DB Immersion Week 1

At the start of this week, I was a bit discouraged as my mentor, Dr. Jonathan Weinsaft, does not see patients directly and was focused on starting me with a computational research project. While I still think my idea of immersion (80/20 clinical/research) is different from JW's (50/50), I found that he can set me up with fulfilling shadowing opportunities.  I plan to fill that extra 30% of clinical time by tracking specific cases long term and seeing procedures with other immersion students.

Catheterization 1 6/10

Mt first clinical experience was seeing a cardiac catheterization (cath). In this type of procedure, a catheter is inserted into the patient's femoral artery. A robotic x-ray machine is used to image the catheter. X-ray absorbing contrast agent is injected to visualize vasculature, abnormal heart movements and is used whenever the cardiologists need to know where they are sticking the catheter.  Initially the catheter is used to measure pressures and temperatures throughout the heart and cardio-pulmonary system to characterize the performance of the heart.

This particular case was routine and uninteresting but it was worth becoming familiar with the procedure and meeting several techs and doctors in the cath lab. An uninteresting cath is one in which hemodynamics are measured and no further procedures are required (or perhaps, no cath procedure can remedy and open heart surgery is required). Note that one convenient thing about caths is that you don't need to scrub in because there's a control room.

Cath 2 6/12

JW had dropped me into the first cath. However, this morning, I missed rounds (didn't know where to go, so sadly) and needed to find something productive to do. I found a cath tech and asked if there was a cath to watch. He sent me to a lab. Dr. Feldman was running the procedure, and wasn't too pleased to see me, but said he'd "do it for Dr. Weinsaft." 

This was an interesting case. A large branch of the left circumferential artery was occluded, which was detectable by contrast agent and a first year med student's knowledge of coronary arterial networks (ie. something is missing). Though I lacked such knowledge, I was able to sit at a free computer in the control room and rapidly search for diagrams and unknown terms. The tech was also very kind and guided me through the procedure. Thereby, I was able to follow it completely.

After detecting the occlusion, a balloon angioplasty was performed in which several balloons were inflated sequentially to gradually increase the diameter of the occluded branch. Finally, a stent was  inserted, markedly restoring blood flow.

Dr. Feldman took time to print out and annotate pictures of his work, which was nice. Caths may be good candidates for walk ins (due to control rooms being ridiculously relaxed), but I will make sure to schedule in advance next time.

Rounds 6/13

I finally made it to cardiac ICU rounds. My contact was fellow Dr. Josh Weisbrot, and Dr. Alicia Macklai was the cardiologist on duty. Most cases were routine, but it was valuable to see clinicians interacting with real patients, and to see the variability between patients in terms of both mental and physical condition.

One rare and interesting case came up: a patient with a ventricular septal defect post myocardial infarction (heart attack). Dr. Macklai and Josh were very receptive to my questions on further treatment for this case. The plan is to occlude the hole with an "occluder" inserted via cath. I am really hoping to see this one, and will definitely figure out when it is and get advanced permission, because it will probably be crowded.

Rounds may become boring over many mornings, but they nonetheless offer the opportunity to find interesting cases to track.