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.