General Surgery II Rotation Summary

Okay, so I have finished two months of rotations and have taken my first exam. All in all I think I have done okay, at least I'm not any worse for wear, and I have actually learned a few things. I was even surprised in my exam today to actually know some of the answers. :)

So this is the summary of my latest rotation. Plastic Surgery with Dr. Carl Williams. It was a good experience. We were a little slow, sometimes really slow, but that is in the stages of changing. He will be moving to Valley soon and so students will be able to do a lot more. Here is an outline of an average week.

Monday's were surgery days at Seven Hills Surgical Center. Make sure you take a packet with you or you won't be able to observe. It isn't listed as a place that you need to badge, but Dr. Williams spends 2 days a week there. It is a very nice facility. Privately owned, as Dr. Williams said it "the Ritz-Carlton of surgery centers." Very nice, and wonderful staff. Mondays are a hand surgery day and they start at 9:30. No need to be there early, just be there on time. They have their own scrubs that you can change into. It is then your job to do the H & P on the pts undergoing surgery that day. Dr. Williams will show up and mark the hand or arm. You are allowed to scrub in at Seven Hills, but Dr. Williams has his own assistant who aids in the operations, all you really do is look over his shoulder, ask questions, and listen to what he has to say. You will also have lunch on these days. The Dr or surgery center (not sure which one) buys the students lunch. Mondays it comes from the Spicy Pickle, a good sandwich place. After lunch you head to the office and see pts for the afternoon. Usually their aren't a lot on Mondays.

*Okay, so as far as seeing pts goes, you will observe for a couple people and then Rob, the Dr's assistant will have you do most of it. There are forms in each chart that are to be filled out. You just ask the questions. It is pretty basic. Not sure if it helps prepare us for the physical exam portion of next years board exam, but at least you get some practice asking questions, even if they do all have to do with pretty much the same thing.

Tuesdays are another Seven Hills day, but that is the cosmetic surgery day. Same thing as before, same time, same routine, but this time Dr. Williams nurse Sandy comes in to assist. She does all the cosmetic consults in the office (you won't be in on those) and then assists on the surgeries, as well as taking before and after pictures of whatever is being done. Lunch is El Pollo Loco and then onto the office to see pts again.

Wednesday is another hand surgery day at North Vista Hospital. Badging was a pain there, I never got my actual badge, but it really doesn't matter. I don't know why they even ask for the packet and scrub class certification; you aren't allowed to do anything, not even scrub in, so it makes it very difficult to see and know what is going on. Just ask lots of questions regarding what he is doing. Dr. Williams is great at explaining and teaching if you ask. On Tuesday you will be given a packet by Judi (she is scheduling and authorization at the office), this packet contains all the info on the pts having surgery that day, their release forms as well as MRI results and other things that Dr. might want to see. You are in charge of making sure it gets there and into the hands of the Dr. Surgery starts at 7:30 am, so be there around 7. They also have their own scrubs that they have you wear. When you get there, change and do the H & P on the first pt. Dr. Williams will get there around 7:30 or 8:00. He will mark the pt and then off you go for breakfast. He takes you into the Dr's Lounge. Technically we aren't allowed in there, only Dr's, but Dr. Williams doesn't care, he said in the beginning that the one thing that wouldn't happen during my rotation with him is that I wouldn't go hungry. After breakfast we all go to surgery, you observe and then you have lunch in the Dr's Lounge. In the afternoon there are 2 things that can happen, either you stay at North Vista and see pts at the satellite office, or you go back to the Anthem office and see pts there. It switches every week. Wednesday night Dr. Williams is on trauma call at UMC, if he gets any cases he will call you. I never got a call, but oh well, I got my sleep. :)

Thursday is an office day, all day. You start at 9:30 usually, but it might be later depending on the schedule. You will see a lot of trauma pts, and a lot of follow ups from trauma. It is cool to see the different stages of recovery from the various surgeries, especially since we aren't there long enough to follow one pt all the way through recovery. Some of these pts follow up for up to a year depending on the trauma or surgery that they had.

Fridays are hand surgery at UMC. Unfortunately I only had one day there, my very last day of rotations. UMC is great because you can actually do stuff. Dr. Williams will teach you to suture. I was able to place a pin in a guys hand. It is a great teaching environment. You will also have breakfast and lunch there in the Dr's Lounge (he will have you take off your badge so they don't know you are a student, they are really strict there, even the residents aren't allowed to eat there). After surgery you are done for the day, no office hrs on Fridays.

So that was a typical week. I think I learned quite a bit. Dr. Williams was great at talking about real world stuff as well, having a private practice and what comes with that. Health insurance and how they worked. Did you know that when an insurance company authorizes a procedure it doesn't mean they will actually pay you for it? Yeah, crazy huh, he said that around 1 in 10 operations won't be paid for.

Oh, you wear scrubs every day. No white coat, and they introduce you to most people as a resident, otherwise some of the high end clients that he has wouldn't let you in the room. It is a nice work environment, kind of a family thing. Rob (the hand assistant), his wife Candi works in the front office. Sandi (the nurse) is Rob's mom, and Judi, well there is no relation. :) They are all very nice and fun to work with. I ended up observing 18 different operations, only 3 of which were cosmetic. Most were hand, carpel tunnel releases, ganglion cyst removals, nothing super exciting, although I did see the Dr. sew the median nerve back together on a pt, that was cool, and then my UMC day was great. If you have Dr. Williams, I hope you enjoy him, oh, and tell him I said hi! :)

Surgery @ UMC

*Disclaimer: there may be some information that might be considered gross and might make some a little squeamish.

Okay, so I know I just posted yesterday, but I wanted to talk a little bit about the surgeries I assisted with today at UMC. Dr. Williams goes to UMC on Fridays. Unfortunately for me, this was the only Friday this month that he had anything scheduled there. I was able to be first assist for 4 different surgeries, place a pin, and do some stitches. So here is the run down of what happened today.

I got there early, around 7:00. Dr. Williams has the student take the pre-op H & P (history and physical). I wanted to get it done by 7:30 (when the first pt was supposed to go back for surgery). Well, I was working on it when Dr. Williams came in. I was surprised to see him because he is usually a little late. Anyway, we got it done and were ready to go and we waited, and waited, and waited, and waited. Turns out the 1st pt of the day didn't want the anesthesiologists that they have at UMC, so we had a guy from a private practice coming apparently, nobody told him that the surgery had been changed from 8:30 am to 7:30 am. So we waited an hour for him to show up, putting us and everybody else slightly behind. :)

The first surgery was a CTR (carpal tunnel release) along with a cubital tunnel release (elbow area). These two procedures free up the median and the ulnar nerves respectively. This pt was having weakness in the arms and pain and tingling in the ring and little fingers. It was a cool procedure. I've seen probably 5 or 6 of these done this past month. The cubital tunnel release requires that they shave off part of the bone that surrounds the ulnar nerve (the medial epicondyl). This helps free things up so the nerve can move freely. I was able to help suture the pts carpal tunnel incision.

Surgery #2 was the removal of osteophytes (bone spurs) on the 2nd, 3rd, and 4th digits at the DIP joint (joint right below the fingernail). This required some rather large incisions shaped like a capital Y. The skin was pealed back and then an instrument, kind of like pliers, was used to removed the osteophytes. Dr. Williams let me suture the incision on the ring finger. Pretty cool. It took me awhile, he finished his two in the time it took me to finish my one but oh well, he is very patient and a good teacher.

*So the picture is not from the actual surgery, just something to give you an idea of what we did, there was only one pin and wire surrounding the bone.

Number 3 was a young male that claimed he had broken his hand 2 weeks earlier. The X-rays showed an old fracture of the 3rd metacarpal bone (the bone in the palm of the hand) and it had a fragment of bone that was joined at the top of the bone, but pointing out as it moved towards the bottom. The doctor made an incision, located the old break and re broke the bone so that he could put the part that was sticking out back in line with the rest of the bone. He then wired it together. The next part was the exciting part; the placement of the pin. Dr. Williams let me do it, he of course guided me, but I was operating the drill. The X-rays taken after the placement of the pin showed that everything was in alignment. Pretty good for my first time. Okay, so it wasn't all me, definitely couldn't have done it by myself, but it was still a great experience. After Dr. Williams closed the inside, I placed the interrupted sutures along the outside.

The 4th surgery was the removal of a sebaceous cyst located on a pts face. It had been there for about 2 years and was the size of a golf ball, located lateral and inferior to the eye. I can't believe it took the pt this long to get the thing removed. I just watched this one, but yeah, sebaceous cysts are really gross, especially when they are punctured. Two years worth of oil and pus (looked a lot like cottage cheese) came out. Sorry for the comparison, hope it doesn't give anybody an aversion to cottage cheese. This pt was closed up and a drain was placed.

Okay, so that was it for the day. Really a great day. I wish that I had more opportunities to operate at UMC with Dr. Williams. He is a great teacher and very patient. He told me (I'm going to toot my own horn here) that I was better than probably 90% of the students that he has come in and suture. Thank you, thank you very much. I can hear the applause. :) He asked me if I had sutured before and I informed him that my dad was a veterinarian and had taught me a little and let me practice on some dogs he had operated on. He said my technique was great and he could tell that I had learned how to handle the instruments. He said my dad must be a good surgeon. Good job DAD!!!! Praise from one of the best hand surgeons in the west (you rock). So that was it. I will give a synopsis of the entire rotation next week, but there was my UMC experience. Hope everybody else has as great an experience as I did.

What is Plastic Surgery?

What is plastic surgery? When I asked myself this question and contemplated my answer I was surprised. My initial thoughts were these: "fake breasts, nose jobs, butt implants, botox, etc." I realized that I had always thought of plastic surgeons as cosmetic surgeons, and they are, but they are also much more. From the little girl in the Philipines with the cleft lip and pallet to the middle-aged man who has mangled his fingers in an automobile accident, plastic surgeons are there putting these people back together and working to improve and retain the function of their lives.

The doctor I have been rotating with this month is also an amazing hand surgeon. I have seen the results of some major reconstructive surgeries. It was explained to me that the loss of use of your hands is the one true disability. Think about it! What kinds of restrictions would you have with only one hand? Tying your shoes, opening jars, dressing yourself, driving, and the list could go on and on. Our hands are so important, they are what differentiate us from other creatures on this earth (among other things), without them, life would not be easy. Yes we would adapt and yes people do adapt when they lose the use of their hands, but how amazing is it when they can be saved.

I have seen pts that have had their hands sucked into engines, machines, crushed by cars and carts, and fingers smashed in doors. It has been amazing to see what has happened with these people. Not all of them have full use, many are still undergoing physical therapy, but they are pleased to have their fingers, to have sensation, and to be able to move them.

Today was a crazy day. The Dr. was late, and we had an office full of people. Of the 20 pts we saw this afternoon all but 2 where hand pts. Many were coming for their first consult, and a couple were traumatic injury pts sent to us from UMC. One pt was attacked last night by a dog and had a terrible fracture of the 3rd (middle) finger. The X-rays were pretty impressive. Another pt was working construction and shot a nail through the finger with a nail gun. That was an interesting X-ray too, with the nail still in place (it was removed, luckily the nail missed the bone and the pt just has two puncture wounds on either side of the finger). It was an interesting and insightful day.

I just wanted to make this post so that people wouldn't think I had just spent the entire rotation doing cosmetic surgery. The 3 cosmetic surgeries that I posted about are actually the only 3 that I did this entire month, but I saw around 15 hand surgeries. So next time when you hear the term "Plastic Surgeon" don't just think of the Dr. putting in DD breast implants. They are amazing talented surgeons reconstructing hands, fixing cleft pallets and lips for children throughout the world, and aiding those that have been disfigured due to traumatic situations. They really are men and women, physicians, surgeons, working to make the world a better place for those that have true needs.

Liposuction

Okay, so on Tuesday I experienced my first liposuction procedure. Liposuction is pretty interesting. It is cool in a gross sort of way. So the pt was prepped, the areas to have fat removed were marked (flanks, lateral thigh, medial thigh, lower and upper abdominal areas), and the pt was prepped for surgery. Now the pt is not completely asleep during this procedure, just heavily sedated. Dr. Williams nurse, who usually is first assist in these cases had to run to the office so I was the man. :)

Now if anyone ever said that plastic surgery was easy (not sure if that has ever been said) they are dead wrong. Why don't you try rolling a completely limp pt, who is not light by any means, from one side to the other on a very thin table that they completely cover? Oh, and add in the fact that they are also kind of wet from the prep and you are wearing vinyl gloves, kind of slippery. I just kept hoping the pt wouldn't slip off the table, either onto me or the doctor, yeah, don't think I would get a very good review if that happened.

Anyway, we started on the flank, then went to outer thigh, flipped the pt to the other side and did the same; put the pt on their back and did the internal thigh and last but of course not least, the abdomen. The procedure is started by making two small incisions at both ends of the area to be lipoed out. The area is filled with a solution made up of lidocaine (to numb), epinephrine (to constrict the blood vessels), and normal saline, this combination causes the fat cells to loosen and helps reduce bruising as well. You then have to wait 10 minutes for the medication to do its job. Then comes the fun part, the suctioning out of that nasty manteca (Spanish for lard). Dr. Williams inserted the cannula (a narrow metal probe that acts as a mini jackhammer); it vibrates and rotates breaking up the fat which is then suctioned out down a long tube, and collected in a nice canister (hence the picture, which is not from the actual pt, just something I found on-line). This was a long process, if you think about injecting the solution, waiting the 10 minutes and then sucking it out. Each area took about 35 minutes. It is also important to go back and forth as you do this, cris-crossing all the areas, this helps to reduce the risk of dimpling. There are also 2 sizes of cannula that are used, one larger for the deep fat and the other is smaller and used for the more superficial fat.

It was pretty crazy to see all of that fat slowly creeping down the tube and collecting in the canister. Our pt had a total of 2350 mL of fat collected, that is about 5 lbs 3 oz, the size of a small baby. Pretty crazy!! I'm sure this pt will be very happy.

I have to admit that I am still finding it hard to understand why people want to undergo these painful procedures. I mean really, the Dr. is ramming a metal probe in and out of your body, over and over again, back and forth. Wouldn't it be a lot less painful to just get a personal trainer at the gym and workout, focus on those problem areas, eat healthy? Now I went on-line and found some prices (not the prices of where I am rotating) and going on the low end of what this pt had done it would be about $8,600. You could hire an amazing personal trainer, buy special meals, do it all for that price. But then again, that would require effort. Okay, I'm going to stop now. I just erased a lot of stuff, I was going off on eating too much and exercising too little. That is a post for another time.

Well, like I said, it was an interesting procedure, and if any of you reading this blog want to go through it, more power to you. I don't think I ever could, it is tempting, I have that little roll around the middle that just won't go away no matter how hard I try. Okay, lets be honest, I haven't tried that hard, I like my sweets and I hate doing sit ups, so yeah, a six-pack is never going to happen for me. Oh well, I guess I will never have the body of the Calvin Kline underwear models, but then again, who does, I mean really, are those guys even real? :)

Plastic Surgery - Nose and Boob Jobs

Okay, so today, I participated in my first 2 plastic surgeries. I mainly just held the suction device to suck up any blood, or smoke from the cautery machine, nothing to exciting, but very interesting to watch.

*Warning, I do go into some detail on these procedures and mention the word breast, so if you find that offensive, you may want to stop reading. :)

The first surgery was a Rhinoplasty (aka: nose job). This pt had 2 bumps on the bridge of her nose that she didn't like. Dr. Williams is very old school, and uses techniques that they apparently don't teach much anymore. For his nose jobs, he makes his incisions inside the nose, not outside, that way you don't have to deal with visible scaring, makes sense to me. The tools they use are pretty cool, they look primitive, but have very specific uses. I was informed that a lot of them were developed by a German Jewish physician, he was a pioneer in rhinoplasty and many of the tools were created and named after him, Jacques Joseph (look up "History of Rhinoplasty" in Wiki if you are interested). Anyway, after making the incisions, he separated the skin from the cartilage and bone, then ground the bumps down, broke the nose, and reshaped it. Very interesting. I was also able to see a pt come in 1 week post op this afternoon. His nose was still swollen, but the differences were remarkable in the before pictures. In spite of the swelling your could see the change. It will be interesting to see the pt we operated on today in a week or two.

The second operation was a breast augmentation. He makes 2 small one inch incisions, one below each breast. He then separates the muscle from the rib cage and creates a space in which to place the implant. A spacer is then inserted and saline is injected to see what size implant to use. It is also used to make sure that everything is balanced. The pt, who is laying with their arms out, as if on a cross, is brought into the sitting position (while asleep) to make sure that the implants will be balanced and symmetrical. If every thing looks good, the pt is laid back down and the spacers are removed. The space is rinsed with saline and antibiotic to prevent infection. The Dr. makes sure there is no bleeding, and then the implants are inserted. They only contain about 100 cc (100 mL) of saline when inserted. They are then filled to the level that was indicated by the spacers. Today's patient was going to receive 350 cc on the right, and 330 on the left, but when that was done and the pt was placed in sitting position again, they just didn't look balanced. I was able to use the skills I have developed as an osteopath to detect the asymmetry (all of those OMM labs on asymmetry payed off). The Dr. made some adjustments, and some saline was removed from the right and added to the left. In the end, the pt ended up with 340 cc on the right and 350 on the left. This pt went from being a very small A, to a full C cup.

So for any of you women out there contemplating breast augmentation, that is how it works. Hope you found that informative and educational. :) If any of you have questions, don't be afraid to ask. I am obtaining a wealth of knowledge, which now extends from gallbladder and thyroid removals to nose and boob jobs. Tomorrow will be hand surgery, adding to my repertoire.

July - Mike O'Callaghan Federal Hospital (General Surgery)

*Warning, this is a long post, you may want to read it in instalments. :) I don't think there is anything too graphic, although I may use actual anatomical words, so hope that doesn't offend anybody. Other than that, I think it is pretty safe.

I spent the month of July doing General Surgery at the Mike O'Callaghan Federal Hospital. It was a long drive every morning. I live in Henderson, NV (southern Las Vegas Valley) and the hospital was in the North. It tooke me about 45 min each morning to get there. I would get up most mornings at 4:30 am, roll out of bed and shower to try to wake up. After getting ready (professional attire, shirt, pants, tie, white coat), I would then grab a "Kellogg's Cinnobon" bar, (man those are good, throw it in the microwave for 10 seconds and you have a great snack) and wash that down with some OJ or Apple Juice, brush my teeth and head out the door. (Yes, I am going to include small details in this. :) I get away around 5, 5:15 am and turn on my Fox News and get my conservative fix for the day, either that or 94.1, my favorite radio station in Vegas.

When I got to the hospital I had to go through security with my car to get on base. The Hospital is located on the Nellis Air Force base. Upon parking I would go to the third floor and meet with the residents. They would assign me a patient (pt) and I would go interview that pt and see how the night went and if anything of importance had happened. It was a good experience and helped in my pt interviewing skills. I was able to better come to know what is important to ask and what is not, at least for surgery pts. I would then write my SOAP note. (For those not familiar with this terminalogy: S-subjective (what the pt says), O-objective (what I observe and find), A-assessment, and P-plan (what we will be doing with the pt that day)) The residents would then view the note, go and see the pt for themselves, and decide whether or not they agreed or disagreed with what I had put. They would then add their own note. At 7:00 am we would head down to the ICU to start rounds with our attending physicians. We would go from pt to pt and report to the physician. I would present my pt and then hear what the physician thought of my plan. It was an educational and enlightening experience. We would discuss specific cases and illnesses, methods of treatment, both surgical and non-surgical.

*A quick note about the residents. They are awesome, now they do change from time to time, but the ones that I was associated with were very helpful: Drs. Reyna, Swenson, Martin, Hollingsworth, and Moss. All really cool and more than happy to answer any questions. We may have had. They also spent some time teaching lectures. I had a lecture on Acute Pancreatitis, Cholycistitis (gallbladder inflammation), and Appendicitis. These lectures were very helpful in furthing my understanding of stomach pain and were usually presented as a specific pt case and then we had to come up with the differential diagnosis, and the steps to take to pinpoint a specific disease. Kind of like a choose your own adventure book, thrilling!!! :)

*A note about the UNR students (University of Nevada-Reno). The ones that were with me were awesome. Very friendly, and it was great to be able to talk to them about osteopathic medicine and the differences between allopathic and osteopathic. They were very open minded and great to work with. Tuesdays were a great day because the UMC (University Medical Center) students and residents (those associate with UNR) were gone all day for lectures. This meant that I was 1st assist for the doctors operating that day. I also didn't have to get up that early because we didn't have to round, so I just made sure that I was there before 7:30 am when the surgeries usually started.

So about my surgeries. I was in the room for 21 different surgeries, of those, I scrubbed into probably 15. It was great. The OR nurses and staff were awesome. It was like one big family and everybody was working together. Everyone was friendly and watching out for each other. There were a few that were kind of crazy and anal retentive, but for the most part they were all really cool. So here is the list of my surgeries: Open left inguinal hernia (LIH) repair, hemithyroidectomy (removal of half of the thyroid), panniculectomy (pannus removal, google pannus if you want more info), breast lumpectomy, lateral sphincterotomy (surgical repair of an anal fissure, or cut that won't heal in the anus, very painful), laproscopic cholecystiectomy x 3, pilonidal cyst excision, colonoscopy w/biopsy, RIH repair (open), removal of basal cell carcinoma of left leg, teratoma removal (google teratoma, it is pretty cool), total laproscopic assisted vaginal hysterectomy (LAVH), partial LAVH, total thyroidectomy, sigmoidectomy (removal of the cancerous portion of sigmoid colon and then resection or putting the two pieces back together), ventral hernia repair (cutting of small bowel adhesions, joining of small bowel, primary closure w/mesh), gastrocnemisu flap with soft tissue graft (part of the pts calf was flopped over his knee, and then skin was taken from his thigh, really cool, kind of like a cheese slicer, but electric and a little more advanced), and finally an APR (abdominal perineal resection, this pt had rectal cancer and we completely removed his rectum and anus, now the poor guy has a colostomy bag, but hey, better than cancer, right?!). So there you have it, all of my surgeries for the month of July. Like I said, it was fun, the doctors were great: Drs Joffs, Dunn, Lal, and Narciso. They are willing to teach, but won't volunteer a lot of info, you have to show interest and ask. Also, don't be afraid to jump right and and help out with stuff, they will let you, they won't take the time to ask you, but if you are ready and ask, they are cool with it.

So, some of the highlights from my month: definately the Teratoma removal was the best, the doctor cut into the ovary and black hair came out, there was also a tooth in there somewhere, luckily, he was able to preserve 1/3 of her left ovary. Sticking my arm in a guys stomach, that was pretty cool, during the APR, we had to feel the liver for metastatic cancer, after the doctor had done so I stuck my arm into the guys abdomen and felt his liver, very very cool to actually feel a soft warm living liver and not just the dead hard ones from anatomy, the guy was also really thin, so we could see his ureters peristalsing, and his appendix; it was great to see the anatomy. Placement of 2 Folley catheters: okay, so this was interesting placing these 2 catheters in guys before surgery, yes they were out, the resident told me to grab his penis like I meant it (whatever that means) and insert, after inserting one, a nurse was telling the surgery tech that it doesn't hurt, just a wierd sensation (that is a bunch of bull, it does hurt and I will argue with anyone that states otherwise. :). There was also the pt that I went in with the doctor to talk to, she called him Mr and he corrected her and say he was a Dr., I informed the Dr. that the pt had dementia, after we left and were talking to the resident, I found out he was a Dr (oops) PhD in Sociology, guess he wasn't that demented. So anyway, those were some of the highlights, along with seeing some pretty interesting gentlemen. God Bless our veterans, you really feel for some of them, some of the stuff they saw and experienced in combat must have really done something to them.

So that was my month. Post any comments you wish. Sorry it turned into such a long post. I didn't realize I had so much to say. All in all I would recommend this rotation to anybody, it was fun and I got to see and do a lot of stuff, a lot of which I couldn't include in this post, but if anybody has any specific questions, feel free to send them my way.