Wednesday, July 2, 2008

Isabella's NICU Journey

Here's is a blog of a parent of a 24-week preemie baby girl, Isabella, who was born in Cornell-NYP hospital and cared for in the NICU. It was a touch-and-go situation from birth and the twin baby boy was lost earlier at 18 weeks. The blog describes the emotional journey of the family and the baby girl in the NICU, and is a really interesting read with many nice photos, especially for the few of you who have already spent some time in the NICU. In addition, many of the doctors encountered in the blog (including Dr. Frayer) are still in the NICU!

First ten rows may get wet

So week two flew by in a whirlwind of surgery, clinic, and 12 hour days. I find it amazing how many hours the plastic surgery residents and doctors put in, yet are able to still produce beautiful cosmetic results. Last Friday, after a potpourri of surgeries, one of the residents realized that over a 36 hour period she had only not been in the operating room for 5 of those hours. Here I was at 7 pm about ready to curl up on the OR floor and take a nap, while she was just suturing away looking perfectly fine. It was actually that last surgery of the day that was one of the more “routine” cases I have seen, a skin graft. I say “routine” because I have seen three of them so far in the 20+ surgeries I have had the chance to look in on. Apparently plastic surgery affords you the luxury of seeing a little more variety in the cases you handle on a week by week basis.

The skin graft procedure also is one of the easier and quicker types of procedures I can describe. Basically what happens is a donor site, usually the upper thigh, has a small slice, about 14/1000ths of an inch, removed via a dermatome. This piece of skin is a layer of epidermis and a partial layer of dermis which still has the ability, if properly cared for, to reintegrate into the affected area. Prior to final attachment, the recipient site is debrided to ensure maximal coverage and post attachment, a vacuum seal created to protect the graft. I stress properly cared for because during clinic hours I have seen a surprising number of follow up patients who have not cared for their grafts properly. This negligence and lackadaisical attitude in not taking an active role in your own healthcare more often than not causes the graft to fail. This ultimately winds up costing the patient, hospital and doctors time, another trip to the OR, and money spent unnecessarily. I suppose it is this lesson of personal involvement that is the greatest one that I am learning throughout the course of my summer. What I have also noticed is that quite a few doctors, once they find out I’m an engineer, seem to request devices that can prevent complications by performing functions that patient’s should themselves have an active role in if they follow all of the doctors orders.

Regardless, I have also seen some dramatic and messy operations. As the title of this post says, things are not always cut and dry. Actually, it never is, so if you ever find yourself in the OR make sure to be on your toes and far enough back to avoid doctors, nurses, and projectile objects. If you are interested in the other cases I have seen that are way more graphic in nature than skin grafts feel free to contact me. Surgeons can do some crazy things with muscles.

My project and second week

As I said last time in my post, I have been working on my project most of time during the past week. My project is to build up a website for updated MR protocols, which can also function as a platform for the quality control of MR scanning and the database for both radiologist and technicians.

The funny thing is the project on which I am working very hard now actually didn't sound very interesting to me at first. Building a website, I am afraid this appears to be more IT related to most of you. Even I at first thought perhaps one skilled IT technician in medical school can finish this project in a week easily too. However, the more I learned about the motivation to do this project from Dr. Prince, the more I feel the reason why I am here is more to learn what kind of difficulties biomedical engineering may encounter in hospital rather than to do some contribution from the engineering side as I thought before.

One thing happend last week made me have this strong feeling. A salesman from one medical software developing company came to Columbia to promote one new program for the CT analysis of liver. Without doubt, this is a fancy program at the first sight. It can automatically calculate the contour of liver from 2D CT iamges and reconstruct a 3D model. Calculating the volume of different parts of liver after incision is also easily achievable. However, this new software is not so satisfactory that Dr. Prince can be persuaded to purchase it. One reason is when he tried out cutting the liver 3D model in a way that surgeons would do to a donor of liver in surgery, it was really an awkward experience for him. He spent 10 more minutes to finally find a satisfactory cutting track, which right across the portal vein and middle hepatic vein. Obviously, it doesn't save much time for the radiologist who are trying to make a decision whether to cut this much liver from the donor or not. From their standing point , this new software is not appealing enough for them to change the current measurement of liver from size to volume, though the latter one is more convincing measurement theoretically.

Is that because the imaging processing technology is still so dumb nowadays that it cannot realize doing all calculation automatically for the busy radiologists? Definitely not. Defining the contour of blood vessels with high enhancement in CT images is actually a piece of cake for most electric engineers. Based on that, it won't be that difficult to reconstruct an incision plane that surgeons will make in surgery. The problem is, the communication between doctors and engineers is still not well enough. Even though both of them know that volume is a better measurement than size in clinic, even though numerous software have been developed to make volume calculation more automatically, in order to get a desired measurement, most radiologists still use size as the only measurement in report, just because they need to put a lot time on defining the desired countours manually on each slice if they choose volume as the measurement.

This story taught me a good lesson that there is actually a big disconnection between engineering and healthcare. When patients come to hospital, they pay more attention to the comfort, efficiency and safety. However, these are what engineers always consider at last when they design the medical equipment. During the last two weeks, I witnessed how much the obese patients suffer when they are "squeezed" into the MRI scanning machine, how the uncomfortable feeling in the scanner resulted from bad cushion, noises and pain make some patients disobedient to doctors' request. In fact, one of the biggest impedance in healthcare now is bad consideration and communication.

Because of this, I think my project is not a only website which an IT technician can hand in perfectly within a week now. Actually, the quality and design of this website directly affects how much the communication between the clinicians and technicians in this hospital can be improved. By putting my observation and learning in this immersion program into this project, I actually experienced a post-engineering stage which most engineers may not notice most of time.

Monday, June 30, 2008

Robotic Prostatectomy

We’re nearing the end of week two and I definitely feel like I've settled into the routine of things here. As well, a few things have come to my attention reinforcing the fact that I do not want to be a doctor. First of all, the early mornings, I'm usually not even awake enough to drink a cup of coffee before our 7:30am surgeries, yet the surgeons and nurses are alert and ready. Secondly, I have to write everything down and then reference my notes to remember the terms and anatomy, let alone the details of any given case. With these two realizations I’ve adjusted my lifestyle for the time being by going to bed early and always carrying pen and paper.

On to more interesting things: my clinician’s most frequent surgeries are robotic prostatectomy and robotic cystectomy. At this point I’ve learned how a patient proceeds through the diagnosis, treatment and recovery of both and thought I’d outline the general process for prostate cancer patients in this blog. As well, if anyone wants to watch a robotic prostatectomy there are a few sites you should check out in advance to better understand what you are seeing. The first link is an anatomical animation of a prostatectomy and the second is a video of a prostatectomy with commentary.

In general, patients with prostate cancer present with an elevated PSA (prostate-specific antigen) score. Patients are then further classified by stage and grade. These levels are defined by the results of a TRUS (Trans-Rectal Ultrasound Guided Biopsy) which can be performed during an outpatient visit. Biopsies are done through the rectum, under local anesthesia, with the guidance of ultrasound visualization of the prostate to ensure biopsies are taken from different locations throughout the prostate. The results of these biopsies are then combined to determine the patient’s Gleason score. At this point, the patient is advised as to which treatment they should consider: radiation, open surgery or robotic surgery. This consultation also takes into affect the patient’s age and current general health status.

If the patient opts for robotic prostatectomy, the surgery generally follows this video’s commentary. Two valuable aspects of robotic surgery are: 1) the ability to spare the nerves required for erectile function and 2) the ability to take biopsies during the surgery and have them immediately analyzed by cytology to ensure that all cancerous tissue is removed.

Last, the patient recovers in the hospital overnight and usually heads home the next day. They keep a catheter in their bladder to allow the new urethro-bladder junction to heal. Postoperatively, urinary control returns followed by erectile function. The recovery period varies by patient and generally tends to depend on age as well. Patients are then followed after surgery every few months for the first year and over progressively increasing time intervals for the years to come. Follow up visits usually include a conversation about the status of urinary and erectile function and a rectal examination of where the prostate was removed to ensure no re-growth has occurred. Overall, the process from diagnosis to recovery is definitely stressful for the patient but often results in very happy conclusions.

Week 2

My second week of summer immersion consisted of working with Dr. Skubas, Dr. Girardi, and Dr. Salemi. Dr. Skubas works within the department of anesthesiology and specializes in echocardiographs. This is extremely important in cardiothoracic surgery because echo is a minimally invasive technique which can monitor the performance and state of the heart. Specifically, they use a process called (TEE) transesophageal echocardiogram in which the device fits down the throat of the patient and can easily monitor the heart because of the close working distance. I plan on working with Dr. Skubas by quantitatively assessing the echocardiograms before surgery under the given state of valvular disease. For example, valvular disease usually consists of stenosis (when there is blockage or resistance of blood through the valve) or regurgitation (leakage of blood through the valve). Using echocardiograms of these diseases states performance of the heart, stress on the heart, and strain on the heart, velocity profiles, and many other interesting features can be assessed. We hope to use these features to better understand the endpoint before surgery and, to observe the role in which hemodynamics plays within the heart as a further promoter perhaps of valvular disease.

Dr. Girardi and Dr. Salemi work within the department of cardiothoracic surgery and specialize in a number of special surgeries such as coronary bypass and aortic valve replacement. These two surgeries I had the privilege to observe in the OR. Understanding the mindset of doctors is important when designing devices because, as shown through surgery, the efficiency and effectiveness between every person and tool is phenomenal. If the device is not consistent and effective within a timely manner, there will be major problems. After speaking with Dr. Salemi, he has many ideas on particular devices in which could be useful for surgery such as minimally invasive devices for valve replacement or specific microfilters which was very interesting. During this week I also completed a few rounds with patients in the ICU after their surgeries. Hopefully next week, I will be able to visit consultations before their surgery as well.

Lastly, my ID card problem continues. After a week of observing the OR, I was told specific paperwork needs to be filled out even after I had received my new ID card. Confidentiality forms, consent forms, and a drug test on top of that. I am waiting to hear back from the department concerning this. This is extremely frustrating because it makes me look irresponsible to the doctors whom trusted me in the first place. It is already the third week and I hopefully by this Wednesday; everything should be back to normal.

i wake up at 7am on the weekends...

I had my first experience in the clinic this week. On Monday, I watched a procedure Dr. Vouyouka called an endovenous ablation of varicose veins. Varicose veins occur when the veins in the leg become more elastic and valves that prevent backflow malfunction. Blood ends up pooling in the leg, leading to enlarged, varicose veins.

To treat this, a catheter is first inserted into the leg and through the length of the varicose vein (usually the saphenous vein) with the help of ultrasound imaging. A laser fiber is then threaded through the catheter. When energy is applied, the tip of the laser fiber is heated up and this burns the blood vessel, causing it to scar and close up. The laser fiber is slowly pulled out of the patient (~0.2 cm/s) so that the entire vein is ablated. Blood will now be diverted to the surrounding healthy veins. During this procedure, the patient may get a funny taste in his/her mouth.

I saw another surgery with Jen. This time, Dr. Vouyouka had to clean out an infected graft in the abdominal region. Afterwards, Dr. Spector took one of the patient’s quad muscles and flipped it upwards to cover the graft, hoping to prevent re-infection.

I found that I enjoy going to the clinic more than watching the surgeries, if that’s possible. The surgeries are certainly very cool, and it’s always interesting watching surgeons work, fight, and play with each other. However, I really like observing the interactions between a physician and their patients—the patient describes his/her symptoms, the doctor diagnoses and treats, and the patient recovers (hopefully). It’s like each patient has their own unique story to tell, and the doctor’s are helping them come up with a conclusion.

In addition to the above, I observed a makeshift cleansing of an infected hematoma and a thrombectomy. I started on a clinical project, which I’ll describe later since this entry is already pretty long and very, very boring, and it needs to end before I fall asleep from writing, and you, from reading.

Babies and Surgery

There is quite a lot to be said for all the things that I've seen, learnt and experienced the last week, but I'll try to keep it short...

1) Not all babies are cute. Most babies are cute... but there are some ugly babies out there. Twins are almost always adorable. There is a pair of twins (a baby boy and girl) in the NICU who are the most adorable creatures around. They were hospitalised for prematurity (multiples are at a higher risk than singletons) and were initially placed in separate isolettes. Now, they are co-bedding in the same isolette right beside each other. Sometimes, you can even see them holding each others' hands! For those who are interested in the kind of diagnoses and treatments that go on in the NICU, do read this blog on premature twins from the perspective of their proud parents. They describe some of the common issues and concerns in neonates, such as PDAs, feeds, infections, ventilation, blood gases, bilirubin levels etc.

2) Surgery can be REALLY cool, but is not always as cool as they make it out to be in TV shows (i.e. Greys Anatomy). In many cases, the condition is a lot more interesting that the surgery itself. One case I observed was encepholocele (PG-rating for potentially gruesome) in an infant. The occurrence was somewhat bizzare and interesting. The surgery, however, was a relative simple procedure - a 1-hour process that involved craniotomy and excision of the cyst. The one really fascinating surgery that I watched was the robotic prostatectomy. There is a series of WCMC youtube videos (6 parts) that guides you through the surgery. If you are ever going for the surgery, you really should watch these. It is amazing how much robotic technology has progressed to the point where we can confidently control it with such precision and accuracy in surgery. But can the robot ever completely replace the surgeon?

Some other quick thoughts: In the past two weeks, I have gotten the impression that doctors are generally the ones who are more interested in "what" happens, whereas scientists are somewhat more interested in "why" something happens. Of course, this is not black and white; medicine and science are not distinct, and both questions often need to be addressed at the same time. What do you think?

Week 2: Goose

A 17 year old boy entered the OR shedding tears with his mom tightly holding his hand. The boy was very nervous, I could tell, and he seemed to know exactly what problems he had in his brain and  the surgical procedures he was about to go through. He could not stop weeping. The mom and the son hugged and cried until the anesthetician started the preparation and the nurses escorted the sobbing mother out of the room.

The boy had a benign tumor in the middle of his left cortex and had to go through an open brain  intracranial surgery. The surgical procedure began by making an incision to open up palm size skin on his left side of the head. As the underneath skull revealed, the surgeons cleaned up the blood and drew a line where they were planning to cut the skull open. I did not see any measurement or any calculation being done-the line was drawn entirely by guessing. From the surface of the brain, the surgeons started performing the procedures while looking through a huge magnifying scope to see the sites better. As the surgeon carefully made their way through the brain tissues to the tumor by carefully making small incisions, he decided to cut the skull a little bit more. The surgery lasted a long time. Finally the tumor was out and the physicians closed the brain up.

I could tell that the surgery was one of the routinely performed procedures for the neurosurgeons. But for the boy it clearly wasn't. The rest of his life depended on it. Other patients I have seen were pretty different cases than him, either they were very young and little or old, and all of the procedures had to be done on the cerebral ventricles which involved the use of minimally invasive endoscopes. However, he was old enough to understand what disease he had, what procedures were to be done on his head, and what consequences he may face after the surgery--I could see it in his shedding tears. For his case minimally invasive technique was not an option. Although the surgeons did their best to avoid any loss in cognitive or motor functions, they could not get to the tumor without making incisions. The boy's brain, the left cerebral cortex, was left with a permanent cavity-he will not be the same as he was before. 

As I saw the procedure I kept thinking and asking why would a tumor form in young patients. Is there a way to prevent it? Is it their lifestyle, genetics, or just a bad luck? Is there any other method to kill the tumor without such a surgery? Why would not the surgeons carefully plan before making incisions and cutting to avoid opening more later? I was bombarded with thoughts like these and was irritated to realize that this may be just about the edge of human knowledge and technology. Of course the boy would otherwise have died by the tumor if we did not have surgeons and techniques that we have. We could praise the current era of advanced technology and health care for sure with a young boy's life just saved. But I could also see that we were just too far from where we could say it is good enough yet.

What have I learned after 2 weeks?

Seeing the way that physicians work firsthand has been a pretty cool experience. Just this week I witnessed a tumor board conference that was focused on diagnosing patients. Not as simple as you might imagine, it turns out. I work in an orthopedic department, so all of the cases in question are centered on bone. The initial tests are all x-rays, and the physicians must be able to spot the smallest abnormalities in these scans. After a while, you start to notice the things that they do, but everything is very subtle. Clearly the consequences of missing these "subtleties" are dire, so that gives me an appreciation in the meticulousness that these people must undertake everything with.

When tumors arise on bone, they are most likely metastases (~100,000 cases/year). Less often, sarcomas, or primary bone tumors are seen (~1000 case/year). Even so, when diagnosing these cases, it is important to distinguish as the appropriate treatment strategy varies. Even for sarcomas, there are a wide range of types depending on which cell type is transformed (osteocytes, chodrocytes, and even giant cells are among the possibilities). Some of these tumors are radiation-resistant, which obviously affects how you might treat it. What I have seen is very pertinent to my research clearly. For one thing, it kind of humanizes the problem, as I am not just looking at cells anymore. For another, it shows me where my research fits into the overriding picture of combating cancer. Using that as segue, I think that one broad thing that this immersion term teaches us is that we as engineers must shape the future. While physicians do their best with what they have, it is us who provides the tools. As we look to the future of disease in general, we are the ones that hold the keys to a better outlook. This experience has shown us the current SOTA- it is up to us to turn art to science and solid cures.

On a closing note, I must say that seeing the NY Philharmonic live in Central Park was a great experience. Enjoying the performance from the Belvedere Tower was the way to go. It was so cool, calm, uncrowded up there, and we could really hear the beautiful music. I almost feel bad for all those that were cooped up on a blanket in the midst of all the extra noise on the Great Lawn. Definitely one of my NYC moments of the past week!