Incompetence in the O.R.

Hello again,

I wanted to briefly talk about medical incompetence and the repercussions it has on patient's lives, specifically from my experiences in various operating rooms. Many times incompetence can be a result of a lack of training, mental state, or more seriously lack of seriousness/care during the operation. I've most commonly seen the lack of training or knowledge associated with being able to effectively work in an operating room as the most common scenario. I've seen nurses and physicians assistants who would consistently make mistakes, which would prolong the operating time of the surgery. Why is this a big deal? As the an operation proceeds, the longer a patient is under anaesthesia and is open to the environment the higher the risk of complications occurring i.e. secondary infections and more commonly unwanted anesthetic effects. The particular individual I saw posed serious risk to the patient by being unaware of the location of certain surgical materials and on multiple occasions bringing the wrong operating equipment into the room, only to be corrected over and over again by the surgeon. Also, during post-anesthesia in an emergency situation this individual got in the way of the doctor directly interacting with the patient because he/she did not know how to operate the bed and other basic equipment and spent significant time trying to figure it out in an emergency situation. Luckily, the patient turned out to be fine, however the outcome could have been much worse due to the lack of knowledge and awareness of this individual. Unfortunately, this situation isn't limited to the experiences that I have and it found in hospitals around the country. The reality is that every profession has its share of incompetence, however in medicine I've seen that the repercussions are much higher. The price of mistakes is the patient's life or quality of health. The most important and valuable lesson I learned in that situation is that as a surgeon, you must act to compensate for the faults of others; you must also be assertive and in control, ready for any complicating factors. You must be aware of what's occurring at all times because the patient entrusted their life to you, thus the responsibility is higher for the doctor than anyone else in the room.

The surgeon handled the situation in the most effective and beautiful way. He didn't waste time yelling at nurses or assistants, instead he authoritatively gave direct orders to everyone, which ended up organizing the situation in a way where control was regained. He formed a situation in which the complicating factor could be logically and cooly dealt with. Even throughout the surgery, the surgeon was very patient and calm as repeated mistakes where made by this individual. After the surgery, he may have made note of the incompetence in the patient record, but he never acted in a way where the person was embarrassed or threatened. The environment was calm and emotion-free because the surgeon behaved with everyone in the room, especially the individual in question, with great professionalism and dignity. From that day onward he became in my mind the perfect doctor; one who spends his time solving problems and worrying about the out come of the patient, without letting emotions and anger get in the way. If a complaint was made, he used the more professional avenues in dealing with it. I feel that this situation was the most rewarding because it's where I was able to learn essential life lessons that will benefit my career as a future surgeon. I have an example in which I can say, "Well this is the way a professional physician would act in intense situations."

First Surgery of the Quarter (7:30 am - 6:45 pm, Monday)

Hello Everyone!

I'm going to reflect on my first surgical observation of the quarter. It is a Mercy from Above, that I am able to watch Dr. ---perform the highest-quality surgical procedures available today. Watching Dr. --- implement newly developed procedures has been invaluable because it allowed me to obtain essential insights into the future neurosurgery; thus I have the advantage of entering the field with concrete expectations and insights in how I would like to contribute and develop the field most effectively. My shadowing experience really puts me ahead of the curve because of the knowledge that Dr. --- has shared with me. For example, as a result of my shadowing, I recently learned that the next generation of treatments that are expected to treat neurodegenerative diseases are the implantation of neural stem-cells. Also, there is a form of drug-delivery that is being research that shows promise in treating brain tumors. Thus as a future neurosurgeon it would be wise for me to look into the current research projects being conducted at UCSF, or other academic institutions renowned for their leadership in the field (which I'm doing, hopefully I get into the CED lab I've been applying for at UCSF! iA) In sum, I now have insights into the direction of advancement for this field 10 years down the line (which is essential because it will be in about 10 years in which I'll be working in this field as a physician!!!!!). I am certain that early immersion in the field will really help me be a leader and an effective contributor in the advancement of neurosurgery.

Now, I'll return to the experience at hand... I love to tangent!
This surgery, in particular, really allowed me to appreciate the beauty of this unique field. For the first time, I was able to notice how much of an art-form neurosurgery really is. The an artform that integrates sculpting, painting, drawing etc. It's an extremely meticulous field which requires a lot of patience, attention, and perseverance. However, one must note that in this art-form the artist must create a masterpiece in order to save his commissioner's life. Moving away from metaphors..haha... Most neurosurgeons operate under a microscope, facing a small incision to the brain or the spine. They use tools such as cauterizers, scalpels, and a variety of other space-age equipment in order to work on a near-microscopic level. Fine tools are necessary for neurosurgeons because they usually work in areas of the brain where neighboring tissue is highly functional, and if the surrounding tissue is damaged there are major repercussions of function-loss or even death to the patient. Also, many areas and regions of the brain exist at near microscopic size, and in order to remove or operate in these regions requires one to use extremely precise viewing and resecting tools. Due to the constraints presented by brain and spinal tissue, neurosurgeons operate with EXTREMELY fine-motor movements (I have the shakiest hands in the world...hopefully that changes); they move scalpels or other tools with extreme accuracy. The spatial aspect neurosurgery lies in the fact, that much of the surgery depends on the neurosurgeon's own intuition, which he/she must use constantly while operating in different areas of the brain, which all tend to look the same; it's not as if the neurons of the substantia nigra have a huge sign pointing to them, and lesions deep in the brain exactly screaming here I am! It takes great anatomical anatomical understanding coupled with fine-motor skills to remove brain tumors. Many times the method or technique used to remove a brain tumor or operate in the spine is up the to neurosurgeon, which is dependent on what he has learned and added to his arsenal of skills since he/she finished their residency program; which is why it's so essential to have a neurosurgeon from a highly respected institution. Lastly, I've noticed that the field is really similar to sculpting; brain tumors or vertebrae are carefully shaved down and shaped with a variety of "sculpting" tools to restore normal brain or spinal shape and function.

The patient was an 81 year old female with a large meningioma, which severely displaced her optic nerves in turn causing ischemia and cell death. She lost vision in her left-eye completely, and about 75% in her right eye. We are removing the fibrous tumor, in order to recover some of the vision she has in her right eye, however there isn't much hope for recovery for her left eye due to the severity of the nerve damage that had already occurred. Meningiomas are brain tumors that originate from the meninges, usually the arachnoid layer; these slow-growing fibrous tumors usually (depending on its location) pose no immediate threat to the health of the patient. However, over the course of many years they may grow large and compress or displace functional regions of the brain, requiring neurosurgeons to either shave them down or remove them completely (which depends on the location of the tumor). Also, due to their rate of growth, meningiomal cases tend to be clinically relevant in older patients in which the tumor has slowly grown to a disproportional size. Younger patients, and many older patients as well, tend to have meningiomas small enough to qualify for Gamma-Knife Radiosurgery (AMAZING STUFF); this procedure precisely aims beams of gamma radiation at tumors 3 cm or less, killing all of the dividing cells within that tumor. Thus, if the tumor is small enough it's growth function can be removed by this treatment, allowing the patient to avoid invasive surgery altogether. Unfortunately, for the patient we were operating on, her meningioma was too large (4.5cm) and too close to her optic nerves to use radiosurgery (although radiosurgery is precise enough to remove the tumor next to other forms of tissue, however they usually won't risk it if its next to the optic nerves due to the repercussion of potential blindness).

The surgery started out with a small incision made through her eyebrow, and above the eye; this is known as a frontal keyhole craniotomy because of a piece of her frontal bone is removed to expose the optic nerves. The risk to the eye was low because its suspended in fat and can be deflected to a certain degree. Brain tissue of the frontal lobe was very carefully deflected (very small deflections), in order to find the tumor located deep in the brain, under the optic nerves. In order to find the tumor, Dr. --- simply looked for the optic nerves themselves which are landmarked by the carotid arteries. The tumor was located in an anatomically unique area of the brain called the carotocerebral vascular triangle (Have to double-check this), but this region is a triangle composed of a carotid artery, optic nerve, and cerebral cortex. In the middle of this triangle was where the tumor was located, which made the surgery technically difficult due the risk of damaging either the carotids or the optic nerves. The fibrous nature of the meningioma made the surgery long and daunting because it had to be shaved down in pieces, and at different angles with a special surgical tool called the cusa (it works by generating sonic vibrations which shave the tumor down and suck the pieces of tumor in via a tube that functions as a aspirator). An analogy to shaving down this tumor would be to try to shave a tree made of hard rubber, covered in a viscous gel matrix (Bottom Line: Pretty Dense Tumor). As some points, Dr. --- also used laser microscopy, which would burn-off pieces of visible tumor layer-by-layer (very cool stuff). The surgery (including preparation time) was from 7:30 am to about 6 p.m. It took so long because of the density of the tumor and it's difficult location which required removed from different angles and entry points.

I would like very briefly to go over some other amazing surgical devices. While Dr. --- was entering the brain, he would seal off small bleeds from lacerated micro-blood vessels by applying Floseal hemostatic matrix gel foam. This foam contains clotting factors which immediately seal the bleeding vessels via clotting. There was also an sophisticated MRI machine which used a wireless probe to localize areas of the brain in relation to previously taken MRIs, which is how the tumor was located in real time. To reseal the bone after the craniotomy, snowflakes or dogbone shaped metal plates with small screws are used to holster the bone to the skull. Well..that's most of the bling-bling!

In terms of enjoyment, I LOVED the surgery. It was hard to stay glued all of the time due to the length of the procedure, and the redundancy of the shaving and burning; my attention span simply couldn't handle that. I give Dr. --- serious kudos for doing surgeries like this all time because it's no easy task; you stay sharp for 11 hours straight on something that may change very little. However, I hope to acquire his level of mental stamina as well because I'm going to need it if I'm going to tread the same path. I think what really made me enjoy the surgery was to see Dr. --- interact with his surgical staff in the OR, who all spent 11 hours there with him, to make sure this patient was successfully treated. I really admired all of the surgical staff's commitment and perseverance to the care of the patient, and it was clear they all understood the true significance of their jobs. So anyways, after about the 4th hour, I entered a temporary trance-like state which was most likely a result mental exhaustion, after exiting this trance (lasted about 5 min) everything started to come together in the operating room. "I thought to myself you know I can do this, I can definitely see myself doing this!" Everything came together in such a spiritually profound way. It was as if my heart was connected with every other heart or soul in the room. It's hard to explain, but if you spend enough time in an OR observing, you reach a state of zen or nirvana and your heart becomes connected with that of everyone else. I felt as thought I knew others so well that I could predict their next move, emotion, thought; it was beautiful. In this zen network (not sure what to else call it), I finally understood that it was this connection that made medicine worthwhile because everyone in the room was able to come together and work single entity. We all understood each other, and had a purpose, a single beautiful purpose. The O.R. staff worked as a single life-saving/promoting, tool that existed solely to preserve life. This deep spiritual experience is where a new type of love for this field started to develop within my soul, and it was at this point where I REALLY started to enjoy medicine on a whole different level.

I have TONS more to write but I'll continue it in my next post because this one is so ridiculously long as it is. Anyways, if you read this far thanks for sticking it through, it came from the heart that's something I can guarantee!

Perspectives, the start of my Spring blog

Hello All,

This Spring, I was lucky enough to continue shadowing with one of the world's (no exaggeration here, it's a fact) greatest neurosurgeons Dr.--- I was lucky to have two different types of clinical experiences this quarter because I received two very different perspectives of the multifaceted field of medicine. I was introduced to specialty care medicine through my shadowing days with Dr. ---. I was able to see that speciality care medicine (a major part of academic/private medicine) contributes immeasurably to society and is essential because it has allowed us to advance the field of medicine by focusing on specific problems and their uniquely complex pathologies; It's the field of medicine which is responsible for pushing the boundaries of health care through the innovation of specific treatments, techniques, and research tailored at tackling sub-specialized pathologies. For example in neurosurgerical research, the recent break-through in the discovery of neuronal stem cells has now given hope to cure degenerative diseases such a Parkinson's. The theory is that by inserting neuronal stem cells into the substantia nigra (Dopamine producing neurons which degenerate resulting in motor dysfunction), we can hope to restore neurons in this area by inserting these stem cells, which may then grow into new neurons and take on the dopamine producing functions of the neurons which have degenerated. The discovery of these stem cells is literally a revolution for the medical field because it offers a potentially viable cure for degenerative diseases which are incurable and can only be temporarily inhibited by current treatment strategies i.e. L-Dopa supplements to restore dopamine levels in the brain for Parkinson's patients. The unique thing about neurosurgery (and many other types of surgery and internal medicine specializations) is it requires specialization due to the complexities of various neurological diseases. Due to the emphasis of sub-specialization we are seeing progress occur at a faster rate. Doctors can now be trained to focus on a particular problem, thus dedicating more of their time and energy in researching and understanding the nuances of their sub-field; the result of sub-specializing is that doctors become experts in dealing with particular diseases or problems. Subs-pecialization translates into higher recovery-rates for patients who choose doctors trained specifically to deal with their disease. For example, a neurosurgeon (i.e. Dr. ---) who specializes in removing pituitary adenomas (a technically-difficult surgery) will fair better than a general neurosurgeon due to the sheer amount of practice and exposure he has with that surgery. Likewise, a neurosurgeon specialized in neurovascular trauma will be able to have more successful outcomes than a neuro-oncologist because he/she will understand the nuances of neurovasculature, and can more effectively use new developments in that field to benefit their patients because they are constantly working in that sub-field, aware of anything new that occurs. Each sub-specialized doctor will gain a technical yet intuitive knowledge of their field and can better track progress in terms of what works and what doesn't. This is all a reflection of what I've learned from Dr. ---, a master in the field of neuro-oncology. He has shown me the real benefits of being trained at a world-renowned institution, where he was able to gain wisdom and insight on what to focus on and how to apply his focus for the benefit of his patients.

My experiences at Bayanihan clinic really opened my eyes of how medicine is practiced for underserved populations, a vastly different perspective than found in academic or private medical institutions. The plight of the medically underserved has tested the practicality of our nation's health care model, and revealed the limitations in the goal of health care delivery for everyone. Medically underserved care is unique because it's progress is dictated by what occurs in the private/academic sector. New drugs and treatment techniques (developed my corporations or universities) are initially available at high cost, and are unavailable to low-income demographics. Even for many common treatments, patients are required to have insurance to avoid bills that range from 500-20,000 dollars. However, in the pharmaceutical industry, if a drug is out long enough and the research costs of the drug are paid off, corporations can sell patents to generic manufacturers such as Target or Wallgreens, which can then sell the drug at a lower cost. I know this because uninsured patients who come to Bayanihan Clinic can get Lipitor (a drug that controls LDL) for cheap ($4) from Target. Glucometers are very cheap these days being that they've been around for a long time and can be made with cheaper materials and simpler technology than before. Unlike pharmaceuticals, treatments and check-ups will always be expensive which is what makes community-free clinics so essential for low-income patients. Medical preceptors at clinics can offer check-ups, which would normally be billed for 150-200 dollars, for free to patients. My experiences in community-free clinics have really benefited me because i was able to see the humanitarian and service aspects of medicine; it has shown me that advances in medicine should be available to everyone because life and its quality is the most precious thing that we have.

Underserved and Academic/Private health care aren't mutually exclusive; they depend on each other to advance health care delivery for the future. Academic/Private health care research and development has given rise to new treatments which can eventually be streamlined to be available at low cost to underserved populations, however the development of such treatments requires cutting edge research and funding from patients and donors who can afford advanced health care. Eventually underserved populations would be able to obtain this care if effort is put forth in streamlining treatments for availability at low cost. For example, when glucometers were first released they were too expensive for general public to access due to the cost of production and research; however, as corporations have refined the device for mass distribution, clinics like Bayanihan can afford to buy them in large quantities. Also, as drugs become generic, companies such as Target can offer them at extremely low prices through contracts with clinics like Bayanihan in turn allowing low-income diabetics with a solution for their disease.