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. 

Clinical Immersion - Week VII

The countdown has begun.

For this past week, I was able to start the collection of data on image resolution of the various images generated on the ongoing MRI study I was assigned to on week three of the program. The program, which can analyze various images simultaneously, offers the results in both visual and written formats. After analyzing the images, I concluded that trabecular depth was not necessarily tied to the level of intensity shown by the images, which rendered any attempt to discern this characteristic inaccurate. With three types of acquistion protocols and four kinds of filters, multiple data sets will be generated over the course of next week before finishing the immersion program. As of right now, I do not foresee a major collaboration continuing into the future but I will certainly hope that my dedication to the project will establish a working relationship between the Cosgrove laboratory and Dr. Potter.
Outside of analyzing image resolution, the week also saw quite a few surgeries of interest at both HSS and Weill Cornell. On Monday I had the opportunity to shadow Dr. Bostrom once again, a day that was mostly devoted to total knee replacements and one instance of revision. The surgeries themselves were brief but rather new to me given that my previous day of shadowing focused exclusively on total hip replacements. At the OR I was accompanied by Amanda and Jacob, not to mention quite a few of Dr. Bostrom's interns. Perhaps the most important aspect that I obtained out of this day was the level of precision in removing bone and carefully choosing which materials to use during the total replacement such as type of implant material (Co-Cr vs. Oxinium) and the use of bone cement.
Wednesday was another surgery day, only this time I had the chance to visit a Weill Cornell physician, courtesy of Dr. Robert Min. The physician, Dr. Jeffrey Greenfield, is a neurosurgeon that oversees anything from trauma-related brain injuries to cranial alterations for a variety of reasons. On the particular day I was shadowing, we saw two cases (the third one being cancelled): the first dealt with edema on the brain of a young child who had sustained traumatic injuries; the surgery inserted a sort of siphon into the top of the cranium. The second case was that of an adult with ongoing medical problems as a result of tissue malformation at the base of the neck; the surgery, called a brain decompression or chiari, had to effectively chip away at the bone laying on top of the cerebellum and remove the first two layers of the meninges before inserting a fill-in soft material and securing the area using a metallic graft. Both surgeries lasted about 2-3 hours although the preparation time was also rather long for a surgery (up to 1 full hour). As a big enthusiast for all aspects of neuronal tissue function, the surgeries enabled me to see how knowledge can help establish an appropriate protocol for the treatment of complicated and delicate conditions in a variety of patients.

Next week will be my last week which means I will try to spend extra hours in lab for Monday, Tuesday, Wednesday, and Thursday in order to have an easier time on Friday to enjoy NYC for one last day before the end of the program. This past weekend saw more shopping in the trendy Madison Avenue along with a visit to a Spanish restaurant in the Upper West Side for brunch and flamenco show. The final event was a return to Cocotte for a quick light dinner in Soho. So far this weekend has seen a visit to a couple of places in both Chelsea and Greenwich Village (speakeasy throwback!) on Friday night and a Saturday morning visit to Smorgasbourg. With an impromptu trip to Montauk taking place tomorrow, this weekend (and the program) is wrapping up nicely.

Restaurant of the Week: Andanada

Week 6

On Monday I joined Dr. Schneider with Mandy and Jacob with the expectation of observing an amputation surgery. However, a few angioplasty cases with higher priority took it place in the operating room. Both cases involved the thrombosis of the periphery artery in legs and causing anoxia and local tissue damage. The surgery started by inserting catheter from the artery of the other leg, reaching the clot region with guidance of X-ray image and contrasting agent, and inflating a balloon to improve blood flow. It is beautiful to see how minimal damage/pain this type of surgery has been done to patients. They fall asleep on the operating table for most time of surgery even without major anesthesia, and there was one female patient even snoring all the time.

Tuesday was another clinic day that seeing over 50 patients. There was an interesting case that the patient looking forward to a revision of hip replacement prosthesis. From X-ray analysis, it was clear that the pelvis socket of the prosthesis was anchored higher and also tilted by a larger angle compared with that in normal case. The abnormality resulted in significant restriction on the lateral movement of the leg and severe pain symptom. The patient explained that according to her previous surgeon such weird replacement location was arranged to save space for the lumbar spine surgery that performed right after her hip procedure. Such explanation seemed making no sense to Dr. Cross as he provided a solution that can perform normal procedure in both cases without any interference. Yet it was too late, despite no infection or dislocation caused by the prosthesis, the height difference on both sides influenced the loading distribution on pelvis and skewed her back, causing significant pain on her even only walking for two blocks distance. When Dr. Cross said unfortunately there was nothing he could do to improve such situation, there was a big sorrowful emotion flashed on the patient face.

Over the week I also attended a couple meetings. In the arthroplasty meeting on Thursday morning, doctors discussed on a complicate case that the patient was diagnosed with osteolysis before the total hip replacement surgery. Soon after the procedure, 2 dislocation spots on the pelvis socket were identified and the socket was stabilized by a lot of screws in a revision. Two years later, the patient felt increasing pain on the lateral side. To solve the issue, a secondary revision procedure was performed during which the lax poly part and the prosthesis head were replaced. At that time, the femur part of prosthesis was still very stable, but it was replaced with a piece of long stem prosthesis as well to prevent future dislocation due to the presence of osteolysis symptom. This time, the pain relieve didn’t last for more than 15 months. The surgeon is really confused about the symptoms this time because the X-ray data analysis shows the prosthesis remains intact. Some doctor suggested the pain might be due to the hyper reaction towards the poly if the patient had been suffered from poly debris during the last revision surgery.

Week 6: Lost his guts!

This week was characterized by a couple of unique cases. For instance, I shadowed a procedure for the youngest patient I've observed in vascular surgery, an 11-yr old girl. This young girl had a previous history of neuroblastoma, which had been successfully treated via removal of 1 kidney. However, treatment of the neuroblastoma led to stenosis of her thoracic aorta, requiring treatment with a graft from her thoracic aorta with anastomoses to her remaining kidney and iliac artery. Unfortunately, she developed high blood pressure, elevated creatine (indication of poor kidney function), and claudication. These symptoms indicated occlusion of blood flow within the graft, and were successfully treated with angioplasty and stent placement. Fast forward to today, in which she is again hypertensive, indicating that restenosis of the stent may have occurred. Indeed, restenosis was observed during angiography, and treated with angioplasty. The procedure itself used much of the same techniques I have observed such as angiography, angioplasty, etc. but her story contrasts greatly with the treatment of aneurysms and atherosclerotic lesions I have observed thus far.

I also had the opportunity to observe the most invasive vascular surgery I could imagine, an aortobifemoral bypass graft placement. In this procedure, the patient's abdomen was exposed, and the intestines were put aside so as to expose the aorta. From there, a polyester vascular graft was utilized to provide a conduit for blood flow from a point just inferior of the SMA to both femoral arteries. This procedure addressed advanced atherosclerosis in the distal aorta that led to occlusion of blood flow and ischemia in the legs.

Week 6

This week I was able to make a more progress on my project. Although I'm not allowed to reveal details of my project but had a chance to talk with several people who work on the same topic. It is very interesting to see people from different communities (Mathematics, Physics, Radiology) apply different approaches to topics related to clinical imaging. For instance, To acquire MRI raw data and process them there are several protocols and algorithms that can be used. Each of them has its own cons and pros in terms of acquisition speed, quality, computation time, temporal and spatial resolution, etc. I met with Dr. Pascal Spincemaille who is a faculty in Radiology department at Cornell and has developed a technique that uses spiral sampling trajectory for temporal resolution acceleration. Another interesting aspect of projects here is that most of them are very close to reality because you'll get to work with patients either directly or their diagnostic tests. So any brilliant idea that is feasible and practical can have a chance to either become a product or a new protocol in standard of care. On Wednesday, we attended the liver conference at Columbia hospital and as before a few cases were discussed. Most of the cases were Hepatocellular carcinoma. There were a few patients who had multiple lesions with different shapes such as nodular, wedge, etc and a few millimeters in size. Some patients were listed on liver transplant cause they met the criteria for that. The overall conclusion for these cases was that the best transplant time that meets all the criteria is the one for advanced liver disease in early stages. Other cases were Cirrhosis, which is improper function of liver due to damage caused by alcohol, hepatitis B and C. The damage is irreversible but further progress of it can be slowed down.    

Week 6!

This week I saw a bunch of interesting cases in the clinic and the OR and happened to catch a talk by Dr. Chubinskaya from Rush University. Early in the week I shadowed Dr. Rodeo and saw patients in the office. Being here has convinced me never to ski despite living in Ithaca because ACL tears are way too common! One patient was not comfortable with MRIs because of the tight space. Instead of MRI, ultrasound will be used on them to check if there are any rotator cuff tears.  I'm curious since MRIs are such clean and useful images that can be used in surgery how not having one may affect diagnosis and treatment in orthopedics issues. Other than that a couple of interesting cases was a few months post-op TKR that had had a buildup of scar tissue indicated by reduced range of motion. I learned about a quick procedure where they apply an epidural in the PACU and just forcibly move the knee around the break up the tissue. I wonder how the floating tissue is tolerated by the joint.
Outside the clinic, I continued with research and finished segmenting all the menisci, huzzah! Hong Sheng and I spoke about the data with Dr. Maher and unfortunately there's not enough data to make a worthwile ORS abstract, so we'll just have to wait. I did learn that meniscus deformation measurements are not so standard as I thought, so I also did a literature search and learned about what we could apply to our segmentations. As I mentioned, Dr. Chubinskaya gave a talk and heard about some treatment agents I've never heard of including OP-1 and notably P188. P188 is a surfactant that is thought to seal holes in the cell membrane of cells during necrosis, and this was used as a chondroprotective agent in a model of cartilage injury. It's a very cool and clever idea and showed promsing results in that it stopped DNA fragmentation and reduced cell death and apoptosis. And finally in surgery this week, there were a couple of neat cases. One patient was under a clinical trial operation this week for rotator cuff repair. The study's purpose is to examine how different MSC sources in the body modulate healing. What was crazy about this patient and apparently the worst ever seen is the weakness of the patient's bone. When drilling a tunnel or turning a screw into the bone, it just fell apart. A special screw and suture system had to be used to secure the cuff. The final and long case of the day was a patient who was roughhousing and apparently only fell but managed to dislocate their patella, tear their MCL, and break a piece of cartilage off their femur! They received some allograft tissue to fill in the defect of the cartilage, and then it took most of the surgery time to re align the patella and fix the MCL. There were ligaments and allograft ligaments everywhere. It amazes me how well the surgeons can keep track of everything and how they choose to do what steps of the repair when. With so much wrong, there are many options for how to proceed and it is really cool to see that process.

Week 6:

I spent much of this week working on my case study because my clinician mentor is out of town. To do so properly, I met with the design engineer of this specific prosthetic device and we went over a number of questions I had regarding the implant. What I expected to be a long conversation to sort out the details of the design turned out to be relatively quick. The patient’s proximal tibial component was retained from his previous surgeries based on intra-operative assessment of fixation, leaving only a distal femoral piece to be replaced. I realized that more in-depth questions I had about the patient’s bone quality were probably not directly addressed. This led me to think about how the aspects of my research in Ithaca could one day improve the long term predictability of implant success. One day, as in many days from now. But for example, this patient is the first of his kind and any additional information about his bone would inform potential complications in the short- and long-term. What’s really missing is a clinically dependable characterization of bone quality and its correspondence to prosthesis outcomes. That’s a lot of work but it seems logical to me. I also began to think about previous conversations I had with Dr. Lane. One afternoon, in between surgeries, we had lunch together and he asked me (again) what I planned to do after getting my PhD. I said “industry” as I always do. Naturally, the follow-up to that answer is somewhere along the lines of “What do you mean?” I’ve always considered prosthetic device companies as my go to example but now I feel like that’s because I didn’t (and still don’t) know how much else is out there. Therefore, I resolved to take a more curious look into what companies are doing with respect to prosthetics, bone substitutes, bone cements, etc. More importantly, I want to evaluate it in terms of what I’ll be doing for the next 4 years. I know the research I do doesn’t necessarily have to dictate my job, but I joined the lab I did because I’m interested in the research questions. It would be ideal to investigate those after the fact and I think that immersion has convinced me of that while also broadening my understanding of how I can do so.

Week 6: A Change In Pace

     This week, I went to Fellows Clinic at the main hospital. Fellows Clinic was a very hectic place compared to the calmness of Dr. Vahdat's office. As soon as I walked out the elevator I stumbled into a crowded patient waiting room buzzing with people. There were three receptionists fumbling around answering phone calls, checking in patients, and switching places. I was directed to the another receptionist down the hall and in the last door on the left who then directed to me to the room the head fellow was in. I was able to see a different side of oncology that served minority patients.

     Later on, I had a meeting with Dr. Ching Tung and Dr. Vahdat. Dr. Tung showed us the data on the cancer spray that he and Young Kim, a pathologist from Korea, were creating. So far, the spray has yielded great results in detecting cancer in various organs especially ovarian. Dr. Tung just does not know if it will work on breast cancer cells. Dr. Vahdat proposed connecting them with a breast surgeon so they could obtain live breast cancer tissue following IRB protocols of course. Since Kim is a pathologist, she would be able to correctly discern the cancerous tissue from the normal. I was excited. I just helped with a collaboration. Just knowing what's going on can help people find potential solutions to problems. 

Week 6: Musical scopes: ischemia edition

This week we observed a major flap case—ALT free flap to reconstruct the foot/ankle of a patient that the plastics team has been seeing for almost all of immersion term. After a fall and ischemic injury to the lower extremity sustained in the home country, this patient has had little to no motion and or sensation below the knee. Dr. Spector has been recommending a below the knee amputation since his first time seeing the patient, and as such had not performed any major reconstruction in the case that the patient and family agree. We have seen several irrigation and debridement procedures for this patient in the OR, and recently saw the ankle pinned in place and the wounds closed with integra and autologous skin graft. The patient has been healing well from these procedures, thus the family seems optimistic that reconstructing the foot may be a step to recovering function below the knee. For this case, Dr. Spector’s team took a perforated flap from the ALT, consisting of only skin and fat, and divided it into two portions (to cover one wound on the foot and one on the ankle) both supplied by the same vessels. However, after already experiencing a delay at the start of the procedure, we encountered an even more critical one in the middle of the procedure, and even worse—in ischemia time.

While a majority of Dr. Spector’s flap cases are performed in general surgery with the same familiar team of OR techs and circulating nurses, this particular case had been scheduled in ambulatory surgery with only one of the usual OR techs. When it came time to start microsurgery, and the flap was already detached from the donor site (i.e. no blood flowing to supply the living tissue with oxygen, nutrients), the circulating nurse had not started up the microscope correctly. When this was finally resolved, the microscope was not to Dr. Spector’s usual settings and he was unable to see clearly through the lenses. By this time (mid/late evening), the main OR staff had already gone home and without the usual circulating nurses he could not locate the appropriate microscope for the procedure. A resident and med student fetched one from general surgery (for those who don't know, it is 7 floors away and in a different wing, and the scopes are very large), only to be told that the scope they had brought up was used by a different team and would not work for Dr. Spector’s purposes. With the clock ticking, phone calls were made to the knowledgable staff who had gone home, and finally we got permission to take the plastic surgery scope from general. As quickly as we could, we moved the second scope out of the room while the third (correct) scope was located and brought up to the room. After more than an hour of ischemia time, the right scope was finally in the room. As soon as it was set up, the first scope was navigated carefully around it and moved out of the room. For the rest of the procedure, we had an additional circulating nurse in case there were any other issues. With such time-sensitive procedures happening, I still wonder why things like this occur. The success of a procedure is dependent on every person in the room playing their appropriate role. However, in this case, some were not equipped for the job, and others had to compensate for this because we were under the wire. This put into context how critical it is to have a standard operating procedure in any OR and to always have staff who understand the demands of the particular case. We were fortunate to have had our usual and amazing OR tech for almost the entire procedure, as well as several proactive members of the plastics team, without whom the case would have been an absolute disaster. Luckily, once the correct scope was set up, the procedure was completed without much further delay, and the patient has been recovering well since.

Week 6: Cells, oh how I've missed you!

This week's highlights were definitely in interventional radiology and pathology so I will focus my blog post on those days.  Otherwise, I've been at the Lung Cancer Screening Center working more on determining the structure of the study for their grant proposal on smoking cessation in the context of LDCT screening centers.

In interventional radiology this week, I got to see multiple lung biopsies, several cryoablations, and an inferior vena cava filter insertion.  The first biopsy was fine needle aspirations (FNA) on an 82 year old female who was biopsied from the prone approach.  I noticed in this case, histology determined how many fine needle aspirations were taken since more samples would be needed if the first samples were inconclusive.  However, the pathologists reported the nodule appeared to be adenocarcinoma so FNA was sufficient and a core needle biopsy (CNB) was not necessary.  Like all the patients with lung procedures, she was ordered to have an X-ray done immediately after her procedure and then after two hours to ensure pneumothorax did not occur.  The second lung biopsy was slightly more complicated since the PA had to deal with an extremely nervous patient.  Her breathing patterns were highly irregular, which made timing the movement of the lungs by the diaphragm for accurate needle placement quite challenging.  However, once the patient was calmed enough to breathe normally, the procedure was uncomplicated.  The first cryoablation I saw this week was actually a soft tissue ablation of a metastatic cervical cancer in the pelvic region.  I asked Dr. Pua what types of tissues can be treated with ablation, and he explained that most regions where there isn't a lumen, organ, or system adjacent to the ablation zone that can be damaged is fair game.  Also, cases like the GI tract where interrupting a lumen causes dysfunction is not a good target for ablation.  After watching this relatively smooth procedure, I took a detour to one of the Angio rooms where a filter was being placed to collect blood clots to prevent pulmonary emboli.  The X-ray guided procedure necessitated that we wear heavy lead vests that remind me of samurai armor.  A neck strap accessory protects the thyroid gland!  It always astounds me to watch how vasculature is navigated using different wires and tools in these procedures.  This surgery complimented the filter removal I saw previously this summer.  Once the guide wire was in the correct position, just slightly above where they wanted the filter in the vena cava, the filter was essentially spat out of the wire, expanding until it was stable in the vein.  The low level of invasiveness allowed by X-ray guidance in filter placement is truly a marvel.  After successful deployment of the filter, I returned to the CT procedure room where another lung cryoablation was about to take place.  This one was running much like the other until the end of the ablation cycle when the lung collapsed slightly as evidenced by a sliver of dark space, signifying air, in the pleural cavity.  As if by magic, Dr. Pua simply took an intimidatingly large syringe, inserted it into the cavity, and aspirated out the space, holding it under vacuum for a short while before withdrawing the needle.  Upon inspection of the latest CT image, he remarked rhetorically, "What pneumothorax?" since it had all but disappeared.  This was a moment I'm slightly ashamed to admit I was excited to be around for since no one wants a collapsed lung during one of these procedures, but I really wanted to see how they intervene if this does happen.

In Surgical Pathology, I had the opportunity to shadow Dr. Narula as she signed out for the day.  I learned that anything removed from a patient has to go to pathology, even if there is no diagnostic assessment needed.  I dived in viewing a lung biopsy along with Dr. Narula and her resident using microscopes connected to the same light path (pretty cool setup).  This patient had a history of prostate cancer, and thus, pathology needed to assess whether the lung mass was a metastasis or a primary lung tumor.  However, the patient's history did not include whether the prostate cancer had well differentiated cells or not so this complicated matters.  To add to the complexity of the case, the patient has a history of smoking, a large risk factor for developing lung cancer.  It was noted that the biopsy showed poorly differentiated cells and immunohistochemical stains for TTF-1 (thyroid transcription factor-1, used to differentiate between primary lung cancer (+) and lung metastasis (-) in adenocarcinoma patients), P40 (marker for pulmonary squamous cell carcinoma), and PSMa (prostate-specific membrane antigen, marker for prostate cancer) were ordered.  Another case along similar lines was a biopsy of lung nodules for a patient that had a history of laryngeal cancer;  a diagnosis was desired as to whether the nodules were metastases or an independent primary tumor.  It was noted that the sample had fibroelastosis, predominantly scar tissue with mild inflammation.  From my understanding, this could be residual from treatment and can complicate the diagnostic assessment since there could still be cancer that was missed by the biopsy needle.  Another interesting case was a Stage IV lung cancer patient who had a biopsy of pericardial effusion that showed no malignancy.  Dr. Narula had been using the terminology "level x #" intermittently so I asked what that pertains to, and she explained that the levels are depth of the specimen in the paraffin block that gets sampled.  For instance, with this patient it had been level x 3, and she wanted to look at level x 5 to ensure they weren't missing anything by not looking deep enough into the block.  This is an interesting compromise between thoroughness and efficiency requiring indeterminate cases to get processed again for additional samples while not wasting processing time on cases that turn out to be quite obvious with a few slides.  There was a case of a 32 year old male with a Stage IIIb germ cell tumor.  Pathology was required to determine if there was any testicular cancer in the biopsy or simply mature teratoma.  This assessment would help determine if chemotherapy would have any effect since it could only kill the testicular cancer not a mature teratoma.  Further staining with OCT4 and CD30 were considered since this case was not striaghtforward.  There was a biopsy of a left-axillary mass identified as metastatic carcinoma that Dr. Narula could do nothing definitive with since there was no patient history; thus, the doctor had to be followed up with later.  We looked at synovium from a left patella fracture where inflammation had been taking place as evidenced by macrophages at the fracture site.  I also learned that occluding plaques removed from vascular surgery have different morphologis pre/post statins.  The most interesting case was the congenital pulmonary airway malformation (CPAM), where the resident actually went and consulted another pathologist who specializes in pediatrics to ensure that the type 1 characterization was correct.  Later, I looked up more about CPAM and noted that type 1 is the most common with larger cysts.  CPAM is a condition resulting from abnormal bronchoalveolar development and can be detected either during neonatal development or later, even into adulthood, with recurrent chest infection.  This sample was from a 19 year old and thus, the case wasn't considered pediatric even though the condition is generally studied by pathologists specializing in pediatric diseases.

All in all, I had a great week being exposed to some new procedures in IR and an entirely new atmosphere in surgical pathology.  Can't wait to see more new things in these next two weeks before returning to Ithaca.

Week 6

This week was more of the usual. I followed Dr. Goodman as she saw patients. One of the patients we saw was a woman who was in for her second appointment this summer. She has RA which had been under control until she was hospitalized in April for a bad case of the flu. Both times that I have seen her she has been complaining of weakness and shaking. She is so weak that she supports her head with her fist under her chin because her neck isn't strong enough. She has been tapering off of her steroids which Dr. Goodman thought may have been causing her shaking. Based on her blood counts all of her medications are working as expected, but she is still symptomatic and Dr. Goodman isn't sure why. Dr. Goodman suggested that she continue with PT to get her strength up and see a neurologist to make sure there isn't a neurological cause of her muscle weakness. I also saw another patient with RA who has mild joint pain (worst in her right hip) but severe pain along the side of her calf. She is planning to get her hip replaced but is worried that this procedure (risky due to her other underlying conditions) won't do anything for her calf pain. Dr. Goodman says it is possible that the calf pain is referred from the hip, but there really isn't a way to prove that. The patient will see a neurologist to get more information before her procedure at the end of the month.

At CAP conference this week another patient with JIA was discussed. This case was not as severe as the last JIA case I heard about. His joints are not as badly fused and he still has a fair amount of mobility and ROM. Until recently he could walk around his house with a walker. But his bilateral knee pain has become so severe that this is no longer possible. He was diagnosed with JIA at age 5 which meant that his growth plates were severely affected by the near constant inflammation. He has a very small stature and "trombone knees". Because of this he would likely require custom total knee replacement implants which are very costly and time intensive. Unfortunately, this patient has a history of missing appointments which makes the surgeons hesitant to take this case. They were going to talk with him more during clinic to see how serious he is about waking again.

I spent one very long day this week in the OR with Dr. Spector, Aaron, and Terrence. The first procedure we saw was what I've been calling an "eye tuck". Dr. Spector removed some of the skin, fat, and other tissue from above and below the patient's eyes to give her a more open eyed appearance. The coolest thing about this procedure was probably the plastic contact-like things put on her eyes to protect them during the surgery. I'm not sure what they were made of but they looked like black plastic and were big enough to cover her entire eye. The rest of the day was spent working on an 18 year old patient with necrotic tissue on his foot. I didn't get his full history but from what I understood, he was in some kind of accident and had surgery on his leg in Peru. He must have lost circulation to his foot at some point during or after the surgery which caused some of the tissue to die to the point that the bone was exposed on the bottom of his heel and the top of his foot. Though amputation was recommended to him when he came here, he chose to try and save the foot. An Integra graft and skin grafts were used with limited success. So during this surgery, Dr. Spector took a large (12 in x 6 in) flap (which unlike a graft contains vasculature) from his thigh to put on the wounds. This procedure was very delicate because the vasculature needed to be carefully detached from the surrounding tissue in the thigh and reattached to a healthy blood supply at ankle. The reattachment process involved micro surgery which was really cool to observe. The surgeons needed to have a lot of fine motor skills. Despite how delicate this procedure was, the microscope they used to do it was wicked bulky and took up a lot of prime real estate in the OR.

The rest of the week was spent working on my research project. One of the other summer students I'm working with needed an abstract for a conference by the end of this week. So I was busy with lots of data analysis.

Week 6: Patience With Patients

The doctor entered the emergency room ward with a smile on his face.  “Good news,” he told the patient,  “your heart is fine”.  Rather than being relieved the patient was confused.

“What are you talking about? I had like eight heart attacks in the last week.”  The doctor smiled knowingly and nodded.

“Based on everything, I’d say they were anxiety attacks.”

“Anxiety attacks?  Do I look like the kind of guy that panics?”  The patient advanced on the physician, who suddenly looked as if he wanted to be somewhere, anywhere else.  The doctor backed away, trying unsuccessfully to conceal the tremor in voice.

“It’s a common thing.  Nothing to be ashamed of.”

“Listen to me you idiot, I had a heart attack, o.k.?” 

“Not according to your EKG…” the doctor trailed off as the patient reached up pulling around the curtain to conceal himself, the physician and the hospital bed from view.  A crash was heard from beyond the drape, the unmistakable sound of the doctor being thrown bodily against the wall…

If the drama above seems like a scene from a movie, it’s because it is.  Specifically, “Analyze This” with Robert De Niro and Billy Crystal.  However, while the details of this scene may be overly dramatic for the sake of thrilling moviegoers, the occurrence represents a very real issue that I observed this week at New York Presbyterian Hospital: the frustration of treating non-cooperative, argumentative, and stubborn patients.

Throughout the week on rounds, I returned day after day with some of the IR physicians to check on one patient that had gotten a reputation for being particularly grumpy.  Without fail, the patient complained each day about not getting enough rest.  The patient felt disturbed by the physician’s presence and not without reason.  Multiple times, as the IR physician’s left, another entered the room, extending the time when the patient had to be awake.  Mostly it was the patient’s attitude toward new procedures that made the treatment difficult.  With fluid accumulating in the patient’s abdomen, two options were available: a paracentesis, in which fluid is drained by IR physicians through a needle inserted with the aid of ultrasound or a drain, a semi-permanent catheter that could be hooked up to a bag to drain fluid even in the patient’s own home.  Refusing to listen to the various merits of each the patient concluded that both options were bad.  The patient had a strong desire, understandably, to leave the hospital and go home.  Although the drain might allow this to happen, the suggestion that additional tube would be hanging out of the patient’s skin seemed as horrifying to the patient as an amputation. 

It is hard to criticize a patient for feeling frustrated with repeated procedures, extended hospital stays and the likely possibility that life would never get back to “normal”.  I can only imagine what it must be like to feel trapped in a hospital, choking on pills, enduring examination after examination, being dragged off to the OR every other day for another procedure, without even the hope of one-day being cured.  Nevertheless, for clinicians, dealing with such a patient is not easy.  I watched the physicians, residents, and fellows patiently explain each new procedure over and over never becoming angry or irritated at the patient’s questions or complaints.   The patient’s comfort was always foremost in their mind.  The physicians worked the treatment plan around the patient’s wishes rather than forcing them aside. 

It seemed to me that the ability to interact well with patients, what we call “bedside manner”, is perhaps one of the hardest parts of the clinical profession.  A cranky patient struggling with terminal illness is only one of the many challenges associated with such interaction.  Before every procedure, informed consent must be obtained, either from the patient directly, or in the event that the patient is not able to provide such consent, a legal guardian, family member or other individual able to make healthcare decisions on the patient’s behalf.  The informed consent process ensures that the patient understands the various treatment options and is able to make an intelligent decision as an autonomous individual.  However, the informed consent process also gives the patient the opportunity to refuse treatment even when such treatment may be in the patient’s best interest.  I witnessed one case, in which anesthesia-requiring procedures could not be performed because the patient had refused the placement of a tracheal tube.  Such refusals can cripple a treatment plan, making what a doctor knows to be the most optimal therapy for a specific condition impossible to perform.

Another type of challenge that can strain the patient-doctor relationship is when a patient or patient’s relative becomes unreasonably argumentative.  This past week, I overheard one of the nurse practitioners describe a phone conversation she had had with a patient’s daughter.  A gastric-tube, used to provide direct access to the patient’s stomach for feeding, had become clogged.  The daughter was wildly angry, accusing the IR physicians who had placed the tube of implanting a faulty device.  The nurse practitioner quietly explained to me that in all likelihood it was attempts to force pills that had not been properly crushed and dissolved through the narrow tube that had caused the blockage, but the daughter didn’t want to listen to reason.  I am sure that the nurse practitioner wished she could simply avoid talking to the daughter, but it wasn’t an option. 

The array of skills needed to join the medical profession is vast: knowledge of disease, diagnosis, and the physical techniques required to apply a given therapy.  My experiences during this week have shown me that another skill is necessary: an ability to work well with people.  It is not that I have never recognized the need for this skill in the past, but rather my observations have underscored the awesome patience that is often required to translate the science of medicine into healing.