Small Aside: Depersonalization of Patient
As this summer immersion experience is coming to a close, I think back to what my preconceptions of this program were and how certain aspects I envisioned were spot on and with other aspects I was completely naive. The hospital, much like the living, breathing organisms that are treated there, relies on harmonious interactions between all of its parts to function. There are roles, from the highly skilled surgeon to the often overlooked administrative and janitorial staff, that are all required in order for this complex system to function. The symbiotic feedback between technological innovations and medical need is evident in the procedures I have watched. Above all, it is imperative that these advances be made with amelioration of the human experience as the highest priority. Speaking of the human experience, I found it striking how patients were transformed from people with concerned families, fears about their health, and hope for their futures into medical cases with statistics, recent studies, and clinician's experience steering the medical decisions. This "muting" of the person in order to make the best medical decisions can be controversial. On one hand, the doctor does not want any emotional distractions so they have a clear mind to focus on the problem at hand, the heart to repair, the blood clot to remove, the tumor to ablate. On the other, does this depersonalization reduce the quality of care deliver? Do doctors care less when a person becomes body parts exposed in a sterile field to cut into, fix, and then stitch up? My personal belief from watching these procedures this summer is no. I believe that many doctors use their love of humanity as motivation for learning their trade such that they can be seemingly impartial in order to provide the best care to as many people as possible without becoming so defeated by inevitable bad outcomes such that their overall good is hindered. It goes without saying that this is not always true. There are always going to be some doctors that care more about money or prestige than healing people. However, the clinicians I've spoken to and witnessed working were definitely from the population of doctors that want to make a difference in their patient's health.
Mandible Reconstruction: Fields of Sterile Blue
On Tuesday, I saw a mandible reconstruction with free-fibula flap being performed by Dr. Spector and a small battalion of blue-scrubbed doctors. The reason for this surgery was an osteosarcoma located in the jaw, which was resected along with the nearby mandible, most likely to achieve optimal resection margins to prevent recurrence or metastasis. The void where the right side of the mandible had been was filled using pieces of the patient's own fibula. This OR room was particularly bustling in comparison to the others I've shadowed in. In perfect synchrony, head and neck, oral, and plastic teams were executing their respective part of the surgery such that by the time the blocks of fibula were cut using a custom 3D-printed cutting guide, the region where the tumor was had been excised and prepped for the incoming flap. The term flap refers to vascularized tissue, in this case, bone with surrounding vascularized muscle. The vascularization is critical to the success of the procedure and requires anastamosis of the vasculature in the flap with the surrounding facial circulation. Technology played an obvious role in achieving the amazing efficiency with which this procedure was performed. Custom 3D printed templates were made from the patient's CT scan and were used to make precise cuts for the mandible and fibula, ensuring an optimal fit of the flap in the defect without any additional augmentation. A microscope on a cantilever was used to allow Dr. Spector to see his work while connecting the vessels of the flap. Overall, I felt privileged to be in the room while this intensive procedure was being performed; although due to the high level of activity and the relative crowdedness of the room, my insight here is somewhat limited.
Neurosurgeries: GPS for the Brain
My next new OR encounters were Thursday and Friday watching neurosurgery with Dr. Schwartz. I watched MRI-guided procedures that utilized a system called BrainLab, which consists of a "pen" and a receiver. The pen transmits its location to the receiver which then shows the surgeon the location of the pen-tip as a green cross hair in the MRI images of the patient's brain. The first procedure was what the surgeons were hoping to be an excisional biopsy; however, the excision was not performed for reasons I don't quite understand. This patient had a suspected recurrence of meningioma, a usually benign tumor arising from meningeal tissue of the brain. Microscopy was vital in this procedure like in Dr. Spector's and a similar microscopy and cantilever system was utilized to allow the surgeons to see their delicate work. However, this microscope had dual viewing lenses, so that two surgeons across from each other could both see what they were working on magnified. From the TV screen in the OR room, I immediately identified striations that told me they were in the cerebellum. Blood was constantly being aspirated away from the site as tweezers were used to delve further into the pulsing tissue. Gauze pads with radio-opaque strings (can be visualized with X-Ray in case they get left behind?) attached were used to soak up blood and fluid and to protect the path the tweezers were following. Samples were extracted using what looked like forceps with tiny opposing melon ballers on both tips, an instrument called tumor forceps. The samples were labeled "right cerebellar hemispheric" and "midline cerebellar hemispheric" since there were two distinct regions of interest. Both biopsies came back in record time with diagnosis of gliomal neoplasm. After this diagnosis, the entry wound was prepared for closing. Duraguard and Duraform were used to act as the dura and prevent CSF leakage while healing occurred. The bone flap that had been removed from the back of the skull to access the brain was screwed back into place and everything was closed up. I could tell things hadn't gone ideally but at least the patient was alright for now and with a diagnosis at hand.
The second neurosurgery procedure I saw was an actual tumor removal, of a pituitary adenoma to be exact. An endoscopic endonasal approach was used to access the tumor, located deep in the skull at the base of the brain. BrainLab was being used in this procedure also, pointing to its universalizability in the field of neurosurgery where position is seemingly always crucial. The sphenoid bone was delicately cut away using what appeared to be a miniature rotary sanding tool. Once access to the cavity was obtained, the tumor was biopsied. Removal then became the primary focus as a tool that was essentially a small circular wire was used to chop up the tumor while the aspiration tube sucked up fragments that came loose. This rather barbaric scene played out on the screen that displayed the feed from the endoscope. I was somewhat shocked that a more delicate method of removal was not needed. To add to the excitement, green fluid started seeping out, which I correctly guessed was CSF (cerebrospinal fluid) that had been dyed using fluorescein green. Although that didn't raise any alarms with the surgeons, there was the possibility of hitting the internal carotid artery, which in the words of one of the surgeons, "would have been catastrophic hemorrhaging." FLOSEAL hemostatic matrix, a foam-like substance of gelatin granules and human thrombin, was used rather liberally in this procedure. This matrix seems to have a wide array of applications in preventing excessive bleeding, prompting me to wonder if it's used for other purposes in the hospital.
