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.
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.
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