The Layers of Medicine: My Summer at Stanford
“Can I get a 5:0 Monocryl and 6:0 Fast Absorbing Gut?” I thought after hearing Dr. Aasi repeat the remark over fifteen times a day through the span of my internship I would get tired of the phrase, but the request was precedent to surgery and watching Dr. Aasi perform surgery was number one on my list of preferred summer pastimes. During the short amount of time I was able to spend at Stanford Medicine shadowing Mohs practitioner and surgical oncologist Dr. Sumaira Aasi, I learned more about the nature of doctors and their teams than I did about the details of medicine. Of course I was intrigued by the effectiveness of Moh’s medicine in removing basal cell carcinomas and the many reasons skin grafts can die after being sutured to an open wound and the exact temperature of liquid nitrogen–all fascinating topics of conversation–but the paramount take away from my summer at Stanford was being able to observe the intricate workings of a hospital clinic.
Dr. Aasi and her team resemble a house of cards. It seems as if they can read each other’s minds, always knowing the whereabouts of every patient’s wandering family members and the next tool Dr. Aasi needs placed in her hand. The team flows, with every factor of the equation solved for. One nurse enters a room as soon as the first exits, the rooms are prepped just in time for the doctor to enter, and the slides are presented at perfect moments between surgeries. There is an unspoken understanding of the way things need to go. My first few days of the observership I was following Dr. Aasi around like a lost puppy, equally befuddled and awed at the clockwork that was their clinic.
The Outside: What Field of Medicine?
Dr. Aasi performs surgeries regarding lesions on the skin that can take the form of basal or superficial squamous cell carcinomas, cysts, lipomas, or keloids. Basal and squamous cell carcinomas are skin cancers that are contained in the outermost layer of the skin, the epidermis. The cells on the topmost layer of skin are called squamous cells, which are constantly shedding and being replaced by basal cells, located in a lower layer of the epidermis. Basal and sqaumous cell cancers are most commonly developed from sun exposure and poor sun protection. They are found in areas such as the face, back of the neck, arms, ears, or hands. The most common type of skin cancer is a basal cell carcinoma, a slow growing cancer that is minimally invasive and rarely spreads throughout the body. A squamous cell carcinoma is less likely but has a higher likelihood of spreading to other parts of the body because it is found in deeper layers of the skin.
The two main surgical procedures to treat these carcinomas are Mohs surgery and excisions. The Mohs procedure is practiced when there is a skin cancer present on visible areas of the face. Mohs is beneficial because it preserves as much healthy skin as possible and keeps scarring to a minimum. This treatment involves subsequently removing layers of skin that contain malignant cancer cells and immediately sending them to the lab for analysis of leftover tumor. If cancer cells are identified under the microscope, the doctor goes back in to remove another layer of the skin, and the process is repeated until there are no leftover cancer cells. Similar to removing a rotten chunk of an apple, the removed portion is tested for residual impurities. The process is repeated until the patient’s slides are all cleared, Dr. Aasi averaging between one to three stages per patient.
An excision surgery is performed when the skin cancer is located in more conservative areas of the body such as the back, chest, or abdomen. The procedure removes a larger portion of the skin and cuts deeper than Mohs procedure. The doctor incises around a predictable margin for the tumor and immediately sutures the incision without waiting for lab results. Then, the sample is sent to the lab and the team notifies the patient of the results in a few days.
The Middle: What I Learned from Watching Surgery
The first surgery I watched was a Mohs procedure on the outer cartilage of the ear. After the nurses numb the area by administering shots of lidocaine with epinephrine, Dr. Aasi enters and incises around the tumored area. She gently holds and lifts the thin layer of skin using a pair of tweezers. Next she makes systematic cuts under the lifted layer of skin and runs them smoothly up the incised area until the entire sample is cut loose. Dr. Aasi also makes two grid-like cuts along adjacent sides of the incision to orient the sample in relation to the patient’s body. These grid marks help her understand what she is seeing under the microscope. The practice seems routine, almost too easy for Dr. Aasi’s experienced hands. Her steady, composed form makes the evidently complex operation seem simple.
The nurses take care of most residual duties such cautery and pressure dressings between stages, while Dr. Aasi is usually out the door and already halfway to the lab before I can even turn toward the exit. After each stage, the clinic sends the sample of skin to pathology where Dr. Aasi sketches the shape of the sample and applies a different color dye to each edge. These preliminary duties help her visualize a general map of the sample under the microscope. By adding the blue, black, and red dyes, Dr. Aasi distinguishes top from bottom and left from right in relation to the sketch, which is always drawn in regard to the patient’s left shoulder. The pathologists flatten and cut the sample of skin into several slides that are put through an automatic dye machine and then arranged for the doctor to read.
The first time I observed Dr. Aasi viewing specimens under the microscope I was baffled at the speed at which she zipped through the slides and made calls to clear the patient. While all the cells looked like identical blobs to me, she was able to differentiate between the misshapen island cells of a tumor and the sweat glands, hair follicles, nerves, and normal skin cells the body produces. Over time Dr.Aasi taught me how to distinguish the cluttered, island like appearance of cancer cells from the rest of the body’s creations. Usually colored darker than the surrounding areas, they show up in clusters, resembling nests of irregularly shaped cells. If any tumor is seen under the slide, Dr. Aasi determines which area of the original sample the tumor is in based on the grid marks and dye she placed on the specimen. Characteristic of Mohs, in subsequent stages Dr. Aasi removes skin only from areas where tumor is still present, preserving as much healthy skin as possible.
The Inside: The Lessons That Changed How I View Medicine
While Dr. Aasi operates on patients she often strikes up conversations about random yet intriguing topics. We find ourselves talking about how classy the Obama family is one minute and the next Dr. Aasi will be reminiscing her college days and how she actually had to go to the library and read a book to do research. These spur of the moment exchanges characterize my most valuable glimpses into Dr. Aasi’s life. She discloses stories about her career in medicine, ranging from her experiences as an attending, the hardships of adjusting to new hospitals, and some of the scariest moments she’s had in an operating room. These stories inspire through character, they mean something because they make the hospital come to life, and it’s stories like this I hope I’m able to tell someday.
Through my time at Stanford I learned so much more than I thought I would. Not just about the nature of dermatologic surgery, which proves to be a job for a doctor, artist, and perfectionist all in one, but also about the unforeseeable speed at which life moves and the pure joy that comes from being able to help people. From hearing the stories of hundreds of patients and watching the doctor cure their illnesses, I got a firsthand glance into the miracles of medicine. After witnessing the pain and suffering associated with cancer, I was moved by the resilience of patients faced with circumstances beyond their control. I was stirred by the selflessness of doctors and the amazed by the rhythm of hospital clinics. I learned more from this experience than could ever be written in a textbook, urging me to learn by facing a constant rollercoaster of emotions. But most importantly I learned to never forget sunscreen.