Overall, I would say that I completed my objectives, and the program more than met my expectations. I learned a lot about the diagnosis and treatment of breast cancer, and I believe that this is knowledge that I will easily incorporate into my research. I successfully identified metastatic disease as the leading challenge to combating breast cancer today. And I believe that I did come away from the summer with a better grasp on medical vocabulary and interacting with clinicians, although this may be the most intangible of my learning experiences.
I successfully gained a well-rounded view of breast cancer, a comfort level with medical vocabulary that I had not possessed before, and a future clinically-related direction to take my research. Most importantly, I feel much more comfortable working with clinical collaborators. Above all else, I will take this knowledge with me in the future. Overall, I was very satisfied with how my expectations were met and my objectives accomplished.
While the immediate impact of summer immersion may not be readily apparent, I believe that this experience has significantly contributed to my career goal of becoming a biomedical engineer. Regardless of what sort of job I end up pursuing, the vocabulary and the perspective on clinical interactions will be of great use to me.
In the short term, I would say that my summer experience served to solidify my desire to pursue cancer research, in many shapes and forms. It helped to point out to me where the biggest need is for advancement – treatment of metastatic disease. Additionally, I feel more comfortable now reading clinical papers pertaining to this area of research. I believe that summer immersion made me a more competent and confident biomedical engineer.
I think that it is difficult to determine at this moment what the precise long term impact is of the summer immersion program on my life and career. Certainly, as I mentioned before, understanding a clinician’s perspective and priorities on a project will certainly be useful in the long term. I think that appreciation for the medical field is sure to stay with me for the rest of my life. I don’t think that people truly understand what a physician does, in terms of the hours and labor and heart that go into this job. Seeing it first hand, I am caught feeling the utmost respect for this profession, even though I know it could never be my own. I am excited to see how the immersion experience will affect and perhaps drive the course of my career. I am very thankful to everyone involved for making this summer a great success for myself and my colleagues.
Tuesday, August 18, 2009
Week 6 – Rounding out the Breast Cancer Experience
During my final week of immersion, I explored a few areas related to breast cancer that did not involve surgery. I shadowed a medical oncologist who deals with metastatic disease, a geneticist who screens patients who have a strong family history of breast cancer for BRCA1 and BRCA2 gene mutations, and I spent some time in surgical pathology learning how samples are processed during and after surgery. Additionally, I observed an aortic valve replacement procedure which has already been discussed by several other immersion students here.
First, I shadowed Dr. Linda Vahdat, who is my mentor for my clinical project. This was very interesting to me, because it is a very different side of cancer than the one that Dr. Tousimis deals with. While Dr. Tousimis’ patients tend to have a very high survival rate, the patients who end up seeing Dr. Vahdat have much more serious cases of cancer, are on strong medication, and are suffering side effects from the intense chemotherapy. Because she sees her patients on a much more regular basis than Dr. Tousimis (who will see follow up patients once a year after surgery), she develops close relationships with them, and obviously cares very deeply about them. Because of the nature of her practice, she has to routinely deal with losing her patients to this disease. It is a very different mindset, and one that I cannot really comprehend. The cases of her patients going into remission do happen, but much less frequently. As part of her practice, Dr. Vahdat is involved with many clinical trials, and has many, many of her patients involved in them. I was able to sit in on an appointment with a woman who has been battling breast cancer for over fifteen years. Her cancer was stage 4, and had metastasized to her bones, which is fairly common. However, more uncommonly, she has a medium sized tumor on her C2-C3 vertebra. Obviously, this is a very precarious situation. Surgery is out of the question (and in fact is rarely done in metastatic patients). Their goal is to shrink the tumor down to prevent it from growing and metastasizing further. This patient had just started a different chemotherapy drug that greatly affected her both physically (she became extremely tired, lost taste and appetite, etc.) and mentally (depression). For a woman who had before been very optimistic and very much a fighter, this was a radical change in behavior. Dr.Vahdat decided to take her off of the new drug, and all of her other drugs except for Herceptin, which she had never had a problem with, and let her body adjust for a few weeks, to allow her to recover and feel more like herself. Then she is going to try a different drug, Arimidex, which has been on the market for a few years and has shown to be at least moderately effective. The patient was very relieved, because she was clearly very worried about the personality changes she had been undergoing. For someone who has been dealing with this disease for so long, it was amazing to me how determined she was to make herself better. I feel like it can be so easy for women to lose hope at this stage, and she was very concerned about the loss of that determination and optimism.
Second, I was able to briefly shadow a geneticist for a patient consult. The patient had come in to undergo genetic testing not for herself, but out of concern for her daughter, who was considering having children. She was an elderly lady full of spirit and stories, and a very interesting family history. Before the test is performed, the geneticist acquires the most complete family history they can from the patient, going back for as many generations as possible and expanding to as many brothers/sisters/cousins/etc as possible to determine the likelihood of a genetic mutation. This process was very interesting to observe, because the patient would go through each side of the family, listing off the ages that cancer was developed, the age of death, etc. In this patient’s case, both sets of grandparents (or great grandparents?) were killed by the Turkish forces during the Armenian genocide. As a result, her family was spread out across the Middle East, Asia, and the US, different family members having fled and ended up in different areas of the world. After the consult, the geneticist told me how she often finds her job repetitive (she goes through the same explanation almost every time), but that hearing people tell their stories is one of the most interesting parts of her job. Anyway, after collecting the family history, the geneticist explains to the patient that they will only be testing for mutations in two genes (BRCA1 and BRCA2), and that having a mutation does not necessarily mean they will develop cancer, or that their children will have the same mutations. It does, however, increase the risk of both. The genetic testing costs about $3500, and is performed by a lab in Salt Lake City, Utah, which owns the patent on the gene. This patient opted to have the test performed, and her blood was immediately drawn and shipped out for testing.
First, I shadowed Dr. Linda Vahdat, who is my mentor for my clinical project. This was very interesting to me, because it is a very different side of cancer than the one that Dr. Tousimis deals with. While Dr. Tousimis’ patients tend to have a very high survival rate, the patients who end up seeing Dr. Vahdat have much more serious cases of cancer, are on strong medication, and are suffering side effects from the intense chemotherapy. Because she sees her patients on a much more regular basis than Dr. Tousimis (who will see follow up patients once a year after surgery), she develops close relationships with them, and obviously cares very deeply about them. Because of the nature of her practice, she has to routinely deal with losing her patients to this disease. It is a very different mindset, and one that I cannot really comprehend. The cases of her patients going into remission do happen, but much less frequently. As part of her practice, Dr. Vahdat is involved with many clinical trials, and has many, many of her patients involved in them. I was able to sit in on an appointment with a woman who has been battling breast cancer for over fifteen years. Her cancer was stage 4, and had metastasized to her bones, which is fairly common. However, more uncommonly, she has a medium sized tumor on her C2-C3 vertebra. Obviously, this is a very precarious situation. Surgery is out of the question (and in fact is rarely done in metastatic patients). Their goal is to shrink the tumor down to prevent it from growing and metastasizing further. This patient had just started a different chemotherapy drug that greatly affected her both physically (she became extremely tired, lost taste and appetite, etc.) and mentally (depression). For a woman who had before been very optimistic and very much a fighter, this was a radical change in behavior. Dr.Vahdat decided to take her off of the new drug, and all of her other drugs except for Herceptin, which she had never had a problem with, and let her body adjust for a few weeks, to allow her to recover and feel more like herself. Then she is going to try a different drug, Arimidex, which has been on the market for a few years and has shown to be at least moderately effective. The patient was very relieved, because she was clearly very worried about the personality changes she had been undergoing. For someone who has been dealing with this disease for so long, it was amazing to me how determined she was to make herself better. I feel like it can be so easy for women to lose hope at this stage, and she was very concerned about the loss of that determination and optimism.
Second, I was able to briefly shadow a geneticist for a patient consult. The patient had come in to undergo genetic testing not for herself, but out of concern for her daughter, who was considering having children. She was an elderly lady full of spirit and stories, and a very interesting family history. Before the test is performed, the geneticist acquires the most complete family history they can from the patient, going back for as many generations as possible and expanding to as many brothers/sisters/cousins/etc as possible to determine the likelihood of a genetic mutation. This process was very interesting to observe, because the patient would go through each side of the family, listing off the ages that cancer was developed, the age of death, etc. In this patient’s case, both sets of grandparents (or great grandparents?) were killed by the Turkish forces during the Armenian genocide. As a result, her family was spread out across the Middle East, Asia, and the US, different family members having fled and ended up in different areas of the world. After the consult, the geneticist told me how she often finds her job repetitive (she goes through the same explanation almost every time), but that hearing people tell their stories is one of the most interesting parts of her job. Anyway, after collecting the family history, the geneticist explains to the patient that they will only be testing for mutations in two genes (BRCA1 and BRCA2), and that having a mutation does not necessarily mean they will develop cancer, or that their children will have the same mutations. It does, however, increase the risk of both. The genetic testing costs about $3500, and is performed by a lab in Salt Lake City, Utah, which owns the patent on the gene. This patient opted to have the test performed, and her blood was immediately drawn and shipped out for testing.
Thursday, August 13, 2009
Week 6&7
These two weeks I observed several plastic surgeries with help of Bori and one of them I ranked the most impressive surgery since I have been watched throughout summer immersion. It is a brain tumor surgery which the tumor located behind the skull between brow ridges. This site of tumor forced surgeons to do open skull surgery which very horrified me. It also reminded me a surgical scene in the movie “face/Off” but now I saw it in real!!!
In the last week, with Dr. Frayer’s coordinating, six of us had an opportunity to observed aortic valve replacement surgery which is a very interesting and impressive. Once the pericardium has been opened, the patient was placed on cardiopulmonary bypass machine. This machine took over the task of breathing for the patient and pumping their blood around while the surgeon replaced the heart valve. When the patient was on bypass, an incision was made in the aorta. Then the surgeon removed the patient's diseased aortic valve and tissue valve was put in its place. Trans-Esophageal Echocardiogram (TEE) was used to verify that the new valve was functioning properly. The overall process took around 7 hours. It was not that long comparing to the 12 hour brain tumor surgery.
Lastly, I would like to thank Dr. Frayer, Dr. Wang, Belinda and voluntary clinicians who contributed greatly to make the summer immersion program happen. I gain a lot of experiences throughout the program. The program provided me a great opportunity to shadow many clinicians and to be around in the hospital to observe several clinical things which are all very fascinating and interesting. Moreover, living in NYC with my fellow BME students is a lot of fun. We all hang out and had a great time together. I will never forget these very great experiences here.
This summer, I believe, must be one of the greatest summers in my life!!!
In the last week, with Dr. Frayer’s coordinating, six of us had an opportunity to observed aortic valve replacement surgery which is a very interesting and impressive. Once the pericardium has been opened, the patient was placed on cardiopulmonary bypass machine. This machine took over the task of breathing for the patient and pumping their blood around while the surgeon replaced the heart valve. When the patient was on bypass, an incision was made in the aorta. Then the surgeon removed the patient's diseased aortic valve and tissue valve was put in its place. Trans-Esophageal Echocardiogram (TEE) was used to verify that the new valve was functioning properly. The overall process took around 7 hours. It was not that long comparing to the 12 hour brain tumor surgery.
Lastly, I would like to thank Dr. Frayer, Dr. Wang, Belinda and voluntary clinicians who contributed greatly to make the summer immersion program happen. I gain a lot of experiences throughout the program. The program provided me a great opportunity to shadow many clinicians and to be around in the hospital to observe several clinical things which are all very fascinating and interesting. Moreover, living in NYC with my fellow BME students is a lot of fun. We all hang out and had a great time together. I will never forget these very great experiences here.
This summer, I believe, must be one of the greatest summers in my life!!!
Week 5: Fai
With help of Femi I observed the first robotic prostatectomy in this week. I shadowed Femi’s mentor – Dr. Tewari who is an internationally acclaimed expert on Robotic Prostatectomy and other minimally invasive robotic surgeries. Dr. Tewari used the da Vinci surgical system to perform prostatectomy. He sat at a console in the corner of the room and remotely controlled the robotic arms while I was viewing the surgery via a real-time 3D monitor--I had to wear polarized glasses to see it 3D. The prostate was excised, inked and sliced to be a small specimen. The specimen then proceeded to the multiphoton microscopy core facility for observation. I watched how to use multiphoton microscope and I found several advantages of multiphoton microscope over confocal microscopy including its deeper tissue penetration, efficient light detection and reduced phototoxicity.
In addition, I had a chance to see Trans-Esophageal Echocardiogram (TEE) and Cardiac Catheterization with help of Laura. TEE is a sonogram of the heart. It uses standard ultrasound techniques to image two-dimensional slices of the heart. A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This allows image and Doppler evaluation which can be recorded. The difficult part of TEE is to put down the probe through patient’s throat. There are several steps before the probe reaching the aimed site, including gargling and spraying anesthetics, coughing and swallowing. Laura told me that in some cases patients felt pain and do not be able to swallow the probe. That led to the cancelation of TEE. However, the case I saw that day went very well. Concerning cardiac cath, Dr. Bergman inserted a catheter into brachial artery and snaked the catheter until reaching coronary artery. It surprised me that doctor can snake a catheter via such a very small and very long blood vessel. After the catheter reach coronary artery, contrast dye is injected to see areas of constriction. It turned out that most of the patient’s coronary artery was occluded. For this case bypass surgery would be the best and only way to treat the patient.
I also went with Bo to Department of radiology at 55th stress to get MRI scan. Bo was doing his clinical research project—writing one chapter of a book about how to operate s MRI scanner for people who have never used it and he needed some volunteers to get brain scan. IMR is safe and it is very expensive procedure. I think it would be great to try it once for fun and to check up my brain (for free). As expected I am (still) normal :)
In addition, I had a chance to see Trans-Esophageal Echocardiogram (TEE) and Cardiac Catheterization with help of Laura. TEE is a sonogram of the heart. It uses standard ultrasound techniques to image two-dimensional slices of the heart. A specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This allows image and Doppler evaluation which can be recorded. The difficult part of TEE is to put down the probe through patient’s throat. There are several steps before the probe reaching the aimed site, including gargling and spraying anesthetics, coughing and swallowing. Laura told me that in some cases patients felt pain and do not be able to swallow the probe. That led to the cancelation of TEE. However, the case I saw that day went very well. Concerning cardiac cath, Dr. Bergman inserted a catheter into brachial artery and snaked the catheter until reaching coronary artery. It surprised me that doctor can snake a catheter via such a very small and very long blood vessel. After the catheter reach coronary artery, contrast dye is injected to see areas of constriction. It turned out that most of the patient’s coronary artery was occluded. For this case bypass surgery would be the best and only way to treat the patient.
I also went with Bo to Department of radiology at 55th stress to get MRI scan. Bo was doing his clinical research project—writing one chapter of a book about how to operate s MRI scanner for people who have never used it and he needed some volunteers to get brain scan. IMR is safe and it is very expensive procedure. I think it would be great to try it once for fun and to check up my brain (for free). As expected I am (still) normal :)
Week 4: Fai
A very interesting clinical experience of this week is breast cancer surgery which I saw both lumpectomy and mastectomy. Thank Casey for her help. Lumpectomy is an operation in which a small volume of breast tissue containing the tumor and some surrounding healthy tissue is removed to conserve the breast. The case I saw was one 30’s woman who had a small cancer (1.4 centimeters) in her left breast. I saw an X-ray image that two hooks on metal wire indicated the site of tumor. In order to access the tumor Dr. Tousimis cut around patient’s aureole (2/3 of aureole circumference). She told me the tissue area has a great ability to recovery and it is hard to see the scar on that area after the surgery. Even though the tumor is a few centimeters in size, the fat tissue which was taken out is about four times more than its size. The reason of doing this is to make sure the entire tumor is removed and taking out such a great amount of tissue have no any physiological and anatomical effect on the patient. For the case of mastectomy, I observed a 50’s female patient who was diagnosed with breast cancer. Mastectomy is usually done to treat breast cancer. However, the decision to do the mastectomy is based on various factors including breast size, number of lesions, biologic aggressiveness of a breast cancer, the availability of adjuvant radiation, and the willingness of the patient to accept higher rates of tumor recurrences after lumpectomy and radiation. Before the surgery, the patient was injected a radioactive dye to localize the sentinel lymph nodes and another dye (blue color) to visually identify the nodes. The sentinel lymph node is the hypothetical first lymph node or group of nodes reached by metastasizing cancer cells from a tumor. It is a rational why sentinel lymph node biopsy is routinely used to determine whether or not the cancer has spread. For the surgical procedure, firstly, the patient’s nipples and aureoles were completely removed. Then, the breast tissue was cut away from the skin and the entire breast was cut away from the muscle underneath. The whole tissue was taken out and replaced with a tissue expander filled with saline. The whole procedure took about 6 hours. Comparing between lumpectomy and mastectomy, I feel much more comfortable to see the former one.
Thanks to Michael, in this week I had a chance to follow him and his mentor –Dr. Cham in the department of radiology. Dr. Cham showed us a lot of x-ray/CT/ MRI images and kindly explained several things in detail. I learned a lot from him. The images came to this department with several reasons. In case of pre operation images, Dr. Cham had to check the images to make sure that the patient is ready for operation. There is nothing abnormal which can lead to failure of operation or bad consequences during or after operation. Dr. Cham also diagnosed disease from the images such as lung cancer, lung tumor, tubercle bacillus or Tuberculosis (TB), pneumonia, heart disease and skeleton disorders. For me, this work has a lot of pressure and it is vital to pay a lot of attention to every single detail -- missing a small dot can lead to very bad consequence if the dot is lung cancer! This must be the reason why every image has to be read by at least two radiologists. I think it is a good idea and it can reduce the kind of error. In some special cases, patients having unknown-cause symptoms, Dr. Cham have to figure out several probable diseases from the image and suggest possible causes of illness to the patient’s doctor. It seems hard to me that one person have to remember all illness and trying to connect any clue from black & white and blurry image to all of possible diseases.
Thanks to Michael, in this week I had a chance to follow him and his mentor –Dr. Cham in the department of radiology. Dr. Cham showed us a lot of x-ray/CT/ MRI images and kindly explained several things in detail. I learned a lot from him. The images came to this department with several reasons. In case of pre operation images, Dr. Cham had to check the images to make sure that the patient is ready for operation. There is nothing abnormal which can lead to failure of operation or bad consequences during or after operation. Dr. Cham also diagnosed disease from the images such as lung cancer, lung tumor, tubercle bacillus or Tuberculosis (TB), pneumonia, heart disease and skeleton disorders. For me, this work has a lot of pressure and it is vital to pay a lot of attention to every single detail -- missing a small dot can lead to very bad consequence if the dot is lung cancer! This must be the reason why every image has to be read by at least two radiologists. I think it is a good idea and it can reduce the kind of error. In some special cases, patients having unknown-cause symptoms, Dr. Cham have to figure out several probable diseases from the image and suggest possible causes of illness to the patient’s doctor. It seems hard to me that one person have to remember all illness and trying to connect any clue from black & white and blurry image to all of possible diseases.
Week 3: Fai
In the first two weeks I followed Dr. Schumann and Dr. Frayer to round in NICU (Neonatal Intensive Care Unit). In this week I got an opportunity to observe a new unit -PICU (Pediatric Intensive Care Unit). I shadowed Dr. Howell’s and Dr. Pon’s team which included one doctor, two residents, and one or two fellows (no nurses and no nutritionist who are usually included in NICU team). The overall process of rounding is the same as that in NICU-the team visits each patient, the residents and fellows report patient’s previous record and then the team discuss and decide about future plan for the patient. It seems that in both units mechanical ventilators and patient monitoring systems are imperative for every patient. However there are several aspects that PICU is different from NICU. PICU deals with the medical care of infants, children, and teenagers so patients’ record is very long and full of diversity. In one case, a three year old boy fell from the third floor of an apartment. Besides knowing the cause of illness and symptoms in order to provide appropriated health care, doctors have to concern other information, for example, is there any witness or not?, who is the owner of the building?, where are the parents?- to make sure that it is not because of neglecting from the parents, etc. If the doctors feel something wrong, they have to immediately report to the relevant authorities.
In this unit I also witnessed one very heart wrenching situation. On Friday morning I shadowed Dr. Pon to round and visit a 15 year old boy who suffered from respiratory arrest for months. His health has regressed everyday and most of his brain has already been damaged. It made Dr. Pon decide to talk with his mom who usually came to visit him every other day. As expected, she came that day. Dr. Pon spent a lot time explained all the reasons to should not resuscitate the patient. Despite knowing the situation very well, it was still hard for her to admit. The whole room had any other sound except her incessant cry. It took her for a while to decide to sign “Do not resuscitate (DNR)” consent form and to become calmed. Then Dr. Pon, one resident and I left the room but one psychologist was still there to talk and to soothe her more. After leaving the room, I sat by myself. I had several feeling at the same time. It is hard to explain if one is not in the real situation. I made me realize that “it is the way of life”.
In this unit I also witnessed one very heart wrenching situation. On Friday morning I shadowed Dr. Pon to round and visit a 15 year old boy who suffered from respiratory arrest for months. His health has regressed everyday and most of his brain has already been damaged. It made Dr. Pon decide to talk with his mom who usually came to visit him every other day. As expected, she came that day. Dr. Pon spent a lot time explained all the reasons to should not resuscitate the patient. Despite knowing the situation very well, it was still hard for her to admit. The whole room had any other sound except her incessant cry. It took her for a while to decide to sign “Do not resuscitate (DNR)” consent form and to become calmed. Then Dr. Pon, one resident and I left the room but one psychologist was still there to talk and to soothe her more. After leaving the room, I sat by myself. I had several feeling at the same time. It is hard to explain if one is not in the real situation. I made me realize that “it is the way of life”.
Monday, August 10, 2009
Week 6 & 7
In week 6 I spent time rotating through the VitreoRetinal (VR) clinic with Dr. Paul Chan. I had not worked in this clinic as of yet so it was intriguing to witness another aspect of ophthalmology. VR specialists primarily treat age related macular degeneration (AMD) and glaucoma, so most of the patients are elderly and have severe vision impairments. A large part of the VR specialists job is to manage vision loss for their patients. Because diseases like glaucoma and AMD are not curable but are a chronic disease state these patients hope to maintain rather then gain back their eye sight. In some cases it is possible that a treatment may work to improve a patient's site, but due to the degenerative nature of these diseases it is not always possible. In addition, the arrange of therapies used in a VR clinic appear to be much more invasive. One of the most shocking procedures I have seen since I have been here was a retinal injection. In this therapy inhibitory VEGF antibodies are injected into the rear portion of the patient's eye. The procedure is done with the patient fully conscious and only local anesthetics are used. The patient's eye is then manually held open using a contractor, and then the specialist procedes to inject the patient's eye with a syringe. It is an intense procedure which only lasts a few seconds, however these patients will continue to need injections to inhibit the development of their AMD. During week 7 I devoted the entire week to finishing my project and preparing my presentation.
Tuesday, August 4, 2009
W33K SE7EN - HU4NG
In week 7, I saw my last surgery. The patient had an aorta with calcified tricuspid valves that needed to be replaced. A cardiopulmonary bypass (CPB) was performed to prevent the heart from beating and support circulation through the surgery. The most astounding thing I saw in this surgery was the process of how the surgeon started from what looked like a mess of needles and threads and pulled the artifical valve in place, fitting perfectly, and once the threads were cut, everything looked magically clean again! Ah the wonders of thoracic surgery...
Through this Summer Immersion experience, I think that I have become much more de-sensitized to surgeries. Before, I had always been a little squeamish about blood and apprehensive about surgeries in general, but now I see them in a new light. It seems that after the surgical site has had antiseptic applied and all other areas are covered with sterile drapes, the little area of exposed skin actually looks fake! So it does not look as scary to cut into this piece of skin, and with a suction tube always present, there is little blood to be seen as well. In all the surgeries I have been in, the OR also had a light atmosphere where doctors and nurses joked around at times. I expected none of this when I first walked into an OR... perhaps I have been watching too much TV.
Through this Summer Immersion experience, I think that I have become much more de-sensitized to surgeries. Before, I had always been a little squeamish about blood and apprehensive about surgeries in general, but now I see them in a new light. It seems that after the surgical site has had antiseptic applied and all other areas are covered with sterile drapes, the little area of exposed skin actually looks fake! So it does not look as scary to cut into this piece of skin, and with a suction tube always present, there is little blood to be seen as well. In all the surgeries I have been in, the OR also had a light atmosphere where doctors and nurses joked around at times. I expected none of this when I first walked into an OR... perhaps I have been watching too much TV.
Vertical Contractions
In week 6, I started focusing on my project, which is to evaluate survival data for patients who have had a nephrectomy at the hospital for their kidney cancer. There are two types of nephrectomies: (1) partial, which is removal of localized cancer that allows most of the kidney to be preserved, and (2) radical, which is removal of all of one kidney as well as the adjacent adrenal gland and neighboring lymph nodes. There are also two procedural types: (1) traditional open surgery, and (2) laparoscopic, which is done through several small keyhole incisions and is less invasive. Finally, to evaluate survival data, the key piece of information is patient last known status, which is divided into four categories: (1) no evidence of disease (NED), (2) alive with disease (AWD), (3) dead of disease (DOD), and (4) dead of other cause (DOC).
For my project, I will be synthesizing several databases containing patient information, contact information, medical history, surgical history, and OR data into one complete spreadsheet that I can use to perform statistical analysis (such as the Kaplan-Meier method for survival rate). In total, there are about 800 patients in the database, but about half of these patients' last known status was before 2008. Therefore, I will also be updating these patients' statuses either by searching for status updates on EPIC or by calling them directly (or their emergency contacts).
For my project, I will be synthesizing several databases containing patient information, contact information, medical history, surgical history, and OR data into one complete spreadsheet that I can use to perform statistical analysis (such as the Kaplan-Meier method for survival rate). In total, there are about 800 patients in the database, but about half of these patients' last known status was before 2008. Therefore, I will also be updating these patients' statuses either by searching for status updates on EPIC or by calling them directly (or their emergency contacts).
Weeks 6&7 - Final Rotations
Since summer immersion is drawing to a close, I have been trying to fit all the different things that I have not seen before I leave while continuing to observe my mentor and his cases. On Monday, I went to office hours at Cornell with Dr. Grant as saw some pre-op and follow-up cases. On Tuesday, I also followed Dr. Grant for office hours and excisions at Columbia. It was a great day because I was able to see many of the patients I have been following throughout my time here. Laura came with me on Wednesday and had a very full day of seeing patients as well as a breast reduction, breast reconstruction, and wound closure.
On Thursday, I was able to see a prostatectomy done by Dr. Tewari who is the Director of Robotic Prostatectomy and Prostate Cancer-Urologic Oncology Outcomes. Dr. Tewari uses the Da Vinci robot to perform the prostatectomy and does around 600 cases per year (he had done 15 cases that week already!). It was very interesting to watch the robotic surgery and Dr. Tewari allowed me to look through the control console towards the end of the surgery. I was very impressed by the apparent dexterity of the surgical instruments within the body cavity and the precise control that Dr. Tewari had over every movement of the robotic arms and camera. The surgery only took 1 hour and I unfortunately missed the first 15-20 minutes so I plan to go to another surgery next week to see the whole procedure.
Afterwards, David and I went down to Greenburg Pavillion and watched a live donor kidney transplant performed by Dr. Kapur. We arrived in the operating room just before the kidney was harvested from the other patient. Upon arrival into the recipient’s room, the kidney was prepared for transplant by Dr. Kapur and his team. They removed the external fat and unneeded connective tissue and then isolated the renal artery and vein as well as the ureter. The kidney was then wrapped in a towel with ice and brought to the patient. The two renal arteries were connected to the iliac artery using an end-to-side anastomosis. The renal vein was connected to the iliac vein in a similar manner. Next, the ureter was connected into the bladder and a stent was placed within ureter to help it remain patent. It will remain there for 6 weeks and then be removed using a cytoscopy procedure. Soon after the kidney had been connected to the blood supply, it became a deep pink color and began to produce urine. Dr. Kapur said that the last transplanted kidney that he had done had produced 1.8 L of urine in the first hour and that the activity of the kidney he had just transplanted looked promising. Dr. Kapur was very helpful and allowed David and I to come to the operating table many times during the surgery to point out what he had done as well as what he was preparing to do—it was a fantastic learning experience!
On Friday, I was able to go on round in the Neonatal Intensive Care Unit (NICU) with Dr. Perlman and Fai. The doctors on this floor are much different than those on the other services that I have visited so far because the patients are unable to express themselves in any way except to cry. Many of the decisions made about the course of treatment are based primarily on the patient’s urinary output, heart rate, frequency of apnea, and willingness to accept food. Since the rounds didn’t begin until about 9:30 am, I was expecting many more of the parents to be present with their children and was surprised to see only a couple sets of families. Many of these children have been in the hospital for weeks and even months and the physicians discussed how it is difficult for parents to even get into the city sometimes. It was difficult to see so many sick babies fighting for their lives but it is amazing what technology has developed to allow these neonates to have a better chance to survive.
During my last week of immersion, I observed Dr. Spector, another plastic surgeon, use a rectus abdominus free flap to replace the tongue of a patient after a glossectomy (removal of the tongue). When I entered the operating room, the glossectomy had already been preformed and the lower part of the patient’s face and neck was completely open and exposed—it was quite startling to see. Dr. Spector dissected out the viable arteries and veins in the neck, removed the flap from the donor site, and began to anastamose the vessels. I was surprised at how the flap was used to form the tongue, a small piece of muscle and skin would comprise the tongue while the rest of the muscle was sutured into place. Although this man’s tongue would appear to be semi-normal, he would likely not be able to speak well or even eat orally again.
I was also able to stand at the head of the table to watch an aortic valve replacement surgery done by Dr. Girardi. During the procedure, the anesthesiologists monitored the heart using a trans-esophageal echocardiogram (TEE). From the TEE, I could clearly see the stenosis of the valve and the calcified lesions that were obstructing some of the flow and causing the valve to be less-compliant. The patient was put on cardio-pulmonary bypass and the heart was stopped using an injection of a concentrated potassium solution into the coronary arteries (so that the cells were unable to pass on the electrical signal). Next, the aorta was opened and the aortic valve was removed along with as much calcification the surgeon could extract. A tool was used to measure the valve size and a bovine magnum valve was prepared to be placed into the aorta. Watching the process of valve placement was very interesting because the surgeon first placed multiple sutures around the aorta and then connected those sutures to the aortic valve replacement. The sutures were then sequentially tightened and knotted so that the bovine valve was lowered into place within the aorta. After the aorta was closed and the TEE showed that the heart and valve were functioning properly off of bypass, the patient’s chest was closed using stainless steel wires. The wires were connected to large needles that can go through the sternum and the whole length of the sternum was prepared with the wires before the chest was closed. The whole process of closing seemed quite brutal but the wires have enough strength to hold the chest closed.
On Thursday, I was able to see a prostatectomy done by Dr. Tewari who is the Director of Robotic Prostatectomy and Prostate Cancer-Urologic Oncology Outcomes. Dr. Tewari uses the Da Vinci robot to perform the prostatectomy and does around 600 cases per year (he had done 15 cases that week already!). It was very interesting to watch the robotic surgery and Dr. Tewari allowed me to look through the control console towards the end of the surgery. I was very impressed by the apparent dexterity of the surgical instruments within the body cavity and the precise control that Dr. Tewari had over every movement of the robotic arms and camera. The surgery only took 1 hour and I unfortunately missed the first 15-20 minutes so I plan to go to another surgery next week to see the whole procedure.
Afterwards, David and I went down to Greenburg Pavillion and watched a live donor kidney transplant performed by Dr. Kapur. We arrived in the operating room just before the kidney was harvested from the other patient. Upon arrival into the recipient’s room, the kidney was prepared for transplant by Dr. Kapur and his team. They removed the external fat and unneeded connective tissue and then isolated the renal artery and vein as well as the ureter. The kidney was then wrapped in a towel with ice and brought to the patient. The two renal arteries were connected to the iliac artery using an end-to-side anastomosis. The renal vein was connected to the iliac vein in a similar manner. Next, the ureter was connected into the bladder and a stent was placed within ureter to help it remain patent. It will remain there for 6 weeks and then be removed using a cytoscopy procedure. Soon after the kidney had been connected to the blood supply, it became a deep pink color and began to produce urine. Dr. Kapur said that the last transplanted kidney that he had done had produced 1.8 L of urine in the first hour and that the activity of the kidney he had just transplanted looked promising. Dr. Kapur was very helpful and allowed David and I to come to the operating table many times during the surgery to point out what he had done as well as what he was preparing to do—it was a fantastic learning experience!
On Friday, I was able to go on round in the Neonatal Intensive Care Unit (NICU) with Dr. Perlman and Fai. The doctors on this floor are much different than those on the other services that I have visited so far because the patients are unable to express themselves in any way except to cry. Many of the decisions made about the course of treatment are based primarily on the patient’s urinary output, heart rate, frequency of apnea, and willingness to accept food. Since the rounds didn’t begin until about 9:30 am, I was expecting many more of the parents to be present with their children and was surprised to see only a couple sets of families. Many of these children have been in the hospital for weeks and even months and the physicians discussed how it is difficult for parents to even get into the city sometimes. It was difficult to see so many sick babies fighting for their lives but it is amazing what technology has developed to allow these neonates to have a better chance to survive.
During my last week of immersion, I observed Dr. Spector, another plastic surgeon, use a rectus abdominus free flap to replace the tongue of a patient after a glossectomy (removal of the tongue). When I entered the operating room, the glossectomy had already been preformed and the lower part of the patient’s face and neck was completely open and exposed—it was quite startling to see. Dr. Spector dissected out the viable arteries and veins in the neck, removed the flap from the donor site, and began to anastamose the vessels. I was surprised at how the flap was used to form the tongue, a small piece of muscle and skin would comprise the tongue while the rest of the muscle was sutured into place. Although this man’s tongue would appear to be semi-normal, he would likely not be able to speak well or even eat orally again.
I was also able to stand at the head of the table to watch an aortic valve replacement surgery done by Dr. Girardi. During the procedure, the anesthesiologists monitored the heart using a trans-esophageal echocardiogram (TEE). From the TEE, I could clearly see the stenosis of the valve and the calcified lesions that were obstructing some of the flow and causing the valve to be less-compliant. The patient was put on cardio-pulmonary bypass and the heart was stopped using an injection of a concentrated potassium solution into the coronary arteries (so that the cells were unable to pass on the electrical signal). Next, the aorta was opened and the aortic valve was removed along with as much calcification the surgeon could extract. A tool was used to measure the valve size and a bovine magnum valve was prepared to be placed into the aorta. Watching the process of valve placement was very interesting because the surgeon first placed multiple sutures around the aorta and then connected those sutures to the aortic valve replacement. The sutures were then sequentially tightened and knotted so that the bovine valve was lowered into place within the aorta. After the aorta was closed and the TEE showed that the heart and valve were functioning properly off of bypass, the patient’s chest was closed using stainless steel wires. The wires were connected to large needles that can go through the sternum and the whole length of the sternum was prepared with the wires before the chest was closed. The whole process of closing seemed quite brutal but the wires have enough strength to hold the chest closed.
Sunday, August 2, 2009
Horizontal Expansions
Robotic surgeries are becoming a popular and integral part of hospital operations, as they offer important advantages, such as minimal invasiveness and significantly faster recovery times for the patients. Robotic prostatectomies, for instance, can potentially reduce the recovery time from months to days.
The potential sensitivity of robotic arms is orders of magnitude more precise than human arms. However, by operating such machinery, we are not simply accessorizing but also integrating our bodies and minds into advanced machino-extensions. We are expanding our bodies in the horizontal manner, i.e. while we are not necessarily becoming taller (or are we?), we are becoming wider- wider in the array of abilities we possess, wider in our sense of self, wider in our understanding of the world.
Al though it seems that we may be changing and evolving into a machino-human hybrid (as mentioned before), perhaps our change is not so drastic after all (if there is any change at all). In many ways, what we expect our robotic enhancements to perform is simply an extension of who we already are; the robots have always been a part of us, and a significant difference between today and yesterday is simply that we have the means to realize this aspect of our personality.
Humans have always strived to achieve more and become more. And, with robo-technology today, we are becoming more and gaining more abilities, but at the same time, if all of these things we are becoming are just things that were already a part of us but simply unrealizable physically before because of technology and knowledge, then are we merely becoming only ourselves in the end? And by becoming more and more different in this manner, are we also staying more and more the same than ever before?
The potential sensitivity of robotic arms is orders of magnitude more precise than human arms. However, by operating such machinery, we are not simply accessorizing but also integrating our bodies and minds into advanced machino-extensions. We are expanding our bodies in the horizontal manner, i.e. while we are not necessarily becoming taller (or are we?), we are becoming wider- wider in the array of abilities we possess, wider in our sense of self, wider in our understanding of the world.
Al though it seems that we may be changing and evolving into a machino-human hybrid (as mentioned before), perhaps our change is not so drastic after all (if there is any change at all). In many ways, what we expect our robotic enhancements to perform is simply an extension of who we already are; the robots have always been a part of us, and a significant difference between today and yesterday is simply that we have the means to realize this aspect of our personality.
Humans have always strived to achieve more and become more. And, with robo-technology today, we are becoming more and gaining more abilities, but at the same time, if all of these things we are becoming are just things that were already a part of us but simply unrealizable physically before because of technology and knowledge, then are we merely becoming only ourselves in the end? And by becoming more and more different in this manner, are we also staying more and more the same than ever before?
Week 5 - Huang
This week I began brainstorming project ideas with my mentor. I attended a few meetings during which Urology residents and a few med students presented their side research projects. These meetings allowed me to get a glimpse into how students with a medical education approach research, and I contrasted this with how engineers approach research. Firstly, the data that medical researchers use is mostly statistical data, while the data that engineers use is mostly experimental data. Secondly, due to their previous education, most med students did not have a background in statistics and programming, so sometimes it was hard to understand what information was being communicated in the graphs that they presented. At times, I felt that certain graphs could have been done differently to communicate the data more effectively, and other times, I felt that a lot of data could have been synthesized into one clean graph. I guess I am just not used to working with statistical data, where there may or may not be anything to show at all. In engineering, we are trained to find trends in data that hopefully support our hypothesis, and then we will spend copious amounts of time making the perfect figures that clearly illustrate our findings. Therefore, I came away from these research meetings still a little confused about what was being shown since I felt that the data was not presented effectively. Again, this could be due to the med students' lack of training in data analysis, or it could just be the nature of these medical statistics.
Week 4 - Huang
In addition to spending time with my mentor, this week I had an MRI scan as a volunteer for Keigo's research project. The scan was of a vein in the knee that moves very little in response to heart beats, therefore making it a good candidate for MR research. The goal of the project is to image the vessel walls without imaging the blood inside, as this would offer better resolution than if blood was present in the image.
Having never had an MR scan before, there were a few things that struck me as I went through the process. Because I am used to being in a hospital setting and am in the biomedical field, I did not think much of getting an MR scan, but I imagine that it could be an unnerving experience for someone who is not familiar with the hospital and its large, complex machinery. Keigo, sharing the same background as me, briefly explained what would happen during the scan, that the scanner is a small enclosed space and there would be loud noises, and we quickly got started. For a real patient, however, I think the technician would have to take a lot more time calm the patient's nerves, walk them through the process in greater detail so that they would know exactly what to expect, and even talk to the patient on the microphone throughout. I also realized that little things such as the well-lit and comfortable waiting room and the availability of blankets really go a long way towards easing patient anxiety. These observations have led me to have a better understanding of the interpersonal side of engineering, that while the biomedical devices that we design may be technological marvels, they also can be useless if patients are unwilling to use them.
Having never had an MR scan before, there were a few things that struck me as I went through the process. Because I am used to being in a hospital setting and am in the biomedical field, I did not think much of getting an MR scan, but I imagine that it could be an unnerving experience for someone who is not familiar with the hospital and its large, complex machinery. Keigo, sharing the same background as me, briefly explained what would happen during the scan, that the scanner is a small enclosed space and there would be loud noises, and we quickly got started. For a real patient, however, I think the technician would have to take a lot more time calm the patient's nerves, walk them through the process in greater detail so that they would know exactly what to expect, and even talk to the patient on the microphone throughout. I also realized that little things such as the well-lit and comfortable waiting room and the availability of blankets really go a long way towards easing patient anxiety. These observations have led me to have a better understanding of the interpersonal side of engineering, that while the biomedical devices that we design may be technological marvels, they also can be useless if patients are unwilling to use them.
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