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!