Saturday, July 12, 2008

Last diverse week! Gotta get my project going from now on.

I have had it with surgeries. This week I attended an arm reconstruction in the plastic surgery unit, which was great, but I think it's gonna be my last one. Nothing is wrong with it; it's just interesting for the first 15 minutes and then after that, it's just a lot of tissues with some blood being push around for a long time. I'm much more interested in trying to figure out what's wrong with the patient and what would be the best treatments. I'd be happy with just hearing about what will be done in a surgery in order to fix the problem rather than watch for 3 hours and try to figure out what's going on. I think the thing I learn the most when observing a surgery is about anesthesia. It seems so much easier in human. I'm not sure if it's because my mouse is way smaller than a person, so it's harder to maintain appropriate level of anesthesia; or may be the anesthesiologists are just a thousand times better with human than I am with mice.

Anyway, a saw or something fell on this patient's arm and almost cut off his wrist since he works as a construction worker. (And don't you dare tell me that this is too much identifiable information on a public blog. There are thousands of young male construction workers in NYC. I'll give you 50 bucks if you can actually identify this patient! --except those of you who saw the surgery, of course) To fix this, Dr. Spector and the team had to reconnect the nerve bundle. The problem is, the nerve tissue was too short to be sew back together, so they used endothelium flap to connect both nerve endings. My thought throughout this whole process was on a talk I attended at one Biomedical Engineering Society conference. One group showed that axon of a neuron can be stimulated to grow up to 15 cm during a period of several weeks if a constant, small PHYSICAL force is applied. I can't help but keep thinking that if the surgeons can preserve the nerve tissues while stretching them for a few weeks, the neurons will grow longer. They can then connect the endings without using the endothelium which doesn't conduct as well as nervous tissues. It seems like it'd work...

Hematology clinics this week was extra cool because I suggested radiation therapy for a patient with uncontrollable Chronic Myeloid Leukemia and Dr. Silver actually took it. I might start asking for a commission if he takes a few more of my wild suggestions :) The patient had very high white count among a whole bunch of other elevated components of the blood. He feels tired and sick and had insomnia and etc. due to his condition and drugs side effects. I'm not sure why, but Dr. Silver never prescribe radiation therapy. He always uses chemo drugs only.

My favorite case this week was with Dr. Prince. It was the first time I observed a physician making a diagnosis by looking at an MRI. An MRI scan of a 74 year old lady showed that she has a stenosis on the artery that goes to her left kidney. She has hypertension because of this incomplete blockage, and her right kidney is dying due to this pressure. However, she feels fine. There's no symptoms whatsoever. Dr. Prince said the location of the stenosis is an easy location to put a stent in, however, there are still risks. The dilemma is that she feels fine. Should she risk putting a stent to fix the arterial blockage? And if she doesn't have this operation, her right kidney will completely stop functioning eventually. If she opens up the blockage, then the hypertension could still remain and that will kill the currently good left kidney. I find the decision making process in order to balance the risks and the advantages more challenging and fun.

Thursday, July 10, 2008

Conduct in General

Entirely Inappropriate

I can understand that we should be as immersed as possible during this term. However, I have reservations getting connected to patients who are terminally ill or patients that have a severe condition. Is it appropriate for us to learn the names of patients considering our limited time at the hospital? I feel that this practice is not appropriate for summer students.

Wednesday, July 9, 2008

A rough day...

Today I think reality set in. I had pretty much a normal day, but at the same time a very rough day. I started off in surgery with Dr. Scherr as normal watching a robotic cystectomy with an Indiana pouch and then left to do NICU rounds with Dr. Frayer. The difficulty began when I walked into the NICU and a group of doctors and nurses were looking at a head sonogram. First of all, the subtleties they could observe was amazing, but the prognosis was also very challenging. As we later made our rounds, I realized this was a baby I had learned the name of just yesterday. And as the doctors and nurses discussed how they would present the situation to the parents, I realized that this tiny baby will have a very rough ride in the days to come. After rounds I returned to Dr. Scherr's surgery which was going very well. The surgeons ran into some difficulties near the end as the patient had previously received radiation and some of the tissue was very fragile. Just as they were finishing though, Dr. Scherr received a phone message from his secretary. A patient from just days before, having received a robotic cystectomy and recovered very well, had fainted in his hotel, was rushed to the ER and had passed away. Dr. Scherr then left the residents to finish closing as he went to find the wife of his patient in the ER and learn what had happened.

Over the past few days I've finally had the chance to do rounds with the residents. While they didn't understand why I would do this, it was very valuable to me to be able to see patients recover. What I didn't expect was the impact of learning the patient names (which I also did in the NICU to be able to keep track of the babies). I had previously tried to avoid writing down names in order to maintain patient privacy, but at this point I feel like I was somehow dehumanizing them by not noting their names. Now I try to keep track because although the two instances mentioned above are very difficult, they're also very real. Today definitely brought me out of the solely science aspect of medicine and into the humanity aspect of medicine.

My Immersion in Radiology Department

This is already the third week of my immersion in radiology department. I find my life here is very different from my classmates: no scrubs, no rounds and no tears. I am not sure whether someone will think this can be called "not immersed yet". However, I actually feel very happy to experience this aspect of the life in hospital. Perhaps I missed many moving stories in ICU, but I learned a lot of episodes "behind the scene". I will talk about this starting from three biopsy cases to which I have been.

Case 1: X-ray-guided Transjugular Hepatic Biopsy. This is a case done at Columbia. Patient is one more-than-seventy-year-old male. The whole biopsy lasted about one hour. Sampling amount is small. There is no too much pain and bleeding after biopsy. Basically the patient didn't suffer a lot from this biopsy. Biopsy report unknown.

Transjugular hepatic biopsy is actually one of the newest technology among all hepatic biopsy methods. In US, the death rate of doing hepatic biopsy is about 1/1000. Most of them are due to the massive bleeding and collapse of diseased liver after biopsy. Considering this patient is old and his diseased liver may be too frail in this situation, this method is definitely a great choice.

Case 2: MR-guided Breast Biopsy. This is a case done at the MRI center on 55th street. Patient is one around-fifty-year-old female. The whole biopsy lasted about forty minutes. Sampling amount is relatively big. The suspicious lesion is very close to some big blood vessels, so the patient bled some after biopsy. Two samples were taken here because the patient accidentally moved her head during imaging, the location of the lesion was then changed. Because of this, patient had some small complains, but in general this biopsy was very successful. Biopsy report unknown.

MR-guided breast biopsy is better at maintaining the natural shape of breast than X-ray imaging. And it is more accurate at telling the location of lesions with the help of the guiding gird.

Case 3: CT-guided Lung Biopsy. This is a case done at Weill. Patient is a seventy-two-year-old female who had an incision of the right breast because of breast cancer ten years ago. Now a nodular solid lesion was found in her right lung. The whole biopsy lasted about half an hour. Sampling amount is very small. This is perhaps the easiest biopsy case among the three - very quick and causes very small cut. However, because of the structure and composition of lung, about 20%~25% of patients may suffer from lung collapse after biopsy. The severity and recovery of collapse vary among different patients. A quick H & E staining was done right after the biopsy. Flower-like cell clusters were found in the specimen, indicating a cancer-like lesion in the patient. More biopsy samples would be sent to Papanicolaou stain and making wax-embedded slides, so that more convincing characterizations of the biopsy sample can be made.

Although no confirmative conclusion about this patient can be made then in this case, I still felt very sorry for this lady when I was watching the biopsy. Ten years ago, she came into the hospital and lost one breast because of cancer. Ten years later, the same disease came back and might jeopardize her life and happiness again. Everything is so tricky when the moment came that as a radiologist, one learned about the coming of a horrible disease earlier than the patients and physicians. However, this radiologist must give comfort, possibility and hope to the patient when everything was not sure yet.

In this small scanning room, drama seldom happens. But all kinds of delicate struggles of inside world are going on. I can feel this on the patients by observing their move and words before and after learning about the scanning results. I can also feel this on the radiologists when they think very hard to give the most likely right conclusion on some cases to the clinicians. Here, no bloody "fighting" happens. But the things happened here give the most important support to the most thrilling surgery in ORs.

3rd Week

This was a bit of a slower week than the previous one for me. I spent some time on clinical rounds with some residents, and I continued to work on understanding how to read x-rays. I have also been looking at some clinical studies of breast cancer patients and learning to understand some of the statistics involved that are unfamiliar to me.

Looking clinical data is sometimes very challenging. As engineers, we usually use mean and standard deviation as our normal statistical measures, generally aiming to condense those SD bars as much as possible. With clinical data, this is not the general procedure however, as the diversity of the population involved is naturally very great. I have been looking at Kaplan-Meier curves for these patients- this is not tough to understand, but at the same time it illustrates the differences in analyzing clinical and laboratory data. When I see huge variance in my data back in Ithaca, I re-do the experiment or scrap it. Here, that is not an option, but we still need to be able to provide rational explanations that enhance our ability to make future predictions.

In clinical rounds, I am basically a statue in the back. While the process shows me a glimpse of how it is to deal with sick people, I have not really been enriched by the experience. It was intriguing the first day of the week because it was new, but within a few patients it became a matter of scant interest. I'm not sure how it really pertains to me or might help me in any way, beyond providing me with insight into another profession. It basically felt like "take your kid to work day" to me, with me playing the role of "kid." Still, I value the initial experience, though I can't say I'm looking forward to more of the same!

I can't believe that immersion is basically more than halfway done! It has flown by. I've gotten a chance to explore one of the greatest cities in the world, and I've seen some pretty interesting things in a SOTA cancer center. Being inside a hospital and having a chance to observe has been great; it has been awkward at times though, as I feel that I am in the way! This is a strange notion actually, because I think that BM Engineers are far from in the way of physicians, as we are actually the vanguard in initiating the next revolution of healthcare in this world.

Tuesday, July 8, 2008

Week 3

My third week during the summer immersion was one of patience. After two weeks of good contacts and meetings, I was ready to begin my clinical research. This consisted of reviewing patients TEE echocardiograms and comparing the hemodynamics of the ascending and descending aorta in diseased aortic heart valves to that of healthy aortic heart valves. Monday morning I was supposed to meet Dr. Skubas in the OR, for him to show me the potential of GE’s echocardiograph machine. Diameters of the conduits, stress and strain both in radial and longitudinal directions, blood velocity profiles, blood pressures, and stroke volumes were all on the list. However, I get a call from my doctor explaining to me that my summer immersion ID was not applicable enough for observing surgeries. Therefore, more paperwork and patience was needed. Consent forms, information forms, and a drug test to be exact. This process took about a week to complete because I could only schedule the drug test for Wednesday at it takes a couple days for
the results to come back from another lab.

While I was waiting for the paperwork to be completed, I completed rounds in the ICU and figured out where I could get scrubs. It turns out, scrubs can be found right outside the OR and there is a locker room which can be used to store your close since scrubs are not supposed to be worn outside without some sort of lab coat or jacket. I also worked with Dr. Skubas in his office looking at past patient data (general information) in order to be ready for next week.

However, writing this now in the 4th week, I gained access to the OR and have observed a few surgeries. My next blog should contain more information about my clinical research because now I am trying to make up for lost time. All in all, I am where I should have been about a week ago but, at least I am there.

Monday, July 7, 2008

Conglomeration of Experiences

So I’ve been pretty specific and detail oriented with my last two blogs. The reality is, I’ve seen and learned a lot! In all actuality, there’s much more going on than I could write in this one weekly blog without it being insanely long. But this week I’m attempting to write more on the variety of my experiences.

First of all, I’ve started my research project with Dr. Scherr. I’ll be helping to do statistical analysis of robotic cystectomy cases that have been recorded over the past year. What I may not have mentioned before is that while robotic prostatectomies are becoming more and more routine, robotic cystectomies are rarer. This report will compare not only differences of pre-op criteria influencing procedure outcome (such as stage influencing recurrence or complications) but also compare the results of robotic versus open cystectomies.

Additionally, I’ve had the opportunity to visit other surgeons and have seen a mastectomy with temporary implant and skin flap, a living donor renal transplant and a laser TURP (trans-urethral resection of prostate) by photoselective vaporization of the prostate (PVP). As well, I’ve attended two lectures on why doctors should and how doctors can participate in clinical trials and hope to round within some of the clinical trial physicians. Finally I’ve visited the NICU and attended an M&M there.

With all of this variety in mind, I’ve been overwhelmed by the process of it all. To be honest, I often find myself engrossed in observing a person rather than paying attention to the information being relayed at the moment. For example, it’s very interesting to watch a surgeon’s face as they feel for the location of an artery or listen to a patient relay their history or current status of pain. As well it can be somewhat disturbing to watch a person under local or general anesthesia naturally flinch or grimace in response to the life saving work that is being done on them. There is so much information to balance and take-in, at times it can all be overwhelming.

I have thoroughly enjoyed two things specifically though. One is a branch of thought from what Goose had posted early on: being an engineer in a hospital. It’s been stimulating and challenging to think of the technical ways engineering has truly aided modern medicine. This has ranged from a more basic metal hinge and bracket system to hold open a cavity during surgery to the precision of interfacing a surgeon with magnified view and the robotic miniscule movements translated from the surgeon’s hand motions. At the same time, there are always improvements to be made and while it’s one thing to dream things up, it’s quite another to implement them and convince surgeons of the improvements. Secondly I’ve really appreciated seeing patients in post-op. The residents were baffled as to why I would want to do rounds if I didn’t have to, but it definitely made the reality of surgery more vivid for me. I had met patients in diagnosis and pre-op consultation in the clinic before. As well, I had seen patients 3 weeks or 3 years after surgery, but to see a patient recovering, surrounded by their family is a whole new experience.

Not the American Automobile Association

The third week has been more or less the same as last week. I mainly shadowed Dr. Vouyouka through her clinic, which, as enjoyable as it is, becomes pretty repetitive after a while. Maybe it’s the batch of patients that have been coming in. Maybe I’ve already learned more than I expected by the third week. Or maybe I’m just really ADD and want the new and shiny things.

Many of the patients who come in with vascular diseases get them fixed noninvasively. The technology has advanced in this field to where most of the procedures rely on catheters. Only the more difficult cases require open surgery, such as fixing an abdominal aortic aneurysm, or triple-A in vascular lingo. I remember a nurse telling me that the triple-A is the most interesting and rare surgery to watch because after opening the patient up, the surgeon has to move the internal organs out of the way (read: out of the body) in order to reach the aorta. A graft is then used to replace the site of the aneurysm.

I thought that because the surgery was so rare that the triple-A itself must be very rare. On the contrary, I’ve seen at least four patients during clinical hours with enlarged abdominal aortas. It turns out that surgeons wait until the aneurysm is either symptomatic (patient feels pain because it pushes against nerves and other tissues) or has a diameter greater than 5 cm. They use this number because empirical data shows that the risks of the procedure outweigh the benefit if the surgery is performed on aneurysms under 5 cm in diameter. For reference, the diameter of a normal aorta should be less than 2 cm. Most of the patients that Dr. Vouyouka has seen have aortic diameters of 4.2 to 4.8 cm.

So if I’ve already seen 4 patients with triple-As, I should get to watch an intense surgery soon, right? Nope. Most of the time the aneurysm grows very slowly and sometimes doesn’t grow at all. All Dr. Vouyouka can do for now is to have the patient come in every 6 months to get CT scans and duplexes (ultrasound) to make sure the aneurysm isn’t growing too fast. Even if the aneurysm turns out to be greater than 5 cm and something needs to be done, there is a less invasive alternative to open repair: endovascular aneurysm/aortic repair (EVAR). With this technique, access to the aorta starts with a catheter being inserted through the groin, and the procedure ends with a stent graft being used to create an artificial lumen for blood to flow through.

I believe younger patients are able to get open repairs since they heal peri-op without as many complications as older patients. Since EVAR is relatively new (started in the 90s) and post-op results are pretty similar to that of open repair, a study is currently being done to evaluate if EVAR is as successful if performed before the aneurysm is greater than 5 cm. This way, patients can get the operation earlier and don’t have to worry about their aneurysm suddenly rupturing, which almost always ends in death.

In other, lighter news, the week ended with Independence Day. A few friends from high school flew up to visit, and we explored NYC, ate fancy French food, and barhopped around NYU. Good times (that don’t need to be blogged about here).

Still Summer Immersing

Last week I took the opportunity to follow Dr. Schwartz on clinical rounds, and I have to say that it was a pretty novel experience that left me with mixed emotions. Many of Dr. Schwartz's days involve hours upon hours of discussion with patients about their specific cases. I'd say that a good 20-30% of these cases are simple surgery follow-ups in which Dr. Schwartz examines an MRI scan, sees nothing wrong with it, then breaks the good news to the patient. However, a vast amount of cases require him to inform a patient of a tumor and then discuss surgery options with them. While these meetings are somewhat depressing, I actually learn more from them than from watching surgeries. I get the opportunity to see a larger variety of cases, and hear Dr. Schwartz's explanations about the situation and options for surgery.

Some of the surgery options are pretty technologically advanced. A lot of patients ask about the use of a gamma knife, which delivers localized radiation to a tumor to kill its cells. The radiation is delivered over multiple sessions at moderate doses, and can be focused to a millimeter scale. Dr. Schwartz has used this tool extensively, but seemed to generally advise that older patients use it primarily because the long term effects of the radiation provided by the gamma knife are still unknown. Furthermore he said that it can only be used on tumors less than 2cm in size, and there are limitations on where the tumor can be. For example, if the tumor is too close to the optic nerve, it doesn't make sense to use a gamma knife because of the damage that it could cause to a patient's vision.

Dr. Schwartz also talked about a pretty cool endoscope, in which hundreds of tiny lenses are placed at the tip. To explain the tool to patients, he used the analogy of an insect eye which has thousands of small optical units that process spatial information separately. Older generation endoscopes have the drawback that they provide only two-dimensional spatial information, but little information about depth. The thousands of lenses enable the endoscope to process depth, and display 3-D images on a screen that doctors can see with special glasses. Cutting edge tools like these perfectly represent a biomedical engineer's ability to advance the medical field.

The Olds, the Youngs, and the Others

At the end of the 2nd week, I attended a talk about suicidal incidence in the elderly in NYC. Some of the conclusions include: NYC needs to build more barricade because jumping from a building is the most popular way here; only 20% of the elderly who commit suicide receive anti-depressant, so we need to look out for depressive disorders in patients; and the difference between teenagers who slit their wrists and an elderly person harming him/herself is that the old one actually means it. It was a somewhat depressing presentation, but the sandwich from au bon pain definitely made everyone much happier.

Since Dr. Silver is on vacation, I've been floating around this week. On Monday, Dr. Schafer hooked me up with Dr. Raik in geriatrics out-patient clinics. Interestingly, patients I normally see in hematology/oncology are older than geriatrics patients, on average. I suppose it makes sense in a way because the really, really old patients tend to have more complications and are referred to specialists. Most patients were very nice but clinically not-so-interesting. Almost everyone receives antidepressant here, which is not too surprising since Dr. Bob (not sure what his lastname was) who gave the talk above works here. One lady who came in was very peculiar. She said she had (or have had) hypogammaglobular anemia, thymoma, fibromyalgia, and cellulitis, etc. She was also clearly depressed: she was crying about being on disability due to her medical conditions, crying about, "No body (meaning doctors) wants to take care of me," and having trouble finding jobs because she is sick and noone wants to hire a sick person. Personally, I thought she had some psychiatric problem. How can someone been through at least 6 doctors and have nothing good to say about any of them? And almost all of her conditions seem to be unrelated. She also changed the dosage of her ~15 drugs, which she showed Dr. Raik during history. The patient complained that one drug makes her throat really dry or her ankles swollen or whatever. I wonder how she could figure out which one exactly did that since she takes like 10 at a time. Dr. Raik told me later on that I was right--all her blood/lab tests were negative for everything. Apart from her attitude, she's fine.

Just some funny things I observed: two elderly male patients had different conditions (adrenal gland tumor for one and the other one had something else). Both of them asked the doctors if viagra pills would cure it :)

I've never noticed how white hematology/oncology clinics are until this week when I saw the first black and hispanic patients (haven't seen an Asian person, yet. May be they're made of steel). Apparently only caucasians get myeloproliferative disorder and/or able to afford to come to this clinics.

For the rest of the week, I spent my days in Neonatal ICU. Wow, half the babies are shorter than a wine bottle. Cardiac and respiratory complications seem to be common in premature babies. It amazes me that the survival rate for this NICU is like 80%+ because some babies just don't look like they would make it: they have some weird murmur in the heart, need CPAP, have to be fed directly to the heart, etc. One baby has a mother who did cocane (although for some reasons she claimed she did heroine) right before birth. So he's on morphine until the doctor can weed him off of drug. What an interesting way to start a life and what a great story to tell your friends in the future! ("Yo, man, I did drug when I was 1 hour old!") There is no rigid guideline on how fast to decrease the morphine, though. It's kind of like adjusting an engine's idle speed: you keep turning the speed down until the engine starts stuttering and doesn't run, then you turn it back up. Here, you turn down the morphine until the baby starts to jitter, then turn the morphine back up.

Another thing I found interesting since I'm normally in hematology is that babies normally have Hct of ~50-60% That's crazy! The risk of thrombotic events increases exponentially as soon as Hct exceeds 42 and 45% in female and male adults! How come those babies are not having strokes left and right? Another funny thing is, one baby who has a trisomy 18 had a transient polycythemia, so he had increased Hct among other things. But what is considered an increase when there's a huge variable range of "normal" Hct in premature babies? I'll ask Dr. Silver when I see him

Week 3: Research and Exploration

This past week, I started working on a project for Jonathan. First, we needed to upload all the data we were going to use in the study, so I entered the workstation every three or four hours to transfer files from the central server to the specific workstation we use.

One study will examine the left ventricle volume at different cardiac phases, and look for correlations between the data obtained and the physiological condition of the data set. This will be interesting, because there is potential for a new diagnostic method using the segmentation software we have.

I also got to randomly explore the hospital a bit, and talked in details about the med school curriculum with some med school and MD/PhD students one afternoon. It was very interesting to hear how the 1st and 2nd year curriculum are intense with memorization and regurgitation; in a way, it was making me feel more comfortable pursuing a graduate PhD degree in BME as opposed to the MD in medicine.

The Fourth of July weekend was awesome; I joined a reunion with my college friends, and we saw the fireworks from the front row at South Street Seaport. We had to wait from 5 for the best seats, and the fireworks began past 9 pm. It was really great. I also went to Broadway with some friends, and saw the Musical, Rent; I'd recommend seeing it!