Fifth Week of Internship (Cont'd)

Sometimes the good things in life must come to an end. Whether we are ending our careless time in kindergarten; reveling at the prospect of attaining our driver’s license; or graduating from the university, we find ourselves longing for these times of joy and content. As such, I ended my internship having gained important lessons for the future, and seeing how a real surgical department operates.

I could not have asked for a better time to spend my summer. I would definitely do it all over again because it showed me the amount of time, dedication, skill, leadership, and teamwork that is required by everyone: nurses, technicians, doctors, and administration. Part of my experience would not have been possible without the guidance of my mentor Maria Cabrera RN, BA, MA. She taught me about everything, literally from “A” to “Z.” And more importantly, she allowed me to enter the OR and see how professional surgeons perform their procedures and pass down knowledge to the next generation. After I had shown her what I was capable of during my first week, she said that I would not learn about surgeons behind a desk shoving papers. She wanted to treat me as an intern attending medical school. I still cannot believe that I saw cases that most people do not see unless they are part of this profession. Mrs. Cabrera is one of the best directors I have seen, exemplifying the true qualities of a great leader. As a surgeon, having leadership is important because he or she is the director that coordinates everyone else. They are given the instruments, asked where they want the patient to be placed, and are made sure that the job gets done well. I see it as having a balance in that a surgeon recognizes his or her positions but does not go overboard and order people around for no reason. I am going to try to work on my leadership and see the benefits it can have for me now and later.

In addition, I want to thank all the doctors that have allowed me to watch their procedures and take a few photos. They place education as the primary goal for anyone thinking of a career in healthcare. They taught me so many things about anatomy, diagnosing patients, and learning to think in different ways. They are all equally an inspiration, and I hope to one day emulate them, teaching a young high school intern or college graduate. For example, my last days were spent learning about plastics with Dr. Zubin Panthaki, Assistant Program Director for Plastic Surgery Residency Program. He was willing to let me observe a breast reduction procedure which was an incredible opportunity to learn about cosmetic surgery. And let me tell you, it is not easy because it requires the same amount of skill that any cardiologist or neurologist possesses. Any medical profession does not undermine the other because if everyone went through the same amount of work and study, the least one can do is respect the specialty he or she chose. Dr. Panthaki took a breast, held it in place and sliced mammary tissue as though it were a cake. I wondered how long it took him to perfect his skill, but I guess one’s job is never complete. Studying and continuing to gain knowledge even after receiving that college diploma is integral to the medical field.

Equally as skilled and intelligent was Dr. Joseph Pearson, Assistant Professor of Clinical Obstetrics and Gynecology, who performed a trachelectomy, a removal of the cervix. It involved intricately cutting around it and removing the malignant muscle. His hands were still and calm during the course of the procedure; I would have been nervous about working in such a delicate area. It was so precise and careful that I do not think a better specimen could have been achieved. He is the type of surgeon that has quick timing and excellent accuracy. It is good to be slow and cautious, do not get me wrong. But something like this should not take two hours. He explained that punctuality is essential in the OR because believe or not there are other doctors waiting in line to start their procedures. Nevertheless, quality should not be sacrificed at the sake of getting out early. He explained it is a skill that few surgeons learn to harness and develop. Looks like I have another technique to work on from here on out!

This last week proved to be one of the most interesting and exciting. The people I have met, the things seen, and the experience earned could not have been any less excellent. Thank you University of Miami Hospital and Clinics for giving me this great opportunity to gain a first look at life in the OR at Sylvester. Surgery’s challenges encompass a scope of patient-relation trust and care, the need to always improve oneself, and the occasional clean up of blood that spewed across the room.

Fifth Week of Intership

Our society is governed by the institution of rules. Some may say that rules are meant to keep us safe and from doing harm to ourselves and each other. Others argue that they are meant to be stretched or broken. Whatever ever the case, all workplaces must follow a set of standards that must be enforced and applied daily. This is especially true when working in a hospital environment. There are many policies and procedures that have to be considered from the moment the patient arrives to their exit in recovery. I really did not fully appreciate patient and employee safety until these past days. (Safety guidelines are posted shown right to remind everyone).

Monday began with a thyroidectomy which is by now no big deal. But I began to see the amount of preparation that takes place per patient. While the surgery may not even take two hours, prepping takes at least one to one and a half hours. First the doctor has to let the patient know what he or she is about to undergo. After, the patient is moved into the OR by two nurses. The anesthesiologist or anesthesia nurse administers the proper dosages needed to numb and put the patient to sleep. If you really think about it, the anesthesia personnel are honestly the ones that can determine life or death for the patient. Giving an incorrect amount or administering the wrong medications can cause the patient to wake up, and thus, complications can arise. Without them surgery would still be in its primitive stages: amputating legs and arms without any sedition, as for example, doctors would often do during World War I.

Later the patient is covered in numerous blankets with the addition of an electric one, designed specifically to keep patients at a safe body temperature and not from getting too cold. The OR can reach almost 65 degrees! Legs are elevated to ensure no blood clot formation, and massagers are wrapped around each leg to allow blood circulation. Then the entire body is wrapped in green, sterile pieces of cloth. Green is the color that identifies an employee as part of the Surgical Staff, so it is used as the color for sterility. Only those individuals that have properly scrubbed in (washed arms and hands with special soap and given sterile gowns with gloves) can place the cloths and be near the patient. Infection control is one of the biggest factors in maintaining a safe OR. Notice how a certain set of standards and measures have to be followed in order for the patient to be safe. I believe that is one of the main reasons that keeps an OR running smoothly. Patients can evidently see how clean and germ-free the area is kept, and they can feel assured they are in good hands. After all, the patient does come first. The care by which nurses and doctors take to save patients from the dangers of bacteria and viruses is absolutely breathtaking.
Shown on top are instruments that are placed into a sterilization chamber subsequently killing bacteria and other human body intruders.

Not only do employees worry about the patients’ safety but of their own as well. Anyone that comes into an OR must be attired with green scrubs, a hat keeping his or her from falling, goggles, a mask covering the mouth and nose, and shoe covers that protect your feet from contamination. While all are equally important, the hat and mask are the most significant. The doctor and/or nurse will ask you to leave if you do not have the proper protection. Think about it; the mask keeps one’s bacteria from entering the patient and vice-versa. Imagine a patient is confirmed to have AIDS and blood is gushed from an artery. Not wearing any of this equipment can potentially infect you with a deadly virus. And everyone cannot stress enough how important hand washing is. Each time one exits the OR, one must make sure to use hand sanitizer or wash with soap and water. I always be careful when I am in the OR and always use the sanitizer when I leave to lunch. I don’t want to be stuck with something that I did not upon entering. Let’s face it, it’s the real world and there is no room for “I will not get sick” or “It will not happen to me.” But the sad truth is that it can happen to anyone. How can one expect to keep people safe when one does not even keep his or herself from harm’s way?

Rules are the foundation of civilization. In the realm of surgery there is no room for announcing one’s political stands on the “Man” or “fight the power.” Keeping safe from infection and ensuring the patient’s safe arrival into recovery is the challenge taken by each person in that department, seven days a week, twenty-four hours a day for 365 days a year. I have seen that it is this fear but cautious attitude that keeps everyone from making mistakes and treating every patient the same whether or not he or she has AIDS, HIV, etc. Just imagine if that patient was your mother, father, or sibling about to put under the care of people that do not protect themselves. I feel that this careful temperament should be harnessed and used during the rest of my life. I want to see myself as a surgeon that maintains a safe environment for my “family” (patients) and keep my employees on their toes about their safety. All of us are in the same long haul so we might as well keep each other safe, and hope for the best.

Fourth Week of Internship (Cont'd)

Shocked by the realization, we find out that something we thought as grand and magnificent turns out to be the complete opposite. Nonetheless, the discovery is canceled out by the new realization of the truth and becomes more amazing than what our imaginations could conjure. There is a reason to why I give this sort of complicated introduction. I guess you can call this learning and partly that is what surgery is all about. For example, the surgeon goes into the OR knowing he or she has to remove a tumor. He or she already has an idea of the size, but once it is excised, that notion can change; he or she learns new about that type tumor. I felt this on several occasions these past two days at the Sylvester Center.

Thursday morning began with Dr. David Arnold, Associate Professor for Otolaryngology. He performed an esophagoscopy, a procedure that involves the surgeon using these red, snake-like tubes to dilate the esophagus. The ultimate goal is that patient can pass substances to the stomach better than his or her current situation. By the way, the constriction was primarily caused by chemotherapy given to cancer patients. At first, when the tubes (shown left) were revealed, I was a little baffled as to how Dr. Arnold was going to use them. But he passed different sized ones down the esophagus to enlarge it. Before I discovered this, I believed they were some kind of cameras that he was going to use to look down into the esophagus and then assess the patient accordingly. Anything that ends with “-oscopy” is supposed to be a noninvasive search using an endoscope. But Dr. Arnold explained that there are always exceptions in surgery and pretty much everything. For me, this was expecting the unexpected, and I learned about what I did not know. This internship has helped open my mind to new ideas and rare insights that many high school students do not see. Who would have thought that is the proper method of dilating an esophagus?

Later I got to view Dr. Arnold remove a tumor from the area close to the ear known as a parotidectomy. The tumor was benign but causing a number of complications for the p

atient. It was a standard operation that goes in four basic steps: incision, cutting of tissue until reaching the core, carefully excise the tumor, and stitch from deep back to the epidermis. I mention this procedure not because of the process but what came after it. Dr. Arnold suggested that I go see how pathology prepares (shown right) the specimen (the tumor), and what findings we can uncover. I arrive at the lab, and it was smaller than I expected (TV shows often depict a large lab with test tubes and numerous chemical instruments). But this lab only contained a freezer that instantly freezes specimens, a work desk with jars containing

chemical preservatives, and in the back a little desk with a microscope and two viewers. The pathologists start inking the tumor and then prepare slides for the microscope. I kind of remembered what Mr. Garcia had taught us about microscopes and how to view a specimen. I felt proud of myself that I could understand the process and the usage of the microscope. He was right about having to use it in the near future outside the realm of the classroom. While the pathology may not have been what I envisioned, it certainly taught me about the importance of what you learned in class and being able to apply it in the future.

Lastly on Friday, I witnessed a hysterectomy, a removal of a woman’s reproductive system, by Dr. Karen Nishida, Assistant Professor of Clinical Obstetrics and Gynecology. I got to see bits and pieces of it because the surgeons were huddled around the area. But despite the traditional way of doing it, they decided to do it laparoscopically because it would be less trauma for the patient. They basically went in, cut the areas that needed to be removed and the entire system was placed on a table for inspection. I was amazed by how different it was! It was the same picture from the textbooks but much smaller in retrospect. I began to wonder how a baby grows in such a tiny place. This had to have been the most incredible thing in all my weeks of different surgeries: seeing an entire body system and discovering its actual size. I guess it goes to show that you learn something new everyday.

Overall these past two days have taught me that success to surgery is more than just focusing in on the actual procedure and already knowing what you are going to do. One must be open-minded and always be willing to learn something new or gain new knowledge on an existing topic. I believe that this can apply to almost any job. One’s learning does not end after college, and if followed, it can ultimately make us a better population ready to take on the situations of now and later. Surgeons, especially, cannot be stuck in the ways of the past and must make room for future techniques. I will take this with me during my next two years in high school, college, and beyond.

Fourth Week of Internship

We mostly do our daily tasks by ourselves. Homework, washing dishes, cleaning our rooms, learning to drive, etc. are things done by a single individual throughout the year. However, it would have been impossible for one person, for example, to create the skyscrapers we see today. You need a construction team, contractors, architects, designers, and other specialized work personnel. In a similar aspect, a surgery functions like the building of a skyscraper. There needs to be scrub techs handing instruments of repair, nurses providing comfort for the patient, and the surgeon with his residents, eager to harness the trade at hand.

I noticed this particular theme of surgery during the course of the procedures I viewed today. I was able to once again observe Dr. Casiano and his ENT cases. I saw two of the same surgeries, called functional sinus endoscopies, that involved removing polyps (masses of nasal tissues formed from disease or allergies) from the different areas of the nose such as the maxillary. But what moved me about the surgery was not the procedure itself, but rather the harmony that exists with these professionals in the OR. Everyone is expected to perform at their best because one person can set off the balance. It reminded me of music; missing even a single beat causes the rhythm to be temporarily lost and discordant. Surgery is homologous to a musical composition. Every note must be played and factors such as timing, consistency, and harmony are essential to a great song or, in my case, surgery.

Imagine this for just a moment. Dr. Casiano is about to start his case and how can he pay attention to the instruments and the patient at the same time. That is where the scrub tech comes into play. He or she gives him the instrument that is requested by the surgeon. But what if the instrument is not available and Dr. Casiano has nothing else he can do. Every minute wasted means more opportunity for contamination and mistakes. The nurse helping in the room can quickly search for the desired tool. Notice how if one of the “notes” offsets the other, then the result of everything is a halt or an “off tune” case. These are often the things that musicians avoid.

I believe that honing this togetherness and exercising good relationships ensures success to any career. It is important to enjoy what you do with other people that hopefully share the same excitement you have. One cannot expect you to do everything; that is why you have people there ready to take on the same case you are. Despite popular belief, the surgeon is not the one who does all the work but has a team that assists him in the success or even at times failure of his or her cases. Ultimately, it is up to us to become respectable and honest to one another because it is this coexistence that defines how the procedure will finish. After pondering over these thoughts, I can now honestly say that there is no “I” in team.

Third Week of Internship (Cont'd)

Optimism is described as having a happy and content outlook on life no matter the circumstances. This is exactly what any surgeon has to entail. One cannot be pessimistic that the surgery can go wrong or focus solely on the level of error. Every surgeon that I have seen comes into the OR with a smile planted, fully ready for the obstacles that lie ahead.

On Wednesday I was able to observe Dr. Brian Jewett the Assistant Professor for Otolaryngology. He performed a scar removal and fixation. Apparently this patient had had a previous surgery in which the stitches were not properly done and most likely caused an abnormal scar. The procedure was a careful excision of the scar and stitching the dermis and then epidermis with precision and care.

However, Dr. Jewett explained to me that technical factors are only some of the effects of bad scarring. He began a conversation, being the professor he is, about teaching yourself to learn as if your brain was a filing cabinet. In that file cabinet each file is marked with something specific such as the scarring in this surgery. Pull out that file and there several sub-categories like “technical factors,” “patient history and genetics,” and “optimized healing.” When we are younger, memorization is often easier to harness than this method. But our memory weakens as we age so this method makes the answering process much simpler. Dr. Jewett stated that he wished he would have learned about this during high school and undergraduate studies because studying would have not been so cumbersome. I immediately thought that this could be something I could in my prospective future as a college student and beyond. Anything that makes the studying process more efficient is vital to survival in school.

Later, I was lucky enough to enter a special procedure that is rarely done in Sylvester. In fact this was the first time the hospital was going to do a hysterectomy, which is a removal of polyps that formed in the walls of the uterus. The endoscopes were extremely handy in this case because it would not make sense to cut into the uterus when it can be done noninvasively. The tiny camera was placed through the vagina and clamps were used in conjunction to literally scoop out the masses of uterine tissue. Dr. Carlos Medina, Director of the Division of Female Pelvic Medicine and Reconstructive Surgery, did the case. It was an overall interesting to see the endoscopes used for something other than noses and ears. It shows how versatile and useful any piece of technology is.

Finally, on Thursday I observed Dr. Donald Weed, the Resident Program Director for the Department of Otolaryngology. He is really funny and sarcastic and finds humor in anything. That is why I was going for in the beginning when I mentioned the importance of optimism. You should enjoy what you are doing and have to a certain level fun in the OR. I got to watch him perform a thyroidectomy, a removal of the thyroid. The surgery lasted about three hours and was similar to one from earlier this week with the parathyroids except much easier because a thyroid is larger.

While this procedure was not that exciting as some of the others I have seen, it was made engaging by Dr. Weed. He explained each section carefully from the moment of incision to the stitch. Part of medical studies is teaching and having that facility allows knowledge to pass from one generation to the next. We will have future thyroidectomies and will need to have surgeons on task with what they have to do from “A” to “Z.” I found the teaching aspect of medicine to be a noble cause and should be made regulatory for all hospitals to have students scrubbing in or watching how doctors speak to patients of potentially fatal disease. Dr. Weed and others like him are definitely making a difference for the future.

Third Week of Internship

Most of us wake in the morning to a breakfast of cereal, toast and perhaps the occasional glass of orange or grapefruit juice. However, my morning is combined with the smell of human flesh being burned using a laser device. It becomes part of the daily cycle of entering the OR at 8:00 a.m. everyday. I mention this tidbit because most of the operations I have seen so far have been about removing certain body parts because they are dysfunctional or unusable.

On Monday, I observed a surgery performed by Dr. Jarrard W. Goodwin the Director of the Sylvester Comprehensive Cancer Center; he also actively practices in ENT surgical cases as well. The procedure was called a laryngectomy which is a removal of the voice box (right). This particular patient has a history of cancer, and radiation from chemotherapy caused scarring of the voice box. So, it had to be excised. This surgery lasted about four hours because it is harder than it looks. It involves carefully cutting the tissues that connect the voice box to the walls of the throat. Each section of tissue is precisely and slowly cut to ensure that there will be no problems upon removal. I would describe this surgery in the same manner as an artist paints something. The artist has to envision what method to utilize before he or she starts painting. A surgeon similarly does the same thing; he or she has to see what is the best route to take before beginning. I definitely saw this as a successful trait to harness, which is also something that has developed throughout my years at school: preparedness and evaluating the situation. Not only being ready but also having patience is essential in surgery. Dr. Goodwin did not at all try to rush the procedure or take shortcuts, even he will have to stay in there for four, five or ten hours. I saw that patience is absolutely a virtue, and it is too valuable to let go.

I also had the opportunity to view the removal of a benign tumor (left) located in the larynx also done by Dr. Goodwin. This procedure was shorter at a length of two hours. A benign tumor is nothing more than an abnormal mass of cells that do not move throughout the body in contrast to a malignant or cancerous tumor. Dr. Goodwin followed the same technique as was done in the laryngectomy; he cut section by section of tissue slowly and carefully. Before starting internship, I never knew that there were so many problems associated with the throat and its components. It shows how much you have to take care of all parts of the body and not just the ones talked about on television such as the heart, lungs, brain, etc.

Tuesday began with a similar removal procedure called a parathyroidectomy performed by Dr. Carmen Solorzano, Chief of the Division of Endocrine Surgery. The parathyroids are the glands responsible for the regulation of calcium in our bodies. This patient had a hormonal imbalance that caused calcium levels to be atypical. The only answer was to remove the glands completely and see if any results are obtained. I particularly found the parathyroidectomy to be fascinating because glands that are extremely small can grow relatively large when an imbalance occurs. Such a regulation in the body has massive effects; one must be careful in dealing with any imbalance as I had learned.

And the end of the day came with, surprisingly, not a removal but an insertion specifically a port insertion done by Dr. Dido Franceschi, Professor of Clinical Surgery. It is a procedure that is given to cancer patients in order to infuse chemotherapy. It is nothing more than cutting a few centimeters into the body cavity (usually on the chest) and placing the port with a tube running into the bloodstream. This port is the mechanism by which medicine will travel through the body during chemo.

Second week of Internship

You know that feeling you get just before a rollercoaster takes off or before entering a dark tunnel; feelings of anticipation, fear and even excitement that overwhelm your senses. My body surged with these emotions before entering my first surgery with renowned otolaryngologist and surgeon Dr. Roy Casiano, Director of the Center for Sinus and Voice Disorders at the University of Miami Health System. Specializing in ear, nose and throat (ENT), Dr. Casiano is highly remarked in the University of Miami Health System for his continuing excellence in this field. He has helped countless people with congested sinuses, unequal vocal cords and dislocated septa to name a few. Mrs. Cabrera asked him if he would be willing to have an intern shadow him this past week, and Dr. Casiano did not hesitate to include me. Although, he did make sure that I do not have problems with the sight or smell of blood because this week I would be entering the OR. Fortunately, I do not, but if I did, then my aspirations to become a surgeon would finish faster before graduating high school!

Dr. Casiano rotates between the different hospitals and clinics of the University of Miami Health System. On Monday we went to the University of Miami Hospital to see two patients with problems in the throat area. The first had a thinning of his trachea, and the procedure needed to evaluate this condition is called a bronchoscopy. Every patient has to go through the routine prep, which is placing the patient onto the surgical bed, putting pillows in the legs and arms to prevent blood clots, giving the correct anesthetic medications to numb the patient and placing heating blankets to keep his or her body temperature at normal. Also anyone inside the OR must have washed thoroughly in the scrub room and worn protective garments. What is interesting is that patient preparation is essential to the surgery; the doctor expects that everything be ready at a certain time and that no problems should occur. It is true that responsibility goes beyond the realm of turning in homework or performing well on exams. Besides the actual operation, preparation ensures that many things that can go wrong are eliminated before they happen.

The procedure begins using an endoscope, which is nothing more than a camera that is placed down the nose, throat and ears and viewed through a separate monitor. Basically the patient will need to undergo a separate operation to place a T-shaped tube that will open his trachea and allow air to pass freely. The second case involved vocal cords that were not separated; in other words, they were too close together which produces inability to speak and difficult breathing. The joint that attaches to one of the vocal cords had to be cut and moved so that space could once again be made. The only downside to this procedure would be that the patient may have a raspy voice, but it is a better trade off than living mutely.

Dr. Casiano explained to me that some surgeries may have some kind of negative effect, and it is some time inevitable. Every surgeon has to let their patients know the risks associated with the procedure and obtain their agreement to the terms and conditions. I believe it gives the patient a sense of reassurance that even though something can possibly happen to them, they have the opportunity to make an educated decision as to what to expect. Part of surgery is not only bringing patients in and out like a load of cattle, but we have to remember that they are people. Compassion is a trait that every doctor must have and cannot expect to work successfully without it. I realized that the patients need someone they can confide in, and what better way then to trust you as more than just a person that is going to operate on you. This quality is something that I take to heart and definitely will use during my future as a surgeon.

On Tuesday, I witnessed a different procedure that moved from the head area to the left flank of the body. Here a section of fatty tissue with a melanoma was removed for the pathology to run tests on the specimen. By the way, these operations often remove and keep specimens to run tests, and bacterial cultures taken are used to see what medications the patients can use. It put into perspective when school has assigned science projects. Collecting data and later performing experiments to test a conjecture is at the heart of the scientific method; it helped me make sense of doctor’s idea of a diagnosis and if it proves false, then it has to be discarded or modified such as a hypothesis.

Wednesday, I went back into ENT cases and saw two patients with similar problems. Both had what are called polyps in the sinus cavities, causing them to have troubling breathing. Polyps are large masses of nasal tissue that form from an infection, chronic inflammation or even allergies in some cases. Thus, the surgeries involved using endoscopes to locate the polyps and remove them utilizing a microdebrider system. For just one nasal passage, it takes about two hours to complete. Imagine in a bilateral functional sinus endoscopy as was the case with the second patient. What I found the most interesting about these surgeries was the facility of performing the operation. In a nutshell it involves plugging in a camera and finding the polyps using a monitor, then removing them with the assistance of the microdebrider. Technology has truly given us the resources to enhance our capabilities and see beyond the norm for humans. I thank MAST everyday for enforcing us to embrace technology because it is honestly the future.

Lastly, I spent the rest of the week in the clinic located in the UM Clinical and Research Building (CRB) across the street from Sylvester. Dr. Casiano saw all kinds of nose and throat problems. I never would have guessed that these areas have so many widespread problems. The most common are when acid reflux causes damage to the throat and vocal cords. Others are more complex such as the polyps mentioned above and a deviated septum that blocks passage completely into a sinus cavity. One has to give it to the patient straight because it does involve his or her health; doctors cannot bend around the bush because they hate to be the bearer of bad news.

For the most part, this week has taught me the value of patients and the results they seek with surgery. They want to be able to breathe, swallow and hear again as was the cause with most of cases I viewed this week. Being an ENT is quite an interesting field, and it is not very known about in layman’s terms. The experience so far has been great, and I cannot wait to see what is in store for me next week!