Black Pean Information #21-23

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Medical commentary on episode 6 (1)

Dr Sera and surgical training

If we look at it in detail, he helped with three surgeries in episode 6.

Sera’s efforts stood out in this episode.

When Dr Tokai’s mother collapsed, he, Dr Tokai and Dr Sekikawa were in the middle of emergency surgery.

Dr Sekikawa was in the lead surgeon’s position (on the patient’s right), with Dr Tokai in the first assistant’s position (on the patient’s left) and Dr Sera in the second assistant’s position (by the patient’s left foot).

You can’t do the entire surgery from the first assistant’s position (on the patient’s left) without a fairly high level of skill. The structure of the heart makes it easier to operate on from the right side, so usually heart surgery is done while standing to the right of the patient, and doing it from the left side is extremely difficult. The valves and vessels also have structures that are mostly easier to see from the right side. Dr Tokai operated on them easily from the left side with poor visibility. Since we saw them use a prosthetic blood vessel and felt sheets, this was probably acute aortic dissection surgery.

Aortic surgery is often performed under circulatory arrest, as I discussed in a previous entry, so compared to normal valvular surgery or coronary bypass surgery, there are a lot of steps and it can look more complicated. Dr Sera is trying his best to follow along with Dr Tokai’s surgery, but there aren’t many residents who can do that well, and there aren’t many senior doctors (like Dr Tokai) who would make them do it.

However, although there are very few surgeons who can do this, you can tell a surgeon’s abilities and potential just by looking at them. It’s like how you can roughly tell someone’s baseball ability by watching them play catch, or their football ability by watching them do keep-ups.

If you judge that someone can do it, you let them hone their craft thoroughly. No matter how much you make someone do it, if they have no sense or potential they won’t be able to, and it will cause problems for the patient.

Dr Tokai must have thoroughly judged Dr Sera’s skills, efforts and mentality and decided that he needs to train him. A surgeon without the passion that makes them cry from wanting to save patients isn’t qualified to operate, of course.

Saying “surgeons these days are all bad”, insulting newer surgeons and so on can easily turn into power harassment, but I think that worrying about that possibility is a danger to current surgical training in itself.

Some people don’t have good sense and don’t make any effort, make a big fuss about being allowed to operate, claim that not being allowed to do it is power harassment, wouldn’t be able to do anything even if you did let them operate, sulk massively if you scold them, have no intention of studying and say they’re going to quit already. They say it’s impossible to work every day. They say they won’t work on holidays.

Why did they become doctors? Saving lives isn’t that easy, you know...

Oh, no. At the moment, the number of candidates to become surgeons decreases every year, and it’s hard to find them in every prefecture. There aren’t enough young people, and in my almost 10 years as a surgeon, I have always felt the lack of junior doctors. I spend every day examining patients, assisting with surgeries, replying to referrals, coordinating transfers, writing summaries, filling in insurance documents, working in the clinic, preparing for pre-surgery conferences, admitting patients, being lectured by my bosses... and amongst all that, I have to study and practice surgery. Back then, they’d put out a schedule every month, and at the bottom of the schedule it said “Yamagishi is in training so has no days off” every month, which was normal then. I really looked up to my senior doctors who saw patients until late at night, practiced and studied surgery in the medical office, did research and sacrificed themselves. It was very tough, but when I did surgery myself and saw patient’s smiling faces as they were discharged, I was never happier.

We have to increase the number of surgery candidates, but the kind of strict training I went through isn’t possible. It would be a problem if they quit.

At the moment, surgeons throughout the country are all worrying about this ambivalent situation.

…

Excuse me. I got carried away.

We need to think carefully about the meaning of Dr Tokai’s passionate messages like “are there any doctors here?” and “I just did what's expected. After all, I'm a doctor.” At least, I have taken Dr Tokai’s message to heart and put my life on the line as I operate. When I put my life on the line to treat someone and experience the unbeatable joy and gratitude of seeing a patient’s smiling face as they are discharged, that’s a bliss you can’t understand unless you’ve worked in medicine.

Are there no passionate surgical residents like Dr Sera?

Next time, I’ll talk about the surgery in the emergency room and about myxoma.

Medical commentary on episode 6 (2)

Operating in the emergency room

In this scene, a lot of patients were brought in after an accident.

There weren’t enough doctors with just the emergency staff, so the heart surgeons also went to help.

Dr Sera and Dr Tokai were dealing with a patient who had an iron pipe piercing the left side of his chest, with injuries to his pulmonary artery and left atrial appendage. This kind of situation does seem to be the kind of thing that emergency medicine reference books describe. In this situation, there’s a strict rule that you have to completely stop the bleeding without removing the pipe, i.e. after exposing the parts of the pulmonary artery and left atrial appendage that were damaged by the pipe. The left atrial appendage is part of the left atrium and is shaped like an ear, which is why it’s called 左心耳 (left heart ear) in Japanese. It is below the left pulmonary artery, so it was damaged when the pipe pierced that area.

The pulmonary artery and the left atrial appendage are both very brittle and require high-level techniques for their repair. They can be torn just by pulling on the thread a bit too hard. If you look carefully, you can see they used a curved clamp called a Satinsky clamp. After Dr Tokai finished repairing the pulmonary artery, he left Dr Sera to suture the left atrial appendage. Just as Dr Sekikawa said, suturing the left atrial appendage isn’t something to be left to a resident, but since Dr Sera had been watching Dr Tokai’s technique closely, trying his best and practicing stitching tissue paper, he decided that he could do it. Dr Sera sutured the left atrial appendage skilfully.

This was also mentioned in the set report, but in breaks during filming Dr Tokai, Dr Sera and Nekota held a suturing tournament. I’m sure you’re getting sick of me saying this, but I was really moved to see how dextrous they all were. Other than doctors, I’ve never seen anyone suturing with a needle holder and tweezers, and I probably won’t see it much in future. It was probably an unusual experience for the actors too, but they are all people who would be able to become surgeons.

It’s often said that being dextrous has nothing to do with surgery, but honestly, that’s pretty much something that dextrous surgeons say, and there’s nothing beyond it. Wouldn’t you dislike a surgeon who said “I’m clumsy, but I do my best”? I said this before, but there aren’t many surgeons who can transfer a needle with a needle holder like Dr Sera. Smoothly transferring a needle in mid-air is fairly difficult, and there are really very very few surgeons who can do it! There are also surgeons who can’t transfer a needle without using their fingers. In comparison, none of the surgical team in Black Pean, meaning none of the Tojo University cardiovascular surgeons, hold the needle directly with their fingers! Even Nekota doesn’t use her fingers for the needle! It’s very important not to hold needles in your fingers to avoid accidentally causing injuries, and if you do it all by hand, it slows down the whole operation. Without taking your eyes off the operating field, fixing your gaze without even turning your head and simultaneously carrying out the operation within your field of vision, you use a needle holder to insert the needle into the tissue, use tweezers or a needle holder to take it back out, then transfer the needle back into the holder and make another stitch - being able to do this entire process at the same time within your field of vision, quickly and with no wasted movements makes for a beautiful suturing technique! Skilled surgeons always keep their eyes on the part where they are operating (the surgical field). Of course, Dr Tokai does this, and his pupil Dr Sera also has a refined suturing and knotting technique and repaired the bleeding part.

As for tying knots, I taught Dr Sera first, then Prof. Saeki and then, for the first surgery scene, I taught Dr Tokai, and they all learned it well within less than an hour, as I think I wrote about before.

Actually, we combine two different types of right-hand-only knots. In heart surgery, those two types of knot are generally enough. I also operate using two types of left and right one-handed knots. The reason we need two types is that if you just tied the same type of knot over and over, it could come undone. We usually tie about eight knots in total, but I hear that digestive surgeons and other types of surgeons use different types of knots and only tie between three and five. I think there are about 20 types of knot in total. Every surgeon prefers the type of knot that they are personally best at. If the sutures come loose, it could cause massive bleeding, and if the knots are tied too strongly, they could pull on the tissue too much and tear it. However, slowly tying eight knots takes too much time, and going quickly is gentler on the tissue, so learning to tie proper knots that won’t come loose is one step towards becoming a surgeon.

Dr Sera has become pretty good at sutures and knots since the start of filming. For his suturing and knot-tying scene in episode 2, we talked about it, and since this character had just started his residency, he deliberately did it a bit hesitantly like a real resident. Do you remember that Dr Sera’s knots were a bit loose in episode 2? That’s acting!

This time, he played a surgeon showing his real ability after strict training by Dr Tokai. His posture while stitching and the way he transferred the needle were perfect!

Next time, I’ll talk about myxoma. Also, in episode 7 there’s a scene that Ninomiya, the director and I have been preparing for a long time that’s even cooler than ever. I’ll write about that later, but please look forward to it!

Medical commentary on episode 6 (3)

The last commentary for episode 6 is about myxoma.

Myxoma

Myxoma probably isn’t a disease many people have heard of. To put it simply, it’s a mass (a tumour) that can develop inside the heart. They are usually benign, meaning they don’t grow back once removed and they don’t metastasise. They can range from the size of a quail’s egg to less than the size of an ostrich egg, but still pretty big. They have a texture like soft jelly. Since they’re benign tumours, you can just remove them surgically, but the problem is that because they’re inside the heart, they can damage the circulation or move out from the heart into the blood vessels, causing an embolism.

Dr Tokai’s mother fainted in the restaurant because of just that kind of circulatory damage.

Myxomas can easily form in the left atrium of the heart. Blood comes from the lungs through veins into the left atrium, passes through the mitral valve into the left ventricle, then passes through the aortic valve and is sent to the rest of the body. If there is a large object (myxoma) in the left atrium, in the worst case it can engulf the mitral valve. This is called “incarceration”, and it’s very bad. The blood can’t flow from the left atrium into the left ventricle at all, so no blood can flow to the rest of the body. In the unluckiest cases, you can die just like that.

In Dr Tokai’s mother’s case, we can assume that the myxoma briefly incarcerated in the mitral valve, preventing blood flow to the rest of her body, so there was no blood flow to her head, causing her to faint. Fortunately, it separated from the valve shortly after engulfing it - I shudder to think what could have happened if it had stayed in place.

Myxomas can be diagnosed by cardiac ultrasound, but with a myxoma as large as Harue’s that could cause loss of consciousness and that could affect the mitral valve again at any time, it’s best to remove it as soon as possible.

In cases with no symptoms that are found by chance, there’s no need to hurry. In Harue’s case, the ultrasound results showed a fairly large myxoma. Dr Kurosaki performed emergency surgery.

I wouldn’t say that myxoma surgery is particularly difficult, but the thing we have to be most careful of is to make sure that the myxoma hasn’t gone anywhere else. Most of the myxoma is lightly attached to the wall of the left atrium. When the patient is moved from bed to bed, we move them gently too. Violent movements could cause the myxoma to detach from the left atrial wall and move from the heart into the rest of the body, and if it went into the blood vessels of the brain it could cause a stroke. A mass the size of a myxoma would be life-threatening if it reached the blood vessels of the brain. It would also be bad if it reached the blood vessels in the abdomen, where it could also cause intestinal necrosis in the worst cases. That’s why we need to be careful with this kind of surgery.

Dr Kurosaki removed Harue’s myxoma, but he left remains in the pulmonary vein. This is the most basic of the basics, but when removing a myxoma, you have to check that there are no other parts of it outside the left atrium. In rare cases when there are parts left behind, they can grow bigger and have to be removed again, so that can’t be allowed in this kind of surgery. Dr Saeki says that an average doctor would leave remains in the pulmonary vein, and it’s true that it could be difficult to confirm whether there are myxoma remains in the depths of the pulmonary veins. However, if CT scans are done properly before the operation, you should be able to tell whether there are any in there.

“We think the tumour remains are damaging her circulation.”

That means the blood flow from the pulmonary vein into the left atrium was being damaged by the myxoma remains. The blood wasn’t flowing from the pulmonary vein into the left atrium, so blood built up in the lungs. This is a very unusual phenomenon.

They used the Caesar to remove the mass from deep in the right pulmonary vein, but that also requires stopping the heart, so they ran the heart-lung machine, clamped the aorta and used cardioplegia solution to stop the heart and perform the operation. Caesar surgery is unlike usual surgery (operating by a midline incision, opening up the middle of the chest) as it involves operating on the heart from a slight distance through the right side of the chest. Everything is at a distance, so it’s a bit difficult to do this, requiring the power of a precise robot arm like the Darwin’s or the Caesar's. If there is no Darwin or Caesar available, it’s possible to operate like this using long-handled surgical tools.

We also use long-handled clamps to clamp the aorta shut. This time, the end of the clamp damaged the tissue on the other side of the aorta.

Looking from the right side of the chest, the pulmonary vein and the left atrial appendage (like Dr Tokai and Dr Sera treated in the emergency room earlier) are behind the aorta. The end of the aortic clamp could have damaged the pulmonary artery or the left atrial appendage, causing bleeding. If the left atrial appendage is damaged, you can open up the left atrium from the right side again, pull the left atrial appendage towards you and repair it from the inside, but if the pulmonary artery is damaged, it’s fairly difficult to repair this from the right side.

Based on the type of bleeding, Dr Tokai decided it was coming from both the pulmonary vein and the left atrial appendage (dark venous blood was coming from the pulmonary vein and bright red arterial blood was coming from the left atrial appendage), so he decided to use a midline incision (central thoracotomy) to suture them and stop the bleeding.

As Dr Tokai’s assistant, Dr Sera did brilliantly.

The line “Move the PA aside.” refers to the pulmonary artery. When suturing the left atrial appendage, moving the pulmonary artery aside makes it easier to suture, which is why he gave that order.

“Don't pull on it too hard.” When suturing, the assistant holds the thread to make it easier, but they have to be careful not to pull on the thread too hard and tear the tissue, which is why Dr Tokai gave that order.

This time, the two of them repaired the pulmonary vein and left atrial appendage in the emergency room and also for Harue. These structures are both very brittle and difficult to repair, but as expected of the Tokai-Sera pair, they repaired them all with no problems!

This got long again. This time, I talked about the rare type of heart tumour called myxoma, but there are a lot of other things I wanted to talk about, like why heart cancer is rare, Takashina’s chivalry and the scene where he gives his own blood in the operating room, operating on one’s own relatives, etc., so I’d like to talk about these in future if I have the chance.

Episode 7 is about to start already. I wrote about this last time, but there’s a scene that Ninomiya, the director and I had meetings about for several weeks before filming it. During filming, I was watching on the monitor next to the director, and after that scene ended we looked at each other and said “wow”, then both spontaneously burst out laughing, and I got goosebumps all over my body and teared up at the same time. More than just memory and ad-lib skills and acting skills and expressiveness and dexterity and coolness, he has some kind of great power that really jolts your heart... I will never forget the impact that scene had on me. Please look forward to episode 7.

Comments

[sarahjohnsf89.livejournal.com]

Thank you for translating and sharing.

[norhawashaifulb.livejournal.com]

Thank You For Sharing <3