Bypass Surgery

I got the opportunity to observe my best friend Anja Strehlow, a physicians assistant in cardiothoracic at the University of San Francisco Medical Center, remove the saphenous vein from the left leg of a patient having bypass surgery. The screen represents the screen that Anja had sight of while using endoscopy to cut all the attaching blood vessels from the surrounding tissues to remove the vein. The doctor requested the length of the patient's whole thigh and then later requested about 2 inches into the leg. 

The picture to the right, shows Anja taking out the vein

Ascending Aorta Replacement Surgery

An ascending aorta replacement was performed by Dr. Merrick on a 53 year old female with an enlarged aortic valve. A sternotomy was performed and the patient was put on a cardiopulmonary bypass, as seen in the mitral valve replacement. The sternotomy, performed to get access to the heart, can be dangerous- I was told the aorta was accidently cut through during this procedure the other day. The medical team worked quickly together to suture the hole in the aorta, as well as prepare the bypass through the femoral artery in the mid-thigh (where a great deal of blood is pumped through to get oxygenated blood to the lower body), instead of using the ruptured aorta. 

The incision made into the heart was at the location of the ascending aorta, above the sinotubular junction and below the aortic arch. Blood enters the annulus through the aortic valve coming from the left ventricle. The aorta carries oxygenated blood from the heart to the rest of the body for gas exchange within the cells.

Stenosis is a narrowing in the aorta (as shown above). Instead this woman's case was different, the aortic valve was larger than normal and in need of a replacement. The aorta was cut through (as shown in figure B). The destroyed tissue was removed with scissors, leaving two flaps on each side called pericardial patches (shown in figure D as dotted lines near the bottom of the aorta). These flaps were used to eventually suture the prothetic valve tighter into the aortic orifice. Sutures were laced on the exterior edges of the aortic orifice to pull in the new aortic prosthesis (as shown in figure C and D). A hole is made by burning each side of the prothesis tube to make an entrance for the right and left coronary arteries to enter.

Every time a prosthesis is used, it must be opened as a new package. Usually the medical device reps are in the OR ready to open the prosthesis for use in surgery. Today the nurse miss-understood the surgeon and opened a new prosthesis that wasn't the right size. It was a $5,000 mistake.

After the heart-lung machine was disconnected and the heart began to beat again on its own, there was an obvious leak of blood from a hole in the aorta from behind. There was no easy way to push the heart out of the cavity and suture the hole, but eventually it was found and fixed. We were lucky not to have had to go back onto bypass because it would have taken at least two more hours. 

I was really lucky to have had the chance to observe my first surgery with my very smart and beautiful best friend, Anja Strehlow. She works as a Physicians Assistant in cardiothoracic and previous PA in my former orthopaedic surgery department. She has always been an inspiration to me in the medical field and has supported me in reaching my goals in all aspects of my life. Tomorrow I'm even more excited to be there to watch her do her thing as she removes the coronary artery from the lower leg for a coronary bypass surgery. 

Mitral Valve Replacement Surgery

During my first day in UCSF's Cardiothoracic Surgery department, I got to observe a Mitral Valve replacement surgery (aka open heart surgery with cardiopulmonary bypass) performed by Dr. Merrick and a female second year fellow. After a little over five hours of standing on my feet, I am a little more experienced on how our cardiopulmonary system works. Made up of the heart and lungs, the cardiopulmonary system receives de-oxygenated blood to the heart through two tubes called the superior and inferior vena cava. Then the de-oxygenated blood flows through the tricuspid valve to a lower chamber called the right ventricle, and then off to the lungs to get oxygenated. Once the oxygenated blood returns from the lungs into the left atrium, it is pushed through a valve-type tissue called the "mitral valve" into the left ventricle. From the left ventricle, the oxygenated blood is pushed through a tube called the aorta to the rest of the body. 

In the case of the need to repair or replace the mitral valve, the oygenated blood from the left ventricle is pushed back through the mitral valve into the left atrium- a process called regurgitation.

This shows the normal blood flow within the heart. The mitral valve properly allows the movement of blood into the lower chamber of the left ventricle. 

The mitral valve insufficiency means the valve is not closing, allowing blood flow back into the atrium. The atrium grows and this can lead to heart failure if left untreated. Mild regurgitation remains asymptomatic while moderate to severe cases cause abnormal rhythm problems and shortness of breath. 

Usually acute regurgitations are caused by a rupture in the chordae tendinae, the long cords extending into the left ventricle from the mitral valve, during a heart attack or other trauma. When the chordae tendinae aren't working properly, the blood volume increases in the left ventricle and causes an increase in pressure in the chamber above. This can cause shortness of breath, fluid accumulation in the lungs, or the body's cells die from starvation of oxygen and nutrients due to the lack of oxygenated blood flow.

After putting the patient completely out via anesthesia, a transesophageal electrocardiogram, aka ultrasound, can evaluate the blood flow through the mitral valve. A probe with a transducer is inserted into the esophogus where the waves echo the heart structures. It was easy to see that the valve was allowing blood flow back into the left atrium when the heat setting was established on the screen. Every time the left ventricle pumped, instead of sending the oxygenated blood solely to the aorta, it flowed forcefully back up into the chamber above. Due to the amount of blood and the force of it, the surgeon decided to perform a mitral valve replacement instead of a repair. Although repairs have shown to be more successful because of the ability to have human tissue instead of a prosthetic one inside the heart, the mitral valve wasn't repairable and a replacement was the only option for this patient.   

The most fascinating thing about the mitral valve procedure is the ability to do surgery on a non-working heart by use of a cardiopulmonary bypass. The heart-lung machine replicates the job of the heart (to oxygenate the blood and get it to the rest of the body) so that the heart can stop pumping during the procedure. The heart, a working muscle, is located in a small chamber within the thoracic cavity. Above is a picture of the heart as it lies inside the thoracic cavity- the sternum bone and its attached rib cage with inner lying intercoastal muscles. Below the heart is an underlying muscle tissue called the diaphram that seperates the thoracic cavity from the lower body. The incision for the procedure is made along the dotted lines, shown in the picture above. A median sternotomy incision is performed (the sternum is sawed down the middle with a sternum saw), allowing an ideal view of the beating heart once the retractors are in place.

All the tubes shown in the photo to the left are the tubes that take the place of the beating heart. Cardiopulmonary bypass involves making a small incision in both the superior and inferior vena cava and inserting a special tube connected to the heart-lung machine. Another incision is made in the aorta and connected to the opposite end of the heart-lung machine. The inserted tubes insure that blood leaves the body before reaching the heart and returns back to the body, allowing the surgeon a still and bloodless area to work with. The constant pumping machine, guided by the perfusionist, works as the heart would by taking the de-oxygenated blood to be exchanged for oxygenated blood and then directed to the rest of the body to exchange among the other cells. The de-oxygenated blood is directed to the machine's resovoir, then to the oxygenator, and then through the pump to be pushed back into the body. I found it to be so amazing how the machine (refer to photo below) is capable of doing the heart's job to allow the heart to be worked on for the procedure, especially the ability to exchange carbon dioxide for oxygen. Once the bypass was set up, 32 minutes after the incision, the heart lost its size inside the cavity and shrunk as it came to a complete stop. The screen that once demonstrated the heart's pressure, EKG, and voltage became clear. Then, like magic, the heart's information appeared on the heart-lung machine's screen. The heart sat in its place silently and the patient continued to live- wow! One of the surgeons told me that the one thing that has stuck with him through medical school were the three things that are needed to keep a patient alive: 1) oxygenated blood 2) blood flow throughout the body 3) continued urination which allows filtration of the blood. With help of the heart-lung machine, these three important factors are allowing the patient to stay alive. 

The most important part of the procedure is keeping the heart at a mild hypothermic level of 34 degrees Celsius. This cold temperature decreases metabolism and helps protect major organ systems from a lack of blood flow because for every 1 degree Celsius drop of body temperature, the metabolic demands of the body are decreased by 7%. Ice was constantly placed inside the thoracic cavity and when levels rose, the procedure was put on hold until the temperature was confirmed to be at a hypothermic level. The blood that ran through the heart-lung machine was also kept at a low temperature for its return to the body. A third tube is also connected to the heart, but not to the heart-lung machine. This tube flushes the heart with cardioplegia, a potassium chloride solution to stop the heart without damaging it. An increased amount of potassium levels in the blood is a condition called hyperkalemia and is what causes heart failure, which is why it is a third of the ingredients for lethal injections.

Once the heart is in view, an incision is made in the right atrium, bypassing the septum to the left atrium. The surgeon's view is directed downwards, looking through the mitral valve into the left ventricle. The mitral valve is examined and determined eligible for a replacement.

 

A replacement is sized and the replacement procedure begins after the damaged mitral valve and tissue are removed. Several sutures, surrounding the circular shape of the mitral valve are performed (refer to photo on right). The prosthetic mitral valve is sutured into place and procedures for closing the heart are initiated. Before the heart is closed, the blood is warmed and the heart is slowly returned to pumping its own blood. The blood lost during surgery is rinsed and slowly returned to the heart as it regresses to its normal behavior. The sternum is finally sutured closed using extra think bone needles and wire. 

Watching the human heart beat really adds to the fascination that I have for the human body, and more importantly it increased my appreciation. 

Below is an animated video of the procedure... 

Closer To Reaching My Goals

"For everyone who asks receives; those who seek find; and to those who knock, the door will be opened." -Matthew 7:8

Fall 2009 semester is over and I am now focusing my time on a successful transition back to my home town of Arizona after 8 years of being away for school. During my last few weeks in San Francisco, I will be observing in the UCSF Medical Center's cardiothoracic department and searching for a position as a full time medical assistant or pharmaceutical sales rep in Arizona. Both of which shall give me motivation to write about.

As part of my prerequisites for medical school and the MCATS, I took Calculus and Organic Chemistry this semester. Calculus went increasingly well, especially since I had one-on-one assistance from my boyfriend Greg and my teacher, Addie. Greg tutors kids in math so he had the patience and experience to help me be successful. Most of the time, Greg helped me with the basic algebra needed to solve the new calculus concepts. Greg was always available for me, even spending time to help me before or after spending 8 hours tutoring kids and his training. My teacher also took so much time to be available for me during her office hours. 

The organization of my class was a new concept that was being tested and studied. It consisted of three days/week hour-long group study time where each small group would discuss and solve several problems that applied to how we would use calculus in the real world. Some of those problems were then due the next week with a full written out explanation of  how it was solved. Then we had two lectures online/week which lasted from an hour to hour and a half, weekly online homework with a tutorial to help solve the questions and three big exams. The online homework usually took from 2-5 hours to complete, usually the latter. We were given a fake exam that replicated the real exam and allowed a cheat sheet during the exam. Overall, I think that the new organization of the class was successful and allowed me to get an understanding of Calculus from all the different ways there are possible for learning. I got A's on the last two exams and an overall B in the class. 

For the first few weeks of school, I was registered in Organic Chemistry II- the second and last semester of the year of Organic Chemistry needed for medical school. I was enrolled in the post-bach program's class since it was the only one honored during the Fall semester. The teacher told me that if I wanted to stay in this exclusive class, I would have to do really well on the first exam to prove myself. I had to prove myself because the pre-med post-bach students were paying $50,000/year to be in prerequisite classes with the best teachers and most of them were passing them with A's. I wasn't enrolled in the pre-med post-bach program because I wanted to save money. I studied hard but did not do well on the first exam. The teacher advised me to re-take Organic Chemistry I- the first semester of Organic Chemistry. 

I enrolled in the lecture for Organic Chemistry I that same day, which was just in time for the deadline. My lecturer was a teacher I had a previous semester for lab. He was from China and did not pronounce the english language well, in fact I did not understand a word he said. His lecture consisted of power point slides with pages directly from the book so I printed them out, read each one and then took notes while reading each chapter in the book, and took well advantage of my dry erase board by re-writing all the reactions over and over again. I attended only one of his lectures, but read page for page of every chapter in the book. I got an A on the final and an overall A in the class. 

I think this semester was a success because I didn't have a job or a race to train for and really spent all my energy into completing my Calculus homework and reading every chapter for Organic Chemistry. Plus, there was no way I could fail with nothing to complain about... I have an amazing boyfriend to look up to for working 10 times harder than I do and a perfect place in the city with a parking spot! 

I made time to swim three times a week for an hour with Greg at the Burlingame Aquatic Center, lift two times a week at the SFSU gym, and bike or run at least twice a week. My training plan was just maintenance throughout the semester. Ever since classes have ended, I have been committed to getting back into training for racing my next triathlon. Teana and I will be racing Nathan Tempe Triathlon September 27th. I have a 16 week plan that focuses on improving my swim and bike portions of the race, leading up to nine hours of biking through out my peak week and a consistent five days/week of swimming. I'm really excited to be able to train with Teana in Arizona and we're living only a few blocks away! I hope to see a lot of improvement in the both of us for this next race and in everything else I have planned, as I reach closer and closer to my goals.

Afra and I in Las Vegas in March during my spring break road trip to Arizona.

Teana and I in Arizona.

My sisters and I on the top of Camelback Mountain in Arizona.

Greg and I at the Wildflower Triathlon in May.

Greg and I swimming in Lake Mendocino the day after my last final.

Greg and I biking Orr Springs Rd. during a trip to the Mendocino Coast.

The Balancing Act

On the path of becoming a physician, I have faced the famous challenge of the balancing act. This Spring 2009 semester, I have decided to follow the advice of my pre-med academic advisor, Dr. Rothman and slooooooooooow down. Slowing down would allow me the ability to focus and be more tentative to the task at hand. Slowing down would mean putting all my effort into my pre-requisites for medical school and would also mean stop competing in triathlons. I respect the advice from my advisor, but triathlons are such a huge part of who I am and what makes me shine. Succeeding at this balancing act was my goal for the semester and so far into the semester, I am feeling very confident about my results.

In February my twin sister, Teana joined my boyfriend, Greg and I in The Desert Classic Duathlon in Phoenix, Arizona. I participated in it because it was a short race at the beginning of the semester that I could be ready for by training during the winter academic break. After returning from Bolivia, where I avoided training at such high altitudes, I had a month to build enough endurance to at least beat my twin sister who was competing for the first time with me. It was such a joy to watch my sister finish her first run/bike race and to participate in a race with Greg for the first time as well. Greg also got a chance to check out the Scottsdale/Phoenix area's training environment so he can have a successful season in triathlon. 

Teana racing with my 2009 Specialized Allez road bike in her first race ever.


Greg racing in his first race of the season.

I am following the advise of my advisor and have postponed my goals of competing in the Arizona Ironman November 2010 and will not be training for any triathlons this Spring 2009 semester. Fortunately, my life is still filled with the sport because of Greg. I have been able to live in the sport through his training, watching him reach his fitness goals and cheering him on at his races. Even though I am not training or competing- so I can put my time into my academics, I feel that triathlon is still a huge part of my life... allowing me to keep on shining.  

Miami International Triathlon, March 15th


Greg and I before his race in Miami.


Oceanside 70.3, April 4th

In July, Greg and I are moving to Arizona as I establish my residency and study for the MCATS in order to get into The University of Arizona's Medical School- Phoenix campus. I will be taking the Princeton Review MCAT Prep Course and hope to find a job that strengthens my academics. My advisor suggested not worrying about my medical/volunteer work for my application because it is already so strong, but to start to put more emphasis on my academics instead. Also, most medical schools want applicants to have a passion in something outside of the medical field, which is triathlon for me. With this in mind, academics and triathlon remain top priority for me.

Through my recent experiences with surgery in Bolivia and at the Surgical Training Facility, I am more than ever convinced that my passion is my niche. The next year will be spent on doing whatever it takes to succeed with the balancing act in dreams of becoming a surgeon. 

The Right Spot At The Right Time

During the last week of my time at Hospital Juan XXIII in La Paz, Bolivia I was beginning to think of taking the rest of the money that I had left over from the fundraiser in San Francisco and donating it to the hospital to do as they felt necessary. Lucky for Trinidad, I was in the right spot at the right time.

I came into the hospital's Trauma surgery department at 8 am and began doing the normal rounds. I was told there was a new patient who was to have surgery that morning. I became excited- only because I loved surgery, and began reviewing the patient's chart as I walked into the patient's room. When I walked into her room, the nurses were already preparing to relocate her to the OR. I introduced myself to Trinidad. As the nurses were trying to transfer her to the OR bed, Trinidad began asking what was going on. She was scared, crying and had no idea what was happening. The nurses began telling her that she was immediately going into surgery. Trinidad looked at me with tears and fear in her eyes and said, I can't pay for the surgery. At that moment, I just knew why I was put in that spot and I told her not to worry. I told her how I was from United States and before coming to Bolivia, people donated money to be able to help people while I was here. I told her that I could give her $100 to pay for the surgery. Unfortunately, that was all the money I had left and it would not cover the full amount of the surgery. The missing amount was close to $20, which she said she could get from her daughter.

Trinidad is a 62 year old lady who weighs 111 kg. Her weight is considered obese and prevented her from being able to walk correctly. A few days before, she fell and landed on her right leg. Due to the fall and lack of proper circulation, the internal bruising began to swell and cause blisters. Trinidad asked her maid to go get some leaves from a plant she owned. She placed the leaves along the shin of her leg and wrapped a bandage around it- a natural medicine cure she had learned during her indigenous life. The next day her leg began to cause her so much pain, she asked the maid to unwrap her leg. After unwrapping the leg, she found it to be worse then it was before and immediately came into the hospital.

Trinidad's surgery consisted of taking off the layer of skin from the anterior frontal compartment of the right leg, then scrapping and cutting through the layers of adipose tissue and muscle to rid of the black, dead tissue that had resulted from the forceful trauma. The leg was left with no skin and required many surgeries to repair- which meant much more money was needed. We covered the open wound with stuff to prevent infection and dressed it in gauze.

I knew that the decision to help Trinidad was right, but I received different opinions from others about it. The plastic surgeon told me that I shouldn't give the money to "the fat lady" and instead should give it to the baby on the 4th floor who had been abandoned by its mother in the hospital. I can understand that the plastic surgeon has had his share of cases where people could not afford the reconstructive surgery necessary and his years of experience has lead him to devise such an opinion about helping those in need. He felt that "the fat lady" was undeserving of the money compared to the abandoned baby. Well, who's to say who is more deserving? I could make an intelligent guess, backed by my experiences to make a decision but my intuition and my heart told me that I was meant to be in that spot at the moment that Trinidad was asking for money. I don't regret my decision and told the surgeon I didn't think of her as "the fat lady" when I made it.

After Trinidad's surgery, I went into her room to see how she was. She was in a lot of pain but happy to see me. Her daughter, Veronica Perez was there by her bedside. Trinidad, who kept calling me "Doctor", could not stop expressing her gratitude. She kept asking my name so she could pray for me everyday. She held my hand and cried. I could barely hold back my own tears but I remained the professional and just smiled back at her. She told me, what goes around comes around... someone will help you out as you've helped me. She was so right, except I knew that I had already been so fortunate in my life. I could recall all the recent acts of kindness from so many special people... Mom, Dad, Frank, Miguel, Thelian just to name a few. Remembering all the acts of kindness that I have been blessed with in my life made me feel that this was just a tiny piece of what I needed to give back. I look forward to being in the right spot at the right time again.

Dressing the wound at the end of the surgery.



Trinidad waiting to come off of the anesthesia after surgery in the OR.

To view graphic photos of the surgery, click here... Trauma Leg Surgery

Hospital Memories

Anesthesiologist in OR

Casting a 19 day old twin with deformed feet

Clinics in Hospital Juan VVIII

OR in Hospital Juan VVIII

Inivido (Trauma patient with destroyed foot tendons and skin)

Trauma Surgery with Dr. Angulo

Dr. Angulo receiving medication from medical sales rep during clinic, Karen (Trauma Nurse)

Alvaro and Ma. Alejandra (my favorite Surgery Interns)

Antonio (University Volunteer-- 1/1000 diagnosed with Denge), Alejandra (University Nurse), Juanita

 

Hospital Rounds at 9 pm.

Jorge (Trauma patient- hit by a car, no injuries)

Nurses at Hospital Aymarra

Alvaro (Surgery Intern) and Trauma Nurse

Hip Dysplasia

Uncommon in United States, half of Dr. Angulo’s clinical patients are referrals from pediatrics to confirm hip dysplasia in babies under 5 months old. Babies after 3 months old are usually referred to an orthopaedic specialist for confirmation that their hips are growing correctly. Hip dysplasia is when the hip bone shifts up and the humeral head shifts out of the socket. The model shows that the yellow part of the humeral head has shifted out of the socket. It can be genetic or formed due to positional circumstances.

It is assumed that babies in Bolivia, and not in other countries, commonly get hip dysplasia because of the way they are positioned during the first few months. The babies are positioned with their legs side by side and wrapped tight in a blanket that goes on the mother’s back to be carried. In this erect position, the baby’s legs are straight, the humeral head faces internally and that forces the hip bones to shift externally. In contrast, American babies are usually carried in the mother’s arms with their legs spread around her side. This position allows the baby’s hips to grow properly because the hip bones are ideally opened up. It is very important to diagnose it as soonas possible to allow repositioning of the hip joint before 5 months, and even more important before 14-16 years old.

When a baby’s x-rays were brought in for review, I measured the hip angle to diagnose hip dysplasia. A line is drawn from the bottom of the pubic arch to the lateral sides of the ishium. This angle must be lessthan 24 cm to be considered healthy. A diagnosis of hip dysplasia is given when the angle is more than 24 cm.

This x-ray shows the left angle at 3o cm and the right angle at 37 cm. A diagnosis for severe hip displaysia.

When the hip is diagnosed early, treatment can correct the deformation. Treatment includes an apparatus (cost is about $11) that holds the femoral bone externally rotated with the legs spread. The apparatus (shown on left) is worn for a minimum of 3 months, 24 hours a day. After the third day, the apparatus can be taken off for 15 minutes to give the baby a shower but must be put on immediately. If the dysplasia is minor, exercises are prescribed. The exercises include moving each hip joint in 10 circles 3 times separately with each side every day until the dysplasia is gone.

Today a 5 month old baby came in and I measured 30 cm on the left hip and 35 cm on the right. In November, the patient was measured at 27 and 27 cm. Within two months the baby had grown hip dysplasia. An apparatus was given to correct the deformity. Another 7 month old came in who had a 38 cm measurement on the right side. Because the baby had gone so long without treatment, the acetabelum had grown a roof (it takes about 11 months to form) and would not allow the humeral head to be pushed back into the socket with treatment alone. In this case, surgery was the only treatment so that the acetabelum could be chipped away at to allow room for movement in the socket.

For most patients living in Bolivia’s indigenous communities, no access to pediatrics, or the Bolivian pediatric doesn’t properly diagnose nor refer thepatient to an orthopaedic specialist, the patient can go undiagnosed and untreated for many years. Going undiagnosed between the ages of 14-16 years old is the most dangerous. Bolivian doctors end up seeing patients who are well into their adult years for hip dysplasia. This is when surgery is the only option.

Hip dysplasia surgery for adults is dangerous and very invasive. If the cartilage in the hip’s acetebelum is still intact, a procedure invented by the Swiss is performed. Most likely, the hip is arthritic. That was probably the primary reason the patient even went to the doctor in the first place, and then happened to get diagnosed with hip dysplasia. When the hip is arthritic, arthroplasty is recommended to replace the arthritic femoral head and acetabelum.

Arthroplasty is very common in United States. 168,000 Americans undergo hip replacement yearly. I have done research and have viewed many hip replacement surgeries by the popular Orthopaedic surgeons (Dr. Bozic, Ries, Jergesen, Vail) at UCSF Medical Center in San Francisco, California. Patients are always pleased and the outcomes are very beneficial for the patient to continue living a normal and active life.

Hip replacement surgery involves making a large lateral incision at the hip, dislocating the hip joint, the femoral head is cut off and then the acetabelum is reamed. A plastic liner is placed in the acetabelum and a metal femoral prothesis is cemented into the hollow hole made in the femoral shaft. Finally a metal ball is attached to the femoral stem and then hip is placed back into the socket.

Last week, my uncle and aunt invited me to have dinner with them at Dr. Cruz’s house. Dr. Cruz and his family are good friends with my mom as well. I was told that Dr. Cruz was as famous in Bolivia as the other Trauma and Orthopaedic surgeon Dr. Zalles from Hospital Juan VVIII, where I was working. He greeted me with a huge hug and immediately started asking me questions. He had to leave for an emergency call but when he came back we talked about, well surgery of course!! He was one of the smartest and friendliest older man that I’d met, which made our conversation so easy.

When he started sharing his new invention for a hip replacement, our conversation just flowed because that was a topic I knew all about. I told him how I worked at The Biomechanical Testing Facility in San Francisco General Hospital. Everything just clicked and we both started scheming how I could help him bring his invention to United States. With a huge smile on his face, he invited me to his office for an interview. That smile plastered on his face the rest of the night was enough motivation for me to go all out with this project.

I went to Dr. Cruz’s office as the first part of the project. He spent an hour explaining his procedure with me. It was something I had pondered about myself so I was very interested. His procedure follows the regular steps for a hip replacement (refer above) up until the plastic liner is placed in the acetabelum. Before the plastic is placed inside, he carves a very special angled triangle into the bone superior to the acetabelum with a special drill saw. He then uses the femoral head bone that was cut off and shapes it to fit like a puzzle into the angled triangle. He either makes the triangle too small or the femoral head piece too big to purposely make a tight fit in order to initiate the like with like rule. Sometimes if the fit is tight enough, he skips using a screw to keep it stabilized. The purpose of this procedure is to make a perfect fitting superior surface for the plastic liner. His theory is that the plastic liner, which can be cemented or screwed into the acetabelum, can move and therefore cause another displacement. Some older patients that grow arthritic hip bones no longer support the screw holding the plastic liner in place and allow the liner to shift, which requires another surgery. Dr. Cruz’s invention has proven to avoid this for hip replacement patients.

Dr. Cruz’s procedure is currently being used by himself and other local surgeons in Bolivia and is titled, “Encastrado de Cruz” (Encased by Cruz). There is another doctor in New Zealand who had invented a procedure similar to his and they are currently competing for the title. Dr. Cruz plans on attending the World Congress Conference in a few months in New Zealand to try to beat his competitor. My plan is to do a research project in San Francisco, demonstrate that the procedure is worthy compared to the original one, publish the article in a medical journal and have Dr. Cruz come work with the surgeons in San Francisco. Seeing his smile again is worth all the work.

To view more photos of the procedure, click here... Dr. Cruz

Hip Fracture Repair

A very thin older lady fell on her left hip due to lack of muscle strength and fractured the left iliac crest and pubic crest (refer to CT scan below). Working with a thin body is ideal because there is little tissue (muscle and adipose) to work through. Had I not seen this lady's face, I would have thought she were a child. 

Before the surgery, everyone kept remarking how long it would be and how it was going to last the whole morning. I really had no worries because I already knew that hip surgeries are of the longest lasting and require a lot of work. I had observed hip replacement surgeries with Dr. Bozic at UCSF Medical Center, but this was to be my first assisting a hip fracture repair. The team consisted of Dr. Angulo, Dr. Chavez, Dr. Lopez and I. Dr. Angulo came in briefly in the middle so it was Dr. Chavez, Dr. Lopez and I working together for the first part. 

We started by disinfecting the entre hip area and then wrapping the patient's hip with a yellow plastic before the incision was made. I waited for the doctor's instructions about how I could be of best assistance. Dr. Chavez was directing and asked me to hold the patient's leg at the knee.

As I was holding the knee, he said, "alto". Alto in spanish is not a command, instead it means either stop or high (as in blood pressure). With the mask covering the doctor's mouth, it was already hard to hear his commands. I didn't know if he was talking to me or the other doctor until Dr. Lopez grabbed my hands and lifted the leg up with me. Then Dr. Chavez shook his head and said, "tonta". Tonta means stupid in spanish. 

Later, I confirmed with several people that "alto" doesn't mean lift up, nor is it a command. He's tonto for speaking improper spanish with an American. I paid no attention to his cockiness because I knew he hadn't earned it until he spent his vacations in another country volunteering his medical services. Dr. Lopez, prior to surgery, overheard a conversation I was having with another surgeon about how I have been spending my vacations volunteering and learning about medicine in other countries. As he listened, he was inspired and asked me how he could get into something like that. That day, his inquisitive earned my respect but Dr. Chavez completely lost mine.

The surgery began with an eight inch lateral incision along the left hip. The muscles that are visible once the incision is open are Rectus Femoris, Ilio Tibial Band, Piriformis, Gluteus Minimus and Vastus Lateralis. There are many femoral muscles to cut, grab insertion end with forceps to tag and allow visibility of the femoral head. The Rectus Femoris overlaps the femoral head, which prevents the ability to dislocate the femoral head from the hip's acetabulum. Therefore, the Rectus Femoris is cut and a vertical cut is made through the head of the femur. The bone is cut by hammering into a thinned bottom metal tool (the only tool I don't know the name for). The femoral head is gradually cut through vertically and placed aside with the Rectus Femoris still attached. The hip is then dislocated by forcefully pulling the leg in the opposite direction of the hip's acetabulum once the surrounding muscles have been cut through, no longer allowing their integrity of the hip socket. 

Once the hip is dislocated, the pubic crest where the fracture is located. The area of the fractured bone is palpated and drained several times to allow a clean and visible bone to put

the metal plates (refer to left). A bending template is used to measure and predict the shape of the metal plate that will be placed on the bone. A bending iron is used to help mold the bending plate. The metal plate is then chosen according to the length and bended with the bending iron to mimic the bending template. The metal plate is then placed on the bone and with a drill sleeve, a hole is drilled into the bone for the screw. A depth gauge is used to measure the length of the hole in the bone. The length is used to chose the screw and the screw is then hand screwed with a T-handle screwdriver or a regular screwdriver, predicting an angle that won't make the screw come out any of the sides. Oblique angles are usually the best for stability. 

Two plates were used on the pubic crest before opening up the superior part of the hip to correct the iliac crest. The fracture was palpated, confirmed with the x-rays and drilled into to place the plate. The wound was then sutured. The bone that was removed from the pubic crest was taken aside and the attached muscle was cleaned off of it. The clean bone was then then placed where it was removed. This procedure follows the surgeon rule: like attaches to like. Muscle will attach to muscle and heal itself that way and the same goes for bone. All the muscles linked with forceps were attached to its insertion with sutures and the muscles that were moved were gradually placed in their proper position. 

The periosteal elevator (shown on left) separates periosteum (bone connective tissue) from the bone. This tool was used to scrape the part of the femoral head that was cut before two screws were used to connect the head back together. This procedure follows the like attaches to like rule. When the perioseum is removed from the bone, it helps to initiate the healing process and the bone heals on its own.

The lady stayed awake during the whole surgery and silently prayed. It was the anesthesiologist who told us what she was saying. It was a four hour surgery and you could hear her mumbling the whole time.  I enjoyed feeling her stomach move as she breathed when I had my hand against her front pelvis to keep it stabilized during the drilling. Once when I had a hold of her leg to keep the femoral head internally rotated, the whole thing moved while the doctor burnt away at her nerves.  These natural reactions were comforting. I was relieved to know I was working on a live person because I've been so used to practicing surgery on cadavers.

The World's Most Dangerous Road

I went with a group of 17 tourists and 3 guides to the mountain tops in Bolivia called La Cumbre at 4,700 meters above sea level. My uncle Thelian, aunt Beny, and friends: Leonardo, Sylvia and Sylvana followed behind our group in a suv like my camera crew. I began my decent at 9:30 am for 12 miles of paved road for 30 minutes on my haudralic braked mountain bike. The decline was at most 80 km/hr and 34 mph average. This first part of the decline was the safest with wide roads that reminded me of riding in the bay area. We stopped several times along the way to take pictures and make sure everyone was caught up. The picture above shows me at one of our stops with the tourist group's special uniform and dorky helmet on.

The climate changed drastically throughout the decent. It went from freezing cold, due to the altitude, to rainy to windy to hot. I eventually took off my pants and wore my shorts, which made my legs feel so much better after the allergic skin reaction I got. I also felt allot faster with my legs free and feeling more like I was on my bike in the Marin Headlands. 

My uncle Padre Thelian Corona (above with video camera) chased after us in car with video camera in hand. Every time the group stopped, he jumped out of the car and filmed the group, narrating each detail of the adventure.

Someone from the group told me, I'm not sure who's having more fun, your uncle or you. My uncle and I are still arguing that one out. Watching him film me doing what I love to do was one of the most enjoyable things about my adventure and he was happy to be apart of what I loved to do. At least I know I burned more calories then him.

The second decent for about 20 miles was the part known as the "Most Dangerous Road in the World". There is an old path that cars and buses used a few years ago that displays crosses along the side of the road representing the hundreds that have died. They most recently built a new road where the cars and buses now drive and can cross more safely. We took the old road, staying on the left (part of the rules-- the left is the clift side?!) and the cars stayed behind us. Sometimes my family and friends drove right behind me and filmed me cycling until I passed people and got too ahead of them for them to follow. I had no idea they were behind me until I saw the video later. The road consisted of rocky, steep roads and views of beautiful green covered mountains and waterfalls fresh from the day's rain. It was my first time mountain biking but I got used to it fast and spent the last miles of the decline racing my male competitors. 

After 30 miles and a decline from 15,158 feet to 3,636 feet, we stopped in a tropical town called Coroico to jump in the cold pool and enjoy an indoor buffet. I was lucky to have my friends and family with me to enjoy the long decline. We all happily ate pico de gallo Corona style and enjoyed the Bolivian beer. We left around 4pm, drove into the town of Coroico and then drove 3 hours home uphill in the rain.