Immersion Adventures Week 1

I arrived with the other first year biomedical engineering students (there are 11 of us) in New York City on Sunday evening June 14^th 2009. We got off the bus and settled into our new rooms at Olin Hall near 70^th Street and York Avenue. One of the hospital residents explained that you always say the streets and avenues in a particular order. My apartment has a view of the street and a mini-fridge (both are good for the soul).

Day 2

The next day we went to the ID office to get official ID cards. The ID guy was nice and helpful and it wasn’t as harrowing as we had been warned to expect (probably because of a great deal of coordinated effort by the people running the immersion program). One thing I found interesting is that they fingerprint the doctors and those get stored in the computer with their profile. I asked one of the doctors in the nuclear cardiology department about it later and it sounds like most if not all permanent employees at the hospital are fingerprinted –however, they didn’t know what kind of data base it went into, perhaps it aids in background checks, preventing serial killers from practicing neurosurgery. Then there was an orientation meeting with Dr. Wang, Keigo, Mitch, and Dr. Weinsaft. Dr. Weinsaft is my summer immersion mentor and this was the first time I had met him in person. The meeting was held in a conference room in the radiology area of the hospital - the waiting room for radiology was classy – there were even real orchids on the tables. The key points from the orientation meeting were – take initiative, completely immerse yourself in clinical experience for the short 6-7weeks available, and the scheduling and interactions are flexible (shadowing with other clinicians and groups is acceptable even encouraged). The girls ran to lunch down the street to a pizza place – genuine NY pizza - and then we went to the Starr Pavilion for part one of an ethics seminar. We discussed badly behaved scientists, ethics versus morality, and different ethical theories.

Next I went to Dr. Weinsaft’s office and was introduced to several of the residents, and Dr. Weinsaft discussed with the group a paper that had been reviewed for the journal Circulation: Cardiovascular Imaging, what changes needed to be made, and what data to be included before it could be published. Then Dr. Weinsaft took me downstairs to Nuclear Cardiology where he had arranged for me to shadow some of the doctors during the first week.

Day 2

The Weill Cornell Medical College and New York Presbyterian Hospital conglomeration is composed of several different buildings that have levels that don’t connect, different elevator towers for individual sections, and veritable maze of hallways and locking stairwells. Essentially I got lost trying to find my way back to Nuclear Cardiology the second day, but seven people’s directions and an information booth later and I arrived successfully. I met several fellows, senior fellows, an attending physician, a resident, a technician, and several nurses in Nuclear Cardiology. I had to run to part 2 of the ethics seminar and then I returned to Nuclear Cardiology. In Nuclear Cardiology they evaluate the perfusion, contraction, and viability of the heart using a stress test and a Positron Emission Tomography (PET) scanner. A radioactive isotope is injected into the patient’s bloodstream, such as Thallium or Technetium. Sometimes the isotope interacts biologically inherently, such as if it is a sodium analog and cells are then inclined to uptake it, or if it is modified with a biological ligand. The radioactive isotope reaches areas of tissue that are perfused by blood, and the isotopes used in Nuclear Cardiology are selected because they target tissues that are particularly metabolically active – e.g. the heart. The patient is injected with a radioactive isotope at two states, rest and stress, and a PET scan taken during each state. Rest is during a resting heart rate and for the stress test the patient is put on a treadmill to excersize and reach an elevated heart rate. During stress the amount of blood directed to the heart and through the coronary arteries should increase as the arteries dilate. The scans show areas of relative brightness of isotope, and when the stress test and resting test scans are compared, defects and areas of incomplete perfusion can be identified. The first full day in Nuclear Cardiology I saw the doctors looking through many scans, they were very helpful with explanations and definitions , and vocabulary learned helped me process information the subsequent days.

Day 3 and Day 4

The next two days in Nuclear Cardiology involved learning variations and more elaborative explanations of the tests for the heart. I actually got to witness the stress test – running on the treadmill with increasing incline for approximately 20 minutes looks hard, some of the patients were in really good shape. If a patient can’t run or walk, adenosine (ADO) can be injected to give some of the similar physiological effects of exercise, such as blood vessel dilatation. One of the most interesting things about Nuclear Cardiology was how the nurses, technicians, residents, fellows, and attending physicians worked in coordinated teams. Everyone seemed remarkably informal and friendly (especially considering that cardiologists have a reputation for being arrogant). Changing combinations of people throughout the day and for each step of the process carried out the necessary tasks to obtain quality scans and analyze them. From the charts and the information about the patient the appropriate approach for excersizing and scanning the patient has to be determined (who can can handle the excersize, how much radiation they can be exposed to, can they lie in all the positions necessary in the machine), the patient has to be consented and the process explained, the patient is exercised and injected with the radioisotope, the patient lies in the scanner and has to hold still for quite awhile or the images are flawed, and then the scans have to be analyzed. During analysis the doctors have to account for attenuation of the radiation through different tissues, such as if the person has a large belly or breasts. Reading of the scans took place in the afternoons by one of the attending clinicians with all of the fellow’s and residents gathered around so that they can learn the process and also offer input and discussion. Everyone heads out of the office around 5:00PM.

Day 5 (Friday!)

In the morning I went to 55^th street to a separate office and met up with Dr. Weinsaft to see cardiac MRI readings. MRI scans of the heart are far more visually detailed than the PET scans, and fluid flow and different tissue type is visible within the heart. I saw a brain scan and a heart scan being carried out by several technicians and nurses. Two cardiologists (Dr. Weinsaft and Joe) read the scans/data and wrote up the reports. One main feature of clinical work that I have noticed so far is that it is highly social - everyone is constantly checking information with eachother, moving in and out of different parts of the hospital, and multi-tasking like crazy. It is quite impressive.