Week 6 and 7

Druing week 6 and 7, I was able to see most interesting and longest surgeries one of which took about 16 hours. The most interesting case was glossectomy which is removing a tongue tumor from a patient's mouth. A patient was 66 year old male who was heavy smoker. Smoking can cause not only lung cancer but also tongue, oral, and trachea cancers. To eradicate the tumor, formerly radiation was treated to the tongue of the patient. However, due to the radiation treatment tongue was seriously swollen so the patient could not move tongue properly, which means swallowing and speech was partially impaired. As the first surgery, mandible and lower jawbone was completely opened and neck was also dissected to remove tongue with tumor. In this case, entire tongue was excised since tumor was internally located at the bottom of the tongue where main blood supply flows through. Even if partial tongue tissues can be saved from tongue tumor, they will not be able to survive without main source of blood supply, the bottom part of the tongue. The picture on the right is a huge tongue specimen from the patient. After taking out tongue, the space on the bottom of the mouth is filled with a lower part of pectoral muscle and the upper part of the muscle with skin was used for neotongue. The first two pictures below indicate front part of pectoral muscle with skin and back side of muscle. The second picture below shows a neotongue made by the front part of muscle with skin.
This neotongue is mainly for aesthetic purpose and partially for functional purpose since the patient will not be able to chew, swallow and speak for a while. Once he gets physical therapy, his mobility of the pseudotonuge can be trained and partially recovered. Even if neotongue cannot move as much as normal tongue can, donor blood vessel and muscle of the neotongue will provide better blood supply to the defect site and better blood supply helps wound healing and protect tissues from potential damage from subsequent radiation. After surgery, I saw the patient during clinical round and his pseudotongue looked as great as original tongue even if still it need to be trained. I believe that both of two surgeries were really great examples to indicate how important blood supply is for tissue to survive and how broad spectrum is for plastic surgery to cover. Plastic surgery can reconstruct from a tiny nerve to the entire our body using either endogenous tissue or biosynthetic material. However, in terms of better blood supply, endogenous tissue still works better than engineered material so this is one of the engineer’s challenges to overcome.
In addition to clinical experience, I tried to finish up my project. As I discussed my project before, I had to find suitable biodegradable material for covering 3-D fluidic vascular network device based on melt-spun sugar fibers (cotton candy). As a simple trial, I tried to make device using a couple of material that I could easily get. For the first trial, I used RGD-modified alginate cross-linked with CaCl2 and made hydro-gel that could cover 3-D cotton candy capillary network. Lower concentration of RGD-modified alginate gel was too soft to keep its shape and let sugar based networking device dissolved away. Thus, I tried to make different stiffness of hydro-gels via changing concentration of RGD-modified alginate to let the shape of 3-D capillary network to stay as it is. While I was trying to make a device using hydro-gel I searched literature relevant to biodegradable material where cells can adhere. Also, I was given a new clinical project additionally which is investigating how successfully “vascularized muscle flap salvage” following bypass or femoral artery surgery were done so far. To pursue this project, I need to get patients' information first so it may take some time to figure out getting an access to patients' information such as patients' pre and post conditions after surgery. While my mentor finds a way to let me get the data, I will get some background information about vascularized muscle flap salvage after bypass or femoral artery surgery via literature search.
I can not imagine how fast time flied by and it is already the last week to get a clinical experience. I have had a great time and I am sure that all of what I have observed and acquired during this program will help me not only pursue my research more creatively and effectively but also make my life more valuable. Also, I hope how we have done in Weill medical college will help next year' Cornell BME Ph.D students to get much more valuable experiences. Lastly I really thank for Dr. Spector, Dr. Frayer, Dr. Wang, Belinda and last but not least Claudia Fischbach to help me to have a great opportunity in Weill Medical College. I really thank for everybody who supports this awsome program and I will never forget 2009 summer in Weill medical colloege.

Week 5

During week 5, most of surgeries were related with hernia which is a protrusion of tissue or part of an organ below the muscle tissue which cover them. Thus, abdominal hernia patients has bumpy intestinal wall, which makes their abdomen uneven. It can result from various reasons such as overweight, being too skinny, weak abdominal wall, and pregnancy. Even if the reasons are various, most reasons cause higher pressure to the abdominal tissues or organs and press them too much. Or weak abdominal wall is too weak to sustain the organs and tissues properly. That is why the tissue and organ are pressed down and transform to a bulky shape. Thus one of the common methods to correct hernia is covering the bumpy area with flattened mesh. Fascia which is connective tissue covering intestinal well is connected to the mesh and they fascia and mesh play role as a covering layer to the organs and tissues. Usually “Prolene mesh” is widely used and helps pressed-down organs and tissues keep stay and abdomen look flat. However, prolene mesh is synthetic polymer so cells and blood vessels cannot grow on the top. Even if this patient took antibiotics, the blood vessels could not go through the mesh and antibiotics also could not reach to the mesh. Thus, this caused infection. Infected mesh and intestinal well muscle were debrided and muscle or soft tissue graft has to be done. Through this, I re-realized that how important blood supply is for giving nutrients and oxygens for cells as well as deliverying drugs such as antibiotics to prevent infection. Also, blood supply is a key point to eradicate tumor as I am interested in tumor angiogenesis. Here is the point that I can interconnect this clinical experinece and my research. Soft tissue is usually used to replace the defect parts since soft tissue such as adipose tissue is well-known to help angiognesis. Also I have seen interplay of cancer cells and adipose tissue has a synergistic impact on tumor angiogenesis. It was a good time to interconnect my research and clinical experience.

Week 7 – Final Comments

Overall, I would say that I completed my objectives, and the program more than met my expectations. I learned a lot about the diagnosis and treatment of breast cancer, and I believe that this is knowledge that I will easily incorporate into my research. I successfully identified metastatic disease as the leading challenge to combating breast cancer today. And I believe that I did come away from the summer with a better grasp on medical vocabulary and interacting with clinicians, although this may be the most intangible of my learning experiences.

I successfully gained a well-rounded view of breast cancer, a comfort level with medical vocabulary that I had not possessed before, and a future clinically-related direction to take my research. Most importantly, I feel much more comfortable working with clinical collaborators. Above all else, I will take this knowledge with me in the future. Overall, I was very satisfied with how my expectations were met and my objectives accomplished.

While the immediate impact of summer immersion may not be readily apparent, I believe that this experience has significantly contributed to my career goal of becoming a biomedical engineer. Regardless of what sort of job I end up pursuing, the vocabulary and the perspective on clinical interactions will be of great use to me.

In the short term, I would say that my summer experience served to solidify my desire to pursue cancer research, in many shapes and forms. It helped to point out to me where the biggest need is for advancement – treatment of metastatic disease. Additionally, I feel more comfortable now reading clinical papers pertaining to this area of research. I believe that summer immersion made me a more competent and confident biomedical engineer.

I think that it is difficult to determine at this moment what the precise long term impact is of the summer immersion program on my life and career. Certainly, as I mentioned before, understanding a clinician’s perspective and priorities on a project will certainly be useful in the long term. I think that appreciation for the medical field is sure to stay with me for the rest of my life. I don’t think that people truly understand what a physician does, in terms of the hours and labor and heart that go into this job. Seeing it first hand, I am caught feeling the utmost respect for this profession, even though I know it could never be my own. I am excited to see how the immersion experience will affect and perhaps drive the course of my career. I am very thankful to everyone involved for making this summer a great success for myself and my colleagues.

Week 6 – Rounding out the Breast Cancer Experience

During my final week of immersion, I explored a few areas related to breast cancer that did not involve surgery. I shadowed a medical oncologist who deals with metastatic disease, a geneticist who screens patients who have a strong family history of breast cancer for BRCA1 and BRCA2 gene mutations, and I spent some time in surgical pathology learning how samples are processed during and after surgery. Additionally, I observed an aortic valve replacement procedure which has already been discussed by several other immersion students here.

First, I shadowed Dr. Linda Vahdat, who is my mentor for my clinical project. This was very interesting to me, because it is a very different side of cancer than the one that Dr. Tousimis deals with. While Dr. Tousimis’ patients tend to have a very high survival rate, the patients who end up seeing Dr. Vahdat have much more serious cases of cancer, are on strong medication, and are suffering side effects from the intense chemotherapy. Because she sees her patients on a much more regular basis than Dr. Tousimis (who will see follow up patients once a year after surgery), she develops close relationships with them, and obviously cares very deeply about them. Because of the nature of her practice, she has to routinely deal with losing her patients to this disease. It is a very different mindset, and one that I cannot really comprehend. The cases of her patients going into remission do happen, but much less frequently. As part of her practice, Dr. Vahdat is involved with many clinical trials, and has many, many of her patients involved in them. I was able to sit in on an appointment with a woman who has been battling breast cancer for over fifteen years. Her cancer was stage 4, and had metastasized to her bones, which is fairly common. However, more uncommonly, she has a medium sized tumor on her C2-C3 vertebra. Obviously, this is a very precarious situation. Surgery is out of the question (and in fact is rarely done in metastatic patients). Their goal is to shrink the tumor down to prevent it from growing and metastasizing further. This patient had just started a different chemotherapy drug that greatly affected her both physically (she became extremely tired, lost taste and appetite, etc.) and mentally (depression). For a woman who had before been very optimistic and very much a fighter, this was a radical change in behavior. Dr.Vahdat decided to take her off of the new drug, and all of her other drugs except for Herceptin, which she had never had a problem with, and let her body adjust for a few weeks, to allow her to recover and feel more like herself. Then she is going to try a different drug, Arimidex, which has been on the market for a few years and has shown to be at least moderately effective. The patient was very relieved, because she was clearly very worried about the personality changes she had been undergoing. For someone who has been dealing with this disease for so long, it was amazing to me how determined she was to make herself better. I feel like it can be so easy for women to lose hope at this stage, and she was very concerned about the loss of that determination and optimism.

Second, I was able to briefly shadow a geneticist for a patient consult. The patient had come in to undergo genetic testing not for herself, but out of concern for her daughter, who was considering having children. She was an elderly lady full of spirit and stories, and a very interesting family history. Before the test is performed, the geneticist acquires the most complete family history they can from the patient, going back for as many generations as possible and expanding to as many brothers/sisters/cousins/etc as possible to determine the likelihood of a genetic mutation. This process was very interesting to observe, because the patient would go through each side of the family, listing off the ages that cancer was developed, the age of death, etc. In this patient’s case, both sets of grandparents (or great grandparents?) were killed by the Turkish forces during the Armenian genocide. As a result, her family was spread out across the Middle East, Asia, and the US, different family members having fled and ended up in different areas of the world. After the consult, the geneticist told me how she often finds her job repetitive (she goes through the same explanation almost every time), but that hearing people tell their stories is one of the most interesting parts of her job. Anyway, after collecting the family history, the geneticist explains to the patient that they will only be testing for mutations in two genes (BRCA1 and BRCA2), and that having a mutation does not necessarily mean they will develop cancer, or that their children will have the same mutations. It does, however, increase the risk of both. The genetic testing costs about $3500, and is performed by a lab in Salt Lake City, Utah, which owns the patent on the gene. This patient opted to have the test performed, and her blood was immediately drawn and shipped out for testing.

Week 6&7

These two weeks I observed several plastic surgeries with help of Bori and one of them I ranked the most impressive surgery since I have been watched throughout summer immersion. It is a brain tumor surgery which the tumor located behind the skull between brow ridges. This site of tumor forced surgeons to do open skull surgery which very horrified me. It also reminded me a surgical scene in the movie “face/Off” but now I saw it in real!!!

In the last week, with Dr. Frayer’s coordinating, six of us had an opportunity to observed aortic valve replacement surgery which is a very interesting and impressive. Once the pericardium has been opened, the patient was placed on cardiopulmonary bypass machine. This machine took over the task of breathing for the patient and pumping their blood around while the surgeon replaced the heart valve. When the patient was on bypass, an incision was made in the aorta. Then the surgeon removed the patient's diseased aortic valve and tissue valve was put in its place. Trans-Esophageal Echocardiogram (TEE) was used to verify that the new valve was functioning properly. The overall process took around 7 hours. It was not that long comparing to the 12 hour brain tumor surgery.

Lastly, I would like to thank Dr. Frayer, Dr. Wang, Belinda and voluntary clinicians who contributed greatly to make the summer immersion program happen. I gain a lot of experiences throughout the program. The program provided me a great opportunity to shadow many clinicians and to be around in the hospital to observe several clinical things which are all very fascinating and interesting. Moreover, living in NYC with my fellow BME students is a lot of fun. We all hang out and had a great time together. I will never forget these very great experiences here.

This summer, I believe, must be one of the greatest summers in my life!!!

Week 5: Fai

With help of Femi I observed the first robotic prostatectomy in this week. I shadowed Femi’s mentor – Dr. Tewari who is an internationally acclaimed expert on Robotic Prostatectomy and other minimally invasive robotic surgeries. Dr. Tewari used the da Vinci surgical system to perform prostatectomy. He sat at a console in the corner of the room and remotely controlled the robotic arms while I was viewing the surgery via a real-time 3D monitor--I had to wear polarized glasses to see it 3D. The prostate was excised, inked and sliced to be a small specimen. The specimen then proceeded to the multiphoton microscopy core facility for observation. I watched how to use multiphoton microscope and I found several advantages of multiphoton microscope over confocal microscopy including its deeper tissue penetration, efficient light detection and reduced phototoxicity.

In addition, I had a chance to see Trans-Esophageal Echocardiogram (TEE) and Cardiac Catheterization with help of Laura. TEE is a sonogram of the heart. It uses standard ultrasound techniques to image two-dimensional slices of the heart. A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This allows image and Doppler evaluation which can be recorded. The difficult part of TEE is to put down the probe through patient’s throat. There are several steps before the probe reaching the aimed site, including gargling and spraying anesthetics, coughing and swallowing. Laura told me that in some cases patients felt pain and do not be able to swallow the probe. That led to the cancelation of TEE. However, the case I saw that day went very well. Concerning cardiac cath, Dr. Bergman inserted a catheter into brachial artery and snaked the catheter until reaching coronary artery. It surprised me that doctor can snake a catheter via such a very small and very long blood vessel. After the catheter reach coronary artery, contrast dye is injected to see areas of constriction. It turned out that most of the patient’s coronary artery was occluded. For this case bypass surgery would be the best and only way to treat the patient.

I also went with Bo to Department of radiology at 55th stress to get MRI scan. Bo was doing his clinical research project—writing one chapter of a book about how to operate s MRI scanner for people who have never used it and he needed some volunteers to get brain scan. IMR is safe and it is very expensive procedure. I think it would be great to try it once for fun and to check up my brain (for free). As expected I am (still) normal :)

Week 4: Fai

A very interesting clinical experience of this week is breast cancer surgery which I saw both lumpectomy and mastectomy. Thank Casey for her help. Lumpectomy is an operation in which a small volume of breast tissue containing the tumor and some surrounding healthy tissue is removed to conserve the breast. The case I saw was one 30’s woman who had a small cancer (1.4 centimeters) in her left breast. I saw an X-ray image that two hooks on metal wire indicated the site of tumor. In order to access the tumor Dr. Tousimis cut around patient’s aureole (2/3 of aureole circumference). She told me the tissue area has a great ability to recovery and it is hard to see the scar on that area after the surgery. Even though the tumor is a few centimeters in size, the fat tissue which was taken out is about four times more than its size. The reason of doing this is to make sure the entire tumor is removed and taking out such a great amount of tissue have no any physiological and anatomical effect on the patient. For the case of mastectomy, I observed a 50’s female patient who was diagnosed with breast cancer. Mastectomy is usually done to treat breast cancer. However, the decision to do the mastectomy is based on various factors including breast size, number of lesions, biologic aggressiveness of a breast cancer, the availability of adjuvant radiation, and the willingness of the patient to accept higher rates of tumor recurrences after lumpectomy and radiation. Before the surgery, the patient was injected a radioactive dye to localize the sentinel lymph nodes and another dye (blue color) to visually identify the nodes. The sentinel lymph node is the hypothetical first lymph node or group of nodes reached by metastasizing cancer cells from a tumor. It is a rational why sentinel lymph node biopsy is routinely used to determine whether or not the cancer has spread. For the surgical procedure, firstly, the patient’s nipples and aureoles were completely removed. Then, the breast tissue was cut away from the skin and the entire breast was cut away from the muscle underneath. The whole tissue was taken out and replaced with a tissue expander filled with saline. The whole procedure took about 6 hours. Comparing between lumpectomy and mastectomy, I feel much more comfortable to see the former one.

Thanks to Michael, in this week I had a chance to follow him and his mentor –Dr. Cham in the department of radiology. Dr. Cham showed us a lot of x-ray/CT/ MRI images and kindly explained several things in detail. I learned a lot from him. The images came to this department with several reasons. In case of pre operation images, Dr. Cham had to check the images to make sure that the patient is ready for operation. There is nothing abnormal which can lead to failure of operation or bad consequences during or after operation. Dr. Cham also diagnosed disease from the images such as lung cancer, lung tumor, tubercle bacillus or Tuberculosis (TB), pneumonia, heart disease and skeleton disorders. For me, this work has a lot of pressure and it is vital to pay a lot of attention to every single detail -- missing a small dot can lead to very bad consequence if the dot is lung cancer! This must be the reason why every image has to be read by at least two radiologists. I think it is a good idea and it can reduce the kind of error. In some special cases, patients having unknown-cause symptoms, Dr. Cham have to figure out several probable diseases from the image and suggest possible causes of illness to the patient’s doctor. It seems hard to me that one person have to remember all illness and trying to connect any clue from black & white and blurry image to all of possible diseases.

Week 3: Fai

In the first two weeks I followed Dr. Schumann and Dr. Frayer to round in NICU (Neonatal Intensive Care Unit). In this week I got an opportunity to observe a new unit -PICU (Pediatric Intensive Care Unit). I shadowed Dr. Howell’s and Dr. Pon’s team which included one doctor, two residents, and one or two fellows (no nurses and no nutritionist who are usually included in NICU team). The overall process of rounding is the same as that in NICU-the team visits each patient, the residents and fellows report patient’s previous record and then the team discuss and decide about future plan for the patient. It seems that in both units mechanical ventilators and patient monitoring systems are imperative for every patient. However there are several aspects that PICU is different from NICU. PICU deals with the medical care of infants, children, and teenagers so patients’ record is very long and full of diversity. In one case, a three year old boy fell from the third floor of an apartment. Besides knowing the cause of illness and symptoms in order to provide appropriated health care, doctors have to concern other information, for example, is there any witness or not?, who is the owner of the building?, where are the parents?- to make sure that it is not because of neglecting from the parents, etc. If the doctors feel something wrong, they have to immediately report to the relevant authorities.

In this unit I also witnessed one very heart wrenching situation. On Friday morning I shadowed Dr. Pon to round and visit a 15 year old boy who suffered from respiratory arrest for months. His health has regressed everyday and most of his brain has already been damaged. It made Dr. Pon decide to talk with his mom who usually came to visit him every other day. As expected, she came that day. Dr. Pon spent a lot time explained all the reasons to should not resuscitate the patient. Despite knowing the situation very well, it was still hard for her to admit. The whole room had any other sound except her incessant cry. It took her for a while to decide to sign “Do not resuscitate (DNR)” consent form and to become calmed. Then Dr. Pon, one resident and I left the room but one psychologist was still there to talk and to soothe her more. After leaving the room, I sat by myself. I had several feeling at the same time. It is hard to explain if one is not in the real situation. I made me realize that “it is the way of life”.

Week 6 & 7

In week 6 I spent time rotating through the VitreoRetinal (VR) clinic with Dr. Paul Chan. I had not worked in this clinic as of yet so it was intriguing to witness another aspect of ophthalmology. VR specialists primarily treat age related macular degeneration (AMD) and glaucoma, so most of the patients are elderly and have severe vision impairments. A large part of the VR specialists job is to manage vision loss for their patients. Because diseases like glaucoma and AMD are not curable but are a chronic disease state these patients hope to maintain rather then gain back their eye sight. In some cases it is possible that a treatment may work to improve a patient's site, but due to the degenerative nature of these diseases it is not always possible. In addition, the arrange of therapies used in a VR clinic appear to be much more invasive. One of the most shocking procedures I have seen since I have been here was a retinal injection. In this therapy inhibitory VEGF antibodies are injected into the rear portion of the patient's eye. The procedure is done with the patient fully conscious and only local anesthetics are used. The patient's eye is then manually held open using a contractor, and then the specialist procedes to inject the patient's eye with a syringe. It is an intense procedure which only lasts a few seconds, however these patients will continue to need injections to inhibit the development of their AMD. During week 7 I devoted the entire week to finishing my project and preparing my presentation.

W33K SE7EN - HU4NG

In week 7, I saw my last surgery. The patient had an aorta with calcified tricuspid valves that needed to be replaced. A cardiopulmonary bypass (CPB) was performed to prevent the heart from beating and support circulation through the surgery. The most astounding thing I saw in this surgery was the process of how the surgeon started from what looked like a mess of needles and threads and pulled the artifical valve in place, fitting perfectly, and once the threads were cut, everything looked magically clean again! Ah the wonders of thoracic surgery...

Through this Summer Immersion experience, I think that I have become much more de-sensitized to surgeries. Before, I had always been a little squeamish about blood and apprehensive about surgeries in general, but now I see them in a new light. It seems that after the surgical site has had antiseptic applied and all other areas are covered with sterile drapes, the little area of exposed skin actually looks fake! So it does not look as scary to cut into this piece of skin, and with a suction tube always present, there is little blood to be seen as well. In all the surgeries I have been in, the OR also had a light atmosphere where doctors and nurses joked around at times. I expected none of this when I first walked into an OR... perhaps I have been watching too much TV.

Vertical Contractions

In week 6, I started focusing on my project, which is to evaluate survival data for patients who have had a nephrectomy at the hospital for their kidney cancer. There are two types of nephrectomies: (1) partial, which is removal of localized cancer that allows most of the kidney to be preserved, and (2) radical, which is removal of all of one kidney as well as the adjacent adrenal gland and neighboring lymph nodes. There are also two procedural types: (1) traditional open surgery, and (2) laparoscopic, which is done through several small keyhole incisions and is less invasive. Finally, to evaluate survival data, the key piece of information is patient last known status, which is divided into four categories: (1) no evidence of disease (NED), (2) alive with disease (AWD), (3) dead of disease (DOD), and (4) dead of other cause (DOC).

For my project, I will be synthesizing several databases containing patient information, contact information, medical history, surgical history, and OR data into one complete spreadsheet that I can use to perform statistical analysis (such as the Kaplan-Meier method for survival rate). In total, there are about 800 patients in the database, but about half of these patients' last known status was before 2008. Therefore, I will also be updating these patients' statuses either by searching for status updates on EPIC or by calling them directly (or their emergency contacts).

Weeks 6&7 - Final Rotations

Since summer immersion is drawing to a close, I have been trying to fit all the different things that I have not seen before I leave while continuing to observe my mentor and his cases. On Monday, I went to office hours at Cornell with Dr. Grant as saw some pre-op and follow-up cases. On Tuesday, I also followed Dr. Grant for office hours and excisions at Columbia. It was a great day because I was able to see many of the patients I have been following throughout my time here. Laura came with me on Wednesday and had a very full day of seeing patients as well as a breast reduction, breast reconstruction, and wound closure.

On Thursday, I was able to see a prostatectomy done by Dr. Tewari who is the Director of Robotic Prostatectomy and Prostate Cancer-Urologic Oncology Outcomes. Dr. Tewari uses the Da Vinci robot to perform the prostatectomy and does around 600 cases per year (he had done 15 cases that week already!). It was very interesting to watch the robotic surgery and Dr. Tewari allowed me to look through the control console towards the end of the surgery. I was very impressed by the apparent dexterity of the surgical instruments within the body cavity and the precise control that Dr. Tewari had over every movement of the robotic arms and camera. The surgery only took 1 hour and I unfortunately missed the first 15-20 minutes so I plan to go to another surgery next week to see the whole procedure.

Afterwards, David and I went down to Greenburg Pavillion and watched a live donor kidney transplant performed by Dr. Kapur. We arrived in the operating room just before the kidney was harvested from the other patient. Upon arrival into the recipient’s room, the kidney was prepared for transplant by Dr. Kapur and his team. They removed the external fat and unneeded connective tissue and then isolated the renal artery and vein as well as the ureter. The kidney was then wrapped in a towel with ice and brought to the patient. The two renal arteries were connected to the iliac artery using an end-to-side anastomosis. The renal vein was connected to the iliac vein in a similar manner. Next, the ureter was connected into the bladder and a stent was placed within ureter to help it remain patent. It will remain there for 6 weeks and then be removed using a cytoscopy procedure. Soon after the kidney had been connected to the blood supply, it became a deep pink color and began to produce urine. Dr. Kapur said that the last transplanted kidney that he had done had produced 1.8 L of urine in the first hour and that the activity of the kidney he had just transplanted looked promising. Dr. Kapur was very helpful and allowed David and I to come to the operating table many times during the surgery to point out what he had done as well as what he was preparing to do—it was a fantastic learning experience!

On Friday, I was able to go on round in the Neonatal Intensive Care Unit (NICU) with Dr. Perlman and Fai. The doctors on this floor are much different than those on the other services that I have visited so far because the patients are unable to express themselves in any way except to cry. Many of the decisions made about the course of treatment are based primarily on the patient’s urinary output, heart rate, frequency of apnea, and willingness to accept food. Since the rounds didn’t begin until about 9:30 am, I was expecting many more of the parents to be present with their children and was surprised to see only a couple sets of families. Many of these children have been in the hospital for weeks and even months and the physicians discussed how it is difficult for parents to even get into the city sometimes. It was difficult to see so many sick babies fighting for their lives but it is amazing what technology has developed to allow these neonates to have a better chance to survive.

During my last week of immersion, I observed Dr. Spector, another plastic surgeon, use a rectus abdominus free flap to replace the tongue of a patient after a glossectomy (removal of the tongue). When I entered the operating room, the glossectomy had already been preformed and the lower part of the patient’s face and neck was completely open and exposed—it was quite startling to see. Dr. Spector dissected out the viable arteries and veins in the neck, removed the flap from the donor site, and began to anastamose the vessels. I was surprised at how the flap was used to form the tongue, a small piece of muscle and skin would comprise the tongue while the rest of the muscle was sutured into place. Although this man’s tongue would appear to be semi-normal, he would likely not be able to speak well or even eat orally again.

I was also able to stand at the head of the table to watch an aortic valve replacement surgery done by Dr. Girardi. During the procedure, the anesthesiologists monitored the heart using a trans-esophageal echocardiogram (TEE). From the TEE, I could clearly see the stenosis of the valve and the calcified lesions that were obstructing some of the flow and causing the valve to be less-compliant. The patient was put on cardio-pulmonary bypass and the heart was stopped using an injection of a concentrated potassium solution into the coronary arteries (so that the cells were unable to pass on the electrical signal). Next, the aorta was opened and the aortic valve was removed along with as much calcification the surgeon could extract. A tool was used to measure the valve size and a bovine magnum valve was prepared to be placed into the aorta. Watching the process of valve placement was very interesting because the surgeon first placed multiple sutures around the aorta and then connected those sutures to the aortic valve replacement. The sutures were then sequentially tightened and knotted so that the bovine valve was lowered into place within the aorta. After the aorta was closed and the TEE showed that the heart and valve were functioning properly off of bypass, the patient’s chest was closed using stainless steel wires. The wires were connected to large needles that can go through the sternum and the whole length of the sternum was prepared with the wires before the chest was closed. The whole process of closing seemed quite brutal but the wires have enough strength to hold the chest closed.

Horizontal Expansions

Robotic surgeries are becoming a popular and integral part of hospital operations, as they offer important advantages, such as minimal invasiveness and significantly faster recovery times for the patients. Robotic prostatectomies, for instance, can potentially reduce the recovery time from months to days.

The potential sensitivity of robotic arms is orders of magnitude more precise than human arms. However, by operating such machinery, we are not simply accessorizing but also integrating our bodies and minds into advanced machino-extensions. We are expanding our bodies in the horizontal manner, i.e. while we are not necessarily becoming taller (or are we?), we are becoming wider- wider in the array of abilities we possess, wider in our sense of self, wider in our understanding of the world.

Al though it seems that we may be changing and evolving into a machino-human hybrid (as mentioned before), perhaps our change is not so drastic after all (if there is any change at all). In many ways, what we expect our robotic enhancements to perform is simply an extension of who we already are; the robots have always been a part of us, and a significant difference between today and yesterday is simply that we have the means to realize this aspect of our personality.

Humans have always strived to achieve more and become more. And, with robo-technology today, we are becoming more and gaining more abilities, but at the same time, if all of these things we are becoming are just things that were already a part of us but simply unrealizable physically before because of technology and knowledge, then are we merely becoming only ourselves in the end? And by becoming more and more different in this manner, are we also staying more and more the same than ever before?

Week 5 - Huang

This week I began brainstorming project ideas with my mentor. I attended a few meetings during which Urology residents and a few med students presented their side research projects. These meetings allowed me to get a glimpse into how students with a medical education approach research, and I contrasted this with how engineers approach research. Firstly, the data that medical researchers use is mostly statistical data, while the data that engineers use is mostly experimental data. Secondly, due to their previous education, most med students did not have a background in statistics and programming, so sometimes it was hard to understand what information was being communicated in the graphs that they presented. At times, I felt that certain graphs could have been done differently to communicate the data more effectively, and other times, I felt that a lot of data could have been synthesized into one clean graph. I guess I am just not used to working with statistical data, where there may or may not be anything to show at all. In engineering, we are trained to find trends in data that hopefully support our hypothesis, and then we will spend copious amounts of time making the perfect figures that clearly illustrate our findings. Therefore, I came away from these research meetings still a little confused about what was being shown since I felt that the data was not presented effectively. Again, this could be due to the med students' lack of training in data analysis, or it could just be the nature of these medical statistics.

Week 4 - Huang

In addition to spending time with my mentor, this week I had an MRI scan as a volunteer for Keigo's research project. The scan was of a vein in the knee that moves very little in response to heart beats, therefore making it a good candidate for MR research. The goal of the project is to image the vessel walls without imaging the blood inside, as this would offer better resolution than if blood was present in the image.

Having never had an MR scan before, there were a few things that struck me as I went through the process. Because I am used to being in a hospital setting and am in the biomedical field, I did not think much of getting an MR scan, but I imagine that it could be an unnerving experience for someone who is not familiar with the hospital and its large, complex machinery. Keigo, sharing the same background as me, briefly explained what would happen during the scan, that the scanner is a small enclosed space and there would be loud noises, and we quickly got started. For a real patient, however, I think the technician would have to take a lot more time calm the patient's nerves, walk them through the process in greater detail so that they would know exactly what to expect, and even talk to the patient on the microphone throughout. I also realized that little things such as the well-lit and comfortable waiting room and the availability of blankets really go a long way towards easing patient anxiety. These observations have led me to have a better understanding of the interpersonal side of engineering, that while the biomedical devices that we design may be technological marvels, they also can be useless if patients are unwilling to use them.

Week 5 - Horizons. Expanded.

During Week 5 of immersion, I explored a few areas outside of breast cancer. I accompanied Laura to observe two (almost three) TEEs (transesophageal echocardiograms). TEEs were used in the cases I observed to check for problems/conditions prior to other, more intense procedures. One patient was having his heart checked so that he could undergo a cardioversion for atrial fibrillation. They found no problems that would prevent the treatment from occurring. In particular, they were worried about clots, which TEE is very sensitive to, but none were observed. The third patient was a very spunky, fiery older lady who looked like the image of old Hollywood glamour – completely decked out in makeup, long nails. She was very interested in talking to Laura and I, and she was a little apprehensive about the procedure. It turns out that she has trouble swallowing (constantly) and her doctors have so far been unable to determine why. However, this was very problematic for the TEE because she was unable to swallow the probe. It was interesting to me because she tried very hard to explain her problem to one of the nurses while they were prepping her, but the nurse’s eyes were kind of glazed over, and her responses were very mechanical, as though she wasn’t really paying attention to the patient. And then they were kind of surprised when they couldn’t get the probe down. As it turned out, it wasn’t critical that the TEE be performed that day, so they gave up, with the idea that they would do it again at a later point, with an anesthesiologist so that the patient could be put under for the scope swallowing. The patient felt really bad that they had been unable to perform the procedure, even though it was in no way her fault.

I also accompanied Fai to the Neonatal Intensive Care Unit (NICU) rounds. We saw four babies. The first baby we saw was a little girl who only weighed 102 grams. She was very tiny, and was made to appear even tinier by the presence of all of the large tubes. She was having respiratory problems that the team was having difficulty in diagnosing. They had ruled out infection, but other than that, they appeared to just be monitoring her situation to learn more (from what I could understand from the doctor-speak). They were debating whether to intubate or not, and I think they decided they should, to stabilize her a little more. It was really heart wrenching to see such a small baby having problems. I’m not sure how premature she was, but she was about the size of one of my hands (and I have pretty small hands!). She was the only case we observed where the baby was still in a delicate situation. The next baby we saw was considerably larger and much louder. He cried several times we were in the room, and seemed to prefer being held sitting up by the nurse, where he opened his eyes and watched us in wide-eyed amazement (in between yawns). His prognosis was good, and I didn’t quite catch what his original situation had been. Another baby had been admitted with sleep apnea, and he was actually going home that day, so the parents were very excited! It was a very different feel than the first patient. The team was happy to see the baby healthy enough to leave, and the parents were very grateful. A second baby was also going to be released – I’m not sure what her original condition was, but she had apparently made a strong recovery as well. This was my first time doing rounds, and it was a very different clinical experience than I have had in Dr. Tousimis’ office hours. Each fellow or resident took primary lead on each baby, explaining the baby’s vitals and improvements/regressions over the previous night. It was nice to see the fellows and attending with very positive attitudes towards the patients. They clearly really enjoy what they do and do get attached to the babies in the NICU. Overall, the ward had a very good energy, and was actually much calmer than any other area in the hospital that I’ve seen.

Additionally, I observed a new surgical case with my surgeon. The patient presented with bloody discharge from her nipple, which is often an indicator of possible cancer. Although a mammogram had all but eliminated the possibility of it currently being cancerous, the decision was made to remove the ductwork behind the nipple. Because the woman was postmenopausal, the entire duct system was removed. Dr. Tousimis explained to me that if the woman had been premenopausal, she would have gone in and removed only the duct that was causing problems. However, since the woman would not be breastfeeding, it was easier and more thorough on the part of the surgeon to remove all of the ductwork. Pathologically, this greatly reduces the chance that cancer could develop. An incision was made and the process was begun as a routine lumpectomy, but then a wire was guided through the nipple, through the duct with the discharge. Dr. Tousimis could see nothing outwardly abnormal, and did not offer any thoughts on why the bloody discharge had occurred. The mass was sent to pathology to be studied to ensure no cancer was present.

My project is going well, and I have excellent prospects for finishing it before immersion ends, which I am happy about!

Week 4

The most interesting thing I saw this week was a lung biopsy with Dr. Yankelevitz. We got to see one in the morning which was done the standard way, during which the needle is guided to a suspicious looking area using CT images in a step wise process. First an image is acquired and the patient is asked to hold their breath while the surgeon moves the needle closer to the target site and the process is repeated several times. In the afternoon we got to see a particularly interesting one. This patient had come in twice already for a biopsy, but each time they missed the spot and didn't get a good sample. The reason for this was that the patient apparently was unable to control her breathing. Dr. Yankelevitz therefore decided to try a third time, but this time using a fluoro CT. This is the same as a CT scan but done continuously (named after the fluorescent screen they used to use for this) and achieves a frame rate of about 6 fps. This procedure is not a preferred option as it involves much higher radiation exposure to the patient and particularly the surgeon (we could actually see his fingers on the images). It was really interesting to see continuous images as the patient is inhaling and exhaling and we were able to watch the heart beat to some extent as well. It also came to show again how important well designed equipment is in the hospital. They rarely do a fluoro CT and so few people knew how to use it. Initially, we could not get the machine to do a continuous image for longer than 30 seconds before it had to process and save all the images it took and reset (~3-5min wait) before the next 30 seconds of images could be taken. This was particularly frustrating as Dr. Yankelevitz was clearly struggling to keep this patient from breathing too much and several times he was close to getting to the spot and then the machine stopped taking images. Finally, a technician was able to get the machine to work for 90 seconds at a time and after the second biopsy the quick stain revealed something and Dr. Yankelevitz believes he managed to get a good sample, but was still not sure though.
In rare cases (especially if the patient isn't good at holding their breath) this procedure can also cause the lungs to collapse afterwards and this happened in this case as well, so they actually had to insert another tube (again using the CT) to deflate the area around the lungs. I think in total the patient and the surgeon had ~5min of continuous x ray exposure and it was obvious why they don't prefer this method.

Week 5 - Clinic

I spent a lot of time in the clinic this week and was excited to see many of the patients that I had seen for pre-op visits and surgeries come in for post-op visits. I think that the length of the summer immersion program is great because it has allowed me to have some continuity with patients and see the whole process from initial visit to final consultation.

After everything that I have seen (from neurosurgery, to breast reconstruction, to mole removal), I have come to realize that the most difficult procedures for me to watch are removing sebaceous cysts from patients. I never realized how long some people will let things go before seeing a physician. Although the cysts are normally not a problem, they can get very large over time, especially if they become infected. Luckily, for the patients, they are straightforward to remove and the procedure can be performed under local anesthetic in the office. Unfortunately, by the time many patients finally get them removed, they are large, odorous, and fluid-filled. I must say that I will not be sad if I never have to watch another cyst excision.

On a better note, I was able to watch my first liposuction case to revise a contour deformatity on a woman who had a previous abdominoplasty. I was surprised at how rudimentary the procedure is: a probe is inserted subcutaneously and moved around to loosen the adipose tissue and then the suction is turned on to remove the agitated fat. The most surprising aspect, however, was that the woman laughed during most of the procedure. Dr. Grant said that it was the first time he has ever had a patient laugh during an procedure but she definitely put us in a good mood for the rest of the day!

week 4

I was so surprised that this week was already our fourth week of summer immersion. However, what made me more astonished were surgeries that I observed during last week.

Last week, fortunately I had a great chance to witness astonishing cases in plastic surgery and neurosurgery. First of all, there were two big plastic surgeries. One was skin free flap to the throat of the oral cancer patient and the other one was soft tissue free flap for patient who had a large size of tumor in the right maxillary region with deformity of ethmoid bone. For the first surgery, the patient was 44 years old women having a chunk of tumor on the area of pharynx. Thus, her neck was dissected and mental protuberance which is the part of jawbone right below the lip was cut to access to the lesion. When neck was dissected, the dissected line was also significantly important. The straight dissected line can cause a lot of contraction of the neck muscle when they are sutured and move. However, if neck was dissected along curved neck line, it will not result in contraction and tension. Lateral jawbone below the right ear was also excised to totally open neck and the half of face under eyes. After tumor was excised, the empty space where tumor was used to be had to be filled. There are several reasons beyond but one of the main reason is the empty space can cause improper movement of tongue. Also, blood supply is essential as well. Thus, about 15 cm of skin and soft tissue on the arm with radial artery and vein was cut and translocated to the empty space. Since there are two arteries on the arm one of which is radial and the other of which is ulnar artery, it is okay to facilitate one artery. Blood can perfuse to the other artery after taking out one artery. Radial artery and vein of skin on the donor site and artery and vein on pharynx were connected under microscope. A coupler was used to connect veins but artery had to be firmly sutured since artery is covered by thick muscle and have higher blood flow and pressure. It was 16 hour long surgery so I was exhausted by the time when I left. However, it was a really astonishing and instructive case since I was able to learn head and neck anatomy and some of principle beyond surgery for oral cancer. The second case was similar as the first case but the difference was where tumor was formed. The patient was 26 year old, young female and a large size of tumor was blocking her nasal cavity since tumor was sprawling from the right side of ethmoid bone to the maxillary region. She had a severe congestion and higher pressure on her right eye, which brought her to hospital and unexpectedly found out the tumor. One of the interesting things was she could not find out until the tumor grew as big as a fist. This was not because she was insensitive but because generally people cannot feel anything growing underneath ethmoid bone until they become noticeably enormous.

In addition to plastic surgeries, I was able to explore neurosurgeries such as endoscopic tumor resection and craniotomy for tumor resection. The first case is endoscopic resection for bilateral tumor which was totally different from what I have seen since most of cases that I have seen in plastic surgeries were open-surgery which means dissecting and totally opening the certain area to debride or get access to the lesion. The patient had 4cm macroadenoma on the pituitary gland and the pituitary macroadenoma can cause hypopituitarism (decrease of hormonal secretion from pituitary gland) and higher pressure within skull and thus compress brain. Through nasalectomy with endoscopic tools, Dr. Schwartz was able to reach the lesion in the pituitary gland and then excised tumor. Subsequently, nasal septum flap had to be followed to protect from leaking cerebrospinal fluid to the outside of brain. Thus, nasal septum was flapped over to the excision part of pituitary gland. Also one of the amazing things was being able to find the specific area in the brain using MRI picture and ‘brain GPS’. While surgery was in progress, we were able to watch how tumor was excised and nasal septum flap was done through screen connected to endoscope and brain GPS. The other surgery was craniotomy for Meningioma resection which was totally opened surgery through drilling skull. The problem of this patient was shifting right side of brain to the left as well as higher pressure within the skull. Shifting one side of brain to the other side can cause malfunction of brain since each side of brain has different functions and characteristics. Once it is compressed and shifted to the other side, the unique functions that each side of brain has will be ruined. One of the interesting parts in this case was that the excised part was not sutured but just covered with soft tissue and a lot of gel type of cream called “Dura Seal”. The soft tissue will not have any role in brain but play a role as filler to the empty space. Also, saline will help compressed brain by tumor come back to the normal shape and location. From the cases that I observed, I could learn how engineering technique is used specifically as well as more about brain and nose, neck anatomy. Also, I really thank a couple of medical school students attending in those cases together for good and detailed explanation which helped me a lot.

Next week, I will try to see more diverse areas and work on my project which will be being a trial patient for liposuction and appreciating how it works for me.

Week 5 – TEEs and Cardiac Catheterization

Week five of summer immersion I shadowed Dr. Healy in TEE, she got me in to see cardiac catheterization, I continued the embryonic stem (ES) cell culture experiments, and on the recommendation of Dr. Frayer I met with Dr. Chen in pediatric cardiology. In TEE on Tuesday there was a patient on the critical care floor who had confirmed dissection of the descending aorta and the TEE was used to check for dissection of the ascending aorta. I met some of the critical care nurses and asked them how their floor was organized. Nurses are apparently assigned to particular home units. I was asked if I was from Europe (where the organization of the nursing floor might be different).
After there was a gap between TEE patients, Dr. Healy escorted me to Cardiac Catheterization Lab where Dr. Bergman was working. Cardiac Cath is separated into two rooms. One room has the patient on the table surrounded by x ray machines. Doctors and nurses and technicians (who are all wearing lead protective gear) are setting up in the room and prepping the patient for the procedure. The other room has computers and monitors and windows that look into the procedure room (this is where I got to sit). In the viewing room I met a researcher who was also there to watch the procedure, and to see if the patient qualified for a clinical study for a Medtronic drug eluting stent. The patient is evaluated using a set of inclusion and exclusion criteria and depending on the findings of the procedure may or may not qualify for the study. First Dr. Bergman guided a catheter into the femoral artery using a wire, the catheter is then navigated into the coronary arteries of the heart. Contrast dye, or fluoroscopy dye that interacts with the x-rays is injected to show the branches of the arteries. When the dye is injected into the blood vessels the screen shows a web of blood vessels around the heart and it is possible to see areas of narrowing or constriction or where downstream flow is restricted. It is also possible to see areas of calcification. The x-rays will give a 2D picture of a 3D structure, so pictures of the same artery from several angles are taken to reconstruct the volume of the blood vessel. The patient had two seriously occluded arteries, the distal circumflex and the obtuse marginal, and the plan was to fix the more significant one with a stent. Note: The diagnosis of the narrowing of the arteries, calling the patient’s primary cardiologist or physician to discuss the results, and deciding to deploy a stent is all done at that time since the catheter is already in place in the patient’s coronary arteries. A wire and balloon is deployed through the catheter to pre-dilate the lesion where the stent will be put. Then a crimped stent and balloon is put in. The balloon is inflated to expand the stent, and then the catheter and balloon is removed, leaving behind the stent in the lesion.
On Thursday, Fai and I went to TEE in the morning and then went to see Cardiac Cath. The patient in cardiac cath was scheduled for a colectomy, but had had an abnormal stress test in nuclear cardiology and needed to have his heart checked out before he could undergo a major abdominal surgery. The patient had an unusual skin problem in the groin area. So, instead of putting the catheter into the femoral artery, the doctors used a brachial approach (traveling up an artery in the arm). While the doctors are searching for areas of narrowing and blockage, they are also looking to see if the heart has formed collaterals, or natural bypasses of blood to areas that have lost their normal blood supply. Unfortunately, this patient had a LAD (Left Anterior Descending) coronary artery with a lesion that was almost 90% blocked in addition to other occluded areas. The doctors felt that even with stents and a month of anti-thrombogenic drugs there might still be incomplete vascularization, and recommended complete bypass surgery before the patient could have abdominal surgery.
On Friday, Casey and I went to TEE. After TEE I was able to meet with Dr. Chen, a pediatric cardiovascular surgeon, and arrange to shadow him during some of his surgeries the following week. Also, cell culture in molecular cardiology continues – I think I am getting better at it.

Week 4: Colds, TEEs, and Stem Cells

I picked up a cold that carried over into week 4. I did not want to interact with any doctors or patients while I was still sick (and be single-handedly responsible for a plague spreading through an innocent, possibly immune compromised population). Dr. Weinsaft suggested I spend my time in the lab and then start clinical rounds up again on Thursday. I am working with Dr. Ann Foley in Molecular Cardiology. My project is aimed at testing the hypothesis that visceral endoderm induces heart formation. I am using four different embryonic stem cell lines, and co-culturing them in embryoid bodies for the experiment.
On Thursday Brooke came with me to TEE where I am shadowing Dr. Healy. A very polite southern gentleman was one of the patients in the morning. He and the woman after him were sunbeams of cheer, and they were talkative and friendly throughout the test preparation. Many people aren’t that nice even when they are in comfortable situations, much less when they are feeling apprehensive about a fairly serious test. The gentleman patient had been having Transient Ischemic Attacks (TIAs) of increasing frequency. He would have an episode of garbled speech for 5 minutes, some memory loss, and shortness of breath. The cause of these episodes was unknown, he had never had a full stroke, and then two months ago it was discovered that his heart had gone into atrial fibrillation. The TEE was being done to look for a clot in the atrial appendage or the atrium. If a patient is going to undergo an ablation surgery for an arrhythmia or electrical cardioversion to reset the heart’s rhythm, a clot could be jarred loose and potentially cause a stroke. They did not find any clots in this patient’s heart.
The next patient was the youngest I had seen come in for a TEE. She was a young school teacher who had a stroke when she was 30, and had been put on aspirin. Now three years later she and her husband want to have a second child. Her cardiologist suspected that her stroke was the result of a clot crossing a septal defect, from one side of the heart to the other. Normally the lungs do a good job protecting against clots drawn up from the legs, but a Patent Formen Ovale (PFO) or hole between the upper chambers of the heart, can allow a clot to bypass the lungs and reach the brain. The TEE procedure was being done to check for the hole between the chambers and assess the size. The possibility of forming blood clots in her legs during pregnancy and then straining during labor increases the patient’s risk of stroke with the septal defect. During the TEE the cardiologist did find a medium to large hole between the atria. After the procedure was finished and the patient woke up, the doctor brought her husband and her father into the room to show them the image results. (The patient may not be able to remember seeing the images so it is nice to have someone else be able to describe it to them later.) TEE is still on recorded on VHS. There was some brief discussion about the patient’s options. Considering the size of the hole, the cardiologist recommended that an anticoagulant be used in addition to the asprin that the patient is already taking. If the patient became pregnant, for most anti-coagulants their use would need to be stopped before delivery of the baby, leaving her vulnerable to blood clots. One other option discussed was a device that would act as a plug for the PFO. It could be inserted by catheter, poked through the septum wall, and then sealed around the hole (like two discs clamping together on either side of the wall). Unfortunately, it has a complication risk of 1%. The patient would still probably need to be on a blood thinner with the device, but it would prevent any clots from crossing over. She and her family will have to decide what risks they want to take and how to best manage them. Doctors are almost like risk management counselors. Sometimes tests start to just seem like an assembly line of procedures and analysis, since there are so many people who need the test. When I actually see the doctors talk to their patients and discuss the ramifications of the tests, I realize that it isn’t as simple as “We know what’s wrong. Here’s your cure. You can go home.”

Week 5

This week I devoted all of my time to working on my project. This included working on a stand that will enable the user to hold a mouse under a microscope for the purpose of carrying out in vivo studies. In addition, I have been working on helping the lab develop and in vitro cell culture system that can be used to study corneal cell migration.

Week 5 - Bo

This week I devoted most of my time on my project. This project is to write a book on how to operate a MRI scanner for people who have never used it. It is related to my research book but it is also quite new for me because operating a scanner is quite different from running a program or designing an algorithm. I worked with Mitch and Cynthia on this book. For the past weeks I have done some initial work but was not very productive. We already finished the first two chapters which are about the fundamentals of operating a scanner and some safety issues. For an outsider, the safety issue can be much more important as thought intuitively. In the scanner room, people are faced with a very strong magnetic field which can cause great hazard if any iron is brought into the room. The rapid changing RF field can deposit heat into metal which is also harmful if it is inside the body. Also the superconductive system contains cryogen and liquid nitrogen. Any inappropriate operation can lead to disasters. Oh, it seems that using MR scanner is so dangerous...while the point is that if you obey the rule in MRI room, everything would work fine. And this is what we want to include in the first two parts, that is, to give people an intuitive idea of how a scanner works and what to pay attention to in the operation.

Besides revising previous work, I wrote a chapter which teaches brain scan this week. There are many pre-installed protocols in the MRI scanner. Even for brain scan, there are many depends on what function you want to see or what symptoms the patient is . In the book, we use a general protocol which includes several basic series to show the brain functions. A set of such series can give sagittal and coronal plane images of the brain. We scanned several volunteers including David and Fai. In this week, we rely more and more on ourselves not others' instructions. The scanning process went on smoothly without any mistakes. Just as Dr. Prince said, after the initial stage, you will get accelerated fast in learning how to scan. That is what we experienced this week. Besides the brain images, we also have to collect screenshot for book illustration. Through writing a chapter, I know it is hard to narrate what you know to others. Sometimes, it takes patience to do a good job. What we know is not necessarily natural to others. So writing a book without missing "trivial " things for the writer and make the knowledge easy to follow is a skill. I am learning this and hope to know more.

Week 4 - Projects and Patients

This past week, a large part of my time has been devoted to working on my project. My project is with Dr. Linda Vahdat, a medical oncologist who is an integral member of the Weill Cornell Breast Center. She works with patients who have metastatic breast cancer to determine which course of therapy – chemotherapy, radiation, etc. – is the best for them. She also has a fairly active research program that is based on clinical studies and clinical trials of new treatments.

The project that I am working on is a collaboration between Dr. Vahdat and Dr. David Lyden’s lab at the Weill Cornell Medical College. This December 2005 Nature paper is the basis of the work. Essentially, Dr. Lyden’s lab has discovered that bone marrow-derived hematopoietic progenitor cells that express VEGFR1 home to tumor specific pre-metastatic sites and form cellular cluster before the arrival of the tumor cells. The tumor cells then attach to the cellular clusters and form micrometastases which develop into new tumors. The idea that the site of secondary tumors is determined even before the tumor cells detach and circulate through the blood is new to me, and it is an idea that completely changes the way we think of cancer. One goal of the Lyden lab is to investigate different methods of preventing the pre-metastatic niche from forming. They have found that certain antibodies prevent the cellular clusters from forming, and therefore prevent the growth of micrometastases. An interesting article that presents an easy to understand version of the research can be found here.

The collaboration involves looking at patients with varying stages of breast cancer, who have undergone various treatments, to determine whether the levels of various cytokines and growth factors change in accordance with the formation of a pre-metastatic niche. Therefore, blood is drawn from patients throughout their course of treatment, and is analyzed by members of the Lyden lab for these certain markers. The person who was in charge of the clinical data (under Dr. Vahdat) went to medical school, and thus there has been a lapse in the collection of samples. My role on the project is to sift through electronic files to determine when the patients enrolled in the study will come back in to meet with their physicians, and to arrange for them to have blood drawn at that time, to be sent to the Lyden lab. In total, there are around 120-140 patients in the study.
While most of my work occurs on the computer, this past week I had the good fortune of being able to personally arrange one follow up sample. A patient was coming in to meet with my physician mentor, Dr. Tousimis, for her biannual checkup. I was able to meet with the patient during her exam, and then took her to have her blood drawn. During the blood draw, she asked several questions about the study which I was able to answer. She was very enthusiastic about participating. I also was able to play the role of courier, transporting the blood to the Lyden lab, where I was able to learn a little more about the project on their end.

In addition to my project, I also went to several lumpectomies and mastectomies this week. I observed my first mastectomy which had immediate reconstruction using adipose tissue from the abdomen. It was fascinating to watch two teams of surgeons working at the same time, on different parts of the body, without interfering with each other. I do not envy the head scrub nurse her job. These ladies (at least mine have all been female) truly make the OR run.

In the last weeks of immersion, I am working to set up times for me to shadow a genetic counselor and a breast cancer pathologist, as well as to shadow Dr. Vahdat and observe the treatment of metastatic disease. My goal is to have a complete story of breast cancer and all of the different ways it is treated and diagnosed before I leave.

Blurry Images in a Blurry World

In diagnostic radiology, anatomical images are necessary and important in determining the condition of and treatment plan for patients. MRI/CT/PET scans give invaluable information to doctors that can ultimately lead to more accurate diagnoses with reduced bodily invasions.

The concept of imaging is of course beyond medicine. From the dawn of humanity, we have utilized images as a means of expression, communication, and depiction of both reality and imagination. In medicine and biological sciences, imaging is an external means of probing our internal states - from organs to cells to biomolecules; we are outside looking in. In art, imaging is often a process of expressing our inner states externally; we are inside looking out. But, no matter which reference frame we are in, we struggle in obtaining that clear image that gives us the absolute answers to our questions. Medical imaging modalities are flawed and (at present) limited. We cannot always detect abnormalities; there is only a 30% chance of an x-ray detecting lung cancer if it were present, according to Dr. Cham. The images from our inner-selves are often abstract and ambiguous; there is no concrete and absolute interpretation of any painting or art form. It seems as though we are stuck in a universe of uncertainty and relativity. No matter how hard we look into the microscope or particle accelerator, there is always a fuzz of uncertainty in our observations (according to the laws of quantum mechanics), and no matter how hard we try to express that inner image of our being, it will always be that uncertain blur, something we can never fully understand- because it is something we never see or experience in the physical external world.

Our world and our lives then seem to be seen only through uncertain images, but this uncertainty also seems to be a defining property of our experience in this universe.

week4

The first three days of my summer immersion week four was spent in the OR. There were eight patients in total that underwent robotic prostatectomy, the oldest was a 78 year old man. The most fascinating thing about robotic prostatectomy with the Da vinci system is the rather early discharge of patients following surgery. Also fascinating to me was the division of labor in the OR, which to me evinces the rather hierarchical nature of the health care profession. As the surgery proceeded, I wondered where a biomedical engineer fits in the "healthcare chain" [doctors being on top] given the presence of the physician assitants, nurses, anesthesiologists, and the Biomedical Engineering Department label on every equipment in the OR.(thought for another day).
Post-op, Dr Tewari follows up on the patients about their sexual function recovery and continence. Also in week 4, I presented a paper on the overexpression of HuR protein and its association with increased cyclooxygenase-2 expression in cystoprostatectomies (removal of the prostate and bladder). For the rest of the week, I spent my time doing literature review on total reconstruction and urinary incontinence.

Week 3

This week I spent more time with the anesthesiologist during the neurosurgeries. It was quite impressive to learn more about how a patient is monitored and controlled during the surgery. The neurological surgeries are particularly challenging for the anesthesiologist as their usual anesthetic increases brain blood flow and they therefore try to compensate by using more of a different type in combination with a much lower concentration of the usual anesthetic (sorry, forgot to write down the name, but will update next week). Further, the patient has to be completely paralyzed right up until the end of the surgery as their head is fixed in a Mayfield head holder http://www.steel-form.sk/en/02/0103/b/images/52.htm. If the patient was woken up while the head is still in this, he/she could seriously injure themselves with just a slight cough. The paralyzing agent is given separate from the anesthesia and both have to be monitored closely. This means that if the patient were to wake up during the surgery, one would not notice this through any patient movement (every anesthesiologist’s nightmare). While the paralysis can be measured by applying a small electric shock at the wrist and seeing the extent of movement, there is no effective device yet to measure the state of alertness (i.e. how deep the patient is in anesthesia). While they have some idea of a patient’s alertness by monitoring the heart rate and blood pressure (i.e. a patient with a low blood pressure and low heart rate is fast asleep, there is still no device that effectively monitors consciousness. This device would be very helpful as every patient responds differently to the anesthetic and requires different amounts. Finding the minimally required amount is also important as too much anesthetic results in various side effects. One company has tried to create what they refer to as a BIS monitor (Bispectral index http://www.aspectmedical.com/patients/bis/default.mspx). This is attached to the forehead and analyzes a patients ECG from the forehead during the surgery. It runs this data through various algorithms and yields a number from 1-100 which is supposed to represent the patients state of awareness. According to the anesthesiologists I spoke to, it doesn’t work very well though and isn’t of much help to them and thus they don’t use it. If however, one were to develop an effective device like this, chances are the FDA would require it during every surgery. Apparently this was tried with the BIS monitor, but due to its limited effectiveness not followed through. So BME students… if you have any ideas… talk to me and lets get a patent :-).

Week 4

This week I followed an interesting case where a patient needed both a cornea transplant and glaucoma procedure. This case was particularly interesting in that the patient had been previously seen by Cornell surgeons and given a series of recommended procedures. The patient decided not to take the advice of the surgeons and headed to another eastern European country for treatment. Unfrotunately for the patient, the procedures did not go well and the eye ended up worse off then it started. The patient returned back to Cornell and underwent a new series of recommened procedures. The patient had sustained damage to the retina, which offered the threat of complete vision loss. But to deal with the retinal problems the patient needed to be treated for a blinded cornea and misplaced glaucoma stent. The first treatment took care of the misplaced glaucoma stent by removal of the original stent tubing and then repositioning the tubing into a more posterior position of the eye. Following that procedure a cornea transplant procedure referred to as a DSEK procedure which involves the replacement of the cornea endothelium with a donor tissue. The procedure went well and the patient should have substantial improvement in vision, and more importantly the patient can now receive the necessary treatment on the retina.

Week 4 - Bo

I went to the ICU (Intensive Care Unit) this week. The team I followed has one doctor, one new fellow and a 2-year resident. Their routine work in the morning is to go around each patient room and record the patient's state of illness. The resident was in charge of reporting the patient's previous records. She had a stack of cases and read them out to the doctor. The doctor took notes on the form of each patient and the team examined the physical state of the patient and added them in the previous record. They also wrote down what the patient's relative told them when they accompanied the patient. The fellow told me they would discuss these records in the afternoon and gave further treatment of next day. In most ICU rooms, there are 3 patients. Most patients I saw were children, with age ranging from several months to 7 years. These children were most in a relative steady state. They did have some tubes attached to them, but not as many as I thought. Actually, I saw some ICU room on the TV before, which seemed to be really "intensive", single room, many nurses outside and tons of different tubes and measurements. The fellow told me that the ICU have different form in different hospital. Here, in Presbyterian, the care in this floor is not that intense.

I went to see a new plastic surgery this week. However it is different from what I observed before. In the OR room, two surgeries were carried out together. One surgery was to cut the skin of the wrist while the other was a throat tumor removal. It was to see clearly what was going on of the throat tumor removal. What I can saw is the throat and half face of the patient was opened. The incision was quite big. That is why the plastic surgery was needed. Dr. Spector carefully cut a patch of skin off which did not quite took time. But he also had to cut two arteries attached with that patch. This process took a while and seemed to be a little bit difficult. That patch was used later to help suture the big incision on the neck. Arteries were necessary to be connected to the original ones in the neck. I watched until noon. By then the wrist skin had been successfully cut off but tumor removal was still in process. I was told that the whole surgery took 12 hours altogether! So the tumor removal part was very hard. And this is the longest surgery I have heard since the summer immersion.

A very interesting and thought-provoking case happened on Thursday. I went to see a lung cancer biopsy procedure with Charlie and Michael. Apparently it was a routine but not hard procedure. But we encountered a patient who was 1 out of 2000. She seemed very painful and uncooperative. She wanted to quit in half of the biopsy for many times. Dr. Cham soothed her and even injected another dose of anesthetic. During this injection, the patient screamed and tried to prevent the doctors. This was a rare scene that a patient can be so uncooperative. But finally Dr. Cham injected the biopsy deep enough to reach the mass center and got some sample. The sample was tested immediately in side the scanning room. In about 10 minutes the result came out, validating that the mass was indeed a tumor. What makes the patient felt so painful is the long process of biopsy because each time the doctor could only move the biopsy forward a little and came out of the scanning room to position where it was through CT. This process had to be taken out for 6-7 times. So maybe a robotic arm fixed on the CT machine would be more helpful. In this case, the doctor doesn't have to come in and out the scanning room. He just need to use the robotic arm, so the movement and relative position of the biopsy can be displayed on the CT image while he moved the robotic arm. Positioning won't be problematic as now.

Week 4 - Patient Compliance

Until now, I have never realized how large an issue patient compliance can be for physicians. Sometimes, how reliable a patient is can even alter the treatment course that at medical doctor chooses to follow. For example, I went to a conference on Monday morning with all of the plastic surgery residents and fellows. The main topic of discussion was emergency wound care but I was surprised to learn that the course of action can be extremely different depending on the perceived dependability of the patient which can lead to vastly different results (all methods provide reliable outcomes but the amount of scarring or degree of functionality after a major wound can be different depending on the treatment protocol). It was interesting to hear the students discuss treatment plans for patients and realize that although every patient will receive adequate care, some patients don’t receive the “best” care because they are unlikely to follow the necessary steps or return to the hospital for further action.

As I mentioned in last week’s blog, I saw a 61 year old woman present with an extremely large tumor. I truly don’t understand how she could have waited so long to see a physician about her problem-after all the breast reduction cases I’ve seen I am sure that she was having back pain in addition to all the other side effects from the tumor. Since the doctors were worried about her returning to the hospital, they scheduled surgery to occur as quickly as possible and I saw the tumor resection occur on Monday. The tumor weighed a total of 2.8 kg (~6.2 lbs) and was removed as one mass (the woman weighed just over 100 lbs so the tumor was over 5% of her body weight!). The surgery was quite intense because they had to tie off so many large blood vessels while holding the huge mass in place so that it didn’t tear away from her body and cause her to lose a lot blood. Once the tumor was removed, Dr. Grant closed the wound as best as possible with the remaining skin by undermining the margins. He used a skin graft from her leg to close the remaining wound and then applied a wound vac to help the area heal. Although she could have gone home after two days in the hospital, her physicians decided to keep her there for an extra day so that they could ensure she got the care she needed in case she decided not to return for her checkup.

Another interesting case (which doesn’t necessarily have to do with compliance as much as it has to do with unwise choices) involved a woman who presented with back pain after going to an unlicensed Columbian doctor in New Jersey. To give her a nicer buttocks region, she had free silicone injected into the area (apparently this is a popular procedure in the local Hispanic population). Unfortunately, after only a few months, the silicone began to migrate all through her back and cause her pain. Because it is free silicone, Dr. Grant explained that it is impossible to completely remove all of it and the microscopic particles are likely to be causing her pain. She explained that just a week earlier, the silicone had coalesced into a large tumor-like lump but had dissipated again. Dr. Grant said that he will do his best to remove any silicone that happens to coalesce again but cannot presently do anything for her.

I cannot wait to see what surprises next week brings!

week 3

During the third week, I tried to see more various cases in plastic surgery and get more profound knowledge in this area, through attending conference, lab meeting, office hour and surgery as well.

Among surgeries during the third week, microsurgery to repair lip cleft was impressive. The patient was 3 year-old young kid having incomplete bilateral lip cleft. Incomplete bilateral lip cleft is a small gap or an indentation in both sides of the top lip but this gap or indentation does not connect to nose. If cleft continues up to the nose, it is called complete cleft. The upper Lip and palates were dissected to several pieces and nasal section also followed subsequently. Since movement of lips and palates are deeply involved in speaking, eating, and facial expression, dissected upper lip and palates had to be reconnected elaborately to make muscles adjacent to the lip move properly. Potential force and tension of facial muscle adjacent to mouth also had to be considered to rejoin the pieces of lips and palates. Even though surgery itself may look like just a successive procedure repeating dissection and suture, actually there are much more invisible factors that has to be considered to make our body function properly. Also, as I observed surgery, I realized that every single step from anesthetizing patients to waking up patients from anesthetic during procedure is critical. One case was not able to be proceeded further since the patient bled severely while anesthetized.

In addition to the surgeries, I attended monthly based conference in the department of plastic surgery, which is called “Morbidity and Mortality”. This conference offers a chance to share extraordinary experiences and propose suggestion to the challenge that they face when they were dealing with those cases. There were several cases discussed. The first case was debridement, spinal fusion and local back wound free flap. Spinal fusion is for patient who has impaired neurologic function and muscle development. The second case was about congenital cleft lip and palate. In this case, several prior surgeries to correct the cleft had been done but they did not work well. Thus, residual cleft and nasal deformity were repaired and even tongue flap was followed. The third case was a patient who had surgery for Glioblastoma but the incision part was infected. Thus, scalp and skull near the infected part were debrided. It was really great time to learn about various cases that I have not seen before.

Also, I was able to interact with patients during post-op office hour and a diabetic patient came back after debriding wound on the feet for skin graft since opening wound part was infected. The infected part totally turned to green like mold. After surgery, especially for immune-deficient patients such as diabetic patients, one of the most critical things is protecting from infection. In this case, open wound was infected by Pseudomonas which commonly causes infection to immune-deficient patients. Thus, keeping operating room cool, injecting antibiotics during surgery and having patients take antibiotics after surgery, patient are efforts to protect patients from infection.

In week 4, hopefully I can get involved in a specific project in addition to clinical experience.

Week 3: Pratt

This week I shadowed Dr. Nasser Altorki, a professor of Cardiothoracic Surgery and the Director of the Division of Thoracic Surgery. I observed him perform several ___. One patient was extremely interesting because she had very-widespread cancer but was still undergoing invasive surgery. She would normally not be a candidate for surgery, however her cancer had responded very well to chemotherapy and apparently her physician thought she had a good chance at survival. The patient underwent and esophagectomy followed by a jejunostomy. A jejunostomy is making an artificial opening in a part of the small intestines to allow feeding tube placement. Throughout the surgery, Dr. Altorki explained exactly what he was doing and what organs were in the line of sight. He mentioned the patient had a relative who was also a physician, who pushed for the surgery to happen. I wonder how often something as simple as personally knowing in the medical field can alter someone’s entire course of treatment.

Week 3 - Brian

This week I was in the OR observing both cornea and glaucoma surgeries. The most interesting glaucoma surgery entailed the repositioning of a drainage stent that was irratating the patient. Basically, these stents are used to drain fluid from the medial area of the eye into the tear drainage duct located near the lower eyelid. The tube used for drainage is extremely small (~1-2 mm diameter) so it does not irratate the patient after implantation. The surgery proved to be successfull in bringing the patient's intraocular pressure (IOL) back to normal levels. This increase in IOL pressure could lead to retina damage and blindness down the road. I also witnessed a cornea transplant surgery called Descemet's stripping with endothelial keratoplasty (DSEK), which is considered the future of cornea transplant surgery. This surgery is minimally invasive (<2mm incission) and a nearl sutureless procedure. It was intriguing to witness such a minimally invasive method of doing a transplant. The surgeons first make a small incission in the periphery of the cornea and then use instrumentation to remove the back layer of the cornea. Next a donor cornea back layer is replaced in its stead. This procedure can work for nearly 80% of the current corneal tranpslant procedures in the US.

Week 3 - Huang

Hey, Upper East Siders! Gossip Charlie here... your one and only source into the scandalous lives of Manhattan's elite. Top story on my homepage: lung cancer. The world's most common cause of cancer-related death can be diagnosed by Dr. Matt Cham's hand... but at what price?

Spotted: cranky patient in left lateral decubitus position inside CT scanner. From previous PET scans, a growth on the patient's lung was discovered and is suspected to be cancerous. To perform the lung tumor biopsy, Dr. Cham had the patient CT-scanned with markers along the patient's back to indicate where the needle should be inserted. Based on these images, Dr. Cham inserted a needle into the patient's back at the proper marker and again scanned the patient to check if the needle was inserted properly and in the right position. Every time he scans, he must step out of the scanning room, so the imaging is not in real time. After adjustments, Dr. Cham pushed the needle further into the center of the tumor and suctioned out a sample. This sample was stained and imaged immediately inside the scanning room (something I was surprised to learn) and was determined to be cancerous (presence of large cancer cells surrounded by smaller neutrophils).

Although Dr. Cham assured us that the procedure is generally not painful and patients don't usually complain, this particular patient we observed was very... difficult to work with (a "1 out of 2000" case). She complained about feeling pain and being cold throughout, and although the doctors/nurses tried to calm her down in the scanning room, they joked around about her behavior outside. You know what they say about the Upper East Side... if you can't stand the heat, there's always a cold shower.

Other than being in the hospital, I've had a good time exploring NYC these last few weeks with fellow Immersion students. Love may fade with the season, but some friendships are year round. Like you and me! You know you love me.

xoxo,
Gossip Charlie

Patient Quote of the Week:
Patient: Ow! That hurt! Don't do that!

Week 2: Fai

Beside round in the neonatal care which I routinely did it almost every day, this week I saw several new things. In early of the second week I had chances to go to the surgery room. This is the first time in my life to see operations in real. I am very excited about it. I saw surgery to remove thyroid tumor and gallbladder. For the thyroid tumor which is kind of a superficial organ around the neck, surgeons used conventional approach to remove it. In this case the tumor was very big. It was around four times bigger than the normal one. For the gallbladder, they used minimally invasive method which the surgeons made very small incisions on the patient's stomach, and the surgical arms were inserted inside. I also saw plastic surgery—two operations. First is cutting the dead tissue on the diabetic patient’s foot and the second is restoration of the patient’s wound by extending the skins around the wound and sewing them together.

In this week I also attended thyroid tumor conference. There were many challenging case studies in the conference. Doctors and surgeons in the meeting discussed several approaches to find the best method to treat each patient. I gained a lot of information about the ways that patients had been treated not only approaches from the US but also Japan and Europe. After the conference I went to Dr Zarnegar’s group meeting. I got the overall idea about the current research being done in his lab which I found very interesting, greatly useful and, the most important thing, related to my research project that I have be done in Ithaca. I am willing to attend the conference and the lab meeting every week since then.

Week 3 - Breast Surgery, An Often Necessary Procedure

What a busy week this has been! In addition to shadowing Dr. Grant on his cases, I also viewed surgeries done by Dr. Tousimis (Casey’s mentor) and Dr. Schwartz (David’s mentor). I have realized that every surgeon has their own techniques, styles, and preferences while operating. The residents, fellows, and medical students rotate with a different surgeon each month so it was interesting to see how the newest set of students interacts with Dr. Grant and the styles they have learned through other surgeons (since they switched on July 1). I have learned that it is essential to talk to as many physicians as possible about preferences and ideas before designing a product that will be used by them as everyone will have a slightly (or even drastically) different opinion about what is best.

A patient who had a breast reduction during my first week of summer immersion came in for her first post-op appointment. I was excited to see how the woman was doing after having her breasts ‘exploded’ to remove tissue and create breasts that were more proportional to her frame. To my amazement, the patient was extremely happy with her procedure and could not say enough good things about how much better she felt. In fact, she said that the pain due to the surgery was not as bad as the back pain that she had been enduring for years due to her enlarged breasts. I honestly expected the patient to be in much more pain since she had an extensive surgery just 10 days prior but it proved to me, once again, how much of an impact surgeons can have on their patient’s lives.

Another patient came to the office because her silicone implants from a surgery 10 years earlier had ruptured. Silicone implants have an average lifetime of 10-20 years and the manufacturer will pay for the second (or even third) set of implants so that the patient only has to pay for the surgical fees. The breast with the ruptured implant had noticeably more ptosis than the contralateral breast. It was determined that the implant had ruptured by palpating the area. The silicone will be removed in a subsequent surgery in which both of the implants are replaced and the breast in slightly lifted (the patient would like to maintain breasts that are normal for her age and body size). She was very satisfied with her first set of implants and had no reservations about replacing them.

My most surprising case of the week was a 61 year old woman who presented with an extremely large cystic-like breast cancer tumor—it was about the size of a basketball. She was very embarrassed by the situation and warned Dr. Grant and I that it was very “gross” before showing us. I had to fight to maintain composure when she removed her gown. I do not understand how someone could allow a tumor to grow so large without seeking medical attention. The woman only weighed about 100 pounds so the breast with the tumor was clearly visible outside of clothing as a deformity and must have been growing for years. Dr. Grant will use a skin graft from the patient’s leg to close the large wound that will be created by excising the tumor. I will be sure to comment on this case more after surgery occurs.

Week 3 - Improving the Quality of Life via Surgery

On Thursday, I accompanied Brooke to see a breast reduction procedure conducted by her mentor, Dr. Grant, at Columbia. We got there early and had the opportunity to read through some articles in the latest editions of the Plastic and Reconstructive Surgery Journal of the American Society of Plastic Surgeons. It was very interesting to me to read papers based on clinical studies and the results of actual operations. For example, one of the articles I read was about skin-sparing mastectomies in which the natural areolar tissue is preserved during surgery, and used to immediately reconstruct the nipple. The primary benefit of this technique is that most of the breast reconstruction occurs in one step (with the exception of when tissue expanders are used). The goal is to achieve more natural appearing results. This article interested me because I was able to compare the techniques used to the techniques used by my surgeon which I have observed over the past few weeks. Additionally, I read another article that was more experimentally-based, in which endothelial cell explants were isolated from intramuscular venous malformations and cultured in vitro. The growth and migratory behavior of these cells was analyzed, as was the expression of matrix metalloproteinases in an attempt to understand the invasive behavior of these cells. This article was interesting to me because the experiments mirrored some that I have performed in Ithaca, and the cells showed behavior similar to that of some cancer cell lines I have used.

Meeting Dr. Grant was a real pleasure. He was very enthusiastic about having another student to teach, and in the brief time I was there, I listened to him and Brooke discussing many different patients and procedures. I am amazed at the variety of different procedures he performs – a big change from the more specialized practice of my surgeon. Additionally, as chief of plastic surgery he is in charge of hiring new surgical fellows, and he took the time to explain to us how the process works. They take on only 3 new surgical fellows every year, chosen from hundreds of applicants, a process he appeared to really enjoy.

After meeting Dr. Grant and having time to read some papers in his office, we went down to meet with the patient pre-op, where Dr. Grant marked lines on her body of where he would cut, explaining to the patient what he would do in the OR. The patient was a woman in her sixties, who was more than ready for this procedure. She explained to us how in her twenties, her breasts were a D cup, and then they progressively kept growing until they reached a G cup. It was clear that they were very problematic to her, causing her quite a bit of unnecessary pain.

For the actual procedure, a cookie-cutter type ring was used to outline a new areola, which would be more proportional to her new breast size. The new areola was cut out, and a flap of skin was removed above the areola, where Dr. Grant and his surgical fellow went in and began removing tissue. It was a truly amazing process to work, because in the process, additional incisions were made, until it literally looked like the breast was “exploded”. The tissue that was removed was placed into buckets – one for each breast, and the buckets were subsequently weighed in order to quantify how much tissue had been removed from each side. The goal was to make the breasts as even as possible. Dr. Grant worked on one breast, and the fellow worked on the other breast, so it was amazing to me that they tissue each removed was quite comparable. After they had removed quite a bit of tissue, they temporarily stapled the breast together and sat the patient up on the table, in order to visually check that the breasts were hanging at the same level, and looked even. The table was laid back down, and more tissue was removed from each side. The total tissue removed weighed well over 1 kg. Then came what seemed like the longest part of the surgery – stitching the breast back together. Delicate stitches were used to stitch the areola back to the breast, and the rest of the incisions were closed as well. A medical student who was also present was able to help by cutting the stitching where Dr. Grant and the fellow requested. Dr. Grant stressed the importance of a smooth stitch, because regardless of how good of a job they do, the patient is left with the scars that remain after the stitching, and the smoother the stitch is, the less noticeable the scar will be.

The entire procedure was much shorter than I thought it would be. I think total the operation took about 2.5-3 hours. Additionally, I was shocked that this was an outpatient procedure – the patient would only be in the hospital for a few hours for monitoring, and then would be able to go home. Remembering how the patient’s breasts had looked in the middle of the procedure and realizing that she would be able to go home the same day, I was absolutely amazed by the resilience of the human body. The best part of the procedure was realizing how much this procedure was going to improve the patient’s quality of life. Her breasts will look more proportional to her body size and, more importantly, she will feel so much better without having that extra weight to carry around, putting pressure on her whole body. Such a short procedure, and it would have a huge impact on her life. It was really an amazing procedure to have witnessed.