Amazement!

I was so ecstatic today! I paid a visit to one of my patients today. Remember the girl I told you about in a previous blog, who survived a plane crash and suffered burns all over her body. Several burn surgeons and I spent countless hours debriding and skin grafting her 2 months ago. She continued to have more grafts… Today, I had an opportunity to visit her in her room in the Burn ICU. As I entered the room, I had to take double looks! She was beautiful! She was setting up, chatting with some nurses… her deep green/blue eyes were open, looking around. Her face was flawless, little to no scars (her whole entire face was burnt). I remember doing surgery on her 2 months back, with her completely frail, hanging on by a thread, and her eyelids sewn shut. I prayed for her each day that she would survive and be there for her children and husband. God answers prayers! As I stood there, I was too much in shock and amazement to approach her. I was too shy to introduce myself to her to say how much I was a part of her recovery and how much I had prayed for her even shed tears for her. I thank the Lord and simply slip out of the room, in complete amazement!

5 hour surgery... "Cultured Epidermal Autografts"

I was involved in a surgery today skin grafting a patient who had a lot of body surface areas burnt in a horrific accident. So, I learned something new... CEA = Cultured Epidermal Autografts. So, there are several types of skin grafts: autograft (from self), allografts (from a cadaver or another human), and xenografts (from another species, most commonly a pig). The main purpose of grafts is to provide coverage for open wounds and to protect patients from fluid loss and infection. So, CEA's are a type of autograft. It was approved by the FDA on Oct 25, 2007. To make CEA's, the company that culture them and produce them takes a biopsy of the patient's skin. Then, they prep and place the parts of skin in a culture medium to 'grow' the new skin. The new skin is consisted of about 10 cell layers thick of keratinocytes and takes about 12 days to grow. (10 cell layers is about 1/2 of the thickness of the grafts harvested from the patient) Each of these new 'autografts' swatches are about 2''x3" and costs about $1,280 per swatch. So, in a person like me, I probably need about 300 to cover my entire body... so, you do the math. Let's say we use 300 of them... it would be about $384,000 for just the autograft swatches alone. This does not include surgeon fees, OR fees, and all the material that goes into it. The surgery took about 5 hours and a lot of swatches!

Then you can ask, why CEA's? Well, when patients have more than 30% of total body surface areas burns, they may not have enough of their own skins for autograft harvesting. So, one way to go around that and still have your own skin coverage is to grow them in a lab then transfer them to your body.

Then you can ask, how much of this CEA are we expecting the body to take and incorporate into the tissue and have it survive? Well, the literature supports the success of CEA grafts to have a mean graft survival rate of about 65%. Some studies state the graft survival rate up to 80-90%. There are several good studies out there: French Study from 1997, Slovenia Study from 2001, Pediatric burn from 2000, and Recent Study 2006. There are lots of good articles in the scientific journals, but they all require subscriptions.

Here is the package insert from Genzyme, the company that produces the CEA's we used today: http://www.genzyme.com/business/biosurgery/burn/epicel_package_insert.pdf

So, I think the surgery is going to give this particular patient much benefit. I do pray that her body incorporate these new cells. God is the healer, we just do the best we possibly can.

The Burn Unit

I am doing well in my Burn Surgery rotation. I am very much enjoying the rotation. I think it comes very naturally to me to be doing procedures, whether it be handling the knife, doing excision and debridement of burns, skin grafting, sewing grafts in, doing wound vacs, performing venous and arterial access and line placements, and anything I can get my hands on. I am absolutely loving it and very comfortable in the Burn Unit. I know the people I treat will most likely never recover their appearance 100%, but, to help them to be able to function with the least amount of disfigurement leaves me feeling very satisfied.

One thing about burn surgery that I didn't know is that usually the Operating Rooms are chilled and quit comfortable even under all the sterile gown and gloves. But, the Burn ORs are tuned to the patient's body temperature... because when we lose our skin, we lose our temperature regulating barrier. We also lose the water keeping barrier, so we dehydrates very fast. So, to keep the patients' body from dropping their core temperature, we keep the room at their temperature. Yeah, imagine operating in a room of 98 degrees F. I was totally drenched in sweat from head to toe!

I also have made some advances today on my own, I have successfully placed several arterial and venous lines today! Yay... I loved it. It is all for the patients' benefit. I am among some really good surgeons here.

That's all for now, don't forget to check out the Sarah Palin video in the blog below. Good night!

My First Day in the BURN unit!

So, I have started my first day of the 4 week surgery rotation in the 2nd largest burn center in the USA: Arizona Burn Center at Maricopa Medical Center. This center admitted over 826 burn patients last year, cared for 1,500 patients in the burn E.R., and over 3,500 outpatient visits. This is also the referral center for areas including the entire state of AZ, western NM, NV, western CA, and northern Mexico. Let me tell ya, there is probably no better place to be trained in how to take care a burn patient than here.

As I started my first-day today, and considering how busy this place is, I was thrusted straight into the O.R. within about an hour of being introduced onto the service. Within 5 minutes in the O.R., I was holding up someone’s arm (skinless with escharotomies on both medial and lateral surfaces of both arms and forearms), the arm was oozing copious amount of serosanguinous fluids, while ripping out staples from the temporary grafts.

Ok, I am being really careful with my words here. I have to say that I have never seen anything in medicine that’s as graphic as this. I don’t have a weak stomach for things like this, and I am very eager to jump right in there and help with whatever needed help and to do surgery. However, I have got to remind myself that not everyone’s stomachs agree with mine. So, this is one topic I probably wouldn’t bring up around the dinner table!

I have seen what having skin grafts do to the patients, they are wonderful! Even though the surgery itself looks barbaric, the end results for the patients are life changing! I feel so interested in this work and at the same time feeling that I am contributing to these patients’ well-being that they otherwise could not have received. Simply Life Changing!!! Also, God really designed our body beautifully to heal itself, even at times under unimaginable traumatic stress!

My hours are very interesting, like all surgical discipline, they are long. I start tomorrow morning at 4:45am and the end of the day is “whenever.” Normally, I would start at about 5 or 6am, and ending “whenever.” No joke… this is how it appears on my schedule “0600 – whenever.”

I feel very privileged to be able to do a rotation here, because there is probably no better place to learn about burn surgery. And besides, I get to see people’s lives change right in front of my eyes. I have a lot of respect for these surgeons and the work they do.

Good night, I’ve got to catch some shut-eye before the rooster crows.

Guess what?! Da Vinci Surgical Robot!

So, I'm half way through my general surgery rotation. I have been doing a lot of exciting surgeries so far. Being the only student working with a group of 4 surgeons, I am treated as an surgical intern. I have to pre-round on all the patients and present them to the surgeons. I also have to do surgical consults in the hospital, the ICU, and the ER. So far, I have been first assist for all the surgeries and also being on call whenever the surgeons are on call. I'm also expected to research and know all the procedures, complications, treatments, managements, and pathophysiologies of all the cases we see and operate on. So, needless to say, I haven't got much free time. Daily we evaluate abdominal pain, obstructions, perforations, and we do surgeries when we need to. I've assisted in removal of cancers, stitching the bowels when they get perforated from ulcers, taking out appendix and gall bladders when they get inflammed, draining fluid out of every infected orfices and wounds, saving people's lives when they get critical, and assisting doctors of other specialties (such as OB/GYN) with surgical needs. I have gotten to do a lot and starting to get a feel of what internship is like and what being a doctor is like. I've got to admit that many times I do feel like I can't ever learn enough. The more I ask questions, the more I've been asked questions, the more I realize that I don't know enough. At times I do get satisfaction to be able to answer questions that are asked, but I still struggle to find ways to retain what I've learned and to keep learning more.

So, today, I met Da Vinci! I can't describe to you how excited I was. Da Vinci is a robotic system that allows doctors to do 'minimally invasive surgeries.' What that means is that this robot allows complicated surgeries to be done with the smallest possible incision sites. The robot has four arms that inserts instruments into the belly. It also has 2 cameras that goes into the belly and projects the images to a screen. The 2 camera system gives the surgeon a 3 dimensional view so they can do abdomenal surgeries with the highest degree of accuracy, also minimize risks and complications. Right now, we routinely do laproscopic abdomenal surgeries with instruments and cameras, but this robot take surgery to the next level. The surgeon is doing surgery in a console. The potential is that you can literally do operations on someone half way across from the globe. How about doing surgeries in the field on wounded soldiers or astronauts in space? The draw back is that the machine is several million dollars to purchase and costs more than $10,000 per month to maintain. I guess for the time being, the art of surgery still involves human touch.

Seriously, the surgeon let me sit in the console and see through the 3D camera... it was so cool! If you want to experience and see what it does, click on this site:

http://www.intuitivesurgical.com/products/da_vinci_video_overview.aspx

I am thoroughly impressed! I want one. I want one NOW!!!

Be a surgeon!

Hey guys, I'm exhausted! I am pretty busy working at the hospital with several surgeons. My typical day consists of doing surgeries all day, assessing patients in the ER, talking to patients before and after the operations, and having to read up on surgical techniques and anatomy. I am studying hard, but very much enjoying myself. A surgeon is the El Capitan of the ship! An operating theatre functions as a well-oiled machine. The parts of this machine consist of an anesthesiologist, a scrub tech, an OR nurse, pre-op and post-op care team, and of course the surgeon and the asistant. The anesthesiologist give the magic cocktail that gives the patient a deep sweet dream; the scrub tech hands the surgeon all the instruments and keeps count on everything that is used; the OR nurse takes care of all the processes of the operation and gets necessary materials during the surgery and also record the timing of all the process; the surgeon and the assistant do the operation. When you enter the operating theatre, the surgeon is the 'chief.' It is quite a rush to be treated as one. A tyical operation for a general surgeon include taking out gall bladders and appendix, fixing all sorts of different hernias, taking out cancer from the breast/thyroid/bowel/skin, doing endoscopies .....

So, the surgical operative procedure has evolved to having to master the 'sterile technique.' Everything from 'scrub' (a special way of scrubing and washing hands from finger nail to 2 inches above the elbow), to putting on gown and gloves, and keeping the operative fields sterile. We owe much of the low rates of post-op infections to this obsessive/compulsive technique.

The surgical patient often is acutely ill. To be able to think and act on your toes makes a well trained surgeon stand out from the other medical specialists. What is unique about being a surgeon is that, when a ill person presents with a surgical problem, a surgeon is often the only one to offer a curative solution.

I have found myself to be extremely fascinated by this field, even though my eyes are constantly red from keeping them open all the time (don't want to miss anything), and my legs are stiff from having to stand hours on end. It is amazing that when we are so focused on something, we can actually ignore our regular bodily functions. I often have to remind myself to move my legs and blink my eyes... I'm glad God made us 'automatic' in many ways, otherwise, I wouldn't be talking with you right now. Ok, it's bed time for me. Talk to you soon.

"Better" by Atul Gawande MD, a general surgeon's notes on Performance

This book is the second book written by a general surgeon, Atul Gawande MD, from Harvard. The theme of this book is about performance in medicine. “As a doctor, you go into this work thinking it is all a matter of canny diagnosis, technical prowess, and some ability to empathize with people. But it is not, you soon find out. In medicine, as in any profession, we must grapple with systems, resources, circumstances, people, and our own shortcomings, as well. We face obstacles of seemingly unending variety. Yet somehow we must advance, we must refine, we must improve.” The picture to the left is from http://www.amazon.com/ you can also buy the book there.

In medicine, there are three core requirements for success: Diligence, Doing Right, and Ingenuity.

• Diligence is “the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles. It is central to performance and fiendishly hard.”
• Doing Right is dealing with and puzzling “over how we know when we should keep fighting for a sick patient and when we should stop.”
• Ingenuity is “thinking anew. It is often misunderstood. It is not a matter of superior intelligence but of character. It demands more than anything a willingness to recognize failure, to not paper over the cracks, and to change. It arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions.”

Betterment is a perpetual labor. Dr Gawande gave some illustrations in the book regarding each of these three principles. For Diligence, he gave stories of the “efforts to ensure doctors and nurses simple wash their hands; one about the care of the wounded soldiers in Iraq and Afghanistan; and one about the Herculean effort to eradicate polio from the globe.” For Doing Right, he gave examples to address some uncomfortable questions about “how much should doctors get paid; what we owe patients when we make mistakes; and participation in executions of prisoners. For Ingenuity, he gave examples of people who have transformed everyday medicine by improving “the way babies are delivered; the way an incurable disease like cystic fibrosis is fought; and exam how much more of us can do the same.”

Those people who can successfully attempt and accomplish these three principles, Dr Gawande calls them the “Positive Deviant.” Here he gave 5 suggestions on how to become one:

1. Ask an unscripted question – our job is to talk to strangers, why not learn something about them?
2. Don’t complaint – “nothing in medicine is more dispiriting than hearing doctors complain. Medicine is a trying profession, but less because of the difficulties of disease than because of the difficulty of having to work with other human beigns under circumstances only partly in one’s control. Ours is a team sport, but with 2 key differences from the kinds with lighted scoreboards: the stakes are people’s lives and we have no coaches. Doctors are expected to coach themselves. We have no one but ourselves to lift us through the struggles. But, we are not good at it. Wherever doctors gather, the natural pull of conversational gravity is toward the litany of woes all around us. But, resist it. It’s boring, it doesn’t solve anything and it will get you down.”
3. Count Something – do a study of your success and failures, count how often mistakes happen of certain sort that interests you.
4. Write Something – put in words your experiences to add some small observation about your world. Don’t underestimate the effect of your contribution, however modest it may be.
5. Change – people respond to new ideas in one of three ways, “A few become early adopters, most become late adopters, and some remain persistent skeptics who never stop resisting. Make yourselves early adopters and look for opportunity to change. Be willing to recognize the inadequacies in what you do and to seek out solutions. The choices a doctor makes are necessarily imperfect but they alter people’s lives. Because of that reality, it often seems safest to do what everyone else is doing. But a doctor must not let that happen.”

Once you become a physician, the question is not whether you have to accept the responsibility. By doing your job well, you have accepted responsibility. Then the question becomes, “having already accepted responsibility, how does one do such work well.”