Week 2- Clinical Success!

I started off my second week rounding with the Cardiac Care Unit (CCU). In the CCU patients with a variety of often serious cardiac conditions are closely monitored. Many patients in that unit are in heart failure or are recovering from myocardial infarctions and need extensive cardiac monitoring at the bedside. Many of the patients had been in the unit for prolonged stays (2+ weeks) and while they arent considered critical or need to be cared for in an ICU setting, they have many of the same needs as critical patients. It was interesting to note how most of the patients were older and suffering from chronic conditions while the few younger patients on the unit had predominantly congenital and structural defects. While I enjoyed rounding with the CCU team, I really wanted to take advantage of Weill Cornell- NYP as a large medical center where some of the most difficult cases are sent for cutting edge procedures. I was primarily interested in observing their Level 1 trauma and burn units so starting Tuesday I started rounding with the Surgical ICU (SICU) team.

SICU is where some of the most critical patients are sent. They have often been involved in large traumas or have several severe co-morbidities and require intense medical and surgical care. Most patients in the unit require multiple extensive surgeries both internal and orthopedic with full medical support in between. A patient will be housed in the SICU if they are an unstable multiple trauma patient, recovering from an extreme, long lengthed surgery, have head or spine trauma that require mechanical ventilation, have a severe systemic disease that is a constant threat to life by being end stage or poorly controlled, aremoribund and not expected to survive more than 24h without surgery and are at imminent risk of sepsis, multiorgan failure, henodynamically unstable, or poorly controlled coagulopathic; basically anyone that needs continuous monitoring and life support.

 I noticed that much of the SICU care could be summarized with metabolic stabilizing and monitoring, respiratory stabilizing and monitoring, and hemodynamic stabilizing and monitoring. The precise and extreme monitoring many of these patients require is much different than that of most patients I had seen; instead of a blood pressure cuff to get blood pressure measurements, these patients require an arterial line which is an invasive pressure monitor placed inside the artery, usually the radial, and is able to give immediate and very precise pressure measurements. While trauma and critical care surgeons run this unit, it is highly interdisciplinary with a variety of specialists needed for consult on most patients and the surgeons there practice quite a bit of medicine. They are hybrids in the surgical- medical divide.

I saw a variety of interesting cases. A young woman with a rare presentation of an already very rare genetic disorder called Proteus Syndrome which left around 40% of her body covered in thick, largely unoperable keloids. A patient with extensive abdominal peritoneal mesothelioma that required resection of the omentum, appendix, spleen, colon, small intestine, and gallbladder and was then treated with Hyperthermic Intraperitoneal Chemotherapy (HYPIC) in which hot chemotherapy is placed directly inside the abdomen during surgery, left in the patient while being rocked for an hour, then washed out. It is an extreme and controversial procedure but one that may give benefits in cases where there is a poor prognosis with traditional methods. A man who fell 4-5 stories off of scaffolding, landed on his head, lacerated his liver and spleen, fractured his skull, and suffered a large intracranial bleed from the fall but with the correct support is expected to make a full recovery. Many cases of peritonitis, intracranial bleeds, and shockingly, severe traumas resulting from bicycle accidents. Dont go biking in NYC, kids. Ive been able to see cases from more or less start to finish from their initial stabilization, workup, transfer between the operating room and the SICU, consults from specialists, to involvement with family, palliative care, end of life planning, step down and transfer care, social service placement, rehabilitation, nursing care, and clinic followup. The amount of social work that goes into some of these patients is remarkable and there is even a coordinator in the unit whose job is to contact and secure all the social odds and ends that are needed whether it is meeting with family to discuss end of life planning or securing the appropriate rehabilitation facility for a patient with multiple intermediate needs (dialysis, IV antibiotics, ventilation, etc). I loved going to the clinic hours and seeing the patients who were returning for followup care after their hospital discharges. Its incredible to see the progress in these patients some of who had such extensive and extreme surgeries just weeks ago to seeing them in the clinic being managed entirely as outpatients.

My research has been a little stalled. Last week we were unable to get our program to work on clinical mentor, Jonathan Weinsaft's computer. We installed the appropriate software but could not get it to run. We expect that in the next week or two we should be able to sort it out by talking with the person who wrote the program and doing some troubleshooting. In the meantime, Ive gotten to spend  more time doing clinical observation. I really hope it all works next week since I really dont want to find another project although my time in the SICU has exposed me to a variety of engineering challenges in terms of the equipment used. Condom catheters could be greatly improved upon to point down to allow for complete drainage, more flexible but less likely to tangle nasogastric tubes, and more absorbant wicking chuck pads. There have also been new applications for the program we currently have such as in examining strain in a monitored aneurysm during the cardiac cycle to give a less subjective measurement of aneurysm severity before surgery or to measure strain in skin contracture using feducial markers.