I like mice

Other than going to clinics for 5 hours, I spent my week in the library in front of my laptop. My research project is on polycythemia vera patients who have mild symptoms when they have high JAK2 allelle burden, or severe symptoms with minimal JAK2 positive ratio. Normally, patients with increasing ratio of JAK2 positive burden have increasing phenotypes of the disease. For some reasons, these people have opposite output than what's expected. Several problems I run into during my statistical analysis include: incomplete/unorganized data (missing from different doctors, etc.), very small sample of patients, and not being able to rule out what causes what exclusively since we can't just test things on human patients. I'm not so sure if a publication is going to come out of this, but my fingers are crossed.

Week 5: Rollin'

Finally back to a regular full week's schedule, unobstructed by the national holidays nor other commitments! The last two weeks have been shortened one way or another, so it's great to be immersed for a full week again!

I spent most of the time bouncing around between Floors 0, 2, and 4 of the Starr Building this week, and reinforcing what I have learned about cardiology and different kinds of imaging so far in the program. Got to ask the fellows, nurses, and techs in each department tons of questions, as well as getting a lot more interesting references and resources to read. It was also great to see the end of the tunnel for my immersion project, for which I now have a realistic timeline to complete the study and possibly a paper or an abstract.

This week, I'll write a little bit more about the software that's used in my project, the LVMetric Segmentor, which was developed at WCMC to speed up the segmentation process of cardiac images. Image segmentation provides a lot of important information, such as the chamber volume, blood mass, etc. which can be used as an indicator for certain diseases. In the past, doctors spend an awfully long time on each image case to segment myocardium from the chambers, while taking into account the papillary muscle mass, etc. For each patient's image, it can take anywhere from 4 to 10 minutes for an experienced doctor like Jonathan to segment the image profiles at the systolic and diastolic cardiac phases. LVMetric, on the other hand is very efficient, as it automates this segmentation process using some nifty image transforms and segmentation algorithms, and does it for all 25 or so different cardiac phases; in a matter of few seconds!

In addition to speeding up the process for doctors, the software can get data point at almost every cardiac phase; this allows us to study the temporal aspects of the chamber volume, etc. at each moment in the cardiac phase. We've recently added a new function to the program, so that it can output a decent amount of data from different cases that we examine. The remainder of my project starting Monday will be to organize, process, and analyze the volume curve for a number of these cases (Jonathan said it would be ~20 or so).

From this study, we are hoping to identify a quantitative indicator of certain physiological defects by analyzing quantitative data that I will work with. So it will be time to hit my Statistics textbooks hiding somewhere in my room next week (where are they?!). I'm really looking forward to wrapping up my project.

Finally, I got to follow Dr. Frayer on the rounds in the NICU this morning; I really must resonate Shawn and everybody else's earlier comments: man those babies are cute!

Interesting experience this week

It is never a rare case to see some patients with breast cancer in radiology department. During the past weeks, I have written about two cases with breast cancer or breast cancer history in my post. This week, an especially interesting case came in, and gave me some brand-new insights into healthcare.

This is a 44-year-old breast cancer patient coming in with a bright blue scarf wrapped around head, which is undergoing hair loss due to the radiation therapy. I talked with her for a while she was waiting for the scan. Different from some other patients, I found her very cheerful throughout the short chat. Rattling super happily and proudly on her twins, she almost made me forget she was actually a cancer patient. The surprising thing happened at the time when I found out she actaully came to do an abdomen scan rather than a chest scan. Was this for checking the possible metastasis? I thought this way at first. But things just surprised me more when I gradually noticed the technicians paid more attention to some abdominal blood vessels. At last the most elucidating yet surprising thing came when I was told she was actually doing this scan for the susceptabilty test of a breast reconstruction surgery.

I know this is still confusing so let me explain more. Obviously this optimistic lady had not underwent a surgery to take out the breast cancer yet. She was doing the radiation therapy right now to suppress the cancer cells, so that they won't metastasize so easily post surgery. At the same time, she was also worried that she won't look so good after the excision of breast and DIEP Flap Breast Reconstruction technology came at the right time. Her surgeons planned to carry out two surgeries - mastectomy and breast reconstruction - on her at the same time, but before that, they need to make sure that her perforator vessels are still intact so that they are able to function as the internal mammary blood vessels later. She was very happy to learn the good news that day: her perforator vessels look super good even after the incision in C-section many years ago.

For me, this story totally refreshed my idea about the role of surgery in healthcare. In my old memory, surgery is always related with pain, wound and scar; surgery happens when medicine fails. However, this time just imagining nowadays patients can actually choose to combine resection with orthopaedics, I am totally overwhelmed. You can get cure and beauty at the same time - one stone two birds - isn't it fantastic?

Of course I understand that this technology must also be very controversial. Just like people would even argue whether this is worthy and safe to create an artificial beauty through orthopaedics, DIEP Flap Breast Reconstruction on a cancer patient is also risky. Recovery from two surgeries is definitely slower, not to mention the underlying risk to keep some breast tissues near lesions for better reconstruction. The fact is, ethic problems always come with healthcare. Nevertheless, the hope for benefiting more from medical technology never dies. Medical care is not all about elongating one's life. It also helps improving the quality of life, and the way we look at life and ourselves. There is nothing more important than that patients find health care help their lives and be happy about it. And I think the impressing part of this case just lies in that it teaches me the function of healthcare CAN be not only for physical well-being, but also spiritual welfare.

New Experiences

Last week I got to see deep brain stimulation surgery. I wanted to see as much as possible because I am supposed to be implanting DBS electrodes in rats for my thesis. Of course I tried so hard to see everything that I kept touching the blue sterile surface. The guy got kind of annoyed with me and I felt stupid and useless. My clinician also was telling me that I was getting too close. It is a very serious surgery, so I understood that I need to stay back to some extent. Nonetheless, it was fascinating. They used a lot of trial and error to find the right position and voltage of the electrode to maximize benefit for the treatment of Parkinsonian symptoms without interfering with motor control. They kept asking the guy to speak the days of the week. Sometimes it was muffled, sometimes it wasn't. I guess it varied depending on the positioning of the electrode. They also told him to flex his feet and open/close his hand. The surgery lasted for several hours.

The next day I saw three plastic surgeries. These surgeons were sooo much less serious. They played music, joked around, and the head surgeon played peek-a-boo behind the door. In the first two surgeries there was a lot of manipulation of the skin. In one, the skin would be stretched over time, then excess skin would be used to replace scar tissue. In the other surgery, the woman needed a skin graft. I could see all the exposed muscle that they were covering up. She also had the biggest blister on her heel that I had ever seen. It looked like a giant diabetic blister or something.

Today I saw open heart surgery. They are right, it is intense. They bypassed the heart and lungs so that they could treat an aortic valve inefficiency. The blood went to a machine that acted as a heart. The resident said they would take a blood vessel from the leg and use it to replace one of the aortic vessels. It did not see the whole thing because I had other things to do.

I really want to learn as much about stereotactic surgical techniques from my clinician as possible, specifically on dissecting rats. He had me hook up with a woman in his lab who plans on doing stereotactic surgery. She said she had never done stereotactic surgery either. Not too encouraging. On the other hand, Yi stated clearly that this work is not meant to be for our theses.

I continued to work on the research protocol that Dr.Frayer says is junk. I was too lazy to change what I was doing and figured that at least I am learning a lot about neuroanatomy, something that is important to me in pursuing a neural engineering career. Now that I have learned about the neuroanatomy of drug addiction, I think about the reward circuit when I pop in snack foods and go out for a run. I have finished writing about the rationale now, so I don't know what he will have me do next.

Week 4: Mathematical Modeling and Montreal

So I missed a few days of the Immersion program teaching for a Math Camp in Montreal. For the summer camp, I was preparing a fun talk that discusses some ways that math can help in the clinical settings. While preparing this talk, I figured there was no better way than asking the immersion clinicians for ideas that I can talk about. So here it is:

As engineers, we often use mathematics as a set of tools for solving problems. From fluid dynamic models of blood flow, to certain clinical data analysis, there are numerous ways to use math in clinical settings. One topic that caught my attention, and fascinated me was the problem of how organ transplants are optimized at the local, regional, and national levels. There is an increasing trend of government funding for an efficient network called the Organ Procurement and Transplantation Network (OPTN). I've seen an analogous problem, (about the renal transplant network) last year in a mathematical modeling contest, and thought this would be a great problem to think about and ask around.
The topic of establishing an effective network is a difficult one, because of the many factors that must be incorporated in developing this model. As there are more organs sought after than there are available, there would usually be a significant waiting list for patients who need a new organ. One could try making a population dynamics model (using a system of ordinary differential equations) to get a holistic idea of how the waiting list behaves over the long course, but many indications suggest that we are all moving more towards larger and larger waiting lists in the future for almost all organs. Supply simply does not meet the demand.

One novel approach for resolving this situation was looking at donor-patient pairs. It is often true that exists a donor who is more than willing to donate an organ to a specific patient (which made sense in the case of a kidney), but the donor's kidneys are not compatible with the patient. If this is the case, it would make sense to establish a two-way exchange, so the two donors would trade their kidneys.

As a mathematician, one would like to generalize into establishing an n-way exchange, and finding a mathematically elegant solution that solves this optimization problem. However, from a clinical perspective, there are additional factors that need to be considered before we consider a similar exchange. First, suppose we establish an n-way exchange, but the chain breaks (eg. extraction fails) at some point. If this happens, what are the repercussions of such failure to the whole chain? One patient will not receive a sought after kidney due to the failure, while its donor, whose kidney is somewhat like a bargaining chip for acquiring his or her patient's new kidney, may break off; would this result in the entire chain of surgeries to fall apart? If so, will that mean that the all n transplants must happen simultaneously? Second is the feasibility of such cyclic surgeries; after all, these n-way exchanges require a lot of clinical manpower. Do most facilities have such capabilities? While it may be possible to model these intricacies using mathematics, it still won't address all the questions that clinicians may have.

Through summer immersion, I've learned that to address these problems properly, it would require more than mathematical problem-solvers developing models; a collaboration with clinical experts who work hands-on with these issues is a must. It is interesting to see where these considerations may lead to: NYP-Columbia Hospital was successful in having a 3-way exchange for the renal transplant recently in 2004, and this was a huge step forward.

Time

Well, time is slipping by so quickly I can hardly believe the summer is almost over. As unfortunate as it is that the final weeks of the program approach, the passing time does afford one huge benefit - human interaction. I have hit the point in my summer that a large number of repeat patients of Dr. Spector recognize me and expect my presence. During clinic hours we see a plethora of pre-op, post-op, and consult patients and, since I’m basically glued to Dr. Spector, interact with all of these people.

After hanging around enough during clinic I get to experience a more personal connection and understanding of each case that is presented. It is all well and good to pop into a surgery because the case is interesting or it is a procedure you haven’t seen before, but I really enjoy taking in the big picture. Going into an OR with a patient whom I have met, talked to, and begun to understand their mindset and choice for undergoing a particular type of surgery brings the experience to a whole new level. It is also incredibly gratifying to visit the patient while they recover in the hospital and then follow them as they come in for subsequent post-op visits. It still amuses me that some patients a day after surgery insist on asking how I am doing when they are the ones bandaged up in a hospital bed. I suppose this whole circle of care is what medicine is truly about and as a biomedical engineer I need to try not to forget to live up to the word medical in my title.

Of course I also so have some amazing surgical stories as well. You wouldn’t think I would leave you without the possibility of being grossed out or astonished by what I’ve seen, would you? So here’s what I’ll leave you with this week: We had a patient that needed exploratory wrist surgery to assess and repair the damage done when a circular saw cut their arm. After increasing the length of the wound, the surgical team found that the patient had nicked their tendon and severed one of their median nerve which supplies sensation to the hand. After repairing the tendon, Dr. Spector decided that to fix the nerve it would be best to make a bridge to connect the two damaged ends and not try to force the two ends together under too much tension. So of course the only logical thing to do was obviously take a 2 cm segment of the patient’s vein, clean it, and then sew this graft to join the ends. Again, who thinks of these things?!?! Apparently for nerve damage repair one can use vein grafts for gaps up to 2 cm and get fairly good results. I tell you, medicine is a kooky place.

Pediatrics and Medical Technologies

I spent most of my mornings this week rounding in the Pediatric ICU (PICU). It was a very interesting experience, having spent a couple of weeks in the neonatal ICU. In the neonatal ICU, the most common issues were nutrition/growth, respiratory distress, and cardiac problems. The cases in the PICU were a lot more varied and more complex. In one of the cases, a child was admitted for fever with irritability and inconsolable crying. But because the patient had such an extensive medical history (despite being so young), which included a repaired paraesophageal hiatus hernia , Lennox-Gastaut syndrome, and myoclonic seizures, it was difficult to diagnose whether the crying was a result of pain from the surgery or a neurological issues. It took an entire week, and consults from multiple departments and hospitals, to rectify the problem at admission. By the end of the week, the child was dramatically better and was due for discharge. It was really satisfying to experience the entire diagnosis process of a complex case that led to resolution of the problem.

In the past month, I've made some interesting observations regarding medical technologies in the hospital too through my time on the floor, and at various conferences. These are key considerations for any technology to be developed for patient care.

1) Mobility: There are so many patient transfers that go on in the hospital everyday - to and from surgeries/deliveries, across the floors, and between the units. It may seem somewhat trivial but the capability of a critical care device to function during transport is a huge deal. A company was promoting a new warmer for NICU with enhanced features, including procedure lights, motion sensors, hourglass heating, in-built sensors and respiratory aids, etc. The new features were exciting but in the end, it came down to whether the product could function at full capability (without wall power) in the time it takes to bring a baby from the delivery room to the ICU. It turned out that it was not able to do that by itself, and it was significant drawback. You can buy an additional universal power supply box at an exorbitant rate for 15min of offline power, but that may not always be sufficient.

2) Speed: This is where lab-on-a-chip technologies will come in. It is surprising to know how the results a relatively simple genetic test can take several weeks to return. This can be dangerous for a patient that requires immediate treatment based on a positive result of the test. This is a very real issue, and there are already lab-on-a-chip technologies used in the hospital. If you look around, you may notice that the blood gases of the patient are obtained at the bedside.

3) Accuracy & Verification: I learnt in a conference that dosing errors are very common in any hospital. Usually, the error is noted before it causes any irreparable damage but sometimes it is not. The source of this error is either from the human (doctor, pharmacist, nurse etc.) or from the machine (dosing and prescription order systems). Fortunately, there are checks that go on at each level to make sure the prescription is right. It would be great if there was a system that could somehow eliminate all the forms of dosing errors.

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.

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.

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.

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.

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!

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!