Blog 3

Blog 3: 12/17/08

I'm continuing my rotation with Dr. D--- this week. Today, I was in the O.R. watching mainly knee replacements. However, I also saw an amazing hip revision! I said this in my last post and I'll say it again, Dr. D--- is an amazing joint-replacement surgeon, in which people from all parts of California come to see. His skills and knowledge in hip and knee replacements in unparalleled, he knows all the intricacies of the procedure on a level most orthopedic surgeons cannot.

As I watch more knee replacements, I'm beginning learn the sequence of steps in the surgery. I've watched maybe five knee replacements so far, and it's pretty cool when you start understanding each step as it's going on. Dr. D--- first enters the knee through small incision and removes parts of the lateral meniscus, which is fibrocartilage that provides cushioning between the left part of the femur and tibia. He then attaches a cutting block to the femur by drilling screws into the bone. After the cutting block is attached, he shapes the distal end of the femur by sawing through the grooves of the cutting block. He then drills a large holes on the left and ride side of the distal femur end to accommodate the femoral implant. The proximal end of the tibia is also cut through the usage of a cutting block, however the cutting block is held to the bone with a large apparatus attached externally to the leg. Once he shapes the tibia with the saw, he makes a hole through the tibial medulla, which accommodates the tibial implant. He then fills the attachment holes in both the femur and tibia with cement, and attaches the implants (The femoral implant was attached way before the tibial implant). A plastic spacer fits on top of the tibial implant to serve as a bearing between the femoral and tibial components. It's a pretty simple concept, and it works flawlessly. At the very end of the surgery the back side of the patella (shaved down in the beginning), has a flag plug inserted. The whole process takes 45 minutes.

K--, Dr. D---'s main PA made a joke that I've watched so many I might as well be a resident. Although, it was a joke, I took it as a compliment. I know, I'm a dork!

Later in the day, I was able to see a hip revision. The particular case I saw was a tough one. The patient had a previous hip replacement from another doctor, but unfortunately the implant twisted and sunk further into his femur. The reason for sinkage may have been because of a fracture that occurred around the femoral component. His previous doctor neglected to really look into it, and gave him crutches. Because the problem was improperly addressed, the fracture healed around the sunken implant, which caused the patient more problems (pain etc.) Dr. D--- had to remove the femoral implant and replace it with one of a larger gauge, so that the new component doesn't sink as well. The surgery was extremely complicated. There were a lot of problems trying to remove the old implant because it was deeply seated and infused with ingrowths of bone. Also, the surgical tool used to remove the implant wasn't working properly and it jammed, so Dr. D--- had to use another tool. The implant came out with the application of a LOT of force (reverse hammering). Unfortunately, when it came off, it did so with a huge chunk of the proximal femur. The sheer force of the removal had caused the patient's old femoral fracture site to re-fracture. Fortunately, it wouldn't cause any problems because the implant didn't need to rely on the fractured portion of bone for it's function. Therefore, there was no need for a bone graft or fixation of the fracture. Because of the unforeseen factors and some technical difficulties, the surgery was an amazing learning experience. I was able to watch Dr. D--- use his vast knowledge in orthopedics to solve problems. He was able to use different tools in new ways because of the technical difficulties that occurred with the normal tools. He's brilliant, and I was EXTREMELY fortunate to a person of his calibre problem solve through the situation. He was able to use bone physiology and fracture pathology to deduce the insignificance of the fracture in relation to hip function; most orthopedic surgeons would have put in a bone graft and tried to treat the fracture further. I would attribute his reasoning skills and vast knowledge to his training at UCSF and other prestigious institutions. I believe his training separates him from all the other orthopedic surgeons who practice in the area.

In one of the knee operations, Dr. D--- had addressed something that had been in my mind for a long time. I always wondered if he got bored or disillusioned by doing one type of procedure all the time. Nothing really changes in his practice, everything is predictable. He told me to look at it in another way. To become the best at anything, you have to do that one thing over and over again. Doing too many different things, leaves you only mediocre at all of them. I assume that once you become amazing at one thing, it may be boring initially; but as it becomes second nature, you're able to really appreciate your own skills. It's a really interesting way to think. He told me that it's the same way in sports. It takes practice in your particular sport to be the best, even though practice may be hard, boring, and repetitive; eventually you become good like Kobe Bryant. I'm going to take his advice and focus my efforts in something I'm passionate about. Neuro-oncology or Spinal & Brain Trauma seem to be just that; I might even have to specialize within those two topics. Specializing and sub-specializing are the way to go! I learned a lot today, and I hope Dr. D--- teaches me more about what he's learned though his journey in medicine.

Blog 2

Blog 2: Second Week 12/15/08-12/17/08

Dr. --- went to Palm Desert this week for a conference. It gave me some time to shadow another internationally-renowned surgeon from UCSF named D--- (Identity Protection). Dr. D--- is maybe the best joint replacement orthopedic surgeon in all of Northern California. He does maybe over 1000 hip and knee replacements a year, and averages about 8-10 surgeries per operating day, which is ridiculous in terms of volume. He had his own private practice and operates on all his patients in Washington Hospital. He does more joint-replacements than UCSF and Stanford combined! Because he only does joint-replacements, and nothing else, he has developed his expertise in one direction. He epitomizes a really interesting concept. If you do one thing, and one thing alone, you will become its expert. Dr. D--- knows all the intricacies of every hip and knee replacement he does; he can do these surgeries in his sleep (actually I really wouldn't be surprised if he could). In fact, he's so used to doing replacements that he can do one surgery in 45 minutes, which is amazing because it takes general orthopedic surgeons 1.5-2 hours. Watching him operate on knees and hips really showed me how experience and expertise he has in his sub-specialization. He moves at an amazingly fast pace, and operates with an extremely high level of accuracy. He's at a point in his technique in which he no longer has to think, he just subconsciously does everything as if he's a machine. Pretty much all of his operations are successful. It's really amazing to see him in action.

Dr. D--- developed his own hip replacement technique. It's minimally invasive, which required him to modify some of his surgical tools to accommodate the great reduction in cavity size. The benefit of this technique is less muscle dissection, less scarring, and a reduced incidence of infection. It's a pretty small hole, and i find it amazing that he can do a full hip replacement through it. He teaches other surgeons how to do it, and I think he might start a fellowship in the future for his technique. Pretty cool stuff.

I always wondered how Dr. D--- maintained such a high volume of surgeries. He told me that his success lies in an established system based on delegation of tasks. In the operating room he has trained physician's assistants that know every part of the surgery. They know what tools are needed every point in the progression of the operation; Dr. D--- doesn't even need to ask for what he needs next. Also, the patients are fully prepped and ready to operate on before Dr. D--- even enters the room, and after the operation is over the PA's close up the wounds. It's so efficient that after one operation is completed the next operation begins right away; another patient is already prepped by another set of PAs in another operating room. It explains how he can finish 8 or more operations in one day. His training and experience doesn't alone account for the speed of the whole process, but it does account for the speed and quality of the operation itself.

Due to his high volume of patients, Dr. D--- has his own post-operative ward, associated with --- Hospital.On Tuesdays, he makes his post-op rounds to check on how patients are doing with their rehabilitation. He addresses any complications that may result such as wound infections, joint malfunction etc. There are also a set of nurses dedicated to this department. It's pretty nice. After his post-op rounds he goes to his private office to do consults.

Dr. D--- has a state of the art office. All of his patients' records are scanned and stored on an electronic medical records system. Everything he needs is on his network. His system consists of 3 tablet PCs that he takes around with him to each consult room. The electronic charts have pre-made templates for his diagnoses. Everything is streamlined, and no time is wasted. Due to the fact that he has a finite set of procedures, all pre-operative parameters can be stored on pre-formed electronic charts. He then takes his cases (stored on the tablet PC) to a a weekly conference where his colleagues discuss upcoming cases. Everything is paperless and cutting-edge, and it's the only way he can store tons of records he has of the 100s of patients he sees. Another way Dr. D--- can keep up with the load of patients, is his usage of PA's in consult. PA's are trained to handle most long-term follow-ups; if they have any problems they call him into the room. He has a very efficient business model. And even though his practice is centered on efficiency, he's a firm believer in quality of care. In his pre-operative consults, he spends a lot of time exploring treatment options and explaining what joint-replacements are to his patients. He never tries to influence patients into choosing joint-replacements when they don't need it; he only presents it as an option among many other available treatments for arthritic hips and knees. He's a really ethical physician, and firmly believes in improving the quality of life for his patients.

By attending Dr. D---'s consults I learned about why people opt for a joint-replacement. Generally as people age, they are susceptible to arthritis due to the wearing away of the cartilage in their joints. The cartilage serves as a bearing between the bones of the joint, preventing friction and therefore bone wear. Once the cartilage is worn away, due to age and loading, it cannot regenerate. Thereafter, the bones of the joint rub against each other causing a great amount of pain. A joint replacement replaces the pieces of bone that make up the joint, with synthetic bits. These synthetic(made of metal and plastic) bits work together to restore joint-function and eliminate pain previously caused by bone friction. Replacements generally last for 20 years, and the patients can start using their new joints within a 1-3 days of the operation. People can eventually ride bikes, go dancing, and take hikes on joints they couldn't even walk on 4-6 weeks before.

Blog 1

Blog 1:

I'm making this blog to outline my rotations with Dr. --- and Dr. D--- over my December break. Even through I have just returned from 3 months worth of clinical rotations in Mexico, my clinical ventures continue to live on over my vacation! When it comes to surgical exposure I'm unstoppable! In my first blog, I will be going over my recent experiences shadowing Dr. ---.

In my first week back, I started rotating with Dr. ---, a world-renowned neurosurgeon who graduated from UCSF's neurosurgical residency program (it ranks in the top 5 worldwide). Dr. --- has a practice at Washington Hospital in Fremont, CA (where I rotate). He also works as attending faculty in the neurosurgical residency program at UCSF; therefore, he has his own residents and research projects (his research is super interesting, it has to do with chemotherapeutic drug delivery into the brain). Because of his experience, intelligence, and humility, Dr. --- is the ideal mentor and teacher. Even if he's busy, he's never afraid to take the time to explain things in great detail. He's pretty much an encyclopedia for neurooncological conditions. I'm really lucky to follow and learn from him, and I know that he will serve as a life-long mentor to me, in my journey through medicine. I'm going to hold on to him with all I've got because it's hard to find teachers with his calibre of expertise, humility, and insight.

12/08/08-12/12/08

My first surgery with Dr. --- would've been on Monday, but the patient caught a form of stomach flu, so the procedure had to be cancelled. Ironically, it was my dad's patient as well, and I found out later that my dad was going to assist while I was observing. In the end, everything worked out because I was able to spend some free time with Dr. --- instead . He went over my future plans and helped me set up a way to do research after I graduate. I decided I was interested in working at UCSF's Brains and Spinal Injury Center to immerse myself with upcoming treatments of biological trauma responses initiated by the body. However, I also really liked current translational research in UCSF's Brain Tumor Research Center. I think I'll have to further discuss with Dr. --- the benefits and differences between the two areas of research; It's still really hard for me to decide which path to pursue. Throughout the week we saw patients with a variety of neurological conditions. I will mention the one's I found most interesting. No names will be used in my cases, in order to protect doctor and patient confidentiality.

The most interesting patient I saw had massive hemorrhaging in the brain, due to relatively unknown circumstances. It was a very odd case, and it was lucky he survived the massive bleed. It was a full two hours before he was operated on, due to the patient's unique circumstances. The procedure involved removing a piece of his skull and storing it beneath the skin of his abdomen. The piece of skull was removed in order to redistribute the intracranial pressure caused by the hemorrhage. The bleed caused the brain to be pushed to one of his skull, potentially causing a variety of neurological damage. Unfortunately by the time the patient was brought into the hospital, most of his temporal lobe was compromised. They were worried that he had lost his speech and language functions, and would remain a vegetable for the rest of his life; however, he made a miraculous recovery. After speech rehabilitation, the patient was able to recover almost all of his speech function, even through most of his temporal lobe was dead. The last procedure he will undergo is the repositioning of the piece of skull from his abdomen to his head.

Another interesting case...well at least to me... was a woman who had benign meningiomas. I liked this case because it was the first case to introduce me to neurooncology. Dr. --- showed me MRI scans of meningiomas and explained to me how they look and act. Meningiomas tend to originate from the dura mater and therefore only appear on the surface of the brain. They're generally benign and aren't cancerous, however they can cause neurofunctional problems by putting pressure on surrounding nervous tissue. These tumors generally grow at an extremely slow pace and cause problems many years after their inception. They're easy to treat. The newest technology, effective in treating all types of tumors smaller than 3 cm (or mm? I have to check again), is the Gamma Knife. It uses highly focused gamma rays to damage DNA, thereby eliminating cell reproductive function and ultimately killing tumor cells. Due to the focused nature of gamma rays, it only works on certain sizes of tumors, and surgical resection maybe required for tumors larger than 3 cm. The advantages of the Gamma Knife is that it doesn't require surgical intervention and has virtually no post-operative side-effects. The Gamma Knife can be used to slow down aggressive metastatic tumors as well, but unfortunately there still isn't permanent fix for metastatic tumors; it prolongs the lifes-pan of stage 4 patients for about 5-10 years.

The last patient had a Stage 2-3 tumor in his brain that Dr. --- resected. The tumor was interfering with his visual function, and caused damage to one of his visual fields. The patient recovered some visual field function. It was sad because even though tumor was resected, it would eventually return as a stage 4 due to the residual cancerous cells mixed in with regular brain tissue. Surgical intervention lengthened the patient's life-span for about 8-10 years. Hopefully, the increase in technology and development of treatments may provide an answer for this patient in the near future. The MRI showed that a huge part of this gentlemen's brain was gone, due to the resection of the cancer invaded brain tissue.

Dr. ---'s cases are fascinating. I've only talked about the three cases I remembered off of the top of my head. Next time I'll take notes (without violating patient confidentiality). I'm increasingly compelled to neurosurgery because it's an increasingly expanding field. The field of neurosurgery benefits from the plethora of research currently undertaken at UCSF, and other prestigious institutions; it's why we see such drastic advances in neurosurgical and neuropharmalogical treatment technology. I was initially interested in orthopedic surgery, but that's changing as I see how much more research intensive neurosurgery really is. I feel that it's a much more diverse field of medicine. I can't wait to continue my rotations with Dr. --- when he returns from his conference. He's a fascinating individual who's pushing the fields of neurosurgery with his research and usage of Gamma Knife technology. I really find it amazing that Dr. --- can integrate his clinical practice with his research; it allows him to be a unique doctor that has perspectives in medicine 10 yrs ahead of everyone else. I can't tell you how lucky I am to be under his mentorship, and I will continue it through my whole medical journey... If he'll let me! haha.