Sunday, June 20, 2010

Week 1 - Ruiz

This week has been a classic case of “hit-the-ground-running.” I touched down on the front sidewalk of Weill Medical College on Monday, with two suitcases to my name and a lot of excitement surging inside of me. I have never worked in a hospital, but with a mother who was once a full-time pediatric cardiologist I thought I had a good idea of what to expect.

I was wrong.

This week was eye-opening in many ways. For my summer immersion I was paired with a plastic surgeon, Dr. Robert Grant. Not only is he a fantastic surgeon, but he is also the Chief of Plastic Surgery for both the Cornell and Columbia Medical Hospitals. I was greatly impressed by his approachability and strong enthusiasm to help me learn and discover as much as I could about the clinical environment around me.

My first day started sharply at 8am when I was thrown into an operating room which involved a tag-team type surgery involving two doctors – Dr. Grant (my clinician/mentor), and Dr. Simmons. Dr. Simmons first performed a mastectomy to remove a recurring breast tumor mass from the left chest wall of a mid-60s aged woman. It was unclear whether the recurring tumor mass was indeed derived from her original instance of breast cancer, as she also had undergone a surgical removal of a melanoma some time ago. Nonetheless, in the operating room (OR) I was bombarded with a jumble of new sights, sounds, and yes, even smells. I never expected that there would be so much commotion inside of an OR. Somehow amidst the teams of anesthesiologists, senior plastics residents, attending surgeons, nurses, and physician assistants there was a master plan that followed through right before my eyes. This surgery was unique in that the patient had to be carefully (and with some difficulty) positioned on her side with her left arm raised in the air so Dr. Simmons and Dr. Grant could reach the region that required a mass excision and plastic reconstruction. After the mass was excised, several specimens were sent out (i.e. posterior margin of left exterior mass) for biopsy and analysis. The full mass that was removed was about the size of a tennis ball, which is why Dr. Grant was called in to assess the excised region and determine how best to cover and fill in the surgical cavity. What was surprising to me was that Dr. Grant had the delicate challenge of transferring muscle flaps to protect the main artery (that brings blood to the arms) from damaging vasculopathy which can be induced by the radiation therapy that this woman was to receive post-surgery. After manipulating the muscle, one of Dr. Grant’s senior plastics residents proceeded (with great alacrity, might I add) to close up the patient with special v-lock sutures. These sutures are an interesting invention because they are barbed and thus require no knots, and also they degrade into naturally metabolized products in the body.

My second OR experience was really interesting because I gained a well-rounded perspective of the entire start-to-finish process surrounding a plastic surgery procedure. First, Dr. Grant performed a last-minute pre-op consult (just to verify that the patient knew what the procedure entailed and what ensuing risks were involved). This patient was a woman in her 70s who had recently received gastric bypass surgery and had subsequently lost >100 pounds. (without serious complications, which is quite impressive since there is a 50% rate of some health problem occurring after the surgery!) The next surgery that Dr. Grant would perform was called a fleur de lis abdominoplasy, which is a specialized technique for removing the excess skin from someone who has lost a great deal of weight. Essentially, skin will be removed and muscle will be rearranged along both the vertical and horizontal axes of the woman’s abdomen. It is quite invasive and leaves a large T-shaped scar. I was able to accompany the nurses and bring the ambulatory patient into the OR, watch as the anesthesiologists put her under, observe as Dr. Grant performed the surgery, and even be there when the patient awoke to help her back to the recovery unit. All the while Dr. Grant was making “teaching comments” on my behalf, such as explaining why he was making a certain cut in a certain direction, discussing why he was removing areas of skin while ignoring others, and even explaining some of the detailed anatomy of the patient’s abdomen so I could follow along more easily. The most impressive part was how drastically changed the patient’s body was after the procedure. Her skin was appropriately taut in all the right places and her muscles were sutured closer together so they helped support the new “tighter” abdomen devoid of loose skin. After this surgery, I was also able to stay in the OR and watch a bilateral breast reduction on a different patient, which was performed by Dr. Rohde, one of the Plastic Surgeons at the Columbia Hospital.

Another day of note was Friday – a full day of patient consults and less invasive surgical procedures in Dr. Grant’s well-equipped patient consult office. Dr. Grant had many patients lined up back-to-back, and I was shocked but also inspired by his unwavering energy and attention for each patient throughout the day. First, he attended to a woman who requested liposuction for her middle abdomen region. Liposuction is not nearly as complicated as I originally thought – it merely involves some physical breaking up of remnant fat and a strong suction device to remove the delineated areas. I was shocked at how quick it was – it took half an hour in total. The next patient came in for a pre-op consult because she was going to have a breast reduction the following week. This was a standard procedure, where Dr. Grant explained the pros and cons of the process and had the patient sign the necessary consent forms. Other interesting cases that day include: a breast cancer patient whose new breast implants induced a hematoma (possibly by the mistake of her previous surgeon), and a young patient who wanted to receive a rhinoplasty to make her nose more symmetrical and to also remove the “arch” in it. Overall, I think this was a formative day for me because I gained a real appreciation for the delicate balance that must be maintained between patient and doctor. Plastic surgeons in particular have the most difficulty in this regard because a large amount of their patients request cosmetic surgeries that are technically “unnecessary” and yet include high risk of complication and/or reconstruction failure or damage. Also, a patient will often ask, “will this make me look better?” or “do I need this procedure?” to which Dr. Grant must skillfully remain neutral because his job is not to tell people how to live their lives, but to advise them on what options they have if they want to make life changes.

That is all for this week, and I hope I can gather more interesting experiences in the weeks to come! Dr. Grant has already become an invaluable source of information and guidance, and I hope that, with his help, I can start to hone in on a viable Summer Immersion Project topic.

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