Yoojin Lee ’16, University of Arkansas Medical School

Eunice-Yoojin-LeeDay 1 
Though it was only my first day at UAMS, my schedule was jam-packed. I met Dr. Erika Petersen ’96 in the lobby at 6:45 am, and as soon as I changed into scrubs, we met the patients she was scheduled to operate on. She talked to each of the patients and their family members as they were being prepared for the operation, providing reassurance and reminding them of the operative procedures that would take place.

The first operation I observed was a laminectomy, used to treat spinal stenosis. Stenosis involves a thickening of ligaments and bone tissue that surround the spinal nerve sac, which often causes pain, stiffness and weakness. In our case, the patient was suffering from pain in his legs, and was unable to stand straight for even the six minutes needed to brew a cup of tea. A laminectomy removes the ligaments and bone tissues to widen the area around spinal nerves and give them more “breathing room,” relieving pressure. The operation took about two hours, and when we went to visit him later in the afternoon, he reported that his leg already felt a lot better. I myself gained a lot of respect for doctors by the end of this first operation; it was hard just to remain standing up for two hours—imagine how hard it would be to stand for two hours straight while operating on a patient under high-stress conditions! The stakes were even higher for Dr. Petersen because the patient was her colleague’s father. 

The second operation was the first of a two-part operation for deep-brain stimulation, Dr. Petersen’s specialty. During this procedure, electrodes are surgically implanted into the brain and are later wired to a generator, which is implanted into the patient’s chest. Stimulation of these electrodes via the generator is said to relieve tremors and treat symptoms of Parkinson’s disease; according to Dr. Petersen, some doctors have also used it to treat anorexia and depression. That day, DBS was used to treat a patient with dystonia, which causes tremors, twisting and abnormal postures. Although Dr. Petersen didn’t expect to see any immediate effects of DBS on his condition, the patient said his muscles felt less tight. Dr. Petersen and her staff will have to run more tests and observe him throughout the next couple of months, but things do look quite promising!

The last operation didn’t take place in the operating room, but in the patient’s ward. The patient had suffered major brain trauma from a motorcycle accident, and the resident doctor was planting an intracranial pressure sensor so that he would be able to monitor pressure changes in the patient’s brain. The operation was relatively quick, and implanting the ICP itself took only ten minutes. According to the doctor, it is impossible to tell how bad the effects of trauma will be on the patient, but hopefully long-term care and therapy will bring as much of him back as possible. 

Day 2
Day 2 started even earlier at six in the morning, which began with Dr. Petersen’s lecture to the anesthesiology department about Spinal Cord Stimulation—which, surprisingly enough, I understood! As its name may suggest, SCS stimulates nerves in the spinal cord, which blocks them from sending pain signals to the brain. Although DBS is Dr. Petersen’s specialty, she performs SCS operations more frequently.

After checking in on Dr. Petersen’s patients, Dr. Petersen and I entered the OR with a busy schedule ahead of us.Y Lee 1 I was able to observe five “day” operations, which means that patients both come in and leave on the same day without having to stay overnight in the hospital. The first two operations were Stage 2 DBS operations, in which Dr. Petersen and a resident physician implanted the generator used to stimulate DBS electrodes that had already been inserted in a previous operation. To connect the electrodes to the generator, the wires were literally tunneled through the head, neck and upper chest area using brute force, which was interesting to watch. The third operation involved a decompression of the ulnar nerve, which is the nerve that runs through the “funny bone” in the elbow. The area around the nerve was very tight, and by removing the tissue around the nerve, Dr. Petersen gave it more “breathing room.”  Next, Dr. Petersen implanted a generator for Vagus Nerve Stimulation, which stimulates the vagus nerve originating from the medulla of the brain. The procedure was very similar to that of DBS. Finally, Dr. Petersen changed a SCS generator that had run out of battery. The last patient kept waking and yelping out in pain from time to time, but all five surgeries ended successfully, and we delivered good news to all of Dr. Petersen’s patients and family members.

At the end of the day, Dr. Petersen treated me to dinner again; this time, we had Mexican food! The bean and cheese dip was delicious; make sure to get it if you happen to visit Senor Tequila in Little Rock any time soon.

Day 3
My final day at UAMS started the earliest, at 5:50 am. I met the neurosurgery residents at the Intensive Care Unit (where patients in the most critical conditions are) and listened in on their meeting, where they went over the current conditions of the patients they were taking care of. After the meeting, I joined Dr. Day (the chair of the UAMS neurosurgery department) and his residents in an aneurysm removal surgery. An aneurysm is a bulge in a blood vessel—not only did this patient have three aneurisms, but these bulges extended from carotid arteries (arteries that supply the head and neck with oxygenated blood) located deep in the brain. A doctor from Japan who was visiting Dr. Day was very helpful and walked me through all of the steps Dr. Day and the residents took to remove the aneurysms. The surgery was intense, which is probably why the entire procedure took six hours from start to finish. Residents had to rotate from one to another, and even Dr. Day had to take a small break!

I then joined Dr. Petersen in her clinic sessions, during which she consulted patients with a variety of conditions, from brain tumors to chronic back pain to face pain. The way in which Dr. Petersen seemed genuinely devoted to her patients’ wellbeing was very admirable, and I hope to become the same kind of caring, committed doctor in the future. She was also very accessible, which is a must for any good doctor. Dr. Petersen’s patients are certainly lucky to have her.

Y Lee 2Overall, the past three days at UAMS gave me a more than worthwhile experience. Not only did I get to observe many intense, interesting surgeries (some of which I had never even heard of before, like DBS!), but I also was able to get a good feel for what it means to be a doctor. Medicine (especially surgery) involves long hours, patients, little sleep and a lot of fatigue, but it really is worthwhile, especially when both you and your patients know that you’ve completely turned their lives around 180 degrees for the better. That one smile or token of appreciation—that feeling of knowing you’ve made a huge difference in someone else’s life—is priceless, and it keeps you going.

Hope Xu ’15, University of Arkansas Medical School

Hope-XuA typical day at the University of Arkansas for Medical Sciences hospital went a little like this: The first operation of the day was scheduled for 7:00 am, so we’re up at 5:30 and ready to meet up with Dr. Erika Petersen ’96 in the Pre-Op waiting room by 6:30. Dr. Petersen takes us to the locker room, where we change into scrubs and masks before entering the Operation Room (OR).

Our first patient was an elderly lady in need of a generator replacement. Certain patients suffering from severe nerve-related pain can undergo surgery to have small rechargeable generators implanted in their bodies. These generators are wired to a series of electrodes connected to the central nervous system, and by creating an electric field, they can interfere and effectively block pain signals to the brain. Our patient originally had her generator implanted in her lower back, but its position had been causing her increasing discomfort as her skin began to sag. Working together with Dr. Gandhi, Dr. Petersen removed the old generator, added extensions that were strung beneath the dermis to the abdomen, hooked the wires to the new generator, and inserted it into an incision just below the rib cage. At all times, an anesthesiologist closely monitored the patient’s vitals and administered the necessary drugs for paralysis or stimulation. We were allowed to observe as Dr. Petersen explained the procedures for proper positioning, sterilization, radiology, and stitching of the different epidermal layers.

The three of us observed a neighboring operation with one of Dr. Pait’s patients, a woman who had recently suffered a spinal fracture and needed to have two of her collapsed vertebrae removed and replaced with a titanium cage. In order to strengthen the spine during recovery, Dr. Pait inserted metal screws into the vertebrae above and below the fracture by exposing the spinal cord from the back (posterior approach) and hammering holes into each pedicle. Using CT technology, the surgeons were able to render a spatial animation of their tools in relation to the patient’s X-rays, making it much easier to carefully guide each screw deep into the bone without pinching nerves or the spinal canal. Once all the necessary screws were inserted, metal rods were strung through each screw to create an even stronger wire frame before the patient was stitched back together and sent back to recovery.

After a quick lunch at a nearby cafe (“Surgeons eat when they can, sleep when they can, and never pass up a bathroom break”), Xu 1Dr. Petersen left us in the care of Dr. Gandhi for our third and final operation of the day. We learned that a patient’s lifestyle can have a profound impact on not only general health, but also on the success of surgery. Being incredibly overweight, the patient was very difficult to position, and cutting through the fat tissue to reach the spinal cord proved to be a long and tedious process. Similar to the second operation, this patient suffered a spinal fracture and needed to have the collapsed vertebrate removed. Several X-rays were taken to confirm the position of the patient’s spinal cord throughout the operation. Near the end of the operation, Dr. Petersen led us back to the locker rooms, where we were given fresh scrubs and a meeting place for the next morning before being dismissed for the day.

In addition, we were able to witness other functional surgeries involving vagal nerve Xu 2stimulators, aneurysm decompressions, and brain tumor removal. Everyone we met at UAMS was incredibly intelligent and supportive of our budding interest in medicine and neurosurgery. I’d like to give my thanks to the entire Neurosurgery staff and the neurosurgery residents for showing us around and giving us a rare chance to really live out their lifestyles, and I’d like to thank the Princeternship Program for giving me this incredible opportunity!

Connie Wang ’14, University of Arkansas Medical School

Connie-WangDay 1: Monday, January 28
Though the sun had barely risen in the sky, the surgical floor of UAMS (University of Arkansas for Medical Sciences) Medical Center was already abuzz with activity at 6:45 a.m. when Hope – the other Princetern – and I met with Dr. Erika Petersen ’96, our alum host. After brief introductions, Dr. Petersen entered the pre-op area to explain the surgical procedure to her patient. We then changed into scrubs and went in to the OR.

Dr. Petersen’s first case for the day involved the replacement of a battery pack for a spinal cord stimulator – a device that electrically stimulates the spinal cord to relieve pain from damaged spinal nerves.  Dr. Petersen invited us to watch the procedure up close from a step by the operating table – on the anesthesiologist’s side of the sterile drapes –and explained each step of the procedure as it was performed, pointing out anatomical details such as the different layers of tissue underneath the skin or the fibrous capsule that the patient’s body has formed around the battery. While Dr. Gandhi, a neurosurgery resident, removed the old battery, Dr. Petersen made the incision to insert the new battery, which was considerably smaller compared to the older model.  With Dr. Gandhi and Dr. Petersen working together, the procedure was completed quickly. After taking X-rays to confirm that the electrodes on the spinal cord have not moved during the procedure, Dr. Gandhi and Dr. Petersen closed the incisions, aligning the edges of each layer of tissue so that the wound can properly heal.

Typically, on Mondays, Dr. Petersen performs a procedure called deep brain stimulation (DBS), in which she installs a pacemaker device that provides electrical stimulation to the brain to relieve the tremors caused by conditions such as Parkinson’s disease.  One of the special things about DBS is that, unlike for most other surgeries, the patient is awake for part of the procedure. On this particular Monday, however, Dr. Petersen’s DBS case was cancelled; thus we spent the rest of the day observing two spine surgery cases – one for spinal fusion and one for spinal decompression –  performed by one of Dr. Petersen’s colleagues. Dr. Petersen and Dr. Gandhi explained the procedures to us using a model of a human spine and the X-rays displayed on the monitors. Both patients had suffered spine fractures. The fractured bone had narrowed part of the spinal canal, compressing the spinal cord and causing pain and numbness as a result.

At one point during the second surgery, Dr. Gandhi invited us to come close to the patient and look into the deep wound on the patient’s side. There, underneath the ribs, was the patient’s lung – dark red and glistening with moisture – rhythmically expanding and contracting with each breath, metered by the ventilator.  There is a certain awe and trepidation in being so close to the insides of a living human body.

Day 2: Tuesday, January 30
On Tuesday, we arrived at the hospital even earlier to experience morning rounds with the neurosurgery residents. After presenting updates on the condition of each of their patients, the residents quickly walked down to the hospital cafeteria to snatch a bite to eat before the conference at 7:00 a.m. At the conference for this particular day, the neurosurgeons were discussing candidates for treatment with the gamma knife, a type of radiation therapy that can deliver a dose of radiation to a very specific location within the brain. After the conference, we followed Dr. Petersen to the OR. Both of her cases for this day involved the replacing components of implants with newer technologies. In her first case, Dr. Petersen replaced older wire electrodes on a patient’s spinal cord stimulator with a new paddle electrode that cannot shift out of place as easily. Her second case was a generator replacement for a vagal nerve stimulation (VNS) unit, an implant that can treat epilepsy that does not respond to pharmaceutical approaches, or in some cases, OCD and depression.

In the afternoon, we observed in the clinic of one of Dr. Petersen’s colleagues who specializes in brain surgery. Dr. Ghandi was also in the clinic on this day and took brief pauses in between seeing patients to explain the features that are seen on the MRI and CT scans and the diseases or abnormalities that are observed.  Using a model of the human skull, Dr. Ghandi traced out the grooves and fissures and pits, pointing out the names of these anatomical landmarks and explaining where a surgeon might enter through the skull to reach the disease or injury deep within the brain.

At 5:00 p.m., we joined the residents and Dr. Petersen at the journal club, where they discussed and critiqued recently published articles in the field. Following journal club, we stayed briefly with the resident on call, whose long night shift began with a drive to the children’s hospital – during a rainstorm and a tornado warning – to perform a surgical procedure on an infant.

Day 3: Wednesday, January 31
Wednesdays are Dr. Petersen’s clinic days. On these days, Dr. Petersen evaluates and discusses possible surgical treatments with her patients or follows up on patients after their operations. While Dr. Petersen met with patients in her clinic, we observed in the OR where one of Dr. Petersen’s colleagues was performing brain surgery. The first case of the day was the clipping of an aneurysm, and the second case was the removal of a brain lesion located perilously near the region of the patient’s brain responsible for speech.

After making an incision in the scalp, the surgeons held the muscles with retractors and removed a plate of bone from the skull.  Cutting through the dura, the thin but tough layer of tissue that surrounds and protects the brain, the surgeons revealed the surface of the brain, with its complex network of branching blood vessels that pulsated slightly with each beat of the patient’s heart. From here, the surgeon switched to operating under the surgical microscope to perform the intricate maneuvers required for the operations. In the darkened room, we watched the procedure on the video monitors as the surgeon’s hands delicately dissected through the brain tissue and blood vessels. Only after looking at the actual wound did we realize how minuscule were the blood vessels that appeared so large on the screen – and how rock-steady the surgeon’s hands must have been.

After the functional neurosurgery conference that afternoon, in which the surgeons evaluated candidates for DBS (deep brain stimulation), Dr. Petersen took us out for dinner. In addition to sharing some of the stories during her time as a Princeton undergraduate, Dr. Petersen also shared some of the experiences on her journey to becoming a neurosurgeon and told some of the challenges of balancing personal and professional lives as a neurosurgeon – challenges that do not go away post-residency. Although this Princeternship was only a short three days in length, I have learned a lot from the amazing and diverse experiences of these few days.  As my first time observing in the OR, watching Dr. Petersen and her colleagues’ surgical procedures was an incredibly eye-opening experience. Through conferences and clinic and the other activities in Dr. Petersen’s and her colleagues’ busy schedules, I have experienced a taste of both the diversity of activities in the daily work of a neurosurgeon as well as the rewards and rigorous demands of this profession. I will remember these experiences – and hopefully also the nuggets of clinical knowledge that Dr. Petersen and Dr. Gandhi shared with us – as I continue to pursue a career in medicine, and I would like to thank Dr. Petersen, her colleagues, and the Princeternship program for providing us with such a truly incredible opportunity!