Saturday, June 19, 2010

Week 1

I am very fortunate to have Dr. Harry L. Bush Jr. as my mentor for the immersion term. He is very nice and has a reputation as a wonderful teacher in addition to being a distinguished surgeon. Residents, nurses and patients alike have been congratulating me on being able to work with him this summer. I have a great deal to learn from him, as well as his team, and I am looking forward to what the next 5 weeks will bring.

After spending a day shadowing Dr. Bush in the clinic, I have a new appreciation for the diverse range of skills that are required in this field as well as the complexity of the problems surgeons face. The first patient we saw had symptoms that could have been caused by his arterial disease or by the problems he had with his nervous system, and it was not necessarily going to be possible to ascertain which was the primary cause. Over the course of the 7-8 hours I spent in the clinic before leaving for a meeting (Dr. Bush was there several hours longer), we saw cases ranging from amputations to vascular disease to mysterious skin conditions that did not appear to be related to the vascular system. According to one nurse, I will soon be able to discern if an individual has gangrene when I pass them on the street.

My first day in the OR was quite exciting and allowed time for sleeping in since I didn't have to be to the hospital till 7am. The morning began with a lesson from a resident in how to procure scrubs from the machine when you do not have a pair to return, and in short period of time I was observing an angiography aided by the new Leonardo system from Siemens. There are only 7 of these systems in the U.S. - 3 in ORs in Weill Medical/NY Presbyterian, 2 in ORs in Columbia Medical, and 2 in radiology suites elsewhere. The lab technicians were happy to explain the system, which just went on-line in January and is still having a few kinks worked out. Leonardo allows x-ray and CT imaging throughout the procedure so surgeons can overlay images (even those taken at a different time and place) with the patient on the table in order to see what is changing in real time. The image processing software quickly provides three dimensional views of the patient and can even use facial bone structure to generate skin on the images. Now, instead of having to send a patient to another room to check for leaks, they can save time by doing everything without leaving the OR.

The first patient, a female in her mid 70's, was suffering from pain in her legs when she walked. This is commonly due to insufficient blood flow to the legs, and the angiograph revealed a stenosis in the femoral artery of her right leg. A small stent was put in place, but I was surprised to learn from the technician that over 90% of patients return within 6 months to a year of having such a procedure due to further damage resulting from an inability to change their life style (exercising, eating a balanced diet, not smoking, etc.). I was also surprised to learn that drug eluting stents have not been approved by the FDA for vascular surgery. The patient's left leg already had a stent, approximately 15cm long, that had been put in place 4 years earlier, but the blood flow was hindered by myointimal hyperplasia (scar tissue formation within the artery) resulting from the placement of the stent. Although this does not occur in all patients, it is possible for the placement of the stent to aggravate the arterial wall in such a way that myointimal hyperplasia results, and this has been described as the "Achilles' heel" for vascular surgery. The patient will have to be re-scheduled for a cryogenic procedure in which nitrogen will be used to freeze the cells in an attempt to stop the inward progression - the normal course of treatment for this condition. If that does not work, bypass will be in order.

The second patient, also a female of approximately the same age, did not have a pulse dorsalis pedis pulse, and ultrasound did not reveal blood flow in the main arteries of her foot. The angiograph revealed the two main arteries of her foot were blocked, and the surgeons were not able to inject die into these arteries in order to image them, even after injecting nitroglycerine (a strong vasodilator). The existing arteries might become wider over time to compensate for the lost blood flow, but this will be a slow process.

The remaining operations scheduled for the day were amputations, and Dr. Bush recommended not observing them on one's first day in the OR. For this I am thankful.

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