Day 3 of General Surgery - Sean

Waking up early was a little harder today, but not so much. I was looking forward to see how many patients there would be during rounds this morning. As usual I arrived a little early. Once my preceptor and one of his residents arrived we all sat at the computer station and they reviewed the status updates of the patients to be seen. Dr. Yu told me that it was important to do the workup correctly and accurately prior to surgeries in order to assess the possible risks of different surgeries.

Today I would count 22 patients. That was a lot more than yesterday. Although it took slightly longer, it still consisted of brief interactions. I noticed that more of the patients today also seemed to have non-surgically related chief complaints. It was then that Dr. Yu enlightened me about the freedom of Taiwan's National Health Insurance Policy. If, for example, a patient required surgery and went to Dr. Yu to perform that surgery, often times that patient would build trust with him because the surgery went well. Because the health insurance policy allows people to see whomever they wish, the patient is allowed to see Dr. Yu (a surgeon) for any problem he/she may have no matter what it is (i.e. fever, headache, stomach problems). This was interesting to me because that means even though Dr. Yu is a surgeon, he must be well grounded in other respective fields so that he may have the knowledge to treat these patients' other ailments. Dr. Yu had confirmed that it was a lot tougher in that sense, and also that it kept him a lot busier because he was challenged to focus on more than his main surgical patients.

Some of the interesting cases I saw today:

• A patient presented with Post-Transplant Lymphoproliferative Disorder (PTLD) following a liver transplant. This condition describes when B-cell lymphomas occur as a result of infection with the Epstein-Barr Virus while immunosuppressed. It is fairly rare occuring in 0.2% of patients within one year of transplant. The original plan had been to take the patient off of immunosuppressive drugs to allow the immune system to rebalance. Dr. Yu palpated the patients lymph nodes and stated that compared to 1 week ago, they decreased in size.
• Many patients that underwent surgery the days before had been examined for follow-up, including: latharoscopic cholecystitis patient (entry point stitches), herniorrhaphy patient (examined stitches for appropriate healing), another partial hepatectomy patient.

I was pimped during rounds as Dr. Yu asked me about the blood supply for the different segmets of the GI tract. However, since I told him I had not had the anatomy yet for that system, he sort of rescinded the pimpage and actually explained it to me. The foregut receives arterial supply from the celiac trunk, and includes the structures from the distal third of the esophagus to the duodenum. The midgut has arterial supply coming from the superior mesentery artery, and includes the structures from the duodenum to the proximal two-thirds of the colon. The hindgut has arterial supply from the inferior mesentery artery, and includes the distal one-third of the colong to the upper part of the anal canal.

Dr. Yu gave me an important lesson about surgeons following that experience. "A surgeon must always be aware of blood supply and anatomy." Mastering these is what distinguishes a remarkable surgeon. Afterwards it was off to the OR. There were quite a few surgeries going on at the same time, so I was able to float around among them. As many of the surgeons were Dr. Yu's colleagues and residents, I became a familiar face and they began explaining more about the prep

Here is a brief list of the surgeries that I was able to observe:

• Modified radical mastectomy --> involves complete surgical removal of the breast, while sparing the pectoralis muscle
  
• Radical proximal gastrectomy --> the first half of the stomach was removed to treat cancer findings; then the esophagus was anastomosed to the distal half of the stomach.
  
• Hepatectomy of segment 6 and partially of 4/5 --> repeat
  
• Latharoscopic cholecystitis --> repeat

Here is an image of liver anatomy to get a sense of the location of these segments:

Overall a good day with lots of variety in clinical rounds and the operating room. Unfortunately, tomorrow will be my last day. It has been wonderful so far, and I hope I get to see as much as I can to make it worthwhile.