Week 3-7 LL

Week 3
I got in contact with Dr. Fragomen in limb lengthening center and he was every generous to let me observe him in the office and in the OR. I went to his office on June 24th and spent a day there. A lot of patients came for post operation checks and some for new consults. I saw several patients with external fixator on. It was developed by Dr. Illzarov which uses a cage frame over the site and inserts several metal rods through bone at different angles to stabilize the frame. The interesting idea behind it is that slightly elongating a bone everyday will enhance bone growth and promote new bone formation. Compressing bone will make bone heal faster but the limb shortening is a problem so this technique was also used on several patient who has uneven legs. It is quite interesting to observe the new patient consults as Dr. Fragomen will perform several simple tests and readings to mark the natural status of both legs, such as angles (inward/outward) in combination with x rays reading. Sometimes there will be a different in hip orientation too because patients with shortened limb tend to lean on one side of the body to balance the weight.
On June 30th, I went to OR for the first time. The procedures was performed by Dr. Fragomen and started at around 5:30pm. The patient has an infected lower leg and Dr. Fragomen put some antibiotic beads into the patient’s leg a few month ago. This time he scooped out the old ones which didn't dissolve and placed new beads into the tibia. The type of beads used is similar to a bone cement material, hydroxyapatite perhaps, which serves as a bone growth support and the central part will not dissolve. After placing the beads, Dr. Fragomen performed an ankle fusing with external fixator. It was amazing to see how doctors insert metal rods into the bone at different angle so in the next few weeks, they can compress or elongate 1cm at a time to promote bone growth and healing. The procedure finished after 9 pm. 
Other than those times with Dr. Fragomen, I went on rounds with Dr. Miller to check on the patients from previous week.


Week 4
I had a quite diverse experience this week. On July 1st, I went to a Catheter-based aortic valve replacement procedure with Jason J in NYP. This was actually a really fun and quick procedure where doctors deliver a catheter that has camera and monitor accessories to find the exact geometry of the heart. After injecting some dyes they delivered a balloon towards the valve which carries aortic valve implants consisting of a fine stainless steel mesh frame with a tissue valve with three leaflets. The balloon was inflated to position the new valve near the old valve and quickly deflated. One of the doctor said that this time, the mesh was slightly above the right position but it is still functional.
On July 3rd I went to Dr. Mayman's surgeries on hip and knee replacements. I watched 4 knees and 4 hips which was an hour each and Dr. Mayman rotate between ORs to do the most technical part. He used a technique called computer assisted knee and hip replacement. There is a camera capturing markers on the leg (for hip replacement) and 3 markers on flat edges. I think the mechanism is similar to a XBOX Kinect. After that, the screen will show the calculated hip location but I personally felt that this was not playing a game changing role in the procedure as doctors had to adjust the implants by rotating legs in the end and even if the computer said that was right, if the movement was not smooth, doctors had to redo it.

Week 5
Highlights of this week is medical ICU and emergency department. The medical ICU was extremely interesting. There are many patients with many complications and require close monitor and if there is a change in vitals, the doctors have to respond and provide correct corresponding treatments. One patient has elevated sodium level in blood, or Hypernatremia. Loss of free water or impaired water clearance can cause that and it is important to know what the true cause is because treating the wrong one can lead to severe consequences. Dr. Berlin was like a physiology teacher and whenever there is chance, he will lecture on what is causing this condition, what can be done, what is similar but shouldn’t be confused, etc. I felt very enlightened and I really like it. 
The experience at the emergency department is mixed. I was assigned to area C and which is relatively smaller compared to area A and has many patient monitor rooms. There wasn’t many patients out in area C to be honest. I was with a resident doctor who was kind to show me some procedures closely like ultra sound guided vein finder which is really cool as I wish to have that during blood draw. Starting from 3:30, there is a shift change and I was following another doctor. Perhaps the most important things I learned was patients lie and they are unreliable in story learning, especially in pain rating. There was a patient with open wounds on head and he was drinking. The doctor let me hold his head while the rest people flip him on side so the doctor can tap on the spine to check if there was anywhere painful but this guy just responded really slowly and said no. He was taken for x rays and then left on sidewalks while the doctor check on other things. I found him took out his neck support and informed the doctor who thanked me for catch this because this guy was drunk (not felling pain) and he broken a bone in the neck and had some fractures on the face too. If no one found out, he might ended up paralyzed. I truly felt that ED needs more nurses. After 6pm, I was actually the doctor to check vitals, find machines, scrubs, and other supplies when those things could have easily be done by nurses. Anyways, that was a memorable experience where I was ‘lucky’ to get hands on experience because of shortage in nurses.


Week 6
This week is pretty regular where I go to rounds with Dr. Miller at infectious disease to check on patients. There were some really sick patients come in. One patient is waiting for a hip replacement with amputation but had infection signs and severe pain. It was really heart breaking to watch him lying on the bed bearing all the pain because no one knows what is going on and he was not given pain medicine yet due to that reason. When patient is suspected to have an infection, if the patient is given or taking antibacterial drug prior to collecting cultures, the results might be false negative and therefore not trust worthy. This patient had a hip spacer in and it created a huge black area on MRI images that can’t be used to find out infected tissues. I feel better engineering could be done on spacers as they just work as a temporary replacement but people usually need to take images.
I spent most of the time working on my summer project. Propionibacterium acnes (p.acnes) is a slow-growing, anaerobic, Gram-positive rod that live on the skin. It is reported to cause mild infection on orthopedic procedures but often leads to prothetic joint implants failure, especially in shoulders. I was given the infection dates, number of positive p acnes cultures and all cultures ever collected here at HSS for patients with p acnes infection during 2008 to 2014 (April). I am hoping to graph patients based on infected site on different years to see if there is any trend. In addition, I got some diagnostic data on half of those patients which I will find out those with prosthetic joint infection and do a chart review. There is a slight mismatch of data but it is probably too late to correct all of them.

Week 7
This is the last week of summer immersion program which So far I got a glimpse of some orthopedic procedures on the lower limb and I was lucky to get to watch spine surgeries with Dr. Huang on July 22nd. The first one was a posterior lumbar interbody fusion (PLIF) revision. PLIF means making an incision from the back and insert a lumbar interbody cage with bone graft into the disc space which eventually fuse the discs to alleviate pain. There is a really good website for spine surgeries and it has great animation to show different procedures: http://www.spine-health.com/treatment/spinal-fusion/posterior-lumbar-interbody-fusion-plif-surgery. The patient had a PLIF before but the screws dislocated so a revision is needed. The tools for spine surgeries have much more interesting shapes and diverse functions than knee surgeries and is fun to watch. During the procedure, Dr. Huang took out all the screws and rods and placed new ones in there. The dislocated disc was not perfect even after reinserting rods so he decided to place a frame along the discs above and below but leave that specific disc (center) free of screws. The second procedure was to remove thrombi from neck with fusion. The incision was small so I didn't get to see the procedure closely. But the vendor associate was really helpful and he showed me the devices his company made, why & where are they used and even give his suggestions on how to improve the device after hearing that I am an engineering student. So that was a fun surgery to learn from a different perspective. In both cases, bone graft material was harvested from ilium crest because it contains large amount of red bone marrow.     　
On Wednesday I went to surgical ICU with Leah and David. This is a bit different from other ICUs where rooms are big enough to do emergency surgeries on site. Many patients have severe complications, such as cancer and etc but the acute diseases or conditions are what is keeping them here. The rounds was very short as the doctors only state all the vitals and conditions but on the other hand, they monitor and even perform surgeries on those patients so they know everything extremely well.
On Thursday, I finally got a chance to see the open heart surgery. I arrived at 8am and the coronary bypass surgery was to use 3 veins obtained on the leg to create a bypass on the heart to detour blood around the blocked arteries. The first half of the procedure was to open the chest, obtain the veins, and connect heart to bypass machine that will circulate blood while the heart is stopped. The second half of the procedure was to use stop the heart and suture the veins to heart and was done by the professor. I was lucky to stand right behind the anesthesia stage and watch it. The speed of suture was amazingly fast and they count on time to finish each vein, usually around 15 min each. The professor was very strict and the whole procedure was like a military task where every plays soldier and was extremely intense. I was a bit surprised that I could see from anesthesia’s side because at HSS, they always pull a plastic curtain around that area and the view is very blurry. I was a bit afraid to introduce any potential contamination since I was watching from above the chest.

On Friday, July 25th, I presented my summer work for the three infectious doctors at HSS. I was quite surprised to find out that they booked a big conference room(I would have prepared more if I knew this!). I presented bar graphs and pie charts showing the statistics of the patients with propionibacterium acnes, categorized based on sites(hip,knee, etc) and I selected 35 patients with prosthetic joint infection and did a chart review on the bio, surgeries, co-infected bacteria. The head of microbiology lab was also present and he was surprised to see that other bacterial infection pie chart has bacterial that should be the same but with different names. The pie chart draws bacteria names from the database directly so the regulation for better data entry and records is necessary. Nothing new is drawn from the presentation as I was given limited data with some defects. Dr. Brause was very interested in using some of the slides for his presentation and I was glad that my work is useful for them. And hopefully the research associate they just hired will continue to collect data and compile into a good paper.

DB Week 7

Cystectomy

This week I saw a bladder and prostate removal via the da Vinci robot followed by the construction of a new bladder from the patient's colon. 

In the robotic part of the procedure, fat and connective tissue was removed to gain access to the ureters, bladder and prostate. There are 3 monitors to watch the robot camera. While this is great, it was very hard to make out what was going on during the start of the procedure. Clamping of the ureters and the sealing of the urethra were noticeable. The actual removal of the bladder and prostate was unclear, just a bunch of cutting and cauterizing. Once removal was complete, the bladder and prostate were bagged inside of the patient by the robot.  

The second part of the procedure was extremely interesting to watch. The patient was cut open and a ton of fat and intestines was moved out of the way. The bagged materials were removed and saved for pathology. A section of the colon was exposed. At this point, I was able to stand on stool right next to Dr. Scherr, getting a surgeon-eye view. About a 10cm length of colon was partially detached such that the blood supply remained intact. A strip of colon was cut and opened flat. Then, two holes were cauterized in the strip. The ureters were inserted through the holes and catheterized to drain urine while the bladder was non-functional. The ureters were dissected on one edge to create flat flaps of tissue that could easily be sown into the colon stratum. Next, the doctor and fellow assembled  the bladder by creating three suture lines, working effortlessly as if sowing the seams of a quilt, constantly asking for more thread. At some point during this process, Dr. Scherr started a conversation where we discussed the procedure and the potential for engineering new bladders from scratch. It was motivating that the surgeon is trying to move beyond this procedure, which seems so ingenious that you'd think no alternative would be in demand. I found it very interesting that this bladder provides continence which is engineered by crimping the exit  to the new bladder with sutures. Dr. Scherr passed a catheter through the opening to test its resistance. Too stiff and the bladder won't empty, too weak and the bladder will always be ready to empty. Since the urethra is shut, a new conduit must be used. Dr. Scherr removed the patient's belly button and promptly threw it on the table. This next part I found really weird and interesting. The colon piece is sowed directly onto the outside of the patient's abdomen. Part of the body that was inside is now outside. A catheter tube was place through the hole for permanent use. Controlled urination from the belly button is now a reality. 

Dr. Scherr is awesome and this was definitely my best OR experience of the summer. 

The rest of the week

Saw some cool things in the MICU and SICU, and downloaded the echos for our research.
Zhe and Alexey were also able to give me an MRI.

Summer Immersion

This was a transformative experience that has given us a perspective into healthcare that we could not achieve in any other way. While I would not consider my experience immersive, as it should have been, hence the title, it was still fulfilling and completely worth it for the best moments.

 Week #7 (Nerymar Ortiz Otero): The End of the Summer Immersion

        In my last week, I spent more time seeing surgeries related with tumor resection, place shunt, and introduce a therapeutic agent. The surgeries are really similar to the surgeries that I saw before. In other word, this week was like a normal week where nothing special or exciting happened.

     One of the surgical procedure that I saw was the pituitary tumor resection via endoscopic approach. I have seen like 6 or more endoscopic surgeries during the summer immersion. However, in this something different happened. In this case, the patient had a cerebrospinal fluid (CSF) leak through cavity where is the pituitary gland. At the begging of the surgery, the nurse injects fluorescein in the back of the patient to stain the CSF to can distinguish it from the blood. I knew that but I never see the function or use of the dye. In this case, I could see how they knew there is a leak because you could see the green fluid there (fluorescein). To fix that, Dr. Schwartz made a graft to close the space and avoid the leak. The graft is made using a fat flap tissue got form the patient at that moment. This is a rare complication that can occur during the surgery.

       At the end of this week, I thanked to Dr. Schwartz because he was a great advisor for me and I appreciated it. I am very grateful with him and with the program for this amazing experience. Is really good have the chance to observe the another face of the biomedical engineering. At the end of the week, Dr. Schwartz gave me and another students two books that are about the experience of resident students in neurosurgery field. Here give details about curious brain conditions to learn more about the neurologic field.

Week #6 (Nerymar Ortiz Otero): Glioblastoma vs. Meningioma

           For this week, I was observing surgeries of patients with severe conditions and how is the healing process for them. I could see the patients before, during and after the surgical procedure and basing this I could determine the healing process.

           For the first case, the patient had a malignant glioblastoma. That was the third surgery for the brain tumor resection. At this time, Dr. Schwartz told me that this is the last shot for her because she has to much neurological damage where she doesn’t have enough time to fight with that (she is dying) . The surgery impressed me a lot because she had a huge space in her brain due the last two surgeries. She had a space in the frontal part toward down. The big space allowed you see the optical cavity inside of the skull. According with the MRI, the glioblastoma was large but they just removed only small parts of this.  Dr. Schwartz could not remove the whole tumor because she will loss to many important brain functions. Before to remove the tumor, they made a brain functionality test to know which parts they could remove from the brain. The removed glioblastoma was put in vessels to bring this to research lab. I could see her two days after the surgery, and she was not doing well. She had to much pain in her body that the nurse could not touch her. Also, she was not conscious and awake.

          For the second case, the patient had a large meningioma in the left frontal lobe. The meningioma extracted was really big and it had many vascularization.  This was put in a vessel to bring this for the research studies. The more exciting moment in this surgery was to observe the appearance of the tumor. This was big with a irregular shape and to many blood vessels inside of it. I could see the patient two days after of surgery and she was doing well.  As consequence of the tumor, she could not move the right arm and its fingers. However, after two days, she could move the arm very well and the fingers slowly. In other word, she was in recovery process where the symptoms are gone.

Week 7- Aniqua Rahman
Unfortunately, I had to leave for Ithaca on Sunday of this week to get some urgent work done there. But I was back on Wednesday to attend the weekly meeting. Overall, I would say that I really enjoyed my time at Weill Cornell Medial College. I know, some of you have some mixed feelings about immersion. But I think we all somewhat agree that it was quite a unique experience. At least for me, it was a good learning experience becasue I didn’t have much exposure to the medical environment in the United States. I really appreciate Dr. Wang and Dr. Frayer’s effort to make this immersion program a great opportunity for us to establish networking and connection to the medical world, which will definitely be beneficial for our future career. And I also feel that this opportunity should be given to future BME PhD students.

Week 7 - I'm coming home

*Cue the music* (https://www.youtube.com/watch?v=k-ImCpNqbJw)

Although this was my last week in NYC, I went about my week just like any other week.

On Monday, I went into office hours to see either new or post-op care patients, many of which were similar to cases I've described earlier in the program. However, one case I wanted to note (and the one I took notes on) was one woman who had a skin graft, but she also had an arterial ulcer. The ulcer restricted blood flow to the region where the graft was placed, which led to lack of healing and necrosis of the graft. I also learned that we can distinguish this from a venous ulcer due to the lack of edema--and if she had a venous ulcer, the graft probably could have healed a bit better.

Tuesday and Wednesday were both OR days. On Tuesday, I observed two cases: an abdominal hernia repair and tumor removal with facial reconstruction with a flap. In the first case, the surgeons performed an open hernia repair--a relatively quick and simple procedure, especially when compared to the second case. Although I didn't see much, the bulging tissue was removed and a mesh plug was used to cover the hernia site. They sutured the mesh (a biodegradable polymer (P4HB, or poly-4-hydroxylbutyrate)) into the surrounding tissue and called it a day.

In the second procedure, it was a similar case to the very first operation I saw. ENT had to cut open the patient's mandible, remove the tumor--which, in this case, was his ENTIRE tongue--prep the flap, transfer the flap up, reconnect some vessels, and close up. It's always an awesome case when someone's head gets cut open. The tongue was also surprisingly small (sorry, no pictures).

Wednesday procedures were simple cases, including another hernia repair and a skin graft placement. Nothing special to note here.

Thursday and Friday were spent in the lab working. On the bright site, I learned how to pull tails to isolate collagen. Yay science.

Last Week of Immersion

This week mainly comprised of me writing my ORS abstract for the conference that is coming up. However, on Monday I was able to shadow Dr. Goodman and few of her colleagues around the hospital and the office. There were two patients that were particularly interesting to talk about. The first patient had Psoriatic arthritis (PA). This is where the body develops an immune reaction that is nonspecific and causes rashes to form on the skin. Unfortunately, this immune reaction sometimes attacks the joints as well. This patient was on Humira, which I learned seems to work relatively quickly (within 1 week). This is different from other AI drugs, such as methotrexate. This patient was having vertigo while on Humira, which seemed to be a big problem and also had pitting of the nails (common with PA). Some new tests that I watched included some specific coordination tests that helped the doctor diagnose if he had any problems with his nervous system (sometimes PA can affect this). This patient also had knee replacement surgery and had some bad nerve pain in his legs. The doctor was only concerned that his vertigo might be the cause from a MS like disease, which is a very rare side effect from taking TNF inhibitors (Humira). Overall an interesting case.

The second patient was a RA patient with severe deformities in her hands. I learned that these deformities could not be corrected. The patient had a bad infection so that she stopped taking her RA medications (which was advised). The patient actually had a reconstructive surgery with her hand to fuse her joints in her thumb so that she could preserve her "pincer movements" with her hand. According to doctors, this is one of the most important tasks that patients need to be able to perform with their hands. The patient also had tendon reconstruction because the deformities and the intense inflammation from her disease caused a couple of tendons to rupture in her wrist. She is doing okay now, but doctors worry that her quality of life is not going to be that good due to her advanced state of disease. Her RA is well controlled, but it was a sad case to see.

Nothing else really happened this week. I plan on working on my report now. It will be on my project and what I learned from my clinical experience over the summer. Time to go back to Ithaca!

The end of time (Jason Guss)

So my last week of summer immersion unfortunately had to end a few days early. I left Wednesday night after our last group meeting. This week was not too exciting overall. I shadowed my mentor some in the office and everything seemed pretty normal regarding the cases. The best part of my week was the Da Vinci surgery I was able to see on Wednesday before I left for Ithaca. Dr. Scherr was nice enough to let me shadow his prostatectomy. I was lucky enough to find a medical student in the room and he guided me through the whole procedure step by step which helped my understanding out so much. The Da Vinci robot was extremely impressive and watching the doctors in the control system machine really was like something out of Star Trek or the movies.  I learned that the arms of the robot have 4 degrees of freedom (more than the hand) and so this allows for delicate maneuvers to be made inside the patient. It really is an impressive feat of engineering that this Da Vinci robot represents and I can't imagine the amount of effort that goes into developing that. I also was able to watch the next surgery where they took a piece of the illeum of the patient and made this into a bladder for them.  It boggles the mind what they can do in the operating room and how the body can recover from it.  I am going to miss this immersion program and really feel like I have got a lot out of it. Before this program I had no idea what happen in the operating room, how many people are in there, what each persons role is, and now I feel as if I could explain this to others.  This unique opportunity will definitely influence my medical related decisions in the future, whether they are academic or personal.

Laboratories Big and Small

This week was not particularly exciting, but I do feel like I got a lot of things done. I focused almost all my time this week into my lab work, and we were able to make some strides on the project I am contributing to. We made several constructs using a variety of different variables over Monday and Tuesday, and then on Wednesday we went down to the multi-photon microscopy lab to image. We took several different Z-stacks, which are a series of images going into the depth of the sample, which we then were able to compile into 3-D images of our scaffolds. We also performed histology and staining. So far, the results are positive in that we have reduced the amount of air entrapment, but the methods are not perfect. I also performed some side work on other projects, including dissections of donated human ear tissue to isolate auricular (ear) chondrocytes.
The second major event of my week was receiving a tour of the Central Laboratory. Part of my work this summer will be writing a few pages summarizing the work that Hospital labs perform. For most people, both patients and doctors alike, the lab is simply a black box, where blood and other samples go in and a variety of numbers come out. However, as both a researcher and an engineer, this answer was never good enough for me, so I took the opportunity of working the hospital to gain access to the lab and see it for myself. I received a tour from Joshua Hayden, a PhD in chemistry who works as the associate director of lab. It was an extremely eye-opening experience. I found out that the central lab is ENORMOUS! It is a mix of a huge, automated conveyor belt system that performs the majority of the tests, with a large support staff of technicians and scientists who perform the other required tests and ensure the integrity of the machine results. The NYP lab performs over 16 million tests per year and covers 10,000 samples per day. It runs 24 hours a day, 7 days a week. It is really unbelievable, but at the same time is the only way a hospital of its size could operate efficiently enough to be successful. In addition, the hospital is in the process of updating its equipment. I would definitely recommend checking it out. Its not the most exciting thing that happens in a hospital, but its definitely a hidden treasure.

Week 6- Aniqua Rahman

There wasn’t any new or interesting case in the clinic this week that I would like to mention here. In addition to clinic, I spent two days in ER and Medical ICU this week. I expected the ER to be busier than other areas, but it was kind of slow on my scheduled day. I was able to follow only one case, but couldn’t even follow it till the end because I had to leave the ER early to attend the weekly meeting.

Therefore, I decided to discuss something else for this week’s blog that I found very interesting in the past few weeks at WCMC. There is a brain cancer clinical study device called the NovoTTF-100A System (manufactured by Novocure), which is on Phase III clinical trial. This system is portable, powered with batteries or power outlets and involves placing electrodes on the patient's scalp to deliver low-intensity electrical fields to the tumor site. Patient has to wear it 22 hours a day, shave their heads and carry all the wires and batteries in a bag while mobile. Novocure is recruiting patients from all over the world to validate the efficacy of its device. The device has already been approved based on results of a single international clinical study of 237 patients with recurrent glioblastoma multiforme who were randomly assigned to either treatment with the new device or chemotherapy. But now they are trying to take a further step by trying to approve this device for newly occurring glioblastoma multiforme, for which they need 800 patients. They need to test their device on at least 800 patients to get approval from FDA. Weill Cornell Medical College is one of the centers, which is participating in this global study of recruiting patients. This device has been on the run for the past 7 years and there are still about 80 slots left for newly occurred glioblastoma patients. When a new patient with glioblastoma comes to Dr. Pannullo’s office, the Cornell clinical research coordinator comes and demonstrates the device to the patient and family.

In the past three years, Cornell hasn’t recruited any patients. Earlier from Cornell, there were only three patients recruited who were interested to participate in the study. This made me realize that it already takes a really long time and research work to design and build a new device and then additional time to go through the legal processes to test and bring it to the market. Only if we could come up with some ideas to legalize a new device faster, then we would have improved quality of many lives easily (even though I completely understand that different phases in clinical trial are just to assure the safety and efficacy of a new device, but there should be some alternative ways!)

Week 6

On Thursday this week I had this exciting chance to Cardiothoracic Surgery (CT). It was my first time ever to observe an open-chest surgery, and it was impressive. It was appreciated that Dr. Gerardi and his surgery group would like to have me around for two of their operation slots.

Early that day, I got to the operation room department in Greenberg, and was given scrub and stuff. After getting oriented around the operation room, I got a rough idea about the patient's condition and the surgical plan. The patient had been implanted a heart valve at another hospital for a while, but it turned out that something wrong happened to it, and patient felt discomfort. The task for surgeons was to replace it with a new one. The entire procedure was pretty much in several major steps, which are anesthesia, Ultrasound insertion, opening chest, stopping the heart and replacing the heart valve.

For me, the most exciting part is to stop the heart from beating. Before doing that, the chief surgeon, Dr. Gerardi, insert the tube into the blood vessels connecting to the heart. Those tube were connected to the circulation machine at the other end. With doctors turn on the switch of the circulation channel, blood began    to flow through the tubes rather than from the heart. It was funny to look at the mechanism fully running without the beating of the heart. After that the surgeon scraped the old valve, piece by piece, from the inner wall of aorta, and sewed back the new one.

The entire surgery was a fresh new experience for me. It made me realize how complicated and delicate the CT surgery could be, and it depends both on personal expertise and team collaboration.

Week 6

This week I finally found meaning and purpose for how to observe, document, and develop needs and design statements based on purely clinical observations from an engineering perspective. I would recommend everyone to read Stanford Biodesign in order to fully understand what we, as engineers, should be gaining from this clinical experience.

Dr. Ahkilesh Sista is one of the main clinicians running this summer biodesign program. I was able to spend some time with him and join his class of 1st year medical students to discuss the elements and organization of observations into worthy clinical needs that one could pursue in advancing the state of healthcare. The ideas and processes associated with this class should be the required for BME students prior to attending Immersion Term. This is the only thing I believe should be a requirement for Immersion, if not the only thing useful I have learned from departmental classes up to this point.

Week 6 - Lab Galore

For the entire week, I spent most of my time working in the lab. Due to the nature of the work, I cannot share too much detail to the public, but I swear, I have been working.

However, Dr. Spector did tell us about an awesome case we missed. I tried to find him that day but it wasn't scheduled because it went through the ER. Basically, a woman got ran over by a bus. Good news: She survived (it was only her foot, I think). Bad news: She experienced what was called a "degloving" injury in which the entire skin below her ankle was detached from her foot in one piece. They operated on her the same day and put a graft over her foot to cover the exposed area. Pretty gruesome. I hope she can use that foot again.

Week 5

Monday I went to the PICU for the morning rounds. I joined the group of Dr. Marianne Nellis, which is the "nursing" group, while the other group is the "cardiac" group. After going through the basic information for each patients on the list, we headed to the first unit. It was a patient with lysosomal disorder, which made her own immune system attack her healthy cells. In order to stop this backfiring, doctor applied treatment to turn down her immune activity. However, this results in her vulnerability towards various infections and contagions, which make it necessary for her to be under close monitoring and intense care.

Another case in PICU was a very young baby. For the infant inside the fetus, sometime it might excrete his/her waste into the amniotic fluid. However, in rare cases, the infant could take the waste into their lungs via the mouth, hence causing damage to the breathing system. This baby was one of those. On the parallel, the baby also suffered from low resilience of lung tissue, and high viscosity between lung compartments, which made it difficult for him to fully breath. In regard of this issue, doctors proposed to perform a genetic test on the baby to determine whether this lung disorder is inherited.

For other time this week, I followed Dr. Prince through some interesting cases. Some of them had a common feature: fluid filled sacs in the kidney, or poly-cystic kidney. With MRI, we are able to differentiate kidney cysts by the contrast provided by different modalities. For example, blood cyst shows as bright region on T1-weighted MR image, but dark on T2-weighted MR image due to its long relaxation time. I noticed that it was huge workload for the radiologist to calculate the cystic ratio of kidney, which was always done manually. Hence it begged the question how we can automatically measure the cyst properties or quantities from MR kidney images.

Week 6 (Jason Guss)

This week some of the new experiences were shadowing Dr. Saboeiro in the radiology department and working with some of his fellows. Dr. Saboeiro focuses on using ultrasound for musculoskeletal related problems for the hospital for special surgery. I got to see ultrasound tests performed on tons of patients for different complaints.  The ultrasound test is normally used after X-ray has already been performed, as well as MRI sometimes. Its benefit is that it provides real time information.  I also was able to see them perform several injections or sampling procedures using the ultrasound machine to help guide their needle in the appropriate area. The most interesting one for me was where they were injecting cortisone into a patient's hand because they had carpel tunnel issues.  The way they injected the cortisone was to completely surround a specific nerve because this is the one that causes the issues for the patient. The ultrasound allows the doctor to move the needle and inject the cortisone and highly specific places.  Another case involved a patients knee replacement becoming infected and before any further treatment was to be performed they wanted to check that the patient's knee was no longer infected. They used ultrasound to guide the needle into the knee to get a sample of the fluid in there to culture it. Also as a side note one of the attending doctors showed me an X-ray of a patient from an ER she worked at where the patient had an arrow through his head!)

I also shadowed in interventional radiology this week and got to see several procedures.  One of them involved a lung biopsy.  The difficulty with this procedure is the patient is awake the whole time and so they can't move. Additionally when the patient breathes the orientation of the lung can change and their body can shift some.  So the patient had to go through 4 injection attempts to get a sample of the mass in the lung.  The doctor advances the needle a little bit then scans the patient to check that the orientation is still optimal, then returns and advances the needle a little more. It seems like a less than optimal system that could potentially be improved upon that would help the doctor and the patient.  After they have the sample the pathologists quickly arrive and inspect the cells with microscopes to determine if the mass was cancer.  This was very important because it determined whether or not the patient would undergo surgery.

Other than this I shadowed my mentor Dr. Vasanth in the clinic some but this has been touched upon in other posts.

Week 4

During week 4, I had this opportunity to the Emergency Department of the NYP hospital. I was assigned to Area C of the ED, which takes care of most nursing cases among emergencies. After I arrived, Dr. Richard Lappin oriented me around the entire area including attending rooms, nursing stations, pharmacy and office area. The ED resident, Zack, helped me a lot when I was trying to figure out the entire nursing procedure after each patient entered the ED. Each patient would be sent to a nursing area or a bed first, fill in basic information, then wait for hours for just meeting the doctor or residents. After checking the patient's status, residents tend to generate some presumptions based on the symptoms shown, then they reported to their attending doctor, Dr. Lappin, and discuss with him for further examination and diagnosis. The seemingly ridiculously length wait time, from my experience, was understandable in the sense that it took each doctor/resident much time on caring each patient: from the physical test, routine imaging protocols (X-ray or CT), to report and discussion with the attending doctor, then finally documenting everything into the archive. It seemed to me that doctors spend lots of time on stuff other than seeing the patients. This was a great experience for me, as an insider of the Emergency Room, to begin to think about what is really happening outside the curtain of the attending room, an experience I hadn't had before either as a patient or a student.