Week 1: Delving into the deep end, fully immersed...

Dr. Spector wasn’t kidding when he said we (Aaron and I) would get an intensive immersion experience. My respect for physicians, particularly the surgeons such as those in the reconstructive surgery team we’d been shadowing all week, has been elevated to new heights. I don’t see how they possess the stamina and mental fortitude to work these type of hours, day in and day out. Guess I’ll detail some of the highlights/general schedule of our week:

June 8, 2015
Bit of confusion/miscommunication when trying to first meet with Dr. Spector as he was gravitating between clinic/rounds/OR, but once we did we hit the ground running. First case was patient in need for reparative surgery for an abdominal hemorrhage. The case was so severe and left untreated for so long that degeneration of the facia and retracted muscles sheathing the abdominal wall made it highly unlikely that he would be able to reconnect without a mesh. The only other question at hand was whether to implement a bioprosthetic (from pig skin) underlying the facia or biosynthetic polymer over the facia, where the former would further require a successive operation to fully complete the closure. He goes on to explain the  patient and us that he can’t determine which may need to be implemented until during the operation where he would have better access to the defect site and re-assess which is better suited on a case by case basis.

We get the gist of Dr. Spector’s daily schedule: he doesn’t have one. Sure, he and his team try to commit Monday/Thursday mornings to clinic and Tuesday/Wednesday primarily to surgery, but it’s highly dynamic, changing in an on the fly basis. In addition to his own patients, he and his team are also conducting consultations for other departments where their expertise for things such as skin grafts/tissue flaps may be required following/in conjunction with another major operation.

Before heading back to the OR for his surgeries, we are introduced to Dr. Spector’s research lab who provide us a brief overview of the projects they are currently working on. It did not sound like he had particular research projects either of us in mind, so I hope to get some ideas to propose after talking with his students and seeing some of the things they are working on. Still trying to get ahold of my bearings…

June 9, 2015
Aaron and I start our first full day of immersion early at 6AM rounds with Dr. Spector’s team of residents and med students for patient post-operative follow-up. Won’t go into detail as they were in very rapid succession and it was a struggle to keep pace with them as we zigzagged across several different floors/wings. The residents had a tight schedule to keep up with, and I quickly learned to keep mental note of any pressing questions I had until we had a brief reprieve (e.g. quick breakfast in the cafeteria). One patient of note had a fibula flap operation as part of a mandible reconstruction, one of the more major surgeries Dr. Spector performs which we’d get a chance to catch starting at 7:30AM. With the patient we saw at rounds, we observed that their recovery was further complicated by their having undergone irradiation which left the surrounding tissue of their jaw ischemic and improperly incorporating with the anastomosed fibula flap. Atleast I got down the members of his surgical team thus far:
Kelly (PA)
John (resident)
Ryan (resident)
Mamoud (resident)
Carmen (med student)

The mandible reconstruction we observed was quite a sight to see, as 3 separate surgical teams went to task, working in such tight quarters in a highly efficient/coordinated manner. Everyone appeared surprisingly relaxed despite the complexity of the case. The procedure was also much longer than I had anticipated, further compounded by the delayed start of the operation. The entire procedure ran approximately from 8:30AM to around 9PM. I found myself unable to make it through the entire operation through to completion, and am hoping I’ll be able to catch those parts in future surgeries. Brief overview of the operation itself:

As they put the patient under with general anesthesia, the surgical instrumentation is meticulously laid out with all the equipment in the operating room being repositioned to ensure the surgeons can receive adequate patient access/room to operate.

Respective teams set to task, thoroughly sterilizing the patient and then setting to task carefully incising the dermal and muscle tissue in order to access the mandible/fibula bone. Thorough separation of bone from muscle tissue is required as one of the residents, Ryan, shows me the various 3D-printed alignment guides obtained from patient CT scans that are used to precisely cut these bones to align these respective segments to match the geometry of the jaw being removed.

Subsequently, the fibula flap, providing a vascular bed as compared to an avascular bone graft, was anastomosed to the vessels of the neck. This was performed by manual suturing major vessels (arteries) and utilizing a coupling device for the venous system.

June 10, 2015
Again, started the day bright and early with rounds at 6AM. Not much to further report as it mainly involved revisiting patients from the previous day to verify there have been no substantive changes to their health status. The day involved another major surgery, this time a laryngopharyngectomy/neck dissection with reconstruction of the esophagus using an anterolateral thigh (ALT) free flap. In such cases, so much tissue had been removed that the remaining tissue cannot be repaired simply via anastomosis, thus necessitating the fabrication of this conduit from muscle tissue.

Mid-surgery, found myself gravitating back towards the research lab briefly. To be honest, I found the amount of clinical exposure I was being presented a bit much the keep up with, and appreciated the familiarity of lab. Learned a bit more about their projects, more specifically about their plasma ozone treatment project. One of their research aims is to determine whether their plasma ozone treatment system is capable of sterilizing colonized, full thickness wounds and if it would then promote accelerated wound healing. After observing their protocol for sample acquisition whilst maintaining a “sterile” environment, I make suggestions of how they may modify their experimental methods in order to work more efficiently.

Returning to the OR, we catch them in the midst of attaching the ALT flap to finish the pharangoesophageal reconstruction, anastomosing the respective tissues and verifying blood flow restoration using a Doppler sonometer, a device which I’m surprised they use so extensively because it looks so dated and possesses so much background static audio.

June 11, 2015
Started clinic with Dr. Spector around 9AM for patient consultations/minor procedures (e.g. cyst removal, botox injections, etc.). One such patient was suffering from trigger finger (stenosing tenosynovitis), where several fingers of his left hand would lock up and get stuck in a bent position. Dr. Spector explains that this occurs when the tendons in the hand become inflamed, narrowing the space between them and their surrounding sheath. This starts essentially a positive feedback loop, as the developing nodule comes into greater contact with the sheath and continues to get inflamed. Dr. Spector recommends against surgery as a first course of action despite the patient’s insistence, and recommends the application of a catabolic steroid which could potentially break the cycle of inflammation. Find it to be a recurrent theme for (some) patients to request excessive treatment/action despite the physician’s recommendations for implementing less invasive methods or even that they take no action and monitor changes in their condition. It seems these patients only look for/see the end result/an immediate remedy versus the physician constantly conducting a risk – benefit analysis for those different treatment options.

As opposed to the previous two days, this day in the OR consisted of shorter/less intense surgeries: one treating an abdominal hernia by rejoining the facia and muscle of the abdominal wall, two mainly involving the Dr. Spector and/or his residents performing wound debridement and implementing a skin grafting, as well as a total mastectomy followed by breast reconstruction. More fast paced as Dr. Spector and his residents gravitating between these respective procedures at different stages of the operations.

At a certain point of the evening, Dr. Spector let us off to head over to lab for a bit. I had quite a few questions on the SMF related projects, where their lab fabricates vascularized tissue-engineered constructs and conduct in vivo microanastomosis to rats. One issue the team was coming across was tracing cellular expression (e.g. VE-cadherin, alpha-SMA, etc.) within their polyculture constructs they’ve developed. I recommended to try transiently transfecting their cell population of interests (e.g. HUVEC) with a vector plasmid that transcribes for EGFP to colocalize the protein expression with their tracing protein during image analysis. Their lab has not used this previously in lab, maybe my summer research may involve implementing these new methods in their lab? I really want to learn more about the microanastamosis procedure. Anyway, on to the next day…

June 12, 2015
No surgeries planned in the OR for Dr. Spector and his team for the day. He recommends to head to lab to checkout more stuff/talk with his people before our 1PM lab meeting.

Aaand that’s it as of today. I anticipate my future postings to be far more succinct, both due to my lack of time and mental capacity to keep track of everything I’m observing on a day to day basis. Guess this is it now...