2/24/16

                 Today I decided to come in to watch one of Dr. Nguyen's cases, a mini-mitral valve replacement. I didn't have any background knowledge about the patient, but being there was interesting enough; this was the first mini I've seen, and also the first operation I had seen performed on the mitral valve. The mitral valve is the first valve to be reached by oxygenated blood coming from the lungs, and is located between the left atrium and the left ventricle. A mini is a minimally-invasive surgery, which relies on 1-4 incisions around the thorax to perform the operation, as opposed to a sternotomy that splits the chest open entirely. Although there are many factors to consider, some people just don't like the recovery time involved with a sternotomy, and might pick a mini operation over it if given the choice.

              The surgery starts with an incision in the lower left of the chest, near the groin; this leads directly into the femoral vein. A cannula (fancy word for tube) is inserted into the vein, and is connected to a heart-lung machine. Another cannula is drawn from the heart-lung machine to the femoral artery, creating a system that draws out blood, reoxygenates it outside of the patient, and feeds it back into the lower body. Another incision is made on the right side of the chest, just under the breast, and the hole is widened with rib spreaders. With his incision opens up a view of the pericardium, the area surrounding and holding the heart, from the ascending aorta to the diaphragm in length. The pericardium is then cut open, and sutured in place to reveal the aorta. Cardioplegia is administered- which slows and eventually stops the heart- so that the journey to the mitral valve can begin.  This process is quite extensive( and definitely looks the part), as the doctor has to get all the way to the mitral valve from a hole in the pericardium. It really ends up looking like a tunnel, and gets even more confusing once the sutures and ties holding tissue in place are set.  The sutures divide the tissue layers, allowing a small hole of viewing space into the mitral valve. Because of how tightly-packed the area was with sutures, clamps and cannulas, it was satisfying to be able to identify the chordae tendonae peeking out from behind the relaxed mitral valve. It was sort of like a medical version of "Where's Waldo."It was around this point that I realized that Dr. Nguyen was doing a full valve replacement. He started clipping away at the mitral valve's leaflets, and removed the valve surprisingly quickly. The replacement valve was to be mechanical, so he began attaching the sutures to the lip lining the mechanical valve, a part of one of the most complicated processes I've seen in the OR- I'm talking about the scaffolding/lowering-of-the-replacement-valve process, which secures the new valve in place. The ends of those sutures attached I wasn't able to stay to see the heart tissues sutured back together, which is a bummer, but I'm glad that I got to see most of the installation process. Because the patient received a mechanical valve, they will have to take Coumadin or Warfarin (blood thinners)  daily for the rest of their lives; the structure of the mechanical valve allows blood clots to develop more easily, so this is a safety precaution.

                Having seen both kinds of surgery, sternotomies and minis, sternotomies are much more appealing from the viewer's perspective. One would assume that it's easier on the doctors, too- the chest is split, and there's plenty of viewing room. It's a direct look at the heart, and all of the doctors surrounding the patient can see what is going on. Minis, on the other hand, are performed through the right of the chest, and docs assisting with the surgery have to rely on the performing doctor's live headcam footage to get a peek. I would've had no idea what was going on without Dr. Nguyen's headcam footage being projected on the nearby flatscreen TV. Even the surgical instruments involved in it are long, complicated and awkward; the highly trained professionals involved with this surgery struggled, at times, to position cannulas and other materials around the chest incision.


Above is a clean picture of the surgery, with clamps, cannulas, sutures and the rib spreader in place. This is still pre-valve installation




Above is a real picture (not mine) of the suture scaffolding, lowering the replacement valve in.

              I thought that this deserved a long blog post, because seeing actual surgery is one of the most interesting things about this internship. The human body is incredible, and what we're able to do with it in regards to medical care is even more astonishing. Hopefully I'll be able to spectate one surgery every month or so, but because they're so long and right in the middle of the day, planning gets a bit tricky.. I'll have another post about this Friday's events (as promised) up by the end of the weekend.

Update 2/19/16

               Dr. Nguyen was unavailable on Friday- so, I'll probably be going early in the week. Progress is still being made on the storyboards for the animation project, and I will likely be uploading full rough draft pictures in the coming posts. I could very well be doubling up on hospital visitation next week, as I have to make up for this Friday and will be going-as per usual-next Friday morning. I'm hoping to spectate a surgery for the makeup day and have a normal morning for next Friday (valve conference, maybe a lecture, patient visits, and project updates), but that all depends on Dr. Nguyen's schedule. It'll be an interesting week regardless, so stay tuned.

2/12/15

             Today was the most radical departure from my normal Friday schedule. Dr. Nguyen was busy in the morning, so I went at three in the afternoon instead. My main goal of the day was to present to him some work that I'd been doing on an animation project, but some patient drama arose just as I got there; this resulted in him rushing over to the Heart and Vascular Clinic across the street, with me in tow, to make sure that a patient's temporary pacemaker got installed. That aside, the project that I'm working on is intended to explain medical conditions in simple terms, so that a layman audience can understand what's going on. There's an entire set of jargon in medicine, and it can be quite challenging for many people to keep track of it all.  I'm using aortic stenosis (the tightening of the aortic valve) as a start, developing a short story around it, and tying in an explanation of the disease. I'll probably post some images of the work, especially once we get it past the storyboarding process, but I thought this would be a good entry- as opposed to the standard blog post about some surgery or disease I just learned about.

2/5/16

                 There isn't a lot to report for today. After a very packed valve conference, Dr. Nguyen went into surgery (at around 9:30, and I had to leave at 10:20)- so I stuck with his PA for the remaining amount of time that I was there. She filled me in on the surgery that Dr. Nguyen was to perform: Valve Sparing Aortic Root Replacement. I like to call it VSARR, because that rolls off the tongue more easily, but it is also known as a David procedure. It's a pretty interesting surgery, and is quite long. If an aneurysm (air bubble) occurs in the aorta, this surgery is done to remove the aortic root, which is the area right above the aortic valve. The aorta gets clamped shut, the heart gets cooled, and the patient is put on a heart bypass machine for the duration of the surgery. Because the aortic root is so close to the coronary arteries and the aortic valve, it's hard to remove the root without doing some additional work- so, the coronary openings are detached from the aortic root, to be reattached later. This is when the aortic graft comes in. Sutures attach this piece to the aortic annulus, a structure that rings the aortic valve, and the ascending aorta above that. Finally, the coronary arteries are reattached through small holes in the graft. Variations of this surgery exist, including one that removes the aortic valve, even if there is nothing wrong with it (though, that isn't really VSARR, because it doesn't spare the valve).  That specific variation is known as the Bentall Procedure. If a patient is a candidate for the David procedure, but has some aortic valve complications, they might as well go through the Bentall procedure to kill two birds with one stone. This is one of the more complicated surgeries I've learned about, although I'm sure that there are some I don't know about that are even more intricate. I really do learn something new every day that I'm here. 

P.S., just to give a visual of what I was explaining: 

1/22/16

          With the winter break and J-term over with, I'm looking forward to getting back to a normal schedule. That means more internship posts. Ironically, Dr. Nguyen will be gone next week (so, nothing next week), but unpredictability is what makes this position interesting. More to come this spring. 

          Anyways, I picked a really good day to return- it started with a resident lecture on vena cava filters, which I didn't know existed. The vena cavae are two veins that lead the body's deoxygenated blood into the heart, through the two chambers, and into the lungs for reoxygenation. The one focused on was the inferior vena cava (IVC), which segments into two veins that lead down the thorax and into the leg. The vena cava filters discussed here were created to treat venous thromboembolism (VTE), which is swelling caused by a blood clot (embolus). They're basically just stents used for keeping the vessels open and preventing blood from settling. The lecture talked a bit about their history and the different kinds of filters available today, but the most interesting part of it was how dangerous these things can be. Some filter installations have penetrated the IVC and leaked into other areas in the chest, while filter complications in one man's femoral artery resulted in his entire leg being amputated. In 2010, the FDA even ruled that they should be taken out if not necessary- and the doctors in the room definitely stood by that. I mean, would you want something called a Bird's Nest in your body? Because that's a real filter type, and it doesn't look fun (picture below). Luckily, these filters are only put into use when anticoagulants- drugs used to break up emboli- do not work, or aren't working well enough to prevent the patient from falling ill. Neat, right?

11/13/15

This was another irregular day; I didn’t have school and Dr. Nguyen had a resident lecture to give early in the morning, so I ended up going at 8:00 instead of 6:50. So, I skipped valve conference and went straight into pre and post-op patient checkups. I usually don’t see a lot of these, but since I didn’t have to get back to school at a certain time, I was able to get involved in two of them:

The first was very, very standard (this is good); the patient was a woman in her mid-60s, who was recovering from an open-heart valve replacement (I can’t remember if it was aortic or mitral) a month or so ago. She was doing fine, but was concerned with the development of bacteria over her scar. To remedy this, she was given some betadine, an antiseptic used for surgery prep. Daily applications of that, along with some gauze, would be more than enough to deal with her issue.

The second was a pre-op patient, a man in his early 60s who worked at an auto shop. He had mitral calcification (his mitral valve was blocked and couldn’t pump as much blood as it normally could), type 1 diabetes, and some breathing issues. Throughout my time in the room with him, he brought up how his vision and memory hadn’t been very sharp in the past few weeks. This led us to believe that something was wrong with his carotid arteries (which lead to the brain). This could be a possible clot, which is an entirely different issue for another department. A recurring theme throughout the time I spent with him was the difficulty he had with the medical terms being thrown around. He was hesitant to attempt saying the names of the surgery options he was given, even refraining from saying cardiologist or MRI. This gives me extra incentive to pursue the stenosis project with Dr. Nguyen; it’s so integral that people know the scope of their condition and what exactly is wrong with them. 

10/30/15

Quick Update: for those of you that actively read this blog (if there are people who do), both Dr. Nguyen and I were out of town last week, making me unable to attend. He will be gone this following Friday as well. I might be going this Wednesday if possible, or at the least discussing the animation project with him and using that info as the next blog post.

Last Friday, I spent most of the morning in the hospital at valve conference. Most of the patients had aortic or mitral stenosis, with nothing too irregular. None of the patients had extreme defects or early heart irregularities, and were mostly old patients in their 70s and 80s that had a past of heart disease. I’ll talk about a few of the cases. 

The first was 66 y/o woman with mitral regurgitation (valve is loose, leaks when pumping blood or drawing blood into the heart), moderate-to-severe in condition. Most of the cardiologists in the room recommended a MitraClip, a minimally invasive catheter-based valve repair device. This did not take long to go over, but more interesting and lengthy case discussions followed shortly after. Another patient had a bypass done in the early 2000s, with a subsequent aortic valve replacement in 2005 that came with some complications. Heading to the present, she was recently admitted to the hospital with acute kidney injury (as well as the continued heart problems), and has been on dialysis almost every day because of this. Aside from her kidney issues, she needed work on both her aortic and mitral valves. Going even further, her lungs were functioning poorly. There was a long discussion over how to deal with this woman’s serious conditions- she’s a high-risk patient with limited long term benefits from invasive surgery, so the best thing right now would be simple medical care and making the rest of the time she has left pleasant. Just being in the room while these talks deciding a person’s life were happening feels very odd, but I’m glad that I was able to get a glimpse into the harder decisions that must be made in a hospital.