Week 7/8:Last call for surgeries/Contemplating research direction

Week 7 was essentially our (mine and Aarons) last week in the hospital seeing patients/observing surgeries/etc. which we’ve become so used to the flow of things. Our last week Dr. Spector would be traveling, and we anticipated us being in lab in our newfound “free-time”, trying to finish up experiments/make whatever we could out of our lab work thus far. Coincidentally, our last major procedure was the same type as we had seen on our very first day of immersion, a mandible reconstruction with a free fibula flap. When I look back at these two experiences, it makes me think of just how far we had come/how much we have experienced in the short amount of time. I walked into the OR with a sense of confidence/familiarity, having accumulated enough knowledge/experience to give context to what’s going on in the room at each stage of the procedure. The surgery played out more or less as was discussed during their video-conference planning meeting the month prior, down to the minute details drilled over and over by the respective surgeons (ENT, Oral, and Plastics (Dr. Spector)). Additionally, for this procedure they were able to hookup the video camera attachment to the microscope, so we could watch with great detail the barely visible movement which Dr. Spector and his fellow were performing in order to isolate/anastamose the respective blood vessels. With the whole room operating smoothly/efficiently, Dr. Spector’s team finished up the operation hours earlier than our first reconstruction (roughly 8AM to 10PM at night).

My final week of immersion was spent in the lab. Initially, I was highly optimistic. After trouble-shooting my MeHA-Megel photocrosslinking protocol (requiring far greater concentration of Inrgacure photoinitiatior/UV exposure time), and undergone training/clearance on the confocal LSM at the college, I was eager to see how the long term viability of seeded HUVEC/encapsulated Pericytes would turn out. Admittedly, my approach in preparing whole subsets of my respective time-points en mass was atypical, and frankly poor experimental design, “placing all my eggs in one basket” if you will. However, given the limited amount of time I had left towards the end, I viewed it as my last chance at obtaining usable data. Alas, it didn’t, and that is all I would like to speak of on that subject if you will… The high degree of cell death could have been due to a number of issues given how substantially I had deviated from my lab’s normal photocrosslinking protocol (e.g. the Irgacure concentration at that point may have been highly cytotoxic). After learning from one of my lab mates from the bioprinting project that they’ve recently been coming into similar issues in photocrosslinking with that newest batch of material I had been using (possibly due to poor methacrylation) I decided to instead finish teaching several new long-term lab members the different assays/imaging/etc. which would be required if Dr. Spector would rather have his students conduct these in vitro studies in NYC versus me conducting them back in Ithaca after more material has been produced (methacrylation/purification is a time intensive process). I outlined the setup/obtained the components necessary for peristaltic pumping systems for conditioning the tissue-engineered microvessel constructs moving forward, as the new lab members were unfamiliar with these systems/process involved. I view it as a necessary component moving forward in preparation of micro-anastamosing these constructs to their rat model. Additionally, the long term viability of the cell lining can be tested at physiologically relevant hemodynamic conditions. I’ll have to wait until after Dr. Spector returns when the three of us (him, my PI, and myself) can discuss the logistics of how to complete these studies moving forward. I am greatly appreciative of the experience overall, having seen so much in the hospital, but am looking forward to getting back into the full swing of things back in Ithaca.

Week 6: A kink in the clockwork...

The most pronounced observation of the week was during another ALT free-flap procedure, in this case used to reconstruct soft tissue coverings for the patients exposed ankle/heel regions. We had seen a number of these type of procedures throughout the summer, most often utilizing the ALT as a well vascularized/large surface area donor site requiring relatively minimal post-op wound care, to cover these deep tissue wounds wherein a skin graft would be insufficient/pose low chance of healthy integration due to the lack of an underlying vascular bed (exposed bone). We have seen this patient throughout most of our immersion term, whom after sustaining a significant/traumatic injury to his leg months back in his home country, has resulted in significant tissue ischemia and little to no motion/sensation below his dislocated knee-joint. Since day one, Dr. Spector had been recommending a BKA (below knee amputation) as the best possible scenario to return functional use of his knee. The complications with his injury made the integration of the muscle-flap and/or skin grafts unlikely, would induce further trauma in the donor sites, and would not return functional usage of the foot anyway. The family and patient remained adamant about saving the remainder of his foot/leg despite these recommendations, and thus had undergone a slew of tissue debridements/irrigations as well as attempted closure with both Integra and autologous skin grafts. While unsuccessful in fully integrating/recovering, the patient wound sites appeared to be making some progress in that direction, leading to the optimistic family to push for the free-flap reconstruction.

For this procedure, Dr. Spector and team segmented the ALT donor tissue in order to cover both defect sites whilst still supplied by the same artery/vein for anastamosis. However, the procedure was complicated by a “hiccup” during a critical point in the procedure – the ischemic window. For starters, the operation was set to take place in the ambulatory surgical wing (where Dr. Spector hardly if ever perform these flap surgeries) and from his usual team, only one of his seasoned OR techs was in the room. When it came time for Dr. Spector and his fellow to perform microsurgery for the detached muscle flap, the circulating nurse had not initiated/setup the microscope, and we further found that this particular scope possessed a nonfunctional eye-piece. By this time, late in the evening, the main OR staff and those whom he could normally contact to obtain a replacement had already gone home. The circulating nurse had no idea of how to locate another scope, at which point Dr. Spector sends off one of his residents and med students to search for one in general surgery and bring it back, a difficult ordeal. When they returned, the scope they had brought up was not suited/sufficient for his intended usage. Eventually, we were able to get ahold of one of the knowledgeable staff members from home, getting permission to use his regular scope in general surgery (which thankfully, was no longer being utilized by another surgical team) and the procedure was finally able to be completed after an additional couple of hours for the micro-anastamosis.

This complicated series of events has made me question how prevalent these type of issues might be. The successful execution of these major operations depend on everyone apart of the surgical team fulfilling their respective roles, each functioning as an integral component in the clockwork nature of the OR. Any breakdown in those roles (e.g. improper setup, equipment checks, etc.) can bring the whole operation to a standstill. I could only imagine Dr. Spector’s level of frustration, but outwardly you would never really have thought it, exuding his usual cool/calm demeanor. I guess operating as a surgeon for all these years cultivates these type of nerves of steel to tackle these complications/issues which are bound to emerge, but really, the system should have been such (inbuilt checks, etc.) that they don’t come up in the first place.

Belated Week 8

I realized that in all the excitement of packing and getting ready to leave I never actually posted my last blog. The last week of Immersion, Dr. Bostrom was out of town, so I don't have much to report. I mostly spent the last week working more on my research project and starting my paper. It was a good way to finish up the summer, by reflecting on everything I had seen and done over the past 8 weeks. It made me realize how awesome this experience has been, allowing me to see so many procedures and technologies being used to help real people. It was nice to see the end result to remind us why we do what we do in the first place. I definitely gained a whole new perspective on what it takes to be a surgeon, and learned a lot about all of the behind the scenes issues not many people are aware of.

Week 7 & 8

Week 7 & 8. 

There’s only couple of days left. For the past few days, I thought I almost see every procedures and was a bit bored to repeated operations but the last two weeks gave me more experiences I expected. Dr. Milsom is an expert in laparoscopic procedure but I finally was able to see the open procedure. The patient admitted had extensively distended abdomen because of the stricture on the small intestine so he had to open her abdomen and got rid of the bad piece. I thought I fairly used to see the small intestine which I saw all the time in the mouse, but it was a bit more intimidating. It was easy to find the obstructed piece and it looked really horrible. The piece of loop of the small intestine was almost blocked by adhesion and hugely swollen. It looked like tied up with rubber band. I have pretty amazed by the fact that adhesion can do lots of bad things in the tissue although it is formed in normal healing process. In another case, he was admitted with huge pain in the abdomen. When we looked at his intestine, there was pretty stiff adhesion along with the small intestine and it made the small intestine tangled up. It was amazing that the swollen small intestine before the stricture was immediately returned to almost normal size once we released the adhesion. I keep realizing the thing that small thing can lead huge consequence, especially in bad way. That would be nice if there is simple drug that can inhibit excessive formation of adhesion after surgery or maybe some kind of biomaterial to prevent it. There was another impressive case of open procedure on Tuesday. That was a second time I saw him in the OR. I remember him because he had two stomas. He has been taken care of by the doctor but he was lying on the table to examine any blockage in his intestine with fluoscopy. As I wrote in previous report, his intestine was able to flow dyes smoothly from one end to the another. However, he came back to OR because he had been suffered from low quality of life. He said he couldn’t eat much although we didn’t find any obstruction so he finally decided to get another procedure. Dr. Milsom opened his abdomen and fixed stricture by strictureplasty near the first ileostomy and closed jejunostomy and rejoining separated piece. It was pretty long and hard. 

During summer immersion, I have got lots of fresh thought in mind. Especially, I think this time is so valuable since I could learn how other people have different interest and perspectives. I truly thank that I was able to work with Dr. Milsom who has active work on both clinics and research sides. I started my Ph.D to help people as a scientist but it is sometimes motivated by intellectual inquiry, which often does not have direct impact (or more say short-term effect) on patients. He kept encouraging me to develop something useful and helpful device,, thinking me what could be a real help to the world. It has been so precious time to be close to the real field and exposed to so much interesting things. By wrapping up my time here, I think I can say that my summer was fully immersed!

Week 8: Concluding with research

My last week of the Immersion term was focused on investigating the impact of stent type upon renal artery morphology which has implications for long-term durability. Thus, the week mainly consisted of establishing and implementing a protocol to make the appropriate measurements while being blinded to the stent type. I've finished the initial measurements, and will continue analyzing the data once I am unblinded back in Ithaca.

Overall, the Immersion term was a valuable experience for a multitude of reasons. Among the various experiences, I found observation of the clinical ramifications of atherosclerosis particularly illuminating. Although I'm not sure how I will incorporate this new clinical perspective into my research, I anticipate it can only help motivate me and provide a source for new ideas as I progress through my doctoral research.

Week 8: The Tasmanian Devil

With Dr. Spector out of town, I spent the final week of immersion in lab. A majority of my time was spent teaching one of the lab’s newer, longer-term members everything that I knew related to my project. This encompassed several protocols, from making PDMS molds, to preparing tumor cell-conditioned media, to seeding the sacrificial microfiber (SMF) constructs.

Aside from this, I also “created” a device that will potentially improve results for all SMF-related projects in the lab. The SMF constructs consist of a patent microchannel (formed using a sacrificial material, hence their name) within a collagen hydrogel, into which the lab seeds various cell types (e.g. aortic smooth muscle cells, endothelial cells) to form a vascular lining. However, one problem that has been mentioned frequently in lab meetings this summer (and I believe prior to this summer) was inconsistent attachment of cells circumferentially throughout the channel. A cell suspension is placed within the channel for an hour before media is placed around the construct. During this one hour, the lab usually orients the construct (within a mold, which is placed in a petri dish) up, down, and tilted for 20 minutes at a time to improve internal surface coverage, but has had varying success. Unfortunately, this also requires close monitoring of time within the incubation hour, limiting the amount of other work that can be done during that time. To make the seeding process more hands-off and consistent, I reappropriated an old peristaltic pump in the lab to clamp and continuously rotate a petri plate (holding up to three constructs) during the one-hour seeding incubation (the lab has named it the Tasmanian Devil after the Looney Tunes character). I think this will generate more consistent cell adhesion along the lumen, but the optimal rotation speed will need to be worked out before it is implemented in all SMF projects.

With all that, immersion term is officially over! I hope that some of the work I did in lab will make a lasting impact, and I am extremely grateful to have had the opportunity to shadow Dr. Spector in the many aspects of his work.

Week 7: C'mon, get flappy

This past week, we saw two flap cases in the OR. First was a mandible reconstruction with free fibula flap, a procedure we had seen in our first day of surgery. This time around though, we had much more context. Having seen the surgical planning meeting a few weeks ago, I entered the OR feeling confident in my knowledge of what was going to happen and with greater appreciation for the entire process. The room was swarming with people as soon as we entered, but in little time formed into a number of teams clad largely in blue. At least one OR tech was scrubbed and ready to assist each team. Oral surgery started by removing any teeth from the length of the mandible that would be cut out. At the same time, the plastics team was locating the vessels that supply the fibula flap, and cutting through several layers of tissue to isolate the fibula. ENT (ear, nose, throat) removed the mandible tumor from an incision below the jawline. In great contrast to last week, it was during this procedure that I was able to truly appreciate the efficiency of an OR in which everyone knows what is happening and how to perform their role appropriately. The anesthesiologists were very responsive to the surgeons’ requests to raise/lower the patient’s blood pressure (although I don't recall seeing an issue with anesthesia in the cases I’ve observed so far), the OR techs and circulating nurses knew what tools were needed and where to find them, and the correct microscope was ready to go when Dr. Spector needed it. We were even able to connect the video camera attached to the scope to the monitors in the OR so that everyone could watch the microsurgical anastomosis. With everything running smoothly, this case was completed hours sooner than our first mandible reconstruction had. This patient even received titanium implants in the fibula flap (posts onto which custom dental implants may be placed), which had not been done for the first one.

The next day, we saw a buccal tumor resection and reconstruction with radial forearm free flap. This was unique compared to cases we had seen before because the vasculature is much closer to the surface of the flap, and the flap was to be used to patch the defect in the patient’s inner cheek. ENT was involved in this case to remove the tumor, and to locate potential vessels at the recipient site. The vascular pedicle extended from the patient’s wrist to about halfway down the forearm, since the vessels would be tunneled from the patient's cheek down to the neck, where the flap would be anastomosed. Aside from navigating another crowded room, the main issue we encountered in this case was poor temperature regulation in the OR. Although we had set the thermostat to a low temperature, the room only seemed to be warming over time. After several calls to the engineering team, someone came with an IR gun to check the vents in the room. It turned out that one thermostat controlled multiple rooms, but there was a leak in the thermostat, causing it to sense cooler-than-actual air coming from our OR. We were all relieved to feel the temperature dropping once this was fixed. The most amazing part about all this was how the surgical team was able to continue working (i.e. do microsurgery) in these conditions; despite their discomfort and complaints, everyone was still able to do their jobs and ensure a successful procedure.

Week 7&8

On the Tuesday of the 7^th week, I had the opportunity to join Dr. Spector’s team with Terence and Aaron to observe a mandible reconstruction surgery. A bone tumor, which was excised in the first stage of the surgery, was diagnosed on the right side of the patient’s lower jaw. To reconstruct the mandible, a piece of fibula flap without skin part is used to restore the defect. A CT-scan 3D printed skull of the patient had been made beforehand as a guidance to excise the tumor structure; and a template served as fibular guide was designed to cut the fibular in the precise location and angle to fit the defect. Because I had to shadowing Dr. Cross earlier that day to see patient, I came to the O.R. a couple hours late and missed the mandible remove part. When I entered the O.R., three teams of doctors including head and neck team, fibular team, and plastic surgery team were working on the patient simultaneously. There was a huge ear-to-ear cut on the patient’s neck and all the skin above had been lifted up to expose the mandible with clear margin for the bone resection. The fibula procedure took a while because the cuts and the holes for the implant need to follow exactly the size and the alignment of the guidance. But once it was removed, the fibula flab fit instantly and perfectly into the mandible. The last part of the surgery was operated with the aid of a microscope to reattach the vessels to neck tissue. Two veins and one artery of the similar sizes from the neck were chosen as the candidates. The arteries were attached by suturing end to end. The veins attachment, due to their smaller size, were performed by anchoring the ends of both veins on a small plastic rings with needles and then being clipped tightly to prevent leaking. The entire surgery took more than 8 hours to be finished. It is very amazing how the pre-designed guide and template help doctor perform the procedure precisely. The functional and aesthetic outcomes were incredible in comparison with those simile surgeries without patient personal guide.

On Thursday morning, I attend the TERR meeting in which a postdoc of Dr. Suzanne Maher presented his research work on stress distribution on knee models of patients with meniscus autograft transplantation. The study utilized MRI imaging technique to monitor the cartilage morphology and mechanical integrity change at the load of half body weight. Based on the MRI results, the decrease in T1ρ signals indicates the decreasing proteoglycan level which is in correlation with a decrease on the hydration level.  T2 value change was also in correlation with the water content and therefore it could be used as a double security on research results. The stress and stain distribution upon the same loading was also monitored by MRI and the results were compared to the data obtained by an intraoperative method. By comparing the results of two methods, the variation on contact surface area and peak stress values were found to be very similarly in each method, which indicated the potential for the MRI to serve as a surrogate non-invasive monitoring technology.

During the last few weeks of the program, I had started a research project in collaboration with Dr. Jason Spector to develop a substituent for current mainstream product in wrinkle smooth market—JUVÉDERM®. JUVÉDERM® is a FDA-approved injectable filler used by cosmetic and plastic surgeons to smooth facial wrinkles and volumize deeper folds. The major component of JUVÉDERM®, called hyaluronic acid (HA), is a family of naturally occurring linear polysaccharide that can be found in skin, connective, epithelial, and neural tissues. To achieve cheek augmentation, cross-linked HA hydrogels can absorb large amount of water and expand up to 1000 times of its own volume upon injection intradermally. Each injection cost at a price of over $500. The purpose of this project is to design and synthesis an effective JUVÉDERM® substitute that has similar/better characteristics but costs less.

In summary, a fantastic summer with awesome experience in hospital immersion is over. I have learned a lot of knowledge in orthopedic field as well as in vascular surgery and plastic surgery. Such experience will greatly benefit my future PhD career and I am looking forward to continue my collaboration with the doctor in the following years.

Weeks 7 and 8

Over the past two weeks I spent most of the time on my project. Making progress on the quantitative analysis part of the project that I’m in charge of. Interestingly, as you spend more time on projects and go deeper into the analysis you'll find it more challenging and the extent of the study increases as you find more results. Another thing to keep in mind is to eliminate inconsistencies in recorded cases arising for different reasons from imaging protocols, motion artifacts, image quality, scanner variability in each scan and etc. This can produce error and decrease confidence level in final results. I also spent good amount of time to perform preliminary analysis through anonymized patient’s diagnostics images with the help of my mentor and his assistants. Since I don’t have access to any database after I go back to Ithaca, it is important for me to collect as many cases as I can to process/analyze them later.  

Overall this was a great experience and an important stage in my life. It is my first time dealing with real world problems. Seeing patients, going through diagnostic images, and see how physicians make decisions based on knowledge and experience they have gained over the years and diagnostics provided by imaging modalities and other tests. Some  of the cases are patients with disease in advanced stages and patient’s life is in the hands of physicians. Interpretation/misinterpretation of the tests and results can either grantee the patient a few more months of survival or shorten and exacerbate his conditions.

One lesson learned from my immersion exposure was that although biomedical engineering is intertwined to medicine and engineers are there to build tools and devices that doctors need to improve diagnosis and decrease errors at different stages of treatment, still sounds like there is a disconnect between these two communities. Each community has its own expertise but when it comes to the point that how much knowledge and information they have from each other, there seems a huge gap. If filled, pace of technological advances in biomedical devices could increase because doctors will know what technologies are available in the market and engineers would have more information on what doctors need. Another important lesson was that the most successful people in this field are the ones who develop expertise in both sides. For instance, a radiologist/physician who knows all the technical details of the MR scanners and how they work can distinguish between an abnormality in patient's diagnostic image vs. any artifact or imperfection resulted from the system and not the patient.      

 I’m grateful to Cornell BME department and everyone involved to provide funding, housing, transportation, and making all the arrangements to make this summer memorable and valuable for future planning. I specially would like to thank my mentor Dr. Martin Prince whom I had the chance to serve for a few weeks, although short I got a chance to learn a lot.   

Week 8

This week was our last! I spent my time working on my poster and other items for immersion assignments. I also said my goodbyes and thank you's to the research team and Dr. Rodeo. This summer has been a great experience overall. I really appreciated the welcome from Dr. Rodeo and his team, and getting to see surgeries and also more clinical animal work. I think being in the OR and seeing patients has given me a new perspective on research later in my PhD. I understand better the line of defense used in treating PTOA and OA, and how research technology could be designed and better implemented. For example, I think working with intra-articular injectables would be an easy way to translate a technology because it is so frequently performed whereas something used in surgery may be much harder to get to that point and also maybe not as accessible to patients. I think I've also built up a good collaboration for the future. Dr. Rodeo agreed to serve as a thesis committee member,though I think it will have to be a "special"-type due to Cornell's graduate school rules, but it will be incredibly helpful and benefit research moving forward to have his clinical opinion and experience with research too.

Week 7

This week was full of interesting patients! A teenager came in who had a syndrome known as congenital indifference to pain and presented with a huge effusion in their knee. The indifference essentially means they had a huge pain tolerance and their body was not very good at communicating when too much activity was actually damaging, which was a large issue when they were younger. Turns out just from squatting at the fridge, they tore their meniscus and were experiencing clicking, clunking, and shifting of their leg. All of this caused a loss of the horn, OCD, marrow edema, and they also had some bone collapse but a stable cartilage surface. Another person came in with a need for an ACL revision surgery, and they had to use the quad tendon since they did not have the standard patellar tendon from prior surgery. This was a source I did not know about until then. I also learned about a new PRP-like treatment where alpha-2-macroglobulin is isolated and injected into the joint to stimulate healing.

In the OR this week, I observed an especially cool procedure in which the patient had lost power in their shoulder and was experiencing pain. From MRI, it looked like the joint capsule had degraded and the subscap of the shoulder was torn and degenerative. To repair this, a part of the pec muscle was transferred over to the subscap insertion to makeup for the muscle loss. Interestingly, the joint capsule was repaired by using an achilles tendon allograft. I had no idea how large a tendon it is! It was not a perfect replacement, but it facilitates the tendon gliding and prevents interaction with the bone.

Outside of clinical time, I also listened to a talk presented by Hongsheng, my research project advisor here, about his work (and mine this summer!). He discussed research methods for being able to apply load to patients' legs during MRI and how images obtained can be quantified to answer clinical questions.

The rest of the week, I worked on finalizing my project data and also discussing loose ends after I leave as this study will continue. I also did some reading in the library on new research ideas to bring back to Cornell.

Week 8: Communication is Key

Sometimes what you say is less important than how you say it; how you communicate information and transform it into knowledge.  Communication is critical in almost any discipline and medicine is no exception.  The communication between doctors and patients, communication between doctors and nurses or other healthcare professionals, even communication between one group of doctors and other doctors has the potential to be a determining factor in the success of a treatment or therapy.  Although I observed these types of communication throughout my time at New York Presbyterian Hospital, certain occurrences this past week specifically reminded me of the importance of communication in medicine.

My observations started with physician-patient communication during morning rounds.  It was the patient’s wife in particular who asked innumerable questions of the attending physician, holding him in the room, long past the few minutes usually spent with each patient on rounds.  The patient was experiencing a number of complex medical issues, and Interventional Radiology had been called in to perform only one procedure that amounted to a small part of the overall treatment plan.  However, as the attending physician explained the upcoming steps and options following the procedure that IR had already completed, it became clear that the patient and his wife were desperate to know what would happen in the future, how the disease would be treated, and what it meant for the patient’s life.  Unfortunately, the patient’s main team of physicians seemed to have not properly explained what the treatment plan would be, nor explained all the reasons behind the choices that had been made so far.  In this case it was not question of not the patient not understanding the information (the wife in particular was very well informed and asked intelligent questions) but rather the other physicians apparently had not taken the time to communicate with their patient or his family.

Communication with patients is not limited to before and after procedures.  While in many surgeries, the patient is anesthetized and completely unconscious, in IR the physicians often chose to perform the procedure with nothing but sedative and a local anesthetic, keeping the patient in a semi-awake (“twilight sleep”) status.  This practice reduces some of the risks associated with anesthesia, but it means that the patient is constantly aware and the physician must take care to communicate with the patient throughout the procedure, letting them know what is happening.  One patient I witnessed became upset upon feeling a constriction around her arm.  The constriction turned out to be a blood pressure cuff, a harmless and routine part of monitoring patient health during the procedure.  However, when a patient is nearly helpless, lying on the operating table, even something simple can be scary.  The experience emphasized the need to maintain a dialogue with the patient throughout the procedure. Even for simple things, if it is something the patient can feel, it is important that the patient be forewarned.

As I worked to complete my summer research project, I discovered an entirely different type of medical communication: recording results of medical studies in a way that could not only be understood by the other members of the research team, but by any physician in the same field.  In my own research I have frequently needed to express my work in a format that would be understandable to together researchers, even those outside my specific field.  The same concept applies to the medical-related research I have worked on this summer, but the audience is different (doctors instead of scientists and engineers).  In order to communicate my work effectively, I need to keep the experience and background of the audience in mind to ensure that my efforts to discover new medical information are able to advance medical knowledge in a way that would hopefully help patients.

Week 7 & 8:

            The last two weeks of the summer immersion were very research intensive. I finished modifying the pulse sequence and had it installed on a hospital scanner. I naively thought that the sequence would run without any problem, but unsurprisingly, I encountered bugs. After a few days of debugging, I got the pulse sequence running. After I confirmed that the sequence can collect data properly by scanning phantoms and volunteers, we decide to scan a few patients. The patient scans are more complicated than I expected, as I found myself bargaining with the tech (and my own morality) on how much data I can acquire and what is the quality of the data that I can acquire. On one hand, I want to acquire all the data I need at the highest quality, on the other hand, I feel bad for keeping the patient in the scanner longer.  Nevertheless, it was a good experience, and I learn to consider the patient’s condition when I write pulse sequence programs.

            The summer immersion has been a rewarding experience. Not only that I got to see some very interesting procedures that made me even more appreciating of the medical technologies, I also met many people that I will work with in the future and familiarized myself with the operating structure of the imaging centers in the hospital. Although this eight weeks program is ending soon, my summer immersion experience will continue, because I will be staying in the city. I will continue to immerse myself into this environment as I work toward my PhD degree for the next few years. 

Clinical Immersion - Week VIII

Epilogue.

After all the endless days of working and restless shadowing of doctors at HSS, my time as a clinical intern came to an end yesterday after a final presentation of my work to Dr. Potter. In preparation for the meeting I spent several days gathering data on image resolution for 468 pictures, resulting in 468 data points that had been categorized based on several parameters impacting resolution (GSI type, keV voltage or image filter, and use of a specialized image formats). The control for the pictures was the old GSI format used by GE on creating the MRI pictures, with all other experimental ones being studied due to their possible increase in resolution level. Creating a neat comparison among all the data points was perhaps the most critical step to making sure that the presentation went smoothly; to accomplish this, I decided to first compare the keV voltages and the use of the specialized filter (in this case, hydroxylapatite on water) among all three GSI types in order to visually how different was the resolution based on the parameters that a user can actually alter. After this was accomplished, I sorted the data once again based on GSI type, a parameter that a user can no longer alter. In this way, the presentation could make the most sense to Drs. Potter, Meyer, and Greditzer.
The data plots supported that careful consideration should be given more to the GSI type than to the use of any particular keV value. However, what was clearest was the fact that certain image formats were particularly advantageous for highlighting microfeatures in the femoral condyles, and possibly being much better at quantifying trabeculae in upcoming studies. The two image formats, work in progress and current standard, seem to be much better at acquiring features in an image (high acquisition value) and establishing a much higher resolution (high avg resolution level). While it was expected that these formats were going to do better, it was still great to see that the program could now quantify just how much better these formats were at capturing the distinct small features of the trabecular architecture present in the femoral condyles.
While much work is still needed before critical research on trabecular microarchitecture using MDCT can take place, the first step is ensuring that the Potter laboratory will move forward with their collaboration with Dr. van der Meulen. So far, I have been informed that my data will be taken into consideration for future research and that the program I made will be taken into consideration for the analysis of more pictures. It has also been suggested that a formal meeting should take place between Dr. Potter, Dr. van der Meulen and I in order to discuss possibly continuing this project as some sort of collaboration.

With regards to my last adventures, it seems that transition was the last theme: from city to beach escapades to a visit to the Museum of the City of New York/Museo del Barrio, the weekend highlighted how people affect their environment and vice versa. On Sunday I had the chance to visit Montauk with Lauren Hapach, a three hour trip taking us all the way to the tip of Long Island where sandy white beaches and multi-million dollar houses are. The stark contrast between the city and the beach were a surprise in their own right. Tuesday was devoted to Uptown Bounce, an event that allowed free admission to two museums on the Upper East Side, both of which featured exhibitions on activism in New York City, dating all the way back to the 1600s. The most informative was the Museo del Barrio's exposition on the Young Lords movement of the 60s and 70s that occurred not too far away from where the museum stands. Eerie snapshots of times past and present struggles on the way to transition. My last day on the city featured a vist to Soho and Prospect Park in Brooklyn before heading back to the Upper East Side.

The clinical immersion experience felt daunting at times and it, necessarily or not, placed me on awkward scenarios where I was left only with my intellect and plenty of time to define the problem and find the solution. While it was not necessarily what I had envisioned in mind (so much coding...), it did provide an insight into what the future will be like after I graduate from Cornell. By keeping an open mind, a problem can become a growing experience that can diversify in multiple ways. That would my advice for the incoming first years (in addition to having fun exploring the city)

Thanks for reading,
Victor Aguilar

Week 7 & 8

During last couple of weeks, I've trying to focus more on my research topic. Since we still does not decide research topic, with taking the Stata course, I and the other two researcher tried to find any statistic relationship between any biological results, such as high blood pressure and re-visiting OR rate. However, the pace is quite slow because three people should get together to take the courses, and it's quite tricky to synchronize the schedules of all three. So far, we could only meet once in a week. I am a bit worried that I will not be able to get involved with any specific research during this summer immersion. 

Even though I might not be able to do any solid research, this summer immersion was great experience overall. First of all, I could experience hospital life like attending in OR and ICU. I am shocked that I could not get any information with no prior knowledge in ICU, and at the same time, I was intrigued that so many cutting-edge techniques are adapted into OR. Besides, experience in hospital, I was able to adapt to the life in NYC, where I will probably spend the rest of my PhD. New York was such a great city to explore and expose myself to various cultural events. I am sure that there is so many facinating things left to be found.  

Week 8: It's the beginning, not the end!

The summer immersion is officially going to end this week. For me, it was just a trailer and a tour of a clinical experience. Actual participation and contribution, i.e. the real movie, will start from now. All these weeks, I spent time understanding the hospital functioning, and the current research and clinical problems. This has helped me to identify and design research projects having immediate and long term benefits for clinicians.

At present, I have three research projects in mind. The first project will start as soon as I receive IRB approval. The second and third projects are more related to my PhD research. Once finished, these projects will lead to new projects, which will be a never ending cycle.

For successful completion of all these projects, I have planned to touch base with my clinical advisor Dr. Ajay Gupta every week. I will also be visiting Weill Medical College once a month to share updates and progress. If required, new research grant proposals will be written. In addition, I will be in touch and in collaboration with Prof. Wang's group for solving research problems pertaining to MRI developments.

However, one challenge still remains related to my expenses and logistics in NYC. Perhaps, I need to learn some financial management skills as well, or find some additional legitimate sources of income. Nonetheless, the research projects continue to flow and will be completed on time.

Thank you summer immersion!

Week 7 & 8: "You Got the Juice Now"

This past week, I was presented with the opportunity to present my findings and observations to present the patient waiting room application to Dr. Robert Min, who is the Chair of Radiology at WCMC/New York Presbyterian Hospital.  Alongside Jae Mo Chang and Willy Leung, both students from Cornell, we discussed the need and goals for the application as well as the plans for a future pilot study.  Following the real-time application demonstration, Dr. Min was very interested in implementing the application right away.  It was exciting to get positive feedback as well as hear that the our findings are actually going to be implemented within the coming months.

In regards to the Breast Imaging Center, I was preparing to work on the other two projects by doing literature searches and writing literature summaries for the relevant journal articles that will be cited within the publications that I will help write when the data is fully analyzed.  The goal of the two projects are to calculate the percentage of magnetic clip migration out of the the total number of cases and calculate the percentage of recalls that are due to lack of prior images or baseline mammograms, respectively.

 Immersion Term is coming to a close and it has been a great summer to say the least.  I have had great times and memories that I will never forget.  The summer flew by so quick, but there were a lot of things that I accomplished.   All in all, I will be contributing to 3 publications that I will help write in the near future, plus I am waiting to hear back from a competition that we submitted a proposal for the patient waiting room application.  Fingers crossed that we are the top 3 finalists.  I have successfully traveled different burroughs of the city, survived adventures on the train, walked fast with the fast paced inhabitants, and now I'm feeling like a Georgia girl walking like New York.  It seems like an abundance of great things that I am looking forward to even though I have to leave the city behind- well, that is, for now.  In closing, it's time to wrap this blog up with homage to one of my favorite movies, Juice, for how I am feeling at the end of this program. Peace, love, and see you on the other side.  Ithaca, here I come....

Week 8

This week was similar to previous ones.  I saw patients and attended the usual meetings and seminars.  The other summer student who has been working on the research project with me is presenting our findings as a poster at the National Medical Association Annual Convention.  This week the poster was finalized and presented to some of the doctors involved in the Combined Arthritis Program.  We discussed what should be done next for the project and seem to have a good idea of where the project is going.  The next major step will likely be to create a questionnaire to send to patients to get more details about why they chose to cancel their surgery.  Some major questions we would like them to answer include if they chose to get their surgery at another hospital and what their economic situation is.  There are a couple of research assistants who will be continuing the project but with fewer people working on it, it is likely to progress at a slower pace than it has this summer.  But I'm hopeful that some interesting results will be found that could impact how doctors and the hospital interact with surgical patients to prevent costly cancellations from occurring.
I spent one day this week in the OR with Jacob and Dr. Schneider.  The procedure was an endovascular thoracicabdominal aneurysm repair.  This procedure involved the placement of a graft in the patient's aorta and four stent branches to support the renal arteries, superior mesenteric artery, and celiac artery.  This procedure was done through an Investigational Device Exemption with the FDA and there are only six centers in the country who could have performed such a procedure.  During the procedure, Dr. Schneider regularly checked the blood flow to be sure that everything was placed correctly.  At one point he noticed that there was a leak from the inferior mesenteric artery that was feeding the aneurysm so he inserted several embolism coils into the leaking part of the vessel.  This was a pretty intense procedure, but it was great to observe because I got to see a lot of different techniques used in vascular surgery all in one day.

Week 7: Loss

The procedure, an angiography/angioplasty for occlusions in the superficial femoral artery, was progressing slowly but steadily. This particular patient had a massive calcium deposit, and even the attending surgeon was having trouble navigating the multiple occlusions with a thin, flexible guide wire. As the surgeons struggled with this patient's arteries, a phone call interrupted their efforts: the attending surgeon listened to the call and wordlessly walked out of the OR. After several attempts by the fellow to navigate the patient's arteries, she elected to wait for the attending to return. Waiting with a patient on the table was strange: 5 minutes turned into 10 minutes, which progressed past half an hour. After waiting about half an hour, a nurse informed us that the situation in the other OR was critical, and that the patient had been coded. After some encouragement, I walked over to observe how the surgical staff respond to an emergency in the OR. From the OR control-room, I observed a scene of frantic effort: the room was packed with physicians, nurses and techs all attempting to save the patient. Despite their efforts, it was not meant to be. Later the next day, I got the full story. This person had very diseased iliac arteries, and the removal of the arterial sheath imposed shear stress that ultimately tore the iliac artery. The resulting blood loss led to a loss of circulatory volume, the development of thrombi, and eventually a pulmonary embolism. Overall, the cause of death was exsanguination, or severe blood loss. I was surprised to learn that even in optimal conditions, such as being in an OR surrounded by skilled physicians, death can be implacable.

Week 7&8: Flap Weeks

     This week, I watched a mandible reconstruction using a free fibula flap headed by Dr. Spector. There were 3 surgery teams present: Head and neck, Oral, and Plastics. The team used a Fibula guide that was designed to fit the left fibula, connecting to the vessels in the right neck. The vessels came off the posterior of the reconstruction. The Fibula Cutting Guide used metal slot inserts. Marking walls with red dotted lines were used to mark the mid body cuts of the fibula. Total length of fibula needed for reconstruction was 60 mm. The dental implants were cylinders. The implant shelf is placed off the top surface of the implant. The preoperative anatomy and simulated postoperative anatomy was planned using Patient Specific Data and Virtual Surgical Planning (VSP) Reconstruction. Come to find out, you can live a productive life as an adult without a fibula since it is not the main load bearing bone.
     I also saw a craniotmy performed  by Dr. Theodore Schwartz to biopsy a tumor. The surgeons entered through the base of the skull using MRI as a guide. The patient had a young meningioma recurrence. The hardware from a previous surgery was removed to expose the previous bone flap. Most of the biopsy could be seen live on the OPMI Pentero. They put in mesh strips called Dura Guard to help close dura matter, prevent CSF leakage, and fusion to skull. They then prepped the old bone flap with hardware, added some DuraForm, and then screwed in the bone flap. Overall, it was nice to see a neurosurgery and another flap.

Week 7

I spent some time this week observing different surgeries outside of HSS. After a failed attempt to watch an amputation last week I was able to see a below the knee amputation on Thursday with Jacob and Jason. The patient had a large sore on the back of his heel that resulted in exposure of the bone, and had no feeling in his lower leg. To perform the amputation, they mapped out the cut so that the soft tissue was cut more distally on the back of the calf, but the bones were cut near the more proximal anterior incision. This allowed the extra soft tissue to be folded over the exposed end of the limb and retain its vasculature. The major blood vessels and nerves were tied off and cauterized as they extended the incision around the limb. A bone saw was used for the tibia, but I was surprised that hand held bone cutters were used to cut the fibula. Since the fibula is much smaller than the tibia perhaps they were trying to protect the soft tissue from potential damage if a saw went through into the tissue behind it. Once everything was prepared, they slid a huge knife between the tibia/fibula and the soft tissue to fully separate the limb from the body. It was kind of strange to see somebody's lower leg just sitting on a table not attached to anything.

I was also able to join Lauren in observing a neurosurgery procedure. We saw an endoscopic endonasal pituitary adenoma removal. They accessed the tumor through the patient's nose, and since the procedure was video guided we could see everything on the screens in the room. They drilled through the sphenoid bone using a miniature version of the Midas bone mill the orthopaedic surgeons use to shape bone grafts. Once the tumor was exposed, they used an instrument that looked like a thin bubble wand to scrape the tumor off of the surrounding tissue and then used the suction to remove the pieces. It seemed like a very imprecise way to remove a tumor, with the potential to leave pieces behind or have pieces that were scraped off migrate somewhere else. That was one of the most surprising aspects of this whole experience. We like to think of surgery as this very precise, planned out procedure, but many times the plan is to go in and make a more complete plan once you get a better picture of what is happening.

Week 7/8: 3D Printing and Neural GPS

Small Aside: Depersonalization of Patient 

As this summer immersion experience is coming to a close, I think back to what my preconceptions of this program were and how certain aspects I envisioned were spot on and with other aspects I was completely naive.  The hospital, much like the living, breathing organisms that are treated there, relies on harmonious interactions between all of its parts to function.  There are roles, from the highly skilled surgeon to the often overlooked administrative and janitorial staff, that are all required in order for this complex system to function.  The symbiotic feedback between technological innovations and medical need is evident in the procedures I have watched.  Above all, it is imperative that these advances be made with amelioration of the human experience as the highest priority.  Speaking of the human experience, I found it striking how patients were transformed from people with concerned families, fears about their health, and hope for their futures into medical cases with statistics, recent studies, and clinician's experience steering the medical decisions.  This "muting" of the person in order to make the best medical decisions can be controversial.  On one hand, the doctor does not want any emotional distractions so they have a clear mind to focus on the problem at hand, the heart to repair, the blood clot to remove, the tumor to ablate.  On the other, does this depersonalization reduce the quality of care deliver?  Do doctors care less when a person becomes body parts exposed in a sterile field to cut into, fix, and then stitch up?  My personal belief from watching these procedures this summer is no.  I believe that many doctors use their love of humanity as motivation for learning their trade such that they can be seemingly impartial in order to provide the best care to as many people as possible without becoming so defeated by inevitable bad outcomes such that their overall good is hindered.  It goes without saying that this is not always true.  There are always going to be some doctors that care more about money or prestige than healing people.  However, the clinicians I've spoken to and witnessed working were definitely from the population of doctors that want to make a difference in their patient's health.


Mandible Reconstruction: Fields of Sterile Blue 

On Tuesday, I saw a mandible reconstruction with free-fibula flap being performed by Dr. Spector and a small battalion of blue-scrubbed doctors.  The reason for this surgery was an osteosarcoma located in the jaw, which was resected along with the nearby mandible, most likely to achieve optimal resection margins to prevent recurrence or metastasis.  The void where the right side of the mandible had been was filled using pieces of the patient's own fibula.  This OR room was particularly bustling in comparison to the others I've shadowed in.  In perfect synchrony, head and neck, oral, and plastic teams were executing their respective part of the surgery such that by the time the blocks of fibula were cut using a custom 3D-printed cutting guide, the region where the tumor was had been excised and prepped for the incoming flap.  The term flap refers to vascularized tissue, in this case, bone with surrounding vascularized muscle.  The vascularization is critical to the success of the procedure and requires anastamosis of the vasculature in the flap with the surrounding facial circulation.  Technology played an obvious role in achieving the amazing efficiency with which this procedure was performed.  Custom 3D printed templates were made from the patient's CT scan and were used to make precise cuts for the mandible and fibula, ensuring an optimal fit of the flap in the defect without any additional augmentation.  A microscope on a cantilever was used to allow Dr. Spector to see his work while connecting the vessels of the flap.  Overall, I felt privileged to be in the room while this intensive procedure was being performed; although due to the high level of activity and the relative crowdedness of the room, my insight here is somewhat limited.

Neurosurgeries: GPS for the Brain

My next new OR encounters were Thursday and Friday watching neurosurgery with Dr. Schwartz.  I watched MRI-guided procedures that utilized a system called BrainLab, which consists of a "pen" and a receiver.  The pen transmits its location to the receiver which then shows the surgeon the location of the pen-tip as a green cross hair in the MRI images of the patient's brain.  The first procedure was what the surgeons were hoping to be an excisional biopsy; however, the excision was not performed for reasons I don't quite understand.  This patient had a suspected recurrence of meningioma, a usually benign tumor arising from meningeal tissue of the brain.  Microscopy was vital in this procedure like in Dr. Spector's and a similar microscopy and cantilever system was utilized to allow the surgeons to see their delicate work.  However, this microscope had dual viewing lenses, so that two surgeons across from each other could both see what they were working on magnified.  From the TV screen in the OR room, I immediately identified striations that told me they were in the cerebellum.  Blood was constantly being aspirated away from the site as tweezers were used to delve further into the pulsing tissue.  Gauze pads with radio-opaque strings (can be visualized with X-Ray in case they get left behind?) attached were used to soak up blood and fluid and to protect the path the tweezers were following.  Samples were extracted using what looked like forceps with tiny opposing melon ballers on both tips, an instrument called tumor forceps.  The samples were labeled "right cerebellar hemispheric" and "midline cerebellar hemispheric" since there were two distinct regions of interest.  Both biopsies came back in record time with diagnosis of gliomal neoplasm.  After this diagnosis, the entry wound was prepared for closing.  Duraguard and Duraform were used to act as the dura and prevent CSF leakage while healing occurred.  The bone flap that had been removed from the back of the skull to access the brain was screwed back into place and everything was closed up.  I could tell things hadn't gone ideally but at least the patient was alright for now and with a diagnosis at hand.  

The second neurosurgery procedure I saw was an actual tumor removal, of a pituitary adenoma to be exact.  An endoscopic endonasal approach was used to access the tumor, located deep in the skull at the base of the brain.  BrainLab was being used in this procedure also, pointing to its universalizability in the field of neurosurgery where position is seemingly always crucial.  The sphenoid bone was delicately cut away using what appeared to be a miniature rotary sanding tool.  Once access to the cavity was obtained, the tumor was biopsied.  Removal then became the primary focus as a tool that was essentially a small circular wire was used to chop up the tumor while the aspiration tube sucked up fragments that came loose.  This rather barbaric scene played out on the screen that displayed the feed from the endoscope.  I was somewhat shocked that a more delicate method of removal was not needed.  To add to the excitement, green fluid started seeping out, which I correctly guessed was CSF (cerebrospinal fluid) that had been dyed using fluorescein green.  Although that didn't raise any alarms with the surgeons, there was the possibility of hitting the internal carotid artery, which in the words of one of the surgeons, "would have been catastrophic hemorrhaging."  FLOSEAL hemostatic matrix, a foam-like substance of gelatin granules and human thrombin, was used rather liberally in this procedure.  This matrix seems to have a wide array of applications in preventing excessive bleeding, prompting me to wonder if it's used for other purposes in the hospital.  

Week 7

This week we needed to send our data to the biostatistician for final analysis, so much of the week was spent getting our data ready and formatted.  The rest of my week involved the usual meetings and conferences and seeing patients with Dr. Goodman.
At CAP conference this week, a patient was discussed who had been diagnosed with Lupus in 1990 and is now speaking to the orthopedic surgeons about a TKR due to debilitating knee pain.  While the surgeons agreed that she would be a good candidate for surgery, they and the rheumatologists questioned her Lupus diagnosis and wanted that question answered before moving forward with surgery.  This patient was diagnosed with Lupus nephritis in 1990 and went on a round of steroids for treatment.  This was also when her SLE was diagnosed.  But it is unclear if a biopsy was performed to confirm the diagnosis.  After the Lupus nephritis cleared up, she stopped taking the steroids or any medications for Lupus symptoms/management for almost a decade when she went on another round of steroids for unclear reasons.  Since that incident she has not had any medication for her disease and does not appear to be at all symptomatic which is extremely rare in SLE patients.  It is because of her current lack of symptoms that the surgeons and rheumatologists believe she was misdiagnosed in 1990.  To cover all their bases, the surgeons want to figure out the correct diagnosis before agreeing to operate on this patient.  A patient with confirmed SLE and bilateral hip and knee pain was also discussed.  This patient was diagnosed with Lupus at age 17 and later suffered from severe Lupus nephritis which resulted in dialysis and later kidney transplantation.  Unfortunately, at some point during her hospitalization she got an MRI with gadolinium contrast agent and she had a severe reaction to the gadolinium resulting in what appears to be nephrogenic systemic fibrosis.  This is a very rare reaction to the contrast agent (none of the attendings in the room had ever seen a patient with it before).  The patient's skin across her entire body had become fibrosed (appearing like severe scleroderma) and her x-rays showed heterotopic ossifications throughout her body (which was likely the cause of her joint pain).  Due to the systemic nature of this condition, the surgeons agreed that there was not anything they could do to help her pain and decided that her best move would be to get a formal diagnosis of nephrogenic systemic fibrosis and to see a specialist in this condition (though the surgeons did not have any specific doctors in mind).  Though this kind of reaction to gadolinium is rare, there are several documented cases and a quick google search will tell you that it is most common in patients with compromised kidney function.  Unfortunately, there does not appear to be an easy/cheap method for determining if a patient will have an adverse reaction.  But now that she has had the reaction, she is stuck with the condition which has no known cure and treatment options with only moderate success.
In journal club this week, an interesting study was presented which examined the variation in orthopedic surgery amongst RA patients in the U.S.  It was found that the liklihood of an RA patient having a surgery for RA-related joint problems depended on the density of orthopedic surgeons and rheumatologists in the patient's geographical area.  While it is not all too surprising that a patient who lives in a region with 10 times more orthopedic surgeons than rheumatologists is more likely to undergo an orthopedic surgery than a patient who lives in an area with more rheumatologists, I was surprised with the amount of variation in the density of doctors across the country.  Rheumatologists seem to be concentrated more in coastal cities whereas orthopedic surgeons seem to be more evenly spread throughout the country.  This leads to the question of how patients can have access to proper care if there aren't any rheumatologists in their area.
This week I spent a day in the OR with Dr. Rodeo.  I observed an arthroscopic shoulder labrum repair.  While it was weird to see a shoulder with a bunch of tools sticking out of it, it was awesome to be able to see the whole procedure up close on the screen.  I was able to see the debridement, the suture anchor placement, and the reattachment of the labrum in great detail.  I also observed an open shoulder procedure.  This patient had undergone a shoulder procedure previously and was complaining of pain and weakness again.  The MRI showed that the pain and weakness could be due to a subscapularis insufficiency and joint capsule insufficiency.  To address these issues, a portion of the pecularis muscle was rerouted to the subscap insertion to increase strength and an achilles tendon allograft was used to repair the insufficient joint capsule.  Unfortunately, because this procedure was not athroscopic it was much more difficult to see exactly what was going on, but the descriptions sounded very interesting.  I was surprised that an achilles tendon was  being used as an allograft since the tendon is somewhat cellularized, I was wondering what kind of immune response it would cause.

Week 7: Neurosurgery is a sophisticated carpentry

All throughout the summer immersion, I was craving for an OR experience. Finally, I got one this week! And what an experience. It was a complicated case lasting 5 hours. It all started with JH emailing me about the surgery days i.e., Tuesday and Thursday. I quickly went to meet him asking the location and time. He also shared his experience and answered my questions on do's and don'ts. Can I ask the doctor to move aside so that I can see the surgery? Where can I throw up if the need arises? Can I use my smartphone in the OR? These were some questions which JH answered in a calm and composed manner. His recommendations were also valuable.

And finally my tryst with destiny arrived on Tuesday. The operation was scheduled at noon. As I mentioned in my first blog, finding a location in the Weill Medical College can be a daunting task, requiring a GPS. I therefore left an hour early. Surprisingly, on my way, I came to know that Obama is visiting the hospital. I was feeling sorry for him as he would not be able to meet me! The previous Saturday, he came to Times Square, but it was too late as I already left to watch the movie "Bajrangi Bhaijaan". His administration should have told him about my schedule!

Gladly, I reached my destination at once without wandering and detours. I received scrub, cap, and mask from the counter desk. Men's locker room seemed a fancy place to change clothes and get rid of all the belongings. It was a great experience until I realized in the OR that scrubs have pockets and I could have brought my phone, wallet, and pen and paper!

The preparation for the surgery started at noon with residents and nurses setting up and taking the first steps of the procedure. The patient seemed anxious. The anesthetist was on the top of her job. I was overwhelmed by the professionalism and synchrony of the people involved. The residents were excited because the patient had some cool problem and required a rare complicated procedure. After the initial steps, the person in the limelight arrived. That person was not the patient, but the surgeon.

Dr. Schwartz immediately got to his job, removing the required portion of skull and observing the brain parts. The patient was awake and talking. I came to know about her first date and other milestones in her life. Being an expert and adept in surgery, Dr. Schwartz located the tumor with the help of the MRI images. Removing it successfully revealed his true skill. Everyone was elated, including the patient. Soon after removing the tumor, Dr. Schwartz left, and junior doctors and residents took the job of closing up. The way the removed skull part was put back and the number of screws inserted to join it with the remaining skull reminded me of carpentry. The art of rough cutting and stitching in both the professions is the same. It is kind of sad to see carpentry stuff happening to people, but it's effective. Maybe, in the future, there will be non-invasive techniques to perform neurosurgery. Till then enjoy the surgery.

Week 7: Choices, Choices...

Berenstein, Sos, Cobra, Pig-tail, Amplatz, Bentson, stiff-angled glide. This list of names may have the slight flavor of a membership roster of a motorcycle gang, but these devices are actually just a few of the many types of catheters and wires that make up the toolbox of an interventional radiologist.  At any given moment during a procedure the physician must decide which of the many different options to select for the job at hand.  I have found that medicine is full of choices, the selection of the right medical device, choosing the right drug, or the decision to go ahead with a treatment or not.  As I shadowed my clinical mentor this week, I tried to find out the reasons behind some the medical choices that he and his fellow physicians make every day.

Early in the week I met a patient exhibiting severe leg edema (swelling), pain and a feeling of heaviness, all symptoms indicative of venous obstruction in the lower extremities.  As my mentor specializes in thrombosis (clotting) and venous disease, I had seen several such patients throughout the summer.  Unfortunately, this particular patient had a problem. The patient had previously had a kidney removed and the one that was remaining was not functioning as well as it should. The contrast agent used ubiquitously by radiologists and interventional radiologists in particular, is toxic to the kidneys, and therefore the use of contrast was contraindicated for this patient.  My mentor left the patient with a choice: they could go ahead with the procedure, potentially risking renal damage that would require dialysis treatments, or avoid the procedure completely and the patient would have to live with the current symptoms.  There are, of course, alternatives to the contrast agent, in particular CO₂ gas.  However, CO₂ is not nearly as effective as highlighting thrombosis and stenosis as contrast and a distinct possibility existed that relying exclusively on CO₂ could mean the procedure was impossible to perform.  There really was no obvious choice and no medical data that could suggest what the most optimal decision would be.  It came down to a question that only the patient could answer: were the symptoms of the venous disease effecting the patient’s quality of life to an extent that the risk was worth taking?

Even if the patient decided to continue with the procedure numerous choices and decisions still remained.  Depending on the type of obstruction, i.e. thrombosis or simple occlusion due to compression of the vein, different methods would be employed to improve blood flow.  Within the realm of thrombosis, many different types of medical devices and techniques could be used to remove the blood clot.  One of the most effective devices for clearing a thrombosis is known as Angiojet.  The device employs a powerful vortex to disrupt the clot and enable it to be removed.  Unfortunately, the same vortex lyses red blood cells releasing factors into the blood stream, which are extremely harmful to the kidneys.  With the patient’s weakened renal system, the use of Angiojet was out of the question.   Another device I have seen implemented several times by IR physicians is known as Penumbra.  It is simply a vacuum pump that can be used to suck a blood clot straight out of a patient’s vein.  Unlike Angiojet, the Penumbra does not risk harming the patient’s kidneys, however, it has its own problems.  Most notably, while useful for small, localized clots such as those commonly seen in pulmonary embolism, the Penumbra seems to be less effective against extensive thrombosis.  Ultrasound had shown that for this particular patient the clot extended from the patient’s popliteal vein (knee) all the way into the common iliac vein in the pelvis, suggesting that the Penumbra would be of limited utility.  Yet a third option is a class of devices that are designed to mechanically break apart thrombosis with a rapidly spinning wire.  There are multiple variations of this device, but at least some of them can actually induce additional thrombosis by causing damage to the endothelial cells lining the blood vessels, thus making the problem worse. In addition, a variety of other treatment options exist, each with advantages and disadvantages.  It was up to my mentor to use his experience to select the most optimal option for the particular patient’s needs.

Once a thrombolysis (clot breakdown) or thrombolectomy (clot removal) is performed, anticoagulation medication (blood thinners) is prescribed for nearly every patient to help remove residual clot and ensure that the thrombosis does not return.  This decision is almost reflexive, yet a variety of different drugs exist, requiring another careful consideration of several options.  One of the oldest anticoagulation medications, called Coumadin (trade name Warfarin), is actually rat poison.  In rats, this drug causes massive internal bleeding, but a failed suicide attempt revealed that in humans, Coumadin has the potential to save lives by preventing the formation of blood clots.  One of the unique aspects of Coumadin is that vitamin K acts as an antidote and can rapidly neutralize the drug’s effects.  Lovanox is another anticoagulant.  It can be extremely effective at preventing thrombosis, but it must be administered via injection and has the potential to harm the kidneys.  A second drug that requires injection is Heparin.  Heparin is a protein naturally found in the body.  Unlike Lovanox, it doesn’t harm the kidneys, but it is not easy to obtain and so its use is typically restricted to hospitals.  Modern molecular biology research has resulted in a class of anticoagulants that target specific points in the clotting cascade including apixaban (Eliquis) and rivaroxaban (Xarelto).  No one drug can be said to be appropriate for all cases.  Every person responds differently to different chemicals requiring physicians to be flexible with their prescriptions, changing a patient’s medication if necessary to accommodate their response.  This is part of the reason physicians need to follow up with their patients: to understand whether the prescribed therapy has been effective.

Naturally a physician cannot force a patient to stick with a particular drug regimen.  The patient has the choice to follow the physicians orders, to ignore medical advice, or do something in between.  This freedom results in one of the largest outstanding problems in modern day medicine, known as patient compliance.  This week I attended a thrombosis board, a sort of conference for doctors in different fields to discuss several peculiar thrombosis patients and together decide upon the most optimal therapy for these patients.  One patient discussed, upon whom my mentor had performed a thrombolysis earlier in the summer, had suddenly stopped taking the prescribed anticoagulants halfway through the assigned time period.  This change has the potential to greatly increase the patient’s risk for thrombosis, yet at this point this is nothing the doctors can do beyond a strong recommendation that the patient return to using the medication. 

The choices that must be made every day in medicine by physicians, nurses, other clinicians and even the patient’s themselves are as diverse as disease types.  Unfortunately there is often not enough knowledge or information available to know which choice is the right one, or even what the best available option is.  It is up to biological researchers to continue to build upon the knowledge that currently exists to enable more intelligent decisions to be made and to biomedical engineers to design devices that can provide information that will help identify the best choice.  Often times, the more knowledge we gain, the more we realize how little we actually understand.  The quest for knowledge is a never-ending battle against the infinite complexities of nature, but it is one that I am eager to help fight.