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.

Week 3

I went to watch Bori's mentor, Dr. Spector's office hour this week. Actually this is my first time to watch how doctors communicate with patients. Dr. Spector showed me photos of several cases of plastic surgery. For me, these cases are unbelievable. In one case, a patient's mouse and jaw are completely opened which is amazing. Then the patient's skin got from the belly is grafted into the jaw and esophagus part. I forgot the exact function of the graft but what I saw in the photos gave me the impression that plastic surgery is related to almost every part of the body and can do whatever you can imagine. Then Dr. Spector met with several patients most of which had breast surgery, either reduction or reconstruction. One patient had different repair on two breasts because the first time she used all her fat in the belly. Dr. Spector told me that it is better for a patient to have both breast repaired at one time in case of such situation. Another patient had problem with the skin graft. She had her neck skin grafted but the scar at the interface of normal and grafted skin was red and inflamed. It seemed that this symptom was normal to skin graft. So she was told to come back several weeks later to have a check again. There were several other cases who had surgeries before and wanted to have further consultation with the doctor. They were given some small treatments. Obviously, doctors in surgery department have much more communication with the patients compared to doctors in radiology. Well, in some sense, facing and talking with patients is not that boring as facing the body images. But here you need more patience and communication skills as well as facing complaints and pain from the patients. Anyway, the life style of the two departments are completely different.

I continued my surgery watch this weak. With the help of Charlie, Michael and I watched a kidney tumor reduction surgery. This patient had tumor mass in the kidney and also colon tumor. This whole procedure included two surgeries. In the first surgery, the patient lay on his side and the doctors cut the patients abdomen open from the side of the body. Some of the big tumor mass was taken out but some residual tumor was treated by burning. As I found, the burning process lasted a long time. That is because the doctors had to make sure all the tumor is removed. In half way, ice was filled in the open abdomen. This could make the kidney shrink and leave more space in the abdomen for operation. Suture was the last part. It was different from what I thought. Human body is truly a precise. Suture has to make sure every layer be connected firmly. There were at least three layers sutured. This process took a long time. After everything was done in the first surgery, the operating table was re-oriented and the patient was placed in a supine position. This time the doctors used endoscopy to position the colon tumor. It was not easy to insert the instrument into the colon. Even though the doctor can monitor the whole process through the screen, the tube got stuck sometimes and the doctor had to push the patient's belly to deform the intestine and let the tube negotiate the big turns. Maybe a tube with a rotating head would be better here which could be a really good biomedical project! I searched online and know that patients had to take laxative. So the colon was pretty clean, except for some small dejecta residual. There are washed off by the water tube inside the endoscopy. When the whole test process was finished, the doctor used another scalpel tube and inserted inside the endoscopy. They positioned the tumor and reached the scalpel there. The tumor was removed by cutting with nope like knot and burning. The whole surgery was successful. But I did spent some time to realize that a tube can reach that far, about over 1 meter, into a person's intestine!

Week 3 - Babies and Brainsurgery

Week 3

Dr. Frayer arranged for me to go on rounds in NICU (Neonatal and Intensive Care unit) with his colleague, Dr. Schulman, and Team 1. The team of nurses, residents, and a fellow all stop at each baby in the NICU with the doctor for a run down, assessment, and discussion of how much the baby ate, what came out of the baby, the baby’s heart rate, and a number of other things that are being monitored. They even check the baby’s tummy for firmness. Some of the babies are wrapped in blankets in normal cribs , but the itty-bitty babies are kept in plastic incubators that have holes in the sides for hands reach in. They look a lot like glove boxes except for the cheerful blankets draped over them (and the baby inside of course). I have never seen babies so tiny (one was 15 weeks premature), and they almost sound like kittens when they cry. Tubes and wires that might seem small on an adult look huge on a baby (especially if the baby’s head appears to be the size of a navel orange). One of the babies heard everybody come up to his incubator, woke up and started to fuss. One of the nurses quickly sterilized her hands and then reached into the incubator to hold the baby – and he calmed down and went to sleep. One baby had apparently suffered a collapsed lung but it was able to reinflate. When the doctor came by his incubator he was really red faced, squalling mad -- the baby not the doctor -- but the doctor said the fact that the baby was able to express his anger so loudly was a very good sign.

One of the big jobs in the NICU seems to be getting the babies to handle eating - getting them used to a nipple, starting them on formula, and moving them up to breast milk. I saw several mothers who had come in to hold and feed their babies, even though they couldn’t yet take them home. The doctors will talk to the parents and the family’s normal pediatrician to make sure that once the baby is ready to go home, the parents are equipped to take care of the baby. Sometimes more than one baby -- as many of the babies in the NICU are part of a set of twins or triplets.

After I left the NICU I ran into David who invited me to see a neurosurgery. This was the first time I got to be in the operating room (OR). David got me scrubs from a scrubs vending machine (I’m sure there’s a more technical name for this) where he put in an account number and then the size of the scrubs needed. After changing into the scrubs, we put on hairnets and booties. In the operating room we stood off to the side where we could watch, but would not touch any blue things. The person undergoing the surgery that day was already asleep with her head clamped into some sort of vise when we got there. She had apparently had at least one craniotomy before. The doctors shaved off all of the hair on the area where they were planning to cut and swabbed her scalp with disinfectant several time. David said that this was the largest tumor resection he’s seen yet. I only started blacking out during the surgery once, and that was when the surgeon started cutting underneath the scalp to peal it back and started clipping blue clamps on the edges (after cauterizing) and all the blood is caught in a bag. The blue clips looked remarkably similar to office paper clips. I had to go outside and get a drink of water but after that I was okay to go back in. The surgery was needed to remove a very large menengioma. After the surgeon cut through the scalp and then the bone (there was lots of irrigation during all of this), the surgeon pealed back the dura to reach the brain. While I was present two fairly large pieces of the tumor were cut out (squishy and white- distinctly different from the rest of the brain) and part of the sample was sent off to be evaluated by pathology). It was very interesting to get to see the OR. There were lots of people present. Two neurosurgeons, one commanding nurse, an anesthesiologist, another nurse, and 3 students (David, me, and a nursing student) were there. The only part of the patient during the surgery that you see is the part of the head that is being worked on, because she was essentially entirely covered by sterile sheets with everything taped down. Neurosurgery is quite distinct from the cardiology imaging I’ve seen thus far, mostly by the nature of the work. In imaging the doctor is trying to figure out what is wrong so that the best approach to fixing the problem can be determined (planning and assessing), but surgery is the action part of the story (cut out and destroy the enemy).

week 2

During the second week, I tried to broaden my view beyond the plastic surgery, shadowing my mentor, Dr. Spector as well. I had valuable and various experiences since I was able to meet patients who have different problems through rounding in the department of pediatric and plastic surgery. Also, I was able to observe robotic surgery in urology.

As I attended Dr. Spector’s Lab meeting, I found out what his lab is currently researching on. Their interest is developing a better device to rend a better blood supply to the skin and tissue. Thus, they formed a 3-D fluidic vascular network using Melt-spun sugar fibers (cotton candy) and are trying to check cells’ viability in the fluidic system. The one of the significant issues in plastic surgery is keeping enough vasculature in the skin or tissue after skin graft or flap, so this device will help clinical treatment in terms of offering better blood supply. Also, diabetic patients are one of the major patients in plastic surgery since their wound healing capacity is much weaker than those of normal peoples they are very vulnerable to wound for a longer period. Thus his lab is also working on how H2S can contribute in wound healing capacity, increasing antioxidant which can protect cells from oxygen stress and lowering anoxia in tissue of diabetic mouse. As all of his research is deeply related with his clinical aspects, I believe that my experience during summer immersion will help me to approach closely to clinical aspects with engineering techniques.

Among surgeries that I watched during the second week, breast reduction surgery was really impressive and interesting. The patient who had surgery was teenager but had inappropriately big breasts which caused serious back pain. Also, there was a potential to keep growing. I thought that comparably it could be easy surgery but it took more time than I expected since not only aesthetic (cosmetic) parts but also primary functions of breasts had to be considered. Main blood supply and mammary gland are connected to the nipples of breasts directly through the soft tissue in the center of the breasts. Thus, the soft tissue directly attached to a nipple in the center of the breasts has to remain for the sake of keeping enough blood supply and intact mammary gland. If blood supply is not enough to support all of the tissue, tissue will be necrotic so enough blood supply is one of the most critical issues. 2.5 pounds of breast soft tissues per each side were taken out and they were the ones surrounding the center part. Also, since breast tissue is fat tissue, breast reduction surgery can have the same impact of liposuction so only certain amount of soft tissue can be removed following the policy of insurance.

Also, I was able to see Dr. Scherr's elaborate robotic surgery in Urology. Robotic surgery was performed under control of three surgeons’ well-coordinated cooperation. Dr. Scherr guided surgery via endoscopically looking through the bladder and two other surgeons controlled robotic arms as much accurately and promptly as possible. Robotic surgery itself looked really nice but for me it was hard to follow the procedure and figure out which part I was looking at since I am not familiar with urological anatomy and the screen showed the exact sites for the surgery only endoscopically but not whole structure. It would be good to have scope that can show the region for the surgery with both higher and lower magnification at the same time.

During office hour, I was able to see various cases and one of the interesting cases is hernia. Hernia is bulging abdominal wall above the disorganized organ or tissues caused by a weak muscular structure of abdomen wall. People who can suffer hernia are abnormally thin, post partum, or have had a surgery such as liposuction, and TRAM flap. Thus, hernia can be shown as a side effect of TRAM flap after mastectomy. Also, what bring a patient who had surgery for squamous cell carcinoma on the forehead back to the hospital is the damaged skin on the forehead because of radiation treatment. Thus, the patient needs to soft tissue skin graft on the fore head since soft tissue on the abdomen has many stem cells which help other cells healthy.

Lastly, I went to round to see infant patients in the pediatric department with Dr.Frayer. Most of new-born babies are twins, or triples or immature foetuses that are considerably tiny and venerable to be infected by dreadful bacteria such as Group B streptococcus (GBS). In general, infection is a really severe issue to infants since infants can be easily infected because of thinner skin. Also, once bacteria spreads to the bone it is hard to eradicate them because of porous structure of bone. Moreover, especially Infection of GBS causes 50% of motility so that it is crucial enough to keep an eye on this infection primarily. After rounding with Dr. Frayer, adult patients since there are limited ways to communicate with infants other than guessing what they feel from crying or smiling.
In the third week, I hope that I will see more variety of cases and learn plastic surgery more in detail.

Week 2

This week I shadowed Charlie's mentor, Dr. Scherr, during some of his surgeries. One surgery was a gall bladder removal followed by the removal of a kidney tumor. A fellow said most gall bladder removals are done robotically here, so we were lucky to observe an open surgery. As a senior in college, I took a biomedical engineering design class that collaborated with local medical device companies and our mentors always emphasized that ORs don't have much free space. Yet I was still amazed at just how jam-packed an OR room is with supplies. And there are always many, many other things that become necessary in the course of a surgery. I wondered how long it takes a nurse to learn where everything is once they starting working in the OR.

I also spent time in Dr. Giannakakou's laboratory. Her laboratory studies the cytoskeleton of cells and how anti-tumor drugs effect the microtubule system. Her lab has a lot of amazing equipment, including a CellSearch machine, which is a circulating tumor cell (CTC) isolation system. It is the commercial state of the art in CTC isolation. Capturing CTCs from a patient blood sample is much less invasive and more practical than performing biopsies on the tumor itself, so this technique is quite popular in many medical and research settings. Researchers have been able to use the CellSearch to corrolate CTC count with patient mortality, but more in depth cellular biomechanics studies are difficult because of the way CTCs are processed by the CellSearch.

I observed how blood samples are prepared for and processed by the CellSearch and how Dr. Giannakakou's lab fixes and stains the CTCs for imaging. Staining and imaging while preserving microtubule integrity is extremely challenging, especially since nonspecific capture of other cell types can confound results. It is very useful to see the benefits and challenges that researchers and clinicians face now trying to use CTCs as diagnostic tools. It helps me understand the scope of my project better and will hopefully lead to new research directions in course of my PhD work.

Week 2

This week I spent time with a glaucoma specialist in the ophthalmology clinic. It was intriguing to observe the many difference in diagnosis and treatment methods going from the cornea patients I observed last week to the glaucoma patients this week. The physicians are more focused on disease management with glaucoma patients as opposed to the more acute treatments performed for cornea patients. Glaucoma specialists must balance a complex range of factors such as patient age and overall health to the impact on their wallets when managing this disease state. In addition, it was fascinating to witness patients with glaucoma shunts which are used to decrease the intraocular pressure and relieve pressure on the retina. Next week I am scheduled to see both cornea transplant and glaucoma surgeries which will be helpful in understanding the clinic to surgery relationship in eye disease treatment.

Week 2 - New Perceptions

In my previous entry, I described in detail the procedures that I have been able to watch thus far, lumpectomies and mastectomies, which is the bulk of what my surgeon does, as a highly specialized early stage breast cancer surgeon. This week I want to discuss my perception of breast cancer and how it has been altered in the short two weeks we've been here.

One thing that I have been struck by repeatedly during my time spent with Dr. Tousimis is how controllable and treatable breast cancer is when it is caught early. There are so many excellent diagnostic tools that have come into regular practice over the last ten years, that it is becoming more and more common to catch breast cancer before it even becomes palpable. To me, the traditional idea of breast cancer is that women do monthly breast exams, and then one month they just happen to feel something in their breast that shouldn’t be there, they schedule a mammogram, and then the tumor is biopsied and then either removed, treated with chemotherapy, or both.

However, with todays advances, women who have a strong family history of breast cancer (meaning either their mother, sister, or more distant relatives have been diagnosed with the disease) are on even higher alert, having routine mammogram and/or MRI’s, which can show even the tiniest of lesions. Most of the surgeries I have observed thus far have dealt with tumors that were under 2 cm – very small in relation to the size of the breast. The tumor (or abnormal cells, or microcalcification, as seems to often be the case instead of just a straightforward tumor) is biopsied, pathologically analyzed, and then an area of the tissue is removed with the goal of having clear margins. During that same procedure, sentinel lymph node biopsy is usually performed, which I described in my previous entry. That way the surgeon and the patient immediately have an idea of whether the cancer has spread, and in many cases, caught this early, it doesn’t.

So I guess that the side of breast cancer that I’ve been able to observe so far has really altered my view of it. My previous belief was that it was difficult to treat, difficult to remove entirely, and would really change a woman’s lifestyle – both physically and psychologically. A substantial portion of breast cancers, though, are caught early, treated immediately, and the woman retains excellent quality of life.

Having said that, I am very interested in learning more about the other sides of breast cancer – what happens when the tumor isn’t just a small group of abnormal cells, but in turn is poorly differentiated and highly aggressive. Dr. Tousimis has a colleague who focuses on metastatic breast cancer, both in her research and in her practice, and I am anxious to get the opportunity to shadow her and learn about the challenges that she faces. Certainly the face of breast cancer has changed a lot in the past 10 years, but metastatic breast cancer remains extremely difficult to treat effectively.

We Become

In the OR, lives are transformed on a regular basis, from fierce nipple reconstruction to tumor removal. Many of these transformations, however, are only possible because of the availability of sophisticated machinery, such as endoscopes, robotic arms, and heart monitors- many of which are due to engineering and physics.

When it comes to engineering, however, it is often important to consider the effects beyond the immediate impact. While we are engineering the OR into a place of advanced medical practice, are we not engineering also our own souls into something more and something different than ever before? Without machines, who are we anymore? Are we just cavemen, or have we evolved into an anthropo-machino-hybrid species?

We see in movies all the time where humans and robots collide in a war between good and evil, in a struggle for the survival of our kind, in an epic journey to find truth and love in a war-torn barren land where hope is scarce and meaning is forgone. Here in this world, however, the dichotomy between man and machine is not so dichotomous after all, for man and machine are but two facets of the same humano-robotic entity (i.e. us). Thus, the theatrics in movies really just depict our inner struggle between becoming machines and maintaining the human quality.

Who we are is not simply defined by who we want to be, but also by who we need to be. We must engineer more tools and technology to help preserve our very being- to prolong the existence of our kind through ICUs and to increase the chances of our coming into existence through neonatal care stations. We want to remain human, with warmth, compassion, love, and harmony, but we need to become machine to maintain our livelihood.

It seems that our future may depend heavily on how we embrace technology and on whether or not we can maintain a concordant symbiosis with the deus ex machina within our souls.

Week 2 - Huang

In week 2, I continued to observe Dr. Scherr's surgeries and got to see the da Vinci Surgical System in action. Dr. Scherr used this system to perform prostatectomies. I found the most interesting part of the surgery to be at the beginning when the system is being set up. After the patient is anesthesized, the surgeons make very small incisions at marked spots on the patient's stomach, and the da Vinci surgical arms are inserted inside, along with an endoscope. Thereafter, two surgeons stood with the patient to guide and move the arms when needed, while Dr. Scherr sat at a console in the corner of the room and remotely controlled the robotic arms. From the endoscope view, I could see that Dr. Scherr could make very precise movements with the arms, therefore allowing him to pay close attention to details that open surgery cannot offer. The arms had little tweezers that could grab onto tissues as well as a heating tip to carefully cut apart the tissue. From watching the endoscope view that is displayed on screens all around the OR, all I could see was a big bloody mess, and I was very impressed that the surgeons knew exactly what blood vessel/orifice/organ tissue was in view.

Other than robotic surgery, I also observed Dr. Scherr performing some cystoscopies, where an endoscope is inserted into the bladder through the urethra. A notable case was a patient in his 80's that had an enlarged prostate that caused him urination problems. As we saw through the endoscope, his bladder was completely full, so Dr. Scherr had to draw out all the urine to empty the bladder. It must have taken 20-30 small vials to completely empty the bladder... it was a lot of urine!

In week 3, I hope to observe some other departments in action, such as neurosurgery, heart surgery, and the neonatal ICU. Also, after reading Bo's blog, I am quite intrigued by his experiences with "fierce" nipple reconstruction, so perhaps I could fit that into my schedule as well.

Patient Quote of the Week:
Doctor: You've got a lot of urine in here, Mr. _____.
Patient: Yeah there must be pee from 1987 in there.

My 2nd week

I want to write down my new experiences in week 2. These are new compared with my first week which was routine life of a radiologist. This week I got the chance to see several surgeries. Although two of them are related to radiology, they make me happy because hospital life in the surgery room or OR room are so different from that in the radiology reading room.

On Monday, Dr. Prince led me to an interventional radiology surgery room to see what happened there. Interventional radiology means that the doctors use X-ray to monitor the whole surgery process. In the control room there are several monitors which showed the whole procedure process. That day, the doctors were trying put an catheter into the patient's artery near the heart. The monitor showed the normal coronal plane picture of the patient's chest. The difference was a clear long wire near the heart. That is the catheter! Before I thought they used the X-ray imaging to see the body image all the time. But that would definitely led to enormous radiation. The doctor told me they just touch the panel once in a while to get one image. This is reasonable. I guess when to touch the panel requires the surgeon's experience because there are some important instants when the catheter reaches certain positions. It is hard to imagine how such procedure can be done without modern imaging technique. In fact, I was able to see how doctors deal with emergency in the surgery. Because of certain reasons, the patient's heart rate reached 140/m and the doctors immediately contacted the cardiologist. They had to stop the surgery in half way and send the patient to cardiology department. Everyone at that time was in a hurry but everything is in good order. Without an end, I finished my first surgery experience.

The second experience is hardly called a procedure. On Wednesday I saw how doctors inject contrast agents when scanning. This is not new to me in theory. Contrast agents is greatly used in vessel imaging. They can change the T1 and T2 time of the water so making vessels very bright which can not be seen in a normal MR image. I was excited to know I can see the injection by myself. And it was operated by Dr. Prince! To have a successful vessel image, timing is very important. When to inject and when to press the scan button are the key. Dr. Prince and another doctor ordered six syringes, each with 30ml Gd. Before the injection, they told the patient about the injection and what she should do during the process. Under Dr. Prince's instruction, the patient took a deep breath in, breathed out and held her breath. Then Dr. Prince and another doctor quickly injected the syringe. They had to be in pace so they watched each other. Then Dr. Prince pressed the button on the scanner directly in the scanner room. This is commonly done in the control room. So for the first time I know that I can press the scan button on the scanner too! The enhanced vessel image was pretty well. They found a blockage in the patient's right shoulder vessel. I have to say that a good timing is truly important, or the blood would have circulated too much. Then the image is ruined. Dr. Prince said MRI is an art. Yes, two different people can get totally two different images even most of the scan parameters are the same. That is why artiest can draw fantastic picture using the same pen. That is always true everywhere in the hospital: experience is top important.

My most exciting experience came on Friday. I was able to see my first real surgery: nipple reconstruction. Thanks to Bori, so I had the chance to know about the surgery time. Actually that was my first day to get in the OR room. I had no difficulty to ask for the scrubs. But it is a little annoying that we can wear nothing inside the scrubs because they are not short sleeved. By inspecting, I assure myself the scrubs are clean... they should be! I was a little late for the surgery and wandering outside the OR room. I really had no idea if I can be admitted in when the operation had already started. I nurse found my situation and kindly led me in to the room. At that time, the doctor was getting fat out of the patient's hip. Oh, I finally got to know how the fat is derived! It is more fierce than I expected. It made me feel that a human body can be so robust that a fierce way like that could do nothing to it. Back to the main topic. Getting fat is the first step. The fat are kept for further use. When the reconstruction is finished, the fat is injected into the breast to give a better shape. After fat is derived, the doctors moved to next step: cutting skins from the inner thigh. The doctor draw the desired shape on the skin and cut them down according to the shape. Then the cut was sutured together. This was how I got shocked again. The cut were both 1 inch wide, but the human skin is so elastic that they can just be pulled together and sutured. That means a one inch skin lost is compensated by suturing the other side together! Surgery moved on. The main step is to cut off the skin in the nipple area incompletely. That means the central part is still attached with the body. Then the peripheral part are sutured together to form the new nipple. Then the skin previously got from the sigh were sutured around the new nipple. So the whole surgery was almost done except that injecting fat in the breast. For a man watching surgery for the first time, plastic surgery such as nipple reconstruction can be a real shock. I know that any part of the human body can be opened, and skin can be used in any part for repair. The modern surgery and repair technique truly changed some people's life, making some impossible possible.