The day began with a slight miscommunication between myself and the surgeon I was set to shadow. I didn’t know where to report and who to report to. This was my very first surgical experience during my internship in California this past summer. I frantically walked to the hospital registration desk and asked them for directions to the Operating Room. They gave me a map, verbal directions and motioned me to the elevators directly behind the desk. Fortunately, a man in scrubs was heading to the OR and volunteered to take the elevator with me. Next, he badged me in through what felt like the doors of no return.
When I entered the surgical suite, I was directed to the charge nurse who oriented me to the changing room. Lined with fresh steal blue linen and boxes of surgical gowning supplies, things started to get real. My hands were shaking a bit until I heard somebody walk in. It was another doctor who came in and began undressing right in front of me into her surgical scrubs. I immediately asked, “is this where we’re supposed to change?”. She laughs and says “ugh yea we’re not that fancy. It’s okay I won’t look”. I reassured her that I was a summer intern and wanted to be in line with protocol. She was persistently texting and ignored my redemption of “newbie” awkwardness.
After that encounter, I nervously thanked her for…answering my question. I was then led to the operating room with the charge nurse.
When I entered the room, there was a team of two Nurse Anesthetists, one Registered Nurse, an Operating Room Technician, and one Surgeon. Before I could advance my third step and strike my Dansko heel to the floor, I was intercepted. I was intercepted by the nurse who laid down the OR ground rules. I won’t list them all here but because I wasn’t fully “scrubbed in”, I was to follow these 2 golden rules.
- One must be aware of ALL sterile fields. A sterile field is draped in Blue or green.
- You cannot touch anything in the sterile field or anyone “scrubbed in” wearing a sterile gown.
The room had a metallic purified air aroma. The temperature was like an early morning in November. The circular ceiling light beam was gleaming down on the focal point of this surgical scene. What I observed next would be a masterful operation of a disease often viewed before the world stage.
The patient was lying supine on the surgery table while attached to IV lines and leads connecting her to vital sign monitors. She was under anesthesia; a state of unconsciousness that occurs in phases like a very deep sleep coupled with unresponsiveness, amnesia, and immobility. I wondered what thoughts could be going through her mind because so many were going through my own.
I wondered how old was this patient? Why was she here? Does she have children? What does she do for a living? Will she make it through this surgery?
Oh god, I really hope so.
My thoughts remained rambled and I kept creating fictional anecdotes of who this woman may be in the grand scheme of society. I wasn’t exactly sure of the indication for this surgery but I knew this was something life changing.
The surgeon was very busy with the procedure, so I stood on a stool and observed her technique from afar. She nodded and said “hello” and remained standing, head flexed and focused.
I observed the surgeon using a tool that was essentially burning away tissue and removing a pearl colored, glistening substance that was surrounded with fatty tissue and blood vessels. The surrounding tissue area turned out to be the right breast, which had been opened into a tissue flap. It was then that I realized, that the surgeon was removing a cancerous lesion. This was such an eye-opening experience to see that insidious, nondiscriminatory, pestering tumor in boldface.
As a medical student, I have held an active role as dissector in Anatomy Lab and I have cut through muscles, fascia, and fat but this looked nothing like that. These tissues were viable, actively bleeding and appeared to be much more demarcated than the cadavers in the anatomy lab. To be honest, I expected to see more cutting and scalpels but instead, the surgeon used a cautery. This is an instrument that simultaneously cuts away at the skin and provides immediate hemostasis aka (stops the bleeding).
As medical “pimping” tradition goes, the surgeon randomly quizzed me on the spot. She asked me which nerves were running along the surgical plane of the mastectomy. Those nerves were the long thoracic and thoracodorsal nerves. I remembered one out of the two. Sorry, Dr. Rich!
About ten minutes later, the surgeon informed me that she was performing a mastectomy which in this case was a nipple sparing mastectomy procedure. This procedure makes the mastectomy slightly more difficult because the surgeon must work within a confined “pocket” of tissue and this patient had very little breast mass for that leeway. I watched as the surgeon occasionally struggled to maintain a comfortable and plain view of the surgical field. In between that, Dr. X would share some research literature about breast cancer and surgery. According to the surgeon, the patients’ presenting symptom of breast cancer was nipple discharge.
In my observation, there was a lot of burning of tissues with subsequent bleeding followed by suctioning. Every shearing force and a cloud of smoke that rose to the ceiling was gradually eradicating cancer from the body.
In surgery, margins are important as they outline cancer and often some excess tissue borders as well. Hopefully, the suction did away with all the tumor cells.
The final part of the mastectomy was making an incision into the axilla and extracting several lymph nodes to locate the sentinel node. The sentinel lymph node is the lymph node that cancer is first to spread too if located in the upper outer quadrant. The lymph node will then be sent to a lab and analyzed to see if cancer has spread.
The second part of the surgery was the reconstruction portion. Some patients opt to have their breasts reconstructed to a satisfactory esthetic.
A new surgeon arrived in the OR for this portion. Coincidentally, it was the same doctor who I had spoken to in the locker room. I will call her Dr. M for practical purposes. Dr. M explained that due to the size of the patient’s breast, she would need an expander placed prior to inserting the implants because this patient will need radiation therapy following surgery. After radiation therapy, it is likely that the skin and breast could shrink and cause intense complications for the patient. The expander prevents such occurrence.
So, the breasts were irrigated and sterilized with a watery solution that disinfected the tissues. The expander and implants were placed and the surgeon sutured the breast closed, cleaned the patient and surgery was complete. This part of the surgery didn’t take as long as I expected. I think It took 30-45 minutes from start to finish which I found remarkable.
I hope and pray that surgery and radiation will be enough to eliminate cancer from that patient’s body. I don’t know the complete diagnosis or prognosis of that patient and I most likely never will. She’ll never know this, but, her surgery made a lasting impact on me. I hate this C-word. It kills me to hear another diagnosis or life lost to this disease.
Like this patient, whose body was only partially revealed through the surgical field, it showed me that cancer has no face. breast cancer has no sympathy or empathy. It can affect anyone of our friends, relatives, or colleagues. In fact, breast cancer affects 1 in 8 women each year. We can only be grateful for our present state of health and pray for those currently undergoing treatment, surgery, and management of breast cancer. Rest in power to those not here with us because you fought a hard fight. Until we find a cure, the battle rages on.
Please remember that early detection is crucial and that can start at home. You can start by doing regular self-assessment breast examinations and keeping up with your doctor visits and screening protocols. I have linked a few resources below for more information on breast cancer prevention and treatment.
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