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Student Reflections

Organ Transplant

Brett Simchowitz, Class of 2013

I found the longitudinal organ transplant experience to be a highly valuable opportunity for a number of reasons. It gave me insight, from a patient's perspective, on the way in which healthcare is delivered over time and across specialties; it presented a highly successful effort by traditionally discrete branches of the delivery system to integrate care; and it offered a rare glimpse into the pool of emotions and motivations that underlie the intensely altruistic act of living organ donation. Organ donation, perhaps more so than many medical specialties, requires close collaboration between the surgical and medical teams, for the sake of both the recipient as well as the healthy donor. Transplant services at UCSF and elsewhere have made significant efforts throughout the process to integrate care, from the multi-disciplinary transplant boards where cases are discussed around a conference table to the coordination of medical and surgical appointments at the same visit. The donor pair I followed, a young woman and her diabetic stepfather, clearly benefited from streamlined communication and from the guidance of a dedicated nurse practitioner who synthesized information and provided regular follow-up by phone and in-person. A social worker was available to the pair to think through the financial and psychological implications of undergoing the operation and to assist the pair with numerous logistical hurdles leading up to the transplant. And while both patients recuperated on the wards in the days after the surgery, a transplant-focused pharmacist helped manage their complicated medical regimens.    

All that hard work seems to have paid off. From what the two shared with me during my time with them, both before and after the surgery, the experience was far more difficult than they anticipated but also far more rewarding. 

Kathy Hamlin, Class of 2013

As someone who is not particularly planning on going into surgery, I thought this elective was an excellent, low-pressure way for me to get more of a feel for what surgery is like, both from a provider's perspective and from a patient's perspective. It was my first time watching an entire surgery, start to finish, in the operating room. It was also my first time experiencing pre-op and post-op appointments and rounds. This elective provided a rewarding, low-pressure and enlightening introduction to surgery.

Interacting with the patients and watching how the doctors interacted with the patients was one of the most rewarding aspects of the elective. It was inspiring to see how much the patients appreciated all of their providers. This must have been an incredibly stressful time in their lives, but with the help of their nurses, physicians and surgeons they took it in stride. I was impressed by how warm the surgeon was with his patients and with how clearly he explained the procedures. The nurse practitioner was more brisk but also very skilled at interacting with patients. It was interesting to see how the different disciplines worked together so closely in the care of the transplant patients. The patients themselves were friendly and open to our being there. We didn't do much other than sit there and watch during their appointments, but still they greeted us with warmth when they saw us, and joked about us not bringing Junior Mints into the operating room.

Perhaps the most surprising aspect of the elective was the observation of the transplant selection committee meeting. The meeting was focused and directed, with an emphasis on achieving the most practical outcome possible. There was something very utilitarian about the proceedings. But choosing who does and who does not get a new chance at life by way of a transplant seems like the closest you can come as a doctor to playing God. My mom's cousin's son and daughter recently went through a kidney transplant as a donor-recipient pair at UCSF, and I couldn't help but think of them as I left the meeting.

This elective gave me a unique perspective on what goes on before, during and after transplant surgeries. I appreciated hearing from the patients and providers alike, and I would recommend the course regardless of a student's interest in a surgical career.

Donor Runs

An Anatomical Mystery Tour - Bogdana Kovshilovskaya, Class of 2013

10pm - Donor Runs Pager goes off
12am - Get into a black van in front of Moffitt Hospital
1-6am - Participate in an organ procurement surgery in Enloe Hospital - Chico
7am - Get back to San Francisco in time for class
..All in all, arguably the most amazing night of my life.

In the van on the way over I talked to the surgeons: a transplant fellow and a fourth year resident about their experiences, their exhaustion, their excitement and their emotions. I didn't know anything about the patient except that her BMI was the same as mine, and it scared me because I was afraid it would be a young woman like myself. I had an emotional experience earlier in the year where a patient my age was in the hospital and getting his history moved me to tears - I was afraid that I would have a similar reaction to a young woman that would be undergoing the surgery. Either I was able to distance myself, or that I was so excited to be in the surgical setting, or that she was thirty years my senior - or most likely the combination of the above, but I was able to maintain my composure and assist in the surgery, all the while being amazed at the human body.

The first thing that the fellow told me was that I was lucky, and that this would be a great surgery for me to watch. The patient had very little adipose tissue and all the organs and vessels were very visible. I had an anatomy lesson in the operating room, and I was amazed at just how different everything looked when it was mobile and not fixed. I remember being most amazed by the gallbladder, which looked nothing like it did in the cadavers in anatomy lab. The surgeons "pimped" me on the anatomy and I was very impressed with how much I was able to recall! They were very friendly and had a great working dynamic with one another and with me. The surgery itself took a little over two hours - they removed the kidneys for transplant and the lungs for research, and I was allowed to close up the body, under the watchful eye of the resident and fellow. It was a very moving experience for me, not to mention practically challenging to sew up a human body, and with some luck and a little bit of procedural memory I was able to get a nice running stitch from the lower abdomen to the umbilicus and one more from the umbilicus to the thoracic cavity. Closing up the body made me think about how much of who we are is concealed under the skin, and yet how little that defines us.

This woman donated her organs to save someone else, to improve someone else's condition, to leave a lasting mark on the world - those desires and that commitment were not in her liver that I was able to palpate, not in her gallbladder that startled me when I first saw it, and not in her heart that I held as it was fasciculating after being removed from the body - it wasn't her anatomy, it was her being, and I feel privileged to have had the opportunity to learn from this woman, even after she lost her ability to communicate that lesson.

Ryan Lee - Class of 2013

When I began medical school, I made it a point to remain vigilant and circumspective in my growth as a student. I'm now halfway finished with my first year of school and I can already exact the turning points that are shaping my values as a future physician, as well as my understanding and expectations of medicine's role in the cycle of life and death. For me, this cycle came around during my procurement run.

I was handed the pager on Friday, about a week before it buzzed. It's every medical student's dream to carry the pager, to feel some utility. But the pager wasn't ringing out of its clip, however. It was sitting there quietly, like a ticking time bomb-its mere presence shook my nerves to the point where I'd wake up dreaming it had rang, only to see that the LCD screen still read "calm down, still no new messages". Lying back down, I realized how strange it was that my excitement was completely dependent on a patient's death, a thought that persisted for the first couple of days that I had the pager. But as the days passed, the routine wore down my anticipation and I began to absorb the anxiety. 

I've had this sentiment before. Dissecting cadavers, interviewing patients, and interacting with doctors used to make me anxious, but are only now beginning to feel routine. Holding the pager was the same; it's an experience that I feel is initially frightening, but will eventually become regimen. 

On Thursday, the pager buzzed. My hand, on standby for the past six days, shot into my pocket and flipped it open. It was anti-climactic: "Pick up 10:30pm" is all it read. I joined Dr. Vagefi and the rest of the transplant team in the van and we made our way to Castro Valley. I wasn't nervous-I had observed many surgeries at UCSF before. But when we arrived at the Eden Medical Center's operating room, something felt different. The OR suite wasn't crowded with surgeons and nurses, and the waiting rooms weren't full of patients and families. The entire hospital was quiet in the night, with plenty of empty ORs waiting for just the six of us. A middle-aged woman was wheeled down the empty hallway on a gurney and prepared for procurement. As I helped move her from the gurney to the operating table and prepare her for procurement, I felt her warm skin against my gloves and I saw her chest rise and fall with each breath, in sync with my own. Dr. Vagefi made the first incision, not just a few inches across the abdomen as I had seen in other operations, but rather from the suprasternal notch to the pubis. The entire body cavity was exposed, and a strange feeling swept over me. To me, this was not a cadaver; her tissues were bright pink and pulsating with the beat of her heart, pumping in the mediastinum. 

As the operation proceeded, Dr. Vagefi and the transplant team worked with incredible efficiency, each step completed with confidence and with perfect communication as if they were actors reading a script. Dr. Vagefi was constantly updating Dr. John Roberts, who was preparing the recipient for transplant at Moffitt-Long. I realized that my own interest in surgery is partly manifested by the confidence and dependence on teamwork. 

Dr. Vagefi and the rest of the team spoke to me throughout the entire procedure, quizzing me on different aspects of transplantation and explaining the variations in the patient's vessel anatomy. I had thoroughly reviewed the ACS chapter given to us by Dr. Vagefi, but I was quizzed until I couldn't answer any more of his questions. I realized that surgical education is different in that students need to be assessed before any direct teaching begins, which therefore makes it critical to do as much self learning before the most difficult concepts can be taught.

When it came time to flush the organs with UW solution, I watched the monitors suddenly become irregular until finally the beeping was silenced and the anesthesiologist thanked and dismissed. The donor's body cavity had been filled with ice, her face no longer flush, but rather pale and withered. It was the first time I saw a body make the transition from person to tissue and my thoughts jumped from the thrill of observing Dr. Vagefi to the family who had lost their loved one just hours before. The placidity of the operating room as the liver and kidneys were packed away brought on a feeling of dejection in me that lasted throughout the ride back to San Francisco. 

Once we arrived at Moffitt-Long, I rolled the cardboard box into the hospital and through the OR doors, where I was surprised by the scene: the recipient, a young man in mid operation, was surrounded by surgeons, carefully resecting a cirrhotic liver, and anesthesiologists, attentively monitoring a regular heart beat. This operating room had a vivacity that dissolved my despondence as I watched Dr. Vagefi clean the liver for transplantation. It was life being given to a man with liver failure-and my thoughts went from the death of the donor to the new life of the recipient. 

This experience was and will be one of the most memorable events during my time at UCSF. I have not only learned the subtleties of organ procurement and transplantation, but also how to approach new situations in order to benefit the most from each new environment.

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