while Dr. Scherr provided guidance and could intervene if necessary (think driver’s ed). Multiple incisions were made and ports were installed to allow the robot to dock and various instruments to be inserted, including a camera probe which provided everybody in the room with the surgeon's view. Dr. Scherr operated the robot using both hands and feet and performed many fine manipulations to cut, suture, tie of blood vessels, etc. In order to gain direct access to the prostate, the bladder was pulled down and out of the way and the vas deferens and seminal vesicles were removed. Equipped with both a monopolar and bipolar cauterizer, the Da Vinci was able to cut and coagulate simultaneously, minimizing the bleeding. Excess blood was removed using a suction. The most intense part of the surgery was when the suction stopped working and Dr. Scherr assertively said, “Okay, everybody STOP.” There was silence. He then gave further step-by-step instructions describing what needed to happen. It was cool to see him in action as the commander and chief of the operating room. While cauterization is an effective tool to minimize blood loss, sometimes it is avoided; for example, on the lateral regions of the prostate where damage to peripheral nerves could prevent the patient from having an erection (that would really be a downer). In addition to the prostate, the lymph nodes were resected and sent to pathology for evaluation. The lymph results will provide a score for metastatic likelihood which can then be used to guide subsequent treatment. The surgery went very well as a whole and the patient should be off to a speedy recovery. 

While the surgical team stitched up the fascae layer and closed the patient, Dr. Scherr moved next door to excise a scrotal mass from a 29 year old patient. Compared to the 4+ hour prostatectomy, this was a simple ~40 minute procedure. The right testicle and the full spermatic cord were removed through an incision in the lower lateral abdomen. It’s nice to know that a sense of humor is welcome in the OR, as the nurse urged the resident not to “drop the ball” as the testicle was transferred into a container for pathology. In addition to Dr. Scherr, Dr. Zarnegar is supposedly another good one to shadow for robotic surgeries and is known for being an innovator, as well as an expert operator.

Sorry for the lengthy post! As you can tell, my week was pretty nuts!