Daria Koren ’15, Massachusetts General Hospital

Daria-KorenDay 1 – January 28

The large glass revolving doors of the Yawkey Center for Outpatient Care swing into a hub of activity at 9 am. I make my way to the third floor to meet Suzanne Morrison ’89, the program director of Partners Orthopedic Trauma Service working with Massachusetts General Hospital. Suzanne takes me around the multi-building hospital, pointing out the Ether Dome (where the first anesthetic was administered) and the Phillips House 22nd floor (from which one can see a spectacular view of Boston).

Soon afterwards, I sit in on an interview for a new Nurse Practitioner. The current NP, Kathleen Burns, is an amazing point-woman for the orthopedic service but the service has grown to an unmanageable size; the hospital needs a second NP who will work well with Kathy and the rest of the ortho team. Suzanne has gotten permission to hire a second NP and conducts the interview with Kathy. The interviewee talks about his previous experience and describes his ideal work environment. Kathy then talks about what a typical day is like and how the MGH staff respects the NPs – something that is not ubiquitous across hospitals. The interview ends on a good note as Kathy proposes for the interviewee to shadow her in order to better understand the MGH environment.

Suzanne and I have lunch at the hospital cafeteria before I am whisked off to the operating rooms of orthopedic surgery. In my clean blue scrubs, I meet the anesthesia attending Dr. Andrea Torri. His smile is perceptible even behind his surgical mask, and he walks around the OR with me, introducing me to protocols, machinery, and personnel. This particular patient has some loosening around the screws holding her ankle plates together due to bone reabsorption, so the surgical team has made a long incision along the outside of the left ankle. I comment on how there is no bleeding nor suction…Dr. Torri explains that a mechanical tourniquet on her thigh has compressed the blood vessels very tightly in order to stop blood flow. I question if that will cause necrosis, and Dr. Torri points to a timer for the tourniquet.

Suddenly, Dr. Torri’s pager goes off – he needs to counsel a resident for a spinal tap. We go to another OR, and Dr. Torri talks the resident into rearranging her hands for better control of the instruments. The resident does the spinal well, and the patient is laid supine for her total knee replacement. The resident then injects a bit of phenylephrine to counteract the paralysis of the sympathetic nervous system. Without this chemical, the blood vessel dilation might cause the heart rate to become dangerously low.

As he is explaining this, Dr. Torri receives another page – another spinal tap must be performed. This one proves to be more difficult, but Dr. Torri quietly advises this resident and his second try is successful. We run back to the knee replacement OR, and I am shocked to see a cut 4 inches deep through her leg, showing femur, tibia and patella bones. I am even less prepared for what happens next: the orthopedic surgeon takes an inch-wide drill and swoops into the femur. I stand there, transfixed by this brutally beautiful manipulation of bone and flesh; I only notice Dr. Torri when he puts his hand on my shoulder. He asks if I need to step out, and I shake my head, saying, “I just didn’t think bones could …do…that.”

Dr. Torri smiles, accepts my answer, and brings me a stepping stool so I can see the surgery better. The surgeons measure the tibia to properly place the replacement joint, and saws whir back and forth. Dr. Torri frequently checks the monitor reading of oxygen saturation, heart rate, and blood pressure. The EKG looks stable and healthy, and Dr. Torri encourages the anesthesia resident to keep up the good work. He then takes me into another OR, where a spinal operation is occurring to remove malignant tissue surrounding the spinal cord. As with the knee replacement, Dr. Torri stands near me to prevent any dramatic reactions to this sight; I do not have any adverse reactions and Dr. Torri feels confident enough to leave me for a bit as he talks with the surgeons and anesthesia residents. We continue this cycle of going from OR to OR, and Dr. Torri patiently explains how certain anesthetics affect the nervous system, how surgical procedures are being carried out, and how machines work. All the surgeries end around 6 P.M.,pm and Dr. Torri brings me back to Suzanne. He tells me I could shadow him the next day on the labor floor and Suzanne consents to this idea. I excitedly agree as well, and Dr. Torri grins and states, “See you at 6:30 A.M amtomorrow then.”

Day 2 – January 29

Getting up at 5 am is a struggle. Somehow I force myself to get up, get dressed, and successfully navigate the MBTA rail lines to arrive at MGH at 6:30 A.M.am Dr. Torri greets me warmly, and I receive my second set of scrubs. We arrive on the Labor Floor as Dr. Lisa Leffert is organizing the teams; residents read off patient histories and Dr. Leffert makes a couple executive choices about Caesarean sections and induced labors. The most urgent cases are discussed and, at 7 A.M.,am Dr. Torri is already supervising a resident performing an epidural in the labor OR. The resident takes care to insert the needle very slowly, stacking his index and middle fingers together to simultaneously squeeze the needle and press against the patient’s skin. I am amazed by such fine motor control, and Dr. Torri seems pleased with this technique. This approach is successful, and the resident inserts the epidural tube and administers the anesthetic.

The woman is laid down, and a privacy sheet is put around her head. Her vital signs all look good and the obstetrics team begins the C-section. Dr. Torri explains how they cut through skin layer by layer, why certain instruments are used in favor of others, etc. The surgical team works quickly and efficiently, and very soon a healthy baby girl is born. As nurses swaddle and coo over the newborn, the surgeons are still huddled over the mother to start the stitching procedure. Once again, layer by layer, skin is gently pulled together and sewn in place. The mother begins coming out from under anesthesia as the surgeons are almost done, and Dr. Torri makes sure she is comfortable. The epidural is still numbing the abdominal region, so the surgeons continue suturing as the mother is shown her baby girl. The C-section goes smoothly, and in the end both mother and child are well.

As this patient is wheeled out of the OR and into her recovery room, Dr. Torri is taken aside for a consult. Another patient has a low platelet count and so cannot receive an epidural; Dr. Leffert talks with Dr. Torri about whether an epidural poses a risk of bleeding out because so few platelets may not be enough to coagulate blood around the entry wound. Dr. Torri requests the patient medical profile and notices that there is a history of family autoimmune disease. A hematological consult is ordered and soon shows that the patient’s platelets are much larger than normal. Dr. Torri and I open a large volume on anesthetic protocols and flip to the section concerning patients with autoimmune diseases. The textbook advises a hematological consult and caution with platelet counts below 70,000. The next blood analysis shows the patient has 83,000 platelets and so Dr. Leffert seizes the opportunity to perform an epidural. The brief procedure is successful and the patient shows no signs of hemophilic tendencies.

While Dr. Leffert is doing this, Dr. Torri is called by one of his residents to assist with an IV for an obese patient. The resident has already tried a couple times without success, and Dr. Torri personally attempts to put in the IV. It takes several more attempts, an ultrasound machine, and a nurse to finally pierce a vein. Dr. Torri apologizes to the patient for the lengthy duration and compliments her patience. His pager goes off just as he finishes – he is called into the labor OR again for another C-section. This case has already been tubed and sedated, but now her oxygen levels are getting low for an unclear reason. The resident wants to be extra cautious and requests Dr. Torri to look over the charts to see if he has missed anything that could explain this. Dr. Torri analyzes the situation and cannot find any outstanding reasons for why this is occurring; he notes that while the oxygen saturation is lower than normal, these levels are nowhere near alarming. He asks for the nurse to bring a second pillow for the patient and the slight elevation of her head brings the oxygen levels up to a good range. Dr. Torri is pleased with his resident’s astute attitude and mentions that laying supine sometimes creates more difficulty breathing when there is another person pushing on internal organs.

The day goes on, and around 3 P.M.,pm another anesthesia attending rounds up the 4 residents for a presentation on the ethics of post-partum tubal ligation. This procedure involves cutting the fallopian tubes after a C-section to prevent any future pregnancies; since the mother already has a deep incision to in her uterus, it makes sense in terms of time, cost, and recovery period to perform this operation right after her assisted birth. However, the attending cautions presents the argument that the mother isn’t in a state of mind to decide this much of her future right after labor and that some women may regret this decision to limit the family size. The general guidelines for even offering a post-partum ligation are announced to the residents, and they acquiesce. The attending wraps up the presentation and we all file out of the room down to the cafeteria for lunch.

I contact Suzanne to tell her how my day is going, and we decide that I will spend the next day shadowing Kathy Burns. Dr. Torri sits with me and explains a few more concepts for anesthesia, and I determine that if I do go forward with medical school, I will most likely decide to do anesthesia as my specialty. The descriptions of the analyses, procedures, and cooperation with surgical teams really appeal to me, and it is thanks to Dr. Torri that I now have a true representation of this profession.

Day 3 – January 30

Another early rise – I am at the hospital again at 6:30 A.Mam. I meet Kathy the nurse practitioner in the main lobby, and we sprint to the grand rounds meeting. Here residents present the cases that have come in over the past 24 hours, and the attendings decide where to slot them in relation to the previously known cases. Kathy, as the sole NP for Orthopedic Trauma, has her hands full with 2 lists of patients: Trauma Red and Trauma Purple. As the attendings argue about urgency order, Kathy makes small notes on her lists to help her remember patient problems and diagnoses.

After the meeting, Kathy and first-year residents go to a computer cluster to input medicine, food, and general treatment orders for their patients. This takes quite a while as previous medications, allergies, and other restrictions must be taken into account. Eventually, Kathy and I visit our first rounds patient who has ileac problems after an operation to fix slight prosthetic problems. Kathy wears a biohazard apron and gloves to prevent a contagious accident. She checks EKG and blood pressure, as well as asks the patient how he is feeling. After verifying that there is nothing more she can do to make his recovery more comfortable, Kathy leaves the room and we go into another rounds meeting.

These interdisciplinary rounds are much shorter, due to the specialization of the departments. Kathy also acts as point-man for the department doctors here, listing the grand rounds decisions for each patient. The other doctors and nurses respect Kathy for her clarity and efficiency in detailing the most salient points about a patient. Kathy conducts three of these interdisciplinary rounds, each with different departments and separate patients. She then takes some more notes and inputs for patient charts.

The next patient we visit has a shoulder fracture and is anxious about surgery. Kathy does her best to conform the patient and even orders a psych consult to see if there is any way that department can allay her fears. Another patient has a ruptured quadriceps tendon but cannot receive Atenolol to relieve blood pressure and ease swelling due to an allergy. Kathy contacts the primary care physician and works out that hydrolozine may possibly work. The chemical is administered through the IV, and it seems to do the trick without any negative effects. Kathy remains worried about this patient due to a slight deviation on his EKG chart.

The final patient I come in contact with is a man with a strangely curved neck. His anatomy is already deviant, and a fall has exacerbated the weakness of the neck. The staff are trying to restrict his movements in any way possible while they search for an unequal neck brace. In the end, Kathy and the hospital personnel decide to combine two different neck braces and set upon the task as I am brought to the Orthopedic Research office.

I am introduced to Jordan Morgan, a recent college graduate, who works on compiling data retroactively to produce papers on the efficacy of certain orthopedic operational and treatment protocols. He talks about how difficult it is to read certain angles of X-rays and how it’s amazing when his data shows statistical significance. I am amazed by some of the minute classifications he must do in order to group certain fractures, and Jordan is happy to explain his research.

As I leave MGH that last day, I am saddened to leave a place that was so friendly and inspiring. Suzanne Morrison was a wonderful alumni host, and I am really grateful for her ability to pick people that could show me the diversity of the hospital. I keep wishing I had more time to spend with Dr. Andrea Torri because his bright attitude and clear explanations made my first visits to an OR that much better. I hope that Kathy Burns get a second NP that compliments her perfectly, for she really deserves a capable partner to run the orthopedic trauma unit with openness, grace, and efficiency. In addition, I hope that Jordan Morgan’s research goes well and I am thankful for his willingness to explain it to me. Overall, I am hugely grateful to all the MGH staff that were courteous enough not only to let me see their hectic work but to actually slow down and explain it to a pre-med student. Their attitudes and abilities definitely make me want to become a doctor – not only for the knowledge, but for becoming a better person as well.