Week 2: When things Go Wrong

It was supposed to be a simple procedure.  I stood patiently in the back of the room wrapped in lead as I watched a resident and a senior fellow place a port in a 4 year old designed to give other doctors access to her vascular system.  Somehow I sensed that things were not going as planned.  Quickly the doctors retracted the various wires they had extended into the patient’s jugular vein, yet I could see on the fluoroscope that a thin wire remained. The fellow spoke, confirming my suspicions that all was not well: “call the attending”. 

The attending physician was shocked to learn that the wire had broken off inside the patient.  In all his years of working in interventional radiology, he had never seen this happen.  Despite the surprise, the attending did not hesitate.  Taking charge of the operation, he rapidly extended wires into the patient’s femoral vein moving up toward the jugular.  Using a device called a snare that looked something akin to a small lasso, he captured the loose piece of wire and removed it from the patient.  Within 10 minutes the emergency was over and the remainder of the port placement continued without a hitch.   

As a researcher in a biologically related field, I have learned to expect the unexpected; nearly every experimental procedure that I try goes wrong at some point due to the unpredictability of biology.  This clinical experience showed me that sometimes the same thing could happen in medicine.  However, when things go wrong with a research procedure, all that is lost is typically time and money, yet mistakes or problems in a clinical procedure can potentially result in death of the patient.  The speed and calmness with which the doctors handled the broken wire ensured that this small mistake remained a minor hiccup and did not cause any lasting damage. 

As the week continued, I noticed other instances when the unpredictability of biology forced clinicians to adapt on the spot.  I found myself midweek watching an interesting procedure known as TIPS (Transjugular Intrahepatic Portal Shunt), essentially a bypass around a diseased liver to prevent excessive blood backup.  The procedure was scheduled to end at 2pm, but the physicians were still working at 4:00 struggling to navigate the tortuous veins of this particular patient.  After consulting with multiple other physicians and trying several different techniques, they succeeded, but it took a grand total of 8 hours. 

Medical challenges are not limited to the operating room.  Shadowing my mentor (Dr. Sista) at his weekly clinic, I witnessed his frustration at not being able to tell patients for certain if a particular procedure would work.  Upon hearing a diagnosis and Dr. Sista’s recommendations for treatment, the patient would inevitably ask: “will the procedure cure me?”  It is difficult for a patient to accept that they could put themselves through a long procedure in the hospital and come out no better than when they went in.  Dr. Sista explained that the outcome could be described by a bell curve. For a small percentage of people, the treatment results in complete resolution of the condition.  For most, the procedure will provide significant relief and for some it doesn’t work at all.  Unfortunately, there is no way to tell beforehand in which of the categories a patient falls. 

As a biomedical engineer, I viewed these experiences as engineering challenges.  How can we design better biomedical devices that will enable clinicians to overcome unexpected difficulties?  One of the most important ways to accomplish this is to provide physicians with better tools to understand what is happening in the body before during and after procedures.  This week I began working on a research project that is attempting to do just that.  Specifically, we are researching new ways of detecting the presence of a pulmonary embolism. One of the main treatments for this condition is anticoagulation, in which anticoagulant drugs are delivered over an extended time period to dissolve the clot (embolism).  Unfortunately, there is no really good way to tell how long anticoagulation should be given as every patient is different.  If anticoagulation is stopped too soon, the clot will continue to obstruct blood flow, yet the longer it is given the higher the likelihood of bleeding complications.  We hope to provide physicians with a method of rapidly identifying when a clot is dissolved in real time, allowing a more appropriate treatment regimen to be prescribed for a given patient.