Friday, August 8, 2014

Andrea's Mega-Blog Post

Yeah, I know how late this post, I am the ultimate procrastinator, but I don’t blame myself this time. I blame the city and all of its distractions. Living in New York City and working at Weill Cornell was surreal.  Between moments of benevolence and of debauchery, I saw humanity in its raw form.  I saw humanity walking in a 3-piece suit down 7th avenue, I saw humanity picking up escorts at 3am, I saw humanity the size of a potato wiggling in a plastic case barely able to open her eyes, and I saw humanity gasping for his last breath.

New York City never sleeps; the bars close at 4am as the cafés next door open for breakfast. You feel alive, electric, as if your blood could match the neon signs that light the city.  The hospital never sleeps either.  The hand of death waits for no man, yet the doctors still fight through the dawn to keep him at bay. Pregnant bellies turn to crying babies at every hour.  Doctors are the bringers and defenders of life. To them, 9-to-5 doesn’t exist.

Here, I tell the story of how my view of life changed in 8 weeks at Weill Cornell through a series of chronological short stories.

Note: Patient names have been changed

Thursday, August 7, 2014

Week 6: First Breath

The most exciting thing I had the opportunity to observe in the hospital this week was the first breath of a new little person! Danielle and I checked the schedule left by the OR front desk and noted that there would be a few scheduled cesarean surgeries (c-sections) taking place in the maternity ward’s OR located on 7 south. We had originally hoped to see a natural birth but it was a lot harder to try and plan given one could happen at any given time and might take hours of advanced planning and waiting to see.

When we arrived to the maternity ward, things were a little hectic while we waited to get permission to observe the surgery. We were almost able to see an emergency c-section but there were 2 other students also observing currently in the operating room so we waited for the next available scheduled surgery they were prepping another OR for. I knew that c-sections were typically performed on individuals that were conscious but it was crazy to actually see it all come together with the patient talking and nervous during the entire procedure. I was actually fairly surprised to realize that the husband/dad was allowed to be present during the surgery.

When the procedure officially started, the team worked quickly to remove the baby from the mother’s abdomen. An incision just large enough to pull the baby’s head out was cut into the lower abdomen of the mom. After going through layers of tissue and fat, the uterus was slit open carefully and before I realized what was happening, the doctor had reached in and begun to pull out a blue-ish tinted object from inside. I soon realized after a bit of pulling and tugging that in fact the doctor had gripped the baby by its butt and was wiggling him out. I was very surprised by how quickly the doctor’s were working and even more surprised to see how they seemed not to be concerned with handling the baby gently. 

After suctioning the nose and mouth for the baby and a few taps on the back, his chord was disconnected from his mother and he began crying loudly. The baby was wiped and cleaned off then weighed in at a nice 7 pounds and 7 ounces. The doctor expressed his enthusiasm and approval for the baby’s wonderful health to the new parents nervously anticipating the arrival of their first child. It was very interesting that not only was the doctor focused on communicating with the medical staff, he also periodically checked in on the mom and would exchange a joke or two while reassuring her that things were going smoothly. I was surprised to see that the dad excitedly left his post near his wife’s head behind the surgical sheet to snap photos of the baby and hold him. He seemed oblivious to the fact that his wife was still on the table with her insides out…yes, her insides were now outside her body!

We had all gotten so distracted by the baby that we (well, those of us not directly involved in the surgery) had for a split second had our attention focused on the little life sitting on a table crying. I looked over to the surgical table realizing I was here to see the surgery to completion, and as I looked over I noticed the doctor insert his hand into the pocket the baby had come out of and he pulled out a fairly large pink object from inside and plopped it on top of the mom’s belly. The doctor proceeded to reach his hand into the large object and clean it out. At first I thought it was the placenta, but a quick glance around told me that in fact the placenta had already been removed. Danielle and I darted confused looks at each other and realized what we were staring at was in fact the uterus! I had no idea the uterus could be pulled out that far from it’s typical home inside the lower abdomen. After a bit of cleaning and then sewing, the uterus was placed back in the patient and she was sewed up and ready to be sent home in a few hours with her little boy.

As I watched the c-section procedure from start to finish, it became clear that there was still a need for improving the medical care provided to both the mother and child even in something like child birth that dates back centuries. While in the NICU, I learned of some research that one of the physicians was interested in studying involving when optimal clamp time of the umbilical chord post birth is.  I was surprised to learn a study involving this concept had not been done before. It makes perfect sense that knowing when to clamp the chord is something that should be standardized so as to help prevent potential complications.

The rest of my week was fairly typical and I spent some time in the multiple sclerosis center as well as wandering the halls of the hospital doing some exploring and planning the next week’s hospital adventures. 

Week 5: …eMeNo…Ppppp

This week I spent a few hours in the Medical Intensive Care Unit, Neonatal Intensive Care Unit, and Pediatric Intensive Care Unit.

I saw many interesting cases in the NICU including a child that was 8 months old and still seeking care there. He had been in the NICU since birth but his twin sister was at home doing well. He had a shunt defect in his heart, ductus arteriousis, which is not uncommon for premature babies, however, this child had significant complications post surgery and had extreme oxygen deprivation to the brain leading to serious brain damage and the doctors assume the child is now completely brain dead as a result.

Another child we checked on was also a twin and he was dealing with a few respiratory complications. In this case, his sister was also home and doing well, but he was still at the hospital being treated. Something I learned fairly quickly when I walked into the NICU is that given the NYC lifestyle, many parents wait to have kids. The later women wait, the more likely they are to have complications in pregnancy. As a result, many couples opt for some sort of therapy to enhance chances of a successful pregnancy resulting in multiples often twins or triplets. In this case, the woman was taking medication to increase ovulation and the husband was sterile so they used donor sperm. Their daughter appeared normal and was doing well, however, the son had underdeveloped genitilia and an extra scrotum. As it turns out, the male donor is a carrier for prader willis which does not show up in the genetic screens typically done for donors. Pradar willis affects 7 genes and plays a role in a number of long term complications for the child, primarily uncontrolled hyperphagia due to constant feelings of hunger which results in excessive weight gain. In light of this news, the parents were seeing a genetic counselor to talk through some of the complications, but from what I gathered, the father of the child is in denial that his son has any sort of genetic condition and when the topic comes up he refuses to address it. It is clear the couple was expecting no complications having opted to go with a sperm donor.

To top off my week, the most memorable experience was in the MICU where David and I met a 93 year old man and his wife both survivors of the Holocaust. They had both been admitted to NYP only a few days apart. Both had elevated levels of Coumadin (a blood thinner) and the thought was that either the home care provider had given them the wrong dosage or that the pharmacy had somehow actually mixed up their prescription. Despite this complication, the older gentleman was also experiencing irregular heart rhythms and a pacemaker was deemed necessary. David and I were able to do follow up on the patient post insertion of the pacemaker and he seemed to be doing very well. The old gentleman was constantly thanking us in Polish for our care of him. It was good to be able to follow up on our patient and track his progress since the patients I have been seeing with Dr. Gauthier in Nuerology are on medication and only come for a few scheduled scans a year to track lesions. 

Week 4: Method in the Madness

This week was primarily spent in the ER and given the short week with 4th of July festivities and plans, it seemed like a good way to spend my time.  I walked in and despite looking the part of a doctor, it was clear I didn’t belong. I wandered around for a few minutes looking confused before someone finally came over asking if I was lost and needed help. I had entered the Emergency Department via the walk-in street entrance and my confused state as to where I should be going and what I should be doing must have caused a little alarm and given the impression that I was in need of medical attention. Anyway, someone was able to direct me to a back room where the residents commune in one of the ER sections where I spoke to the ER attending about the Immersion program and explained some of our goals. He quickly showed me around the different stations and explained the general progression of patient care: TriageàUrgent Careàmain ER (sections A, B, C).

My first stop was triage and the ER front desk in the patient waiting room. I spent a good bit of my time with a physician’s assistant in charge of minimizing the NYP door to provider time. Upon review, NYP had a 1 hour wait time for patients that would walk into the ER before they would even see a doctor. The PA I worked with met with patients as soon as they walked in the door asking them why they had come into the ER and what they were experiencing differently that had lead them to feel the need to come in. Then he would decide the urgency of the patient’s conditions. Depending on this initial assessment and what needed to be addressed, the patient would either go into triage or urgent care.

After spending an hour or so following a few mundane cases of back pain, dizziness, and nausea concerns, I figured it was time to graduate on to the main ER. When I first walked into the section A of the ER, I was surprised to find patients sitting on beds in the hallways while doctors and nurses maneuvered through what seemed like a maze of patients and medical equipment to get from one end to the other. Despite what seemed like a chaotic situation, there was surprisingly good organization of patient care and once you got a sense of the place, it was not too difficult to keep pace with everyone. I followed a few cases one of which involved a man walking through a construction zone and having a 2000 pound cement pole drop 10 ft and hit him in the back. The concern was that he had damaged his spine but a few x-rays later and it was determined the man was quite lucky. The pole had hit him in just the right spot that it had missed his spine and he only had a very large bruise. Another case I was able to follow involved a biker accident.

The girl had come in after being taken out on her bike when a car door opened and she went flying over the handle bars landing on her left shoulder. She was in considerable pain and the consensus was that she had likely simply dislocated her shoulder but the ER doctors were hesitant to try and pop the shoulder back into it’s socket on their own instead of have someone from orthopedics come down and without confirmation from x-rays that the shoulder was in fact just dislocated.  Despite the pain medication she was given, she was still in considerable pain and kept asking when someone would be able to pop her shoulder back into place. After a few hours, the x-rays taken were not sufficient to determine whether or not the shoulder was simply dislocated or if in fact there was a fracture so they needed to take another set. While having her arm positioned in multiple angles for the x-ray, there was a loud pop and the patient felt an immediate sense of relief.

The color that had originally been drained from her face was quickly coming back and we could all sense her relief. Although the resident physician following her case was happy to see his patient transition so quickly to a more comfortable state and that his initial diagnosis of shoulder dislocation was correct, it was clear regardless of the new x-ray results they had already decided they could not put the shoulder back in place themselves and would need to wait for someone from orthopedics had her shoulder not accidentally popped back into place on it’s own during the second set of x-rays. I learned that even within a medical team of certified doctors, there are still limitations and regulations as to what one can or can not do which if not followed could then result in a serious malpractice lawsuit.

Tuesday, August 5, 2014

Weeks 5-7 for Derek

Sooooooo, I apologize for the delay, but my last few weeks of the immersion term were quite hectic. I spent most of my time on research in collaboration with the famous Mary Goldring lab, but I also spent some more time observing surgeons in the clinic. So I'll break each week down one-by-one.

Week 5: During Week 5, my main goal was to become adept at RNA isolation, a process that involves a huge amount of micro-pipetting, something that I have not done much of in Ithaca. Miguel and Kirsty from the Goldring gave me a great protocol to follow. Briefly, I begin by harvesting articular cartilage from a mouse knee joint, which is not an easy task and requires a lot of skill with a scalpel. Then, the RNA isolation begins, which takes usually takes two full days. Finally, we measure the purity and quality of the RNA, and if it is good enough, we can perform qPCR to determine gene expression in the articular cartilage. I successfully isolated high-quality RNA with my six practice samples. In addition to research, I spent some time with Dr. Bostrom in the clinic visiting patients. Dr. Bostrom has been a hip and knee replacement surgeon for over 25 years, and he is one of the best at what he does. It's interesting how each surgeon has his/her own way of talking to patients and explaining to them what their options are. In the case of joint replacement surgeons, the options are actually quite simple: either deal with the arthritic pain, get a steroid shot, or have your joint replaced. But surgeons of course are very courteous to their patients, and explain things in a very comforting way. Dr. Bostrom was very good at ensuring his patients would get the best treatment.

Week 6: This was the week that my animals were finally of age to begin experimenting, so once again, I was in the lab a lot! I was also teaching an HHMI grantee how to use our tibial loading device, as he will be using it in the near future. It felt great to teach someone the methods that my lab has developed over the years. Besides experimenting, I continued my practice for qPCR, as the real thing was coming up next week. Again practice went very well. Besides my time in the lab, I attended a research meeting with my mentor, Dr. Cross, where I presented both my research from Cornell and from my clinical work I was doing in the city about malnutrition and infection post-total hip replacement. The rest of the research team was very interested in both of my projects. I also had some time to observe Dr. Cross in the OR to see more joint replacements.

Week 7: A very unfortunate last week resulted from my RNA isolation failing. As I mentioned earlier, my practice samples went extremely well, but when it came to the real thing, my RNA purity was terrible - I'm still not sure what I did wrong. But I did perform some more experiments, and Kirsty and Miguel are helping me out by performing RNA isolation themselves while I'm in Ithaca - they're two of the nicest and smartest people I know. So, hopefully my second batch turns out better than the first. I also spent a lot of time on my clinical project and managed to obtain data for sixty patients, so I'll have some solid preliminary data for my immersion term paper and poster. My final day in the city I spent with Dr. Bostrom on his sail boat in the Long Island Sound. IT WAS AWESOME. We did some swimming, some tubing, and he treated us to drinks and dinner. It was a great way to end a busy seven weeks in the city. Overall, the clinical immersion term was very helpful, and I have a huge amount of motivation to improve treatment for osteoarthritis. I know there is something else out there that can help treat/prevent the disease, and I will figure it out in the rest of my years as a PhD student at Cornell. Thanks for reading!

One (Two?) last crazy case(s) before I blow this joint- Week 7

Ive seen crimes, criminals, brain death, organ donation, burns, scalping via commode, bike accidents, motor vehicle collisions, and all manners of trauma and morbidity in between but this last case has a little bit of everything (except brain death and organ donation. Probably) so it was a good case to close it all out with.

A 40yo male with sickle cell disease complicated by Hepatitis C and IV drug abuse was admitted to Interfaith Hospital for a sickle cell crisis. He was at the hospital for 4d and stable when he had an "unwitnessed fall from ground level" and was found in his bathroom. Well this fall really seems to be "went to smoke crack in the bathroom where he was then assaulted by an unknown assailant" but since no one saw the incident and he was just found down, they went with "unwitnessed fall." Well this "ground level fall" resulted in a severe subarachnoid hemmorhage, 1-2 R rib fractures, left 6-8 lateral rib fractures, 9 left posterior rib fracture, bowel wall edema, and hemothorax. He was transferred to Cornell-NYP after a severe regression in his alertness ending in non responsiveness where he was initially picked up by neuro-ICU for the head bleed despite the trauma. SICU requested he be transferred and had to argue with Neuro to get the patient. He was finally transferred after it was seen that he had a complete left lung opacification and malpositioned left chest tube that he arrived with (that still put out 800cc). He began to bleed massively until a massive transfusion protocol was begun on him. He eventually required 21u of blood over the next 36h. Needless to say, he wont be sickle for a while after that. Thoracic surgery was called due to the opacification and massive hemothorax and despite the need for mass infusions, hemorrhagic shock, and the setting of abdominal-thoracic compartment syndrome they did not do a thoracotomy the first time. They opted for a VATS (Video Assisted Thorascopic Surgery) where over a liter of clot was evacuated and no source of the bleed was found. The thoracic fellow insisted that the bleed was not surgical thoracic and instead medical, despite medical bleeds rarely if ever requiring 20+ units of blood. Finally with full on shock and compartment syndrome thoracic finally agreed to take him for a thoracotomy while surgery went in for a laparotomy. Immediately upon cutting the abdomen and thorax he depressurized and immediately returned to hemostasis. One fellow described cutting the abdomen for the laparotomy as "you know those snakes in a can of peanuts toys? How the snakes just explode out when you pop the top? Yeah, thats how his bowels were." But he significantly stabilized upon the thoracotomy.  He was still bleed so severely that they kept the abdomen open before returning him to the SICU. He more or less had a bedside exploratory lap twice in the next 36h since he kept bleeding so heavily that he needed to be unpacked, examined, cauterized, repacked, and VACed twice. That was a pretty crazy procedure to see on the unit and not in an OR where most ex-laps occur. Needless to say, this patient caused some pretty big tensions and dramatics between the SICU and thoracic surgery with the thoracic fellow almost getting into a brawl with a SICU resident. It was pretty ridiculous.

Despite all the blood, guts, and disease Ive seen in my tenure at the SICU, this last patient took home the prize for most gut wrenching trauma: a tourist from Spain was getting ready to go home and while crossing the street, her foot alone got run over by a bus. Somehow, the bus wheel degloved her foot which is exactly as it sounds- her foot skin came off like a rubber halloween prop in one whole sheet including cleanly amputated toes inside her shoe. Remaining, was a neatly deskinned foot tendons, vasculature, and all out in the open. It was a very visually arresting injury. I do not recommend Googling. Plastics could do nothing about the toes, but they tried to skin graft her degloved skin back onto the foot. Hopefully, the graft will take, but if it doesnt they will need to amputate the foot.

Overall, this program was poorly run, confusing, and very disorganized, but I managed with sheer luck to wind up in a good unit, with a fantastic team, and by coming back to the same people, patients, office, and unit day after day I managed to get a very broad and detailed view of at least how things work in the SICU and trauma teams. I do believe this program needs to figure out if it cares more about having us understand the clinical care side of things or form research collaborations with Weill Cornell clinicians. Trying to do both lead to stress and confusion and not being able to successfully do either. Hopefully, subsequent classes will be able to enjoy a smoother experience.

Dont ride bikes in NYC and make sure you chew before you swallow- Week 6

The SICU has 13 beds. Almost always, 1-2 of those beds are occupied by bike trauma patients-bicycle bikes not motorcycle bikes. Growing up in the country, I never thought of biking as an inherently dangerous activity unless you decided you bomb down a mountainside or something like that. Not the case in NYC. It seems bikers can be doing risky things like flying down Lexington Ave during rush hour or doing presumably safe things like casually biking through Central Park, but the crowds, cars, trucks, noise, and construction permeating everything in the city will do a biker in every time. Even wearing helmets, many of the bikers experience moderate to severe head trauma and almost all of them present with some form of an intracranial bleed. Usually its a not particularly severe small subdural hematoma, but some patients present with very severe cerebral hemorrhages. Then theres the fractures, hematomas, contusions, and occasional internal organ injuries. Basically, dont ride a bicycle in NYC.

This past week an otherwise healthy young man with no trauma appeared on the unit! Well, bad for him, but interesting for the rest of us. A 20 year old male had been eating a sandwich and was so voracious he swallowed the whole toothpick and didnt even notice he did. Well, 5 days after ingesting the toothpick the patient presented to the ED with a very high white blood cell count, distension, fever,  right lower quadrant pain, and nausea. All signs pointing to a perforation which upon exploratory laparotomy, he indeed did have. He actually had some very severe obstructions and perforations and needed 10cm of ileum resected where the toothpick perforated which was surrounded by distended and congested small bowel and mursky ascites. Knowing he would need further abdominal surgeries in short succession, his abdomen was left open  and VACed close temporarily.

Speaking of VACs, they fascinate me. Several surgeons and doctors have told me that they have been the greatest contribution to medicine in the last 20 years. Not only do they close wounds in a natural manner, encouraging the tissue to close from the inside out in a zippered fashion, they keep wounds clean and dry, sealed, and they seem to actually encourage wound healing through means beyond these methods. As an undergraduate I worked on trying to tease out some of these ulterior mechanisms and determined the vibratory frequency the VAC applies to the wound bed is in such a range that it drives fibroblast migration and differentiation. Using this, my group developed a simple device that is able to apply the same vibratory frequencies a VAC does to superficial wounds which in small sample size animal trials, seemed to work pretty well. This summer Ive gotten to see tons of VACs in action. Brilliant machines.