This week I finally started to get a sense of routine, still with some new twists thrown in. Monday, I was in the Lung Cancer Screening Program where I continued to shadow the coordinator, Brooke, and smoking cessation counselor, Kate, while researching smoking cessation in the context of lung cancer screening programs. Tuesday, I watched several lung and liver biopsies that were guided by CT scan. As Dr. Pua described the cases for the day, he explained the process from injection of lidocaine into the chest cavity, "pleural bump," to piercing the tissue and positioning the needle (CT guides this) all the way to the retraction of sharp center of the needle to leave a sheath that would allow a core biopsy to be taken. I learned that with lung biopsies, there can be a 10-15% chance of lung collapse, which would require a catheter in the chest cavity to establish a vacuum overnight, a possibility that does not sound appealing. I watched as the first biopsy was performed on a woman to determine whether a anterior mediostinal mass in her chest was thymic cancer or lymphoma. This diagnosis is important since lymphoma can be successfully treated systemically while thymic cancer is best treated with resection. The next biopsy was a liver biopsy to look for possible conversions in a patient that has a history of follicular lymphoma. Based on a prior PET/CT, which overlays results from both imaging modalities for optimal presentation of visual information, there was elevated metabolic activity in the liver, a sign of a potential tumor. Ultrasound is generally the modality used to guide liver biopsies; however, there were too many ribs nearby the site of interest and thus, CT was used. The next case for the day was a bone biopsy at the spine using a more robust biopsy needle specialized for brittle, hard bone. I officially met some other members of Dr. Pua's team, the radiology technicians, nurses, and other doctors. For each case, histology was called down and the biopsies were processed.
After watching some biopsies, Dr. Pua recommended that I watch a particularly complicated blood clot removal performed by Dr. Sista. The complications were twofold. First, the patient had such a large volume of clotting caught in an inferior vena cava filter causing extreme edema in his right leg. Second, TPA (tissue plasminogen activator) is usually administered after this procedure; however, this patient was recently in an accident where neural trauma, particularly hemorrhaging, was sustained. After the description of the procedure, I donned an X-ray proof lead vest complete with neck guard and watched as a huge team set about getting a catheter into the patient's femoral artery(?) I watched the remainder of this procedure from the control room since things were crowded around the patient so my view wasn't that good anyway. All I needed was a view of the computer monitor to watch the X-ray guided procedure. The novel part of this procedure was that a "flow retrieval" device was used to remove the clots. Apparently, this was one of about 15 surgeries that have used this device thus far. Later on Tuesday, I attended the Breast Tumor Board with Monet and Korie. The case presented was of a 43 y/o female with bilateral breast masses with a history of breast mass excision 4 years ago. A core needle biopsy had been performed, and a mammogram had been done. The diagnosis was a benign fibroepithelial lesion with fascicular PASH. The result of this diagnosis was a lumpectomy to remove the masses. It was really great that I was familiar with the characterization of breast tumors from my Cancer for Engineers and Physicists course this spring. The tumor was found to be ER/PR- HER2- Ki67 low index. This LGASC (low grade adenosquamous cell carcinoma) is a rare variant of metaplastic carcinoma, which is indolent despite being triple negative.
On Wednesday, I was back at the Lung Cancer Screening Program and got to watch a shared decision making visit conducted by Brooke. The 71 year old woman was a 50-pack-year smoker but had quit 14 years ago. I felt super uncomfortable and realized its the human interaction aspect of medicine that I can’t deal with very well. When the patient is just a collection of chest scans or a body on a surgical table, I’m perfectly fine, but the moment they’re talking about moving their daughter to California this weekend or about how they quit smoking the year their daughter got married, I get way too wrapped up in the what if’s and imagining how a positive finding would affect her and her daughter. I’m amazed at doctors who can maintain a cordial disposition with their patients and still function effectively as clinicians. Anyhow, after that consultation, I went to Thoracic Tumor Board. Things were definitely more lively at this tumor board than the one from Tuesday. You could tell that certain clinicians had polar opposite opinions on what was best practice. Instead of just one case being presented, in this meeting each doctor would call out patient IDs that they wanted the group’s opinion on.
I shadowed in chest radiology again on Thursday. There wasn’t as much as last week as far as interesting cancer cases go, but there was an emergency possible pulmonary embolism that needed a scan to diagnose. There was an interesting case of patent ductus arteriosis (PDA), which is a persistent opening between two major blood vessels leading from the heart. Normally this opening closes after birth, but sometimes it remains open leading to circulation issues. I also learned how to identify dual lead pacemakers versus AICDs in CT scans.
Friday took an unexpected turn since at the end of the day Thursday, I got a call to see if I wanted to watch one of Dr. Salemi’s surgeries the following day. Of course, I said yes. So my Friday started earlier than any of my days in this program thus far with me meeting one of the fellows in cardiothoracic surgery, Dr. Huang, at 7:15am for rounds. Again, I am not very good with observing doctor-patient interactions, maybe over the course of the summer, I’ll manage to improve. The worst was a really far gone patient getting “bronched” to remove fluid in his lungs so his pneumonia wouldn’t worsen. He seemed completely out of it probably due to the dyskenesia of his jaw, jerking from side to side, but in his eyes, there was still cognition. The post-surgery suite wasn’t that bad until I heard the back-story on one of the patients that I gathered did not want placed on a ventilator or to undergo any major interventions for his ailments. He simply wanted to be able to function to take care of his wife, who has end-stage cancer. After the rounds were over, I learned about the surgery that I was here to shadow, CABG! What is CABG you might ask? (I know I sure did.) CABG stands for coronary artery bypass grafting, which is used to treat people with coronary heart disease (CHD). CHD is caused by plaque buildup in the coronary arteries and thus, actually ties into CRK lab interests. This case, like the last surgery I watched had additional complications. This man was obese, barely being contained on the operating table. His heart function was in an extremely poor state with the left ventricle weakly contracting. Last issue: normally, the saphenous vein is used for grafting but the patient had varicose veins so a cryogen from a cadaver was going to be used instead. Dr. Huang told me that these veins are not ideal since they have a 5 year potency rate of ~50%. I was shocked to see the painstaking process by which the heart was accessed after much cauterization to get through the ample volume of tissue to the sternum. I was also really excited to see extracorporeal membrane oxygenation (ECMO), something I had learned about in undergraduate studies. Of course, this was being used because the heart had been stopped using Cardioplegin, a drug that uses potassium to inhibit myocardial contractions. While the heart was stopped, the cadaver in was attached to the appropriate bypass locations using sutures. Things got a little rough in the middle of the surgery with the patient’s cardiac index reaching 1.2 so a balloon pump was brought in. Dr. Huang and the entire team was super tense so I didn’t get to ask many questions but fortunately, for most of the key stages of the surgery, I had an excellent view hovering directly above the patient’s head. All in all, there were no major complications and the patient’s heart showed immediate improvement after the bypass was completed.
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