Week 3- Aniqua Rahman

This week was very similar to last two weeks. I saw patients with Dr. Pannullo as usual.  From my observations so far, I have realized that most of her patients either have recurrence of brain lesions after resection of the primary tumor or metastasized cancer, which had metastasized to brain from a primary tumor in breast or lung. According to her nurse practitioner, about 65-70% patients have recurrence/primary malignant or benign brain tumor and 30-35% patients have metastasized brain lesions. In addition to seeing patients, I went to an IRB meeting. Honestly, I had a hard time understanding the technical terms and didn’t quite understand the main purpose of the meeting. Like last two weeks, I attended the tumor board meeting (Floor 8A, Starr Pavillion, Tuesday 4:00pm). This week, it was my turn to observe round in Pediatric ICU. I spent my morning with the neuro team in Pediatric care.

One of the highlights of this week was observing Stereotactic radiation surgery in Stitch Radiation Center (located in the basement of Starr Pavillion). The device they have for radiation therapy is called LINAC (Linear accelerator). The term “Stereotactic radiation” surgery refers to the combination of advanced radiation tools and complex three-dimensional (“stereotactic”) surgical planning techniques. Radiosurgery procedures done on the brain are performed by a multidisciplinary team that includes a neurosurgeon (like Dr. Pannullo), a radiation Oncologist (like Dr. Wernieke), a medical Physicist (like Dr. Sabbas) and a nurse (like Kathleen Dempsey), all of whom have undergone special training and certification in stereotactic radiation surgery. The surgery itself is very quick, but the preparation and treatment planning take about one and a half week before the actual surgery can start. The pre-op plan includes outlining the MRI images of parts of brain that need to be exposed to radiation or saved from radiation (Neuro-surgeon’s task), making a facial mask for the patient so that the head stays on the same place throughout the surgery (medical technician’s task), determining the dimensions of radiation exposure (radiation oncologist and medical Physicist’s task).

I also discussed my immersion project with Dr. Pannullo. Dr. Pannullo said that they are installing new software called ExacTrac, which  is a patient positioning system that drives faster treatment times and maximizes throughput while offering flexible treatment protocols and quick planning, setup and delivery. My project will be some sort of analysis using ExacTrac.         

This week, I had a sad experience also. One of Dr. Pannullo’s patients (26 years old male) whom I mentioned in my first blog died last Monday. He had late stage Glioblastoma.

Week 3 - Round and Round I Go

You might expect from the title that I've been going on a lot of rounds. Nope. Just one. I've been hopping about the entire week to different departments--and occasionally into the lab.

23 June 2014

I started off the day with pediatric ICU (PICU) rounds at 8 AM with Dr. Pon. It was definitely a different experience from the plastic surgery rounds, notably the length of care and the amount of information regurgitated. In plastics, no more than 5 minutes were spent per patient, but this was generally fine since the residents and med students just changed dressings and checked up on the patient. At the end of the round, the team gathers somewhere (generally in the hallway) and recaps the 1-1.5 hour round.

In the PICU, the full story and history of the patient since admission to the hospital was explained before any further treatment. The attending was also constantly grilling the resident for alternatives and justification to the diagnosis.

I've outlined some of the patients in the 3-ish hour visit:

1. 6 year old boy diagnosed with Rhinovirus, which according to the trusty Wikipedia article, is the a major cause of the common cold. This kid did not look like he had the common cold with multiple breathing problems. Either way, they injected a slew of drugs (perhaps antivirals?) and continued to monitor him.
2. 18 year-old girl (I didn't think 18 year-old patients were considered pediatrics... the more you know) who was apparently found disoriented and non-responsive. Apparently it was a planned suicide via overdosing on some drug after some relationship issues (awkward). Yeah. Let's not commit suicide over a breakup kthxbai. (But seriously, people should seek help in these situations.)
3. Young girl with a possible staph infection.
4. 17 year-old girl that had leukemia and received bone marrow and core blood transplant.
5. Young boy received surgery due to multi-organ failure from E. coli contamination.
6. 11 year-old boy had a shunt placed in his brain because of a mass that was removed.

Next, I went into Dr. Spector's office hours, and some of the cases were... interesting. I'll just highlight two of them.

1. 22 year-old male patient had a HUGE open on his thigh (lateral) which stemmed from a 12 year-old salmonella infection. 12 YEARS. Oh, the femur is also infected. No big. I'll just go on with my life WITH THIS HUGE LACERATION ON MY LEG. The patient came in for a consultation, and Dr. Spector told him that a fibula flap transplantation is needed, and the procedure is highly risky and needed to save his limb.
2. Older male patient (think ganster-esque) with his man servant came in to change some dressings. The dressings were located on his underside (i.e. his bottom). Okay, sure, whatever. Things happen. When he was taking off his pants, we saw sores all over his leg, and apparently it was from shooting up heroin. Alright. Seemingly normal. But when he flipped over, there were LARGE gaping holes the size of my fist. I have no idea if this was associated with heroin, but I won't be injecting heroin any time soon (at least not near my legs).

24 June 2014

I went into lab and sectioned slides. Very exciting. I also saw a skin graft procedure, which was very quick.

25 June 2014

I finally met up with Dr. Skubas from the cardiac anesthesiology department, which was interested in 3D printing of heart valves. I went into the OR with him to observe an aortic valve replacement due to calcification. Apparently, most procedures here use bioprosthetic valves instead of mechanical valves since there is no added benefit to the patient from using mechanical valves (these patients are elderly--70+ years of age). Dr. Skubas showed me the 3D echocardiogram, which is an amazing piece of technology, but the rest of the procedure, although interesting, was quite bland since the surgeon (Dr. Girardi) was not a big fan of talking. Everyone in the room was silent once the procedure started, which is in contrast to many of the plastics procedures.

26 June 2014

I observed two cardiothoracic surgeries involving coronary artery bypass graft (CABG, or cabbage). Again, I found the procedure interesting, but I didn't learn much due to the lack of talking in the OR. Oh well. It comes with the territory, I suppose.

27 June 2014

I went into lab and did great things. And by great things I mean sitting around until lab meeting because the time kept getting pushed back.

Weeks 1 and 2: "Gahh, they took my freakin' kidney!"

I can finally post to the blog! Apparently all the emails that Belinda sent about the blog were going to my spam mail for some reason. Thanks to Alberto, I finally figured that out!

Post for Week 2: 

This is pretty ridiculous, but if you haven't seen it, here it is. Someone showed it to me for the first time years ago, and I thought it was pretty dumb. Yet, I still remember it for that last line...and the creepy way in which they say Charlie's name. Anyway, that being said, the most exciting bit of exposure to clinical work I had last week was that I actually got to go into the OR! It was a long time coming, but I saw three surgeries in one morning. It was crazy. I shadowed Dr. Joseph Del Pizzo, a urologist at NYP, and his surgical team.  Honestly, I could not have asked for a better first experience in the OR. If you're looking to see surgery and haven't yet, go to the 9th floor of Starr Pavillion Urology Department and ask to meet with Dr. Del Pizzo's secretary, Marina. She's great, happy to help, and sends in all your paperwork pronto to get you in for surgery the next morning even though the form says must have at least a 48 hour notice. 

The next morning, I was pretty sure I was going to get rejected for surgery because I had no idea if the head RN who is supposed to sign off on requests to see surgeries had approved me. Especially since my form was submitted less than 12 hours before I walked in to ask for scrubs. The key? Act confident. I walked up to the OR front desk as though I belonged there but when I got to the desk, I panicked when I realized no one was there but I needed to be in surgery in less than 15 minutes. I managed to flag a random nurse down and turned out she was scrubbing in for the same surgery I was hoping to see. She tossed me some scrubs and told me to come on back to the OR when I had changed. That's it? I can just go in? I didn't have to shell up an arm and a leg to get scrubs?! Nope. Ok, sure thing! I'm not gonna ask any questions! So much for going through so much trouble to get approved and ID-ed in advance. (Heads up, if you get to the OR before 6AM, chances of anyone giving you a hard time are slim AND they will always have your size). I ran to the women's locker room only to realize that I couldn't swipe in, so I went over to the nearest bathroom did a quick change and dashed back to the OR. I was told Surgery started at 6AM sharp and patient prep would be at 5:30AM. Turns out the patient arrived at 6AM-ish and prep took about an hour. The prep was longer than the surgery itself. I was amazed at what needed to be done before a patient was ready for surgery. The banter and jokes that took place following the anesthesia was pretty entertaining...although not comforting to think of ever having to undergo a major surgery like that. The doctors and the nurses in the room prepping the sterile equipment and patient for surgery were discussing what was actually involved in most surgical procedures and how if anyone knew what was involved, they would never actually opt to give out a body part...let alone have unnecessary plastic surgery done. 

Anyway, back to the surgeries! The first surgery that I got to see was a laproscopic donor nephrectomy. I was standing around awkwardly just observing and trying not to get stepped on when the nurse who had tossed me the scrubs earlier, Jessi, looked at me and said, "Wanna help prep the patient?" I was a bit uncertain that I would actually be able to contribute to the team, but with a few instructions, I was helping in small but meaningful ways; I actually existed to these people! An hour later Dr. Del Pizzo casually strolled into the room and started to get people positioned. I was a bit intimidated, but walked up and introduced myself anyway. He noticed my excitement and after a brief conversation, he realized this was my first time in the OR. He made sure I had a "front row seat" and instructed the nurses and residents to make sure I could see the entire procedure and that I had someone to answer my questions throughout the surgery. I learned quite a bit just watching and listening and every now and then, I'd have a few questions to ask. During moments of downtime, Dr. Del Pizzo would talk to me about what he was doing or about to do and explain how this novel approach (laproscopy) had a profound impact on how surgeries were done. In the past, a kidney transplant procedure involved a large incision in the side/back of the patient to get to the kidney which involved cutting through not only fat but muscle, making patient recovery time 3-4weeks not to mention very painful. Now, a small incision near the belly button is made then using a scope/camera and small surgical utensils, the kidney is removed all through one small cavity (craziness!). It was actually fairly impressive. 

Following the kidney nephrectomy, I followed Dr. Del Pizzo out of the OR in Greenburg to another operating room specifically for the Urology department on the 9th floor of Starr Pavilion. The next procedures involved a kidney stone (DRINK LOTS OF WATER-- you do not want to have to undergo this procedure let alone deal with the pain of passing a stone!). One part of the surgery required the insertion of a stint removal/replacement to provide the patient a pain free way to relieve himself while bypassing the kidney. Following that procedure, the kidney stone was broken up into smaller pieces using a holmium fiber laser that was inserted via the ureter to the stone location. Watching the resident surgeon work to repeatedly position the laser and blast the stone into smaller pieces then maneuver a small gasket to clamp and pull out pieces of stone by watching the screen oddly reminded me of watching my brother play video games growing up (I would have taken the controls myself except he always hogged the remote).

Post for Week 1 (abbreviated to make up for the length above):

My first week was fairly uneventful. I spent most of my time looking up papers to read and working in the library. I did meet with my physician Dr. Guathier multiple times to talk about potential projects as well as hash out summer plans. Dr. Gauthier is a nuerologist specializing in Multiple Sclerosis. Her life is a balance between research and clinical responsibilities; she spends 3 days of her week working on research related things and 2 days working in the clinic seeing patients not to mention her other responsibilities within the hospital as an attending. I also teamed up with some of my peers and did rounds in other departments as well as explored parts of the hospital while trying to stay out of the way of people actually working to save lives. 

Week #2: Tying not to drop the ball

The week began in rheumatology where I shadowed Dr. Kasturi in the arthritis clinic. I was not expecting a hands-on experience examining patients, but I learned how to identify inflammation via touch, feeling for warmth in the knee or other inflamed areas. One of our patients had been diagnosed with juvenile idiopathic arthritis (RIA) when she was 3 years old. Now 38 years old, she has numerous surgeries under her belt (spinal fusion, wrist fusions, etc) and continues to live in a great deal of pain (especially in her hip). I got to examine her “telescoping digits” -- soft, swollen fingers resulting from joint destruction and bone loss. The patient opted not to get a steroid injection to relieve the pain before going on vacation due to time constraints. While much of the patient's life was confined to a wheel chair, I was inspired by her reliance and positive outlook.

I also attended the “comprehensive arthritis clinic” where a special case is examined in detail by a room full of doctor and students. This week’s patient was a young Chinese girl diagnosed with multicentral carpotarsal osteolysis (aka “vanishing bone syndrome”). This mysterious condition was unknown to the majority of the room. Turns out, it is caused by a mutation in the MAFB gene (codes for a transcription factor/regulatory protein responsible for osteoclast maintenance and renal function). While the patient had many skeletal deformities and considerable wasting in the right hip, there was some reluctance to treat her (e.g. with a hip replacement, etc.) because of her lack of pain and the possibility of infection and further complications. Risk assessment appears to be a HUGE component of medical decision-making and this is one area where biomedical engineers may help design tools/techniques/quantitative methodologies for deciding the best way to intervene and WHEN.

After spending another day with my mentor, Dr. Ebben, meeting with patients in the Sleep Lab, I finally had my opportunity to explore the OR. For those looking to observe surgeries, the best way I have found is to check the schedule for the following day at 4pm at the OR desk (it is not out in the open so you have to ask). Pick a surgery that looks cool and visit the surgeon’s office and speak with his/her assistant (or directly with the surgeon). You might have to get paperwork signed, but you will then be good to go for the following day. Urologist Dr. Douglas Scherr is very willing to have students shadow and he was the first surgeon who I observed.

I watched a robotic prostatectomy which utilized the Da Vinci surgical robot to remove a cancerous prostate. This was one of the craziest things I’ve ever seen. As I quietly rocked out to Adele’s “Set Fire to the Rain” which the OR nurse had put on, I had the eerie feeling of being in a SciFi movie where a large alien octopus was hovering over the body, ready to operate. A dual consul setup enabled a fellow to operate the machine while Dr. Scherr provided guidance and could intervene if necessary (think driver’s ed). Multiple incisions were made and ports were installed to allow the robot to dock and various instruments to be inserted, including a camera probe which provided everybody in the room with the surgeon's view. Dr. Scherr operated the robot using both hands and feet and performed many fine manipulations to cut, suture, tie of blood vessels, etc. In order to gain direct access to the prostate, the bladder was pulled down and out of the way and the vas deferens and seminal vesicles were removed. Equipped with both a monopolar and bipolar cauterizer, the Da Vinci was able to cut and coagulate simultaneously, minimizing the bleeding. Excess blood was removed using a suction. The most intense part of the surgery was when the suction stopped working and Dr. Scherr assertively said, “Okay, everybody STOP.” There was silence. He then gave further step-by-step instructions describing what needed to happen. It was cool to see him in action as the commander and chief of the operating room. While cauterization is an effective tool to minimize blood loss, sometimes it is avoided; for example, on the lateral regions of the prostate where damage to peripheral nerves could prevent the patient from having an erection (that would really be a downer). In addition to the prostate, the lymph nodes were resected and sent to pathology for evaluation. The lymph results will provide a score for metastatic likelihood which can then be used to guide subsequent treatment. The surgery went very well as a whole and the patient should be off to a speedy recovery. 

While the surgical team stitched up the fascae layer and closed the patient, Dr. Scherr moved next door to excise a scrotal mass from a 29 year old patient. Compared to the 4+ hour prostatectomy, this was a simple ~40 minute procedure. The right testicle and the full spermatic cord were removed through an incision in the lower lateral abdomen. It’s nice to know that a sense of humor is welcome in the OR, as the nurse urged the resident not to “drop the ball” as the testicle was transferred into a container for pathology. In addition to Dr. Scherr, Dr. Zarnegar is supposedly another good one to shadow for robotic surgeries and is known for being an innovator, as well as an expert operator.

Sorry for the lengthy post! As you can tell, my week was pretty nuts! 

Week 2: Making Friends in the OR - Kaminski

Here we are again, Dr. Girardi was out of the office for most of the week, and I wasn't feeling well the end of the week and have some personal things to take care of so I spent a little less time in the OR this week than usual. However, when I was in the OR, I was with a really wonderful 3rd year med student who explained SO much to me. We went over not only what all the lines and tubes going to and from the patient were, but also what the read outs meant and why that lead to the decisions it lead to and why certain drugs were given at some times and others at other times. This was particularly helpful because he also asked me questions instead of just giving me answers. There have been major pay offs this week, and I'm sure for the rest of my time here just in terms of comfort. It's also a lot of fun to look at the monitors and think to myself, "they're probably going to ask for epi," or "seems like they're gonna need some amiodarone". For those of you looking to go into the CT OR in the next few weeks I would suggest making friends with the med students and the anesthesiologists. Also, I'm planning on putting together a cheat sheet of helpful terms, tests, and roles in the CT OR to keep track of it all myself - I'll post it on the BME Immersion facebook group for everyone to look over if they want.

Aside from starting to feel at home with the orange team, I also got to go the the morbidity and mortality (M&M) meeting in CT. In this meeting the chiefs, fellow and a few others discuss difficult cases and try to trouble shoot what went wrong. Last week there weren't any mortalities, and honestly most of it went over my head....I'll give a better report next week. =)

I did take a step into the land of babies this week. I spent Tuesday on Labor and Delivery, and wow, it is another world. It's pretty much like a whole little hospital all of it's own. There is a triage, which is like a small ER, the delivery rooms, the recovery rooms, and the OR for C-sections. It was pretty much as different as you could get from CT, but just as intense in a crazier sort of way. Everyone is always moving and always busy. But, I learned a lot, and did get to see some patients with the residents. I'm planning on going back another time to see a C-section and hopefully a delivery!

The next day I saw pediatric cardiac surgeries. The first case was a ventricular septal defect (VSD) in a 5 month old. The hole was shockingly large, about the size of a nickel! That procedure seemed to go well, and we were very quickly onto the second surgery which was a patent ductus arteriosis (PDA), or shunt between the pulmonary artery and aorta. This is there so that in utero the fetuses blood doesn't need to circulate through the lungs since it is getting oxygenated by the mother and typically closes on its own after birth. However, there are patients where this doesn't close and surgical action is needed. This procedure is done via thorachotomy (incision through the ribs) and is fixed with a simple metal clip.

Overall, the sites, sounds, smells, and pace of the OR continue to be fascinating, but overwhelming. Moving forward I think I'm going to only spend three full days in the CT OR, and my other time working on a research project (which I may have identified!) and visiting in other areas.

Derek's second week at HSS

This week, I was able to join three different surgeons in the OR. Two of them were sports medicine specialists and the other was an arthroplasty surgeon. With the sports medicine surgeons, I saw how X-rays and MRI scans play such a key role in deciding on which surgeries to perform. Both of the sports medicine surgeons frequently used the arthroscope to make the surgery as minimally invasive as possible. With the arthroscopic camera, they are able to see inside a patient's joints, which allows them to remove diseased tissues, repair torn pieces of cartilage, etc. With the arthroplasty surgeon, I witnessed a total hip replacement. Simply put, it was awesome and I want to see more.

I have also been busy gaining access to everything I need for my research projects. My clinical project should be up and running by next week, and I have been collaborating with the Goldring lab to determine the next appropriate steps for my research in Ithaca.

DB Week 2

The part you might want to read

If people are interesting in seeing caths, EP or ccu rounds, let me know. I've already taken Danielle and Aniqua, and joined up w/ Jason, so pairs work in cardiology.

Tracking the VSD case

As you all remember from last week, I have been tracking a patient who has a ventricular septal defect. This week, the patient went in for her cath to place an occluder device in the defect. On echo, there was a clear defect near the apex of the heart, so at the time it seemed like it would be straightforward. What I didn't know at the time was that it took 3 echo techs and many tries to actually locate a hole. The only reason they kept trying was because her mermer was drastic.

At the start, the doctors realized that extra permission from her family was needed to perform a balloon angioplasty of her stenoic aortic valve. After the BA, contrast agent was injected near the site detected on the echo. It didn't show up. If anything, it looked like there was a hole more central in the septum. They were able to interrogate a hole after about an hour of poking and calling in a trans-esophogial echo. Upon injecting contrast, there was obviously still a leak, in fact the leak was more obvious than before! Ultimately, in terms of heart efficiency, the procedure did seem to help. She was removed from balloon pump support and appeared to be stable. However, that night she became hypotensive (~70/20) and went in to afib right when I went to rounds in the morning.

I watched her post op echo live. Again, the tech had a very hard time visualizing the defect and the occulder. It was great to witness the occuder in place, seeing the results of the cath first hand. There was still a clear leak around the apical side of the occulder. She was put back on the balloon pump and continues to need support. If she does not stabalize soon, the doctors will need to inform the family that they will not be able to stabilize her.

Mapping Cardiac Electrophysiology (EP)

Patients require EP mapping when they have dead heart tissue that creates abhorrent electrical circuits. The heart is mapped to find the tissue, which can then be burned using radiofrequency ablation.

The EP lab looks like the cath lab 100yrs in the future. They use a technique called stereotaxis where two large magnets are used to guide a metal catheter inside the patient's heart. The doctor need simply control the vector of the magnetic field with a mouse pointer, and the insertion and withdrawal of the catheter with the mouse wheel. Stereotaxis allows the EP lab to map the electrical properties of the heart point by point onto the patient's heart geometry, which can be initially be obtained by echo slices and is refined as the doctor probes the heart.

Interestingly, the EP lab has the ability to induce arrhythmias by pacing (shocking) the patient's heart. Before cath insertion, the patient demonstrated several PVCs, indicating that there were several possible sources of arrhythmia. At one point, they induced a ventricular tachycardia that caused the heart to completely destabilize. The doc asked "is he out?" and before the nurses could answer, he proceeded to say "Shock him." The patient was defibrillated. Jason Jones and I thought this was insane, to be euphemistic.

This happened 3 times in the procedure, which took 5 hours. While his VT was harder to induce by the end of the surgery, he was sent back the next day to have an ICD (intracardiac defibrillator).

I saw the ICD implant, finally getting into a surgical room (not quite an OR). At the end of the install, a VT was induced and the patient's new ICD dutifully shocked his heart back to normal.

Second Week= Second Weak? (Guss)

So the second week in the immersion term I have finally settled into a routine that involves shadowing my mentor Dr. Lisa Vasanth in the office in mornings, as well as the fellows staff in the office. There are several clinics that I normally follow the fellows around from 9-12 in the morning.  They are the arthritis clinic, comprehensive arthritis clinic, rheumatology new patient clinic, and the connective tissues clinic.  I also shadow the fellows and the attending doctor around in consult services everyday. I find these particularly interesting because I get to hear the fellows discuss the patient first and then we get to visit them and we can keep track of their progress over their stay in the hospital.  This week the one case that stood out was a women with dementia as well as severe rheumatoid arthritis (RA) and they were worried that the RA could affect the spine and cause more trouble.  Another favorite part of the week is meeting with one of the teaching professors Dr. Paget.  Once a week for about an hour all the fellows (and me) crowd into his office and he reviews cases he finds particularly importnat or worth while for us to know. He explains a lot which is great for me because I am definitely the least knowledgable person in the room.   Overall this week was not as exciting as my first but was definitely a good experience.

Week 2

Not a whole lot this week. My mentor is still gone, and I have little interest in reciting any patient medical charts or recording my observations during rounds, as I have already spent two years as a medical scribe.

Observed a few robotic prostatectomies with Dr. Scherr. These surgeries are pretty cool, especially since you are able to see everything happening endoscopically. I would recommend that anyone having a difficult time seeing other surgical procedures or understanding A&P team up with Dr. Scherr and one of his residents for one of these. The residents are usually pretty helpful since they do not gown up for the surgery.

Week 2 - Aniqua Rahman

This week Monday, Tuesday and Wednesday, Dr. Pannullo had to go out of New York City. Therefore, this was my opportunity to explore other areas at Weill Cornell Medical College.

On Monday, I teamed up with Danielle. Her Mentor, Dr. Nanus, is a prostate cancer specialist. Together, we went to three meetings with him. First meeting was with a group of Hematology oncologists. In this meeting, one of the Hematology oncologists presented a case of lymphoma. This case was about 43 years old female patient who was diagnosed with Asymptomatic Follicular Lymphoma about two years. That time she was doing completely fine and didn’t want to start chemotherapies or any other treatments because she has children under age of 10 to look after. So, the doctors suggested that in her case, they could ‘wait and watch’ her disease status. Because one of the British clinical journals, published around 2004, discussed that a brief period of “wait and watch” might not make a difference on the possible life span of patient’s with asymptomatic follicular lymphoma. But now after two years, the patient is back with some symptoms like sore and fatigue, and she is ready to start some kind of treatments. The main reason for calling this meeting was to discuss possible treatment options to provide a better quality of life and increased life span to the patient. The doctor who presented the case was quizzing junior doctors on how they would treat this patient after looking at all the test results. It was quite interesting to see how different doctors had different opinions on the same case. I realized sometimes (or most of the time), it is really hard for doctors to select a treatment for the patient. They rely a lot on clinical research studies to make decisions for a patient. The second meeting was a clinical-trial research meeting, where doctors were just making sure that the patients who are supposed to be on clinical trial drugs (or injection shots) were coming on regular scheduled time and getting their treatment (drugs/injections) on time. Because at the end of their treatments, doctors have to report back the efficacy of the drugs on patients. The third and last meeting was the tumor board meeting. This meeting was similar to the Brain Tumor board meeting that I attended with Dr. Pannullo. Here, oncologists went over several prostate cancer cases.

On Tuesday, I teamed up with David and spent the entire day in Cardiac ICU and Cath lab. We started rounds at 8:30am, which lasted until 12:00pm. During the rounds, getting to watch the real time cardiac ultrasound on patient was the most interesting.  During the rounds, we found out that an 80 years old female patient was going to have a surgery in a Cath lab. So we decided to follow the patient. This patient had abnormal heart murmur after heart failure. Doctors suspected Myocardial infarction (MI), but the result came out negative. Therefore, Ventricular Septal Defect (VSD is a hole in the wall separating the two lower chambers of the heart). She was not in a good condition for open-heart surgery. The best option for her was to place an occluder through catheterization procedure. This surgery lasted for almost more than four hours.  At first surgeons had real difficulty finding the hole (this delayed the surgery). But the at the end, the surgery was successful.

I went back to my regular schedule, seeing patient with Dr. Pannullo, after she came back on Thursday. I met two patients with metastasized breast cancer. These two cases really grabbed my attention as my actual research with Dr. Reinhart-King is on breast cancer metastasis. Here are brief summary of the two cases:

• 66 years female patient. Right-handed. She was diagnosed with breast cancer and had mastectomy, but her cancer was metastatic. There was a lesion found in her brain in 2012 and was treated with radiation surgery. Now reoccurance of two more lesions in brain stem. Dr. Pannullo suggested Stereostatic radiation surgery.
• 71 years old female patient with metastatic Breast Cancer. She had Cyber knife surgery which was not effective and then had gamma knife surgery to the left hypothalamus, which seemed to be effective. But recent MRI shows left frontal metastasis. She is here to have stereostatic radiation surgery.

Week 2

This week is similar to last week where I followed Dr. Miller to check on patients every day. A lot of Dr. Miller's patients have been discharged and Unfortunately the office for approving scrubs and OR access has been slow in response and I finally got an account on Friday.  Also a lot of test results came out from last week and Dr. Miller is able to apply the right antibiotics to the "unsure" patients. I shadowed Dr. Henry on Monday afternoon and some patients were surprisingly ill. Mostly patients I have been observed at HSS only have fractures or joint replacement and bacteria makes it more complicated however people with self immune diseases or genetic bone problems are suffering a lot and doctors often work together to discuss the right dosing so parallel treatments are not affected. There is one case of lupus patient who is under going kidney dialysis came to Dr. Miller about pain in mosquito bites. Turned out that patient have chickpox and the symptom that patient has is classic shingles. 

We had the meeting from radiologist Dr. Prince on Thursday at 11am on Thursday. We discussed cases from X rays, CT and MRI. The case for me is an external fixation example which was an easy guess because I visited one patient with this treatment once. I think I will go back to the basic principles of those imaging tools because I felt a lot of easy questions like why this show up, what color should it be, what type of imaging was used and why, etc can be answered easily if I know the mechanisms of imaging better. In the afternoon after I got back to Dr. Miller, he took me to see a radiologist to check on one of his patient. We looked at the MRI which showed some abnormal fluid (I really appreciate the lecture earlier to help me understand) but not a clear sign of infection. This patient complained about abnormal pain in shoulder but no other symptoms. I stayed late to watch they taking fluid from shoulder and lavage samples using ultrasound to locate the fluid. The procedure looks extremely painful as a huge needle was inserted and they were moving around to find fluid sample which was not quite enough for analysis. 

I didn't go to the weekly meeting on Tuesday but I went to the bug of the week meeting on Wednesday as mentioned in last week's post. Some very interesting fungi and bacteria as always but there is a sample from a burn patient is particularly sad. The one bacteria shown is a super resistant strain which they haven't been able to find a treatment. It is also very rare and the last patient who had it was years ago and that patient died a few days later and the doctors said the chances are small for the burn patient too. I went to a lecture by Dr. Henry on Friday at 1pm on urinary tract infection and arthroplasty. He presented and analyzed statistical data from literature which is actually quite limited. Few studies have been done in this area. The conclusion is that it is inconclusive and they will still follow the standard guidelines on what HSS has. I was constantly confused during the lecture as doctors used a lot of abbreviations and I still have trouble following them. Another interesting aspect I noticed is that those lectures consists mostly data analysis which is like the follow seminars I attended last week. This is very different from graduate schools where people usually spend a slide or two.