Final Day

In this last post I would just like to thank both my mentors for this incredible opportunity to observe the life of a surgeon.  It was an incredible and inspiring experience.  After seeing both of these doctors do amazing work, I am seriously considering starting down the long road to becoming a doctor.  I love the ability to change someones life that goes along with this career, and the constant forward motion in the medical field.  Being able to pinpoint the problem, figure out a way to fix the problem and then actually fix the problem is an amazing task that takes a lot of knowledge and creativity.  Looking inside someone at the pieces that make up that specific human being is incredible.  The medical field comes with responsibility, sadness and loss but on the flip side had the ability to heal, help and make a difference.  

Slippage

In your spine you have vertebrae and disks that work together to keep your back curved correctly and function.   Today I saw a surgery where the patient had a slippage of one of the vertebrae.  One of the vertebral bodies is out of alignment causing instability in the spine.  In the surgery that I observed the surgeon took instruments and place two screws in three vertebrae.  L4, L5, and S1, L5 was the vertebrae that had "slipped" essentially.  Once the screws were placed a rod was put between L4 and S1.  A device was then used to pull L5 back into place.  The outcome was better than expected.  The vertebrae was back in place and there was a space where the disk used to be.  To add more stability,  a mesh bag was placed in the space between L5 and S1 filled with bone.  This would fuse the two vertebrae together.  Over all very interesting and exciting day.
 
https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhTc6epmLzLGj0UT3PlOMQOjmsJRs6qTkkTXeeA0RC-wxB7NjQpMFKOHCJtoVo6kobnIumLMCTehiESe-aJZeRNmrtNYde27RlcuIM3oi8Ed0b6ugvANRsKGliG5vAizb2CRwXK83mTVg0/s1600/lumbarspine.jpg

Osteogenesis Imperfecta

Osteogenesis Imperfect or OI is a disease that causes extremely fragile bones.  It is a congenital disease caused by a gene defect.  The severity of the condition depends on which gene was affected.  Because of the fragility of their bones people who have this disease are very prone to fractures.  depending on the severity of the disease it could cause bowed legs and arms, kyphosis, and scoliosis.  The patient with OI that I saw today, thankfully had a mild case of the disease.  Currently there are no cures for the disease, but there are measures to treat the symptoms,  OI is categorized into different types depending on the severity.  Some of types are demonstrated in the figure below.

 

Craniotomy

Today I saw someones brain.  It was pulsing with the heart monitor, it was a purple grey color, and had a bright blue vein running across.  It was one of the most incredible sights I've seen.  The procedure started with a incision across the skin of the skull which was then pulled apart to expose the bone.  Then holes were drilled into the skull and then a drill was used to connect the holes.  Once the skull flap was remove, the dura, a protective layer between the skull and the brain, was then retracted.  This exposed the brain.  The purpose of this was to remove a malignant brain tumor where the cancer from her lungs had metastasized to the brain.  The surgeon then proceeded to  remove the tumor.  I could not tell the slightest difference between brain mater and tumor, but when I asked about it later he said that he can tell by how it fells, the color and other indicators that he learned from experience.  It was a very large tumor and took about five hours to completely resect.  One part of the removal process involved a tool that aspirates the tissue using ultrasound waves which, in a way well beyond me, turns the tissue into liquid. Tools like that really show you the crazy and amazing advancements in medicine.      
 
http://drugline.org/medic/term/craniotomy/

Are Doctors Trying to Turn Us into Borg?

Medicine has come a long way, but still has a long way to go, however, modern technology and procedures are pretty incredible.  Because of arthritis and other wear and tear to our joints they sometimes need replacing.  What do we do? Well we create new tissue out of some high quality synthetic material, slice open the knee and stick it on in.  For those of you who are not Star Trek fans, Borg are creatures that are half human and half machine.  They are evil of course, and fly around turning more people into Borg.  Anyway, thinking about knee replacements and seeing a doctor place screws in someones back makes one wonder.  At some point will we be able to replace every piece of our body?  Medicine is an amazing field that allows one to live longer and hopefully better lives.  Medicine will continue to advance and create more opportunities for humans to heal.  I am honored to watch these amazing doctors do there work.  Below is a video of a knee replacement.
https://www.youtube.com/watch?v=YengS_Z1jAs


http://www.avera.org/mckennan/services/pain-management/procedures/total-knee-replacement/

What Exactly is Arthritis?

I talked about arthritis is past post as a cause of a problem but I haven't really explained what it is.  Arthritis usually begins with a break down of cartilage in the joints.  Cartilage allows the bones to move smoothly together and it also absorbs some of pressure on the joints when one is walking or lifting something.  When this cartilage is worn, the bone begin to have direct contact with the other bone involved in the joint which causes inflammation, pain and stiffness.  In response to this new pressure and irritation the body will sometimes grow new bone in attempts to lessen the pressure.  Unfortunately it usually hurts more than helps, as was seen with spinal stenosis and how these bone spurs can put pressure on nerves.

We're All in This Together

After a long and exhilarating  drive, I was driving the stick shift, I arrived in Farmington, NM.  I shadowed a different neurosurgeon today in clinic.  We saw a lot of cases with varying degrees of spinal stenosis and a herniated disc, both of which I have seen the corresponding surgery.  It was very interesting to experience three different doctors and to see the different way they handled themselves and addressed/diagnosed problems.  It was not only the doctors that I observed and contrasted, but I also looked at all the different jobs that go into running a hospital.  This day was a great opportunity to look at some of the other career choices in the medical field.  Each person in a hospital has their own special way of contributing the the healing and care of patients.          

Carpal Tunnel, Not Carpool Tunnel

I was shadowing the orthopedic surgeon today and we were in clinic.  There were two patients that had carpal tunnel syndrome which is when the nerve that supplies feeling and movement to the hand is compressed.  This causes numbness and/or pain as seen int the picture below.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001469/

This syndrome is caused by inflammation in the wrist that pinches the nerve.  There are some conservative measures such as wearing a  brace and corticosteriod injections, but the most effective method is probably surgery.  The carpal tunnel is the space that the tendons that control your fingers and the nerve pass through. What you can do to relieve the pressure in this area is the carpal transverse ligament will be cut as seen int the photo below.  I did not get to see this procedure and in fact the two people who came in had already addressed the problem.  It was interesting to see the same resolved problem in both patients.  

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001469/

If You Think You're Getting Shorter, Look to the Spine

Today I took my independent study day that to replace Friday.  I read two packets given to me by the neurosurgeon from a website called Up to Date which is a online database used and updated by doctors and other people relevant in the health care system.  It basically keep up to date with the latest discoveries and standards in medicine.  He had me read one on spinal stenosis and the other on evidence-based medicine.  I also did some independent research on knee replacements because this Thursday the orthopedic surgeon is preforming that procedure.  I am not a hundred percent yet that I will be able to observe but am very hopeful.  I work a little on my project but my computer broke and is making the process very slow.  Hopefully it should return any day now.

Spinal stenosis most basically put is the narrowing of the spine.  It is seen most commonly in older people and is cause by degeneration of the bone and/or the discs.  It is also commonly cause by arthritis.  As the bone starts to degenerate the bodies response is to grow more bone to reduce the pressure, however this can cause the canal where the nerve exits to narrow and cause pain as well as numbness and weakness.  It is also when the spinal canal narrows compressing the spinal cord as seen is the picture below.  I think that the most probable cause of shrinking, to go back to the title, would be degeneration of the disc in between the vertebrae. As I said before, I'm not good with titles.

Balloon in the Spine

I was supposed to have an independent study day today but there was a change in plans.  The neurosurgeon had two surgeries today and wanted me to observe as well as check in about some of the research he had assigned me to do.  He will be out next week and so I will be taking my independent day on Monday and on Wednesday I will be shadowing one of his colleagues.  Today I observed a posterior cervical fusion and a kyphoplasty.  Both of these procedures were to treat spinal fractures.  The first was to treat a fracture of the dens, a part of the C2 vertebrae just below the base of the scull.  The second was to treat a compresion fracture where the vertebral body was crushed.   The kyphoplasty was a fascinating surgery because the surgeon went in and filled a high tech balloon in the spine to restore height and stability the vertebral body.             

Don't Shoot!

I have concluded that coming up with post titles is not my specialty.  Today I was with Dr. Forrest an orthopedic surgeon.  I learned about trigger fingers, hence the title.  There were two patients today that came in with trigger fingers although both originally believed it to be caused by arthritis.  Luckily a trigger finger is easily treatable. From my understanding, in your finger there is a tendon that goes from the final phalanges to a bone in the palm of your hand (not sure which on and it also probably depends on the finger with the problem).  This tendon is held to the bone with other tendons to keep it from bow-stringing out.  A trigger finger is when the area where the tendon and the overlying tendon gets inflamed.  This causes the tendon to snag and the finger to get stuck in a curled up position.  The problem can be addressed with a small surgery where you go in and cut the tendon that is holding part of the tendon to the bone.  The other remaining tendons just pick up the work.  The other is to inject cortisone into the joint to hopefully relieve some of the irritation.

The Ahha Moments

Today I again shadowed the neurosurgeon.  The first thing that we did was a follow up surgery on the women who had the Anterior Lumbar Interbody Fusion on Monday.  The patient was morbidly obese and the surgeon had some concerns about the spine staying stable while the bone fused.  To lessen the likely hood of complications another surgery was preformed.  This one was a  percutaneous pedical screw placement where two screws and a rod where placed through two small incisions through the back like the picture below except only two entry points.

  This was a fascinating surgery because it not very invasive and required all sorts of fancy tools. The end result looked a little something like the x-ray below.
       

I also followed the surgeon as he made his rounds through the clinic.  There was one case that was especially interesting because it was a textbook case and I was able to see how a doctor can use his knowledge of anatomy and the symptoms  that the patient is having to isolate the problem.  Of course doctors do this when every they see a patient but because it was so straight forward I was able to understand the diagnosis.  A women came in with a herniated disc.  The doctor was able to locate the exact nerve being affected by how the paint went down her leg and the weakness in her leg. A dermatome is an area of skin where the feeling is mainly supplied by one spinal nerve.  From the spinal cord, from my understanding, spinal nerves come out of the spinal cord and are essentially in charge of  certain area that can be seen in the picture below.  He identified that it was either the L4 or L5 nerve that was being effected by the ruptured disc by the description of where her pain was ( From the lower back to the side of the thigh, the front of the calf and the big toe. He then tested her strength by asking her to push down with her big toe, the left side was weaker, and then to push down with the ball of her feet which showed no significant change in strength telling him that is was the L5 nerve that was being affected.  I really enjoyed seeing this direct correlation symptoms and cause.
   

Second First Day

I titled this post second first day because though it is the second day of the internship, it was my first day with Dr. Forrest.  This means a whole new facility with all new people.  This day was much different than my first.  It was a clinic day rather than a OR day.  I shadowed Dr. Forrest as she examined and checked in with patients. Though it wasn't quite as exciting as my first day, it was very interesting and gave me a peak into the other side of being a doctor.  One of the down sides of being a doctor is paper work.  Each individual patient comes with their own set of insurance forms, medical notes, prescriptions and tests.  I learned some about less invasive measures to treat a patient such as physical therapy and drugs rather than cutting them open.  I also got to see how it takes everyone in the facility to effectively treat the patient. You need the patient to give an accurate history and explain the symptoms so that the doctor can make a diagnosis.  You need the doctor to bring all the individual facts together.  You need the physical therapist to work with the patient on a regular basis for healing measures as well as preventative measures.  You need some one to file and organize the paper work, test, labs and other collected data already done on that patient.  You nee the x-ray technicians to get a clear image to inform the doctor.  All in all it was a good day.    

First Day

Today I shadowed a neurosurgeon and experienced the true meaning of long hours.  I got up this morning at around five o'clock AM and got back to my house around eight PM.  During this 15 hours I observed two surgeries.  The first was a Posterior Spinal Fusion where the surgeon went in through the back, exposed the spine, and removed the spinous processes the lamina and the facets to decompress the nerves.  This was to relieve severe back and leg pain as well as to stop the small amount of paralysis that she was experiencing in her legs.  To do this the doctor had to remove bone around the nerve and the fuse the transverse processes together by using the bone graph collected from the bone removed.  Of course the bone does not grow instantly, so to stabilize the spine the doctor places screws and rods as scene in the picture below.


The patient I saw today had the vertebrae from L2 (lumbar 2) to S1 (sacrum 1) stabilized.  There are seven cervical vertebrae, twelve thoracic, five lumbar vertebrae, and five fused sacrum bertebrae.

   

The second surgery was an Anterior Lumbar Interbody Fusion which came from the front of the body.  A general surgeon had to come and navigate the through the patients organs to expose the spine for the neurosurgeon.  In this surgery the disc between L5 and S1 was removed because it was causing the patient pain and then it was replaced with at surgical implant filled with cadaver bone and BMP(Bone Morphogenetic Protein). The implant was then secured with crews effectively stabilizing that portion of the spine and hopefully relieving the pain.
Watch this video to see a demo of the procedure:
https://www.youtube.com/watch?v=waal6ysBxco