Week 6: First Breath

The most exciting thing I had the opportunity to observe in the hospital this week was the first breath of a new little person! Danielle and I checked the schedule left by the OR front desk and noted that there would be a few scheduled cesarean surgeries (c-sections) taking place in the maternity ward’s OR located on 7 south. We had originally hoped to see a natural birth but it was a lot harder to try and plan given one could happen at any given time and might take hours of advanced planning and waiting to see.

When we arrived to the maternity ward, things were a little hectic while we waited to get permission to observe the surgery. We were almost able to see an emergency c-section but there were 2 other students also observing currently in the operating room so we waited for the next available scheduled surgery they were prepping another OR for. I knew that c-sections were typically performed on individuals that were conscious but it was crazy to actually see it all come together with the patient talking and nervous during the entire procedure. I was actually fairly surprised to realize that the husband/dad was allowed to be present during the surgery.

When the procedure officially started, the team worked quickly to remove the baby from the mother’s abdomen. An incision just large enough to pull the baby’s head out was cut into the lower abdomen of the mom. After going through layers of tissue and fat, the uterus was slit open carefully and before I realized what was happening, the doctor had reached in and begun to pull out a blue-ish tinted object from inside. I soon realized after a bit of pulling and tugging that in fact the doctor had gripped the baby by its butt and was wiggling him out. I was very surprised by how quickly the doctor’s were working and even more surprised to see how they seemed not to be concerned with handling the baby gently. 

After suctioning the nose and mouth for the baby and a few taps on the back, his chord was disconnected from his mother and he began crying loudly. The baby was wiped and cleaned off then weighed in at a nice 7 pounds and 7 ounces. The doctor expressed his enthusiasm and approval for the baby’s wonderful health to the new parents nervously anticipating the arrival of their first child. It was very interesting that not only was the doctor focused on communicating with the medical staff, he also periodically checked in on the mom and would exchange a joke or two while reassuring her that things were going smoothly. I was surprised to see that the dad excitedly left his post near his wife’s head behind the surgical sheet to snap photos of the baby and hold him. He seemed oblivious to the fact that his wife was still on the table with her insides out…yes, her insides were now outside her body!

We had all gotten so distracted by the baby that we (well, those of us not directly involved in the surgery) had for a split second had our attention focused on the little life sitting on a table crying. I looked over to the surgical table realizing I was here to see the surgery to completion, and as I looked over I noticed the doctor insert his hand into the pocket the baby had come out of and he pulled out a fairly large pink object from inside and plopped it on top of the mom’s belly. The doctor proceeded to reach his hand into the large object and clean it out. At first I thought it was the placenta, but a quick glance around told me that in fact the placenta had already been removed. Danielle and I darted confused looks at each other and realized what we were staring at was in fact the uterus! I had no idea the uterus could be pulled out that far from it’s typical home inside the lower abdomen. After a bit of cleaning and then sewing, the uterus was placed back in the patient and she was sewed up and ready to be sent home in a few hours with her little boy.

As I watched the c-section procedure from start to finish, it became clear that there was still a need for improving the medical care provided to both the mother and child even in something like child birth that dates back centuries. While in the NICU, I learned of some research that one of the physicians was interested in studying involving when optimal clamp time of the umbilical chord post birth is.  I was surprised to learn a study involving this concept had not been done before. It makes perfect sense that knowing when to clamp the chord is something that should be standardized so as to help prevent potential complications.

The rest of my week was fairly typical and I spent some time in the multiple sclerosis center as well as wandering the halls of the hospital doing some exploring and planning the next week’s hospital adventures. 

Week 5: …eMeNo…Ppppp

This week I spent a few hours in the Medical Intensive Care Unit, Neonatal Intensive Care Unit, and Pediatric Intensive Care Unit.

I saw many interesting cases in the NICU including a child that was 8 months old and still seeking care there. He had been in the NICU since birth but his twin sister was at home doing well. He had a shunt defect in his heart, ductus arteriousis, which is not uncommon for premature babies, however, this child had significant complications post surgery and had extreme oxygen deprivation to the brain leading to serious brain damage and the doctors assume the child is now completely brain dead as a result.

Another child we checked on was also a twin and he was dealing with a few respiratory complications. In this case, his sister was also home and doing well, but he was still at the hospital being treated. Something I learned fairly quickly when I walked into the NICU is that given the NYC lifestyle, many parents wait to have kids. The later women wait, the more likely they are to have complications in pregnancy. As a result, many couples opt for some sort of therapy to enhance chances of a successful pregnancy resulting in multiples often twins or triplets. In this case, the woman was taking medication to increase ovulation and the husband was sterile so they used donor sperm. Their daughter appeared normal and was doing well, however, the son had underdeveloped genitilia and an extra scrotum. As it turns out, the male donor is a carrier for prader willis which does not show up in the genetic screens typically done for donors. Pradar willis affects 7 genes and plays a role in a number of long term complications for the child, primarily uncontrolled hyperphagia due to constant feelings of hunger which results in excessive weight gain. In light of this news, the parents were seeing a genetic counselor to talk through some of the complications, but from what I gathered, the father of the child is in denial that his son has any sort of genetic condition and when the topic comes up he refuses to address it. It is clear the couple was expecting no complications having opted to go with a sperm donor.

To top off my week, the most memorable experience was in the MICU where David and I met a 93 year old man and his wife both survivors of the Holocaust. They had both been admitted to NYP only a few days apart. Both had elevated levels of Coumadin (a blood thinner) and the thought was that either the home care provider had given them the wrong dosage or that the pharmacy had somehow actually mixed up their prescription. Despite this complication, the older gentleman was also experiencing irregular heart rhythms and a pacemaker was deemed necessary. David and I were able to do follow up on the patient post insertion of the pacemaker and he seemed to be doing very well. The old gentleman was constantly thanking us in Polish for our care of him. It was good to be able to follow up on our patient and track his progress since the patients I have been seeing with Dr. Gauthier in Nuerology are on medication and only come for a few scheduled scans a year to track lesions. 

Week 4: Method in the Madness

This week was primarily spent in the ER and given the short week with 4^th of July festivities and plans, it seemed like a good way to spend my time.  I walked in and despite looking the part of a doctor, it was clear I didn’t belong. I wandered around for a few minutes looking confused before someone finally came over asking if I was lost and needed help. I had entered the Emergency Department via the walk-in street entrance and my confused state as to where I should be going and what I should be doing must have caused a little alarm and given the impression that I was in need of medical attention. Anyway, someone was able to direct me to a back room where the residents commune in one of the ER sections where I spoke to the ER attending about the Immersion program and explained some of our goals. He quickly showed me around the different stations and explained the general progression of patient care: TriageàUrgent Careàmain ER (sections A, B, C).

My first stop was triage and the ER front desk in the patient waiting room. I spent a good bit of my time with a physician’s assistant in charge of minimizing the NYP door to provider time. Upon review, NYP had a 1 hour wait time for patients that would walk into the ER before they would even see a doctor. The PA I worked with met with patients as soon as they walked in the door asking them why they had come into the ER and what they were experiencing differently that had lead them to feel the need to come in. Then he would decide the urgency of the patient’s conditions. Depending on this initial assessment and what needed to be addressed, the patient would either go into triage or urgent care.

After spending an hour or so following a few mundane cases of back pain, dizziness, and nausea concerns, I figured it was time to graduate on to the main ER. When I first walked into the section A of the ER, I was surprised to find patients sitting on beds in the hallways while doctors and nurses maneuvered through what seemed like a maze of patients and medical equipment to get from one end to the other. Despite what seemed like a chaotic situation, there was surprisingly good organization of patient care and once you got a sense of the place, it was not too difficult to keep pace with everyone. I followed a few cases one of which involved a man walking through a construction zone and having a 2000 pound cement pole drop 10 ft and hit him in the back. The concern was that he had damaged his spine but a few x-rays later and it was determined the man was quite lucky. The pole had hit him in just the right spot that it had missed his spine and he only had a very large bruise. Another case I was able to follow involved a biker accident.

The girl had come in after being taken out on her bike when a car door opened and she went flying over the handle bars landing on her left shoulder. She was in considerable pain and the consensus was that she had likely simply dislocated her shoulder but the ER doctors were hesitant to try and pop the shoulder back into it’s socket on their own instead of have someone from orthopedics come down and without confirmation from x-rays that the shoulder was in fact just dislocated.  Despite the pain medication she was given, she was still in considerable pain and kept asking when someone would be able to pop her shoulder back into place. After a few hours, the x-rays taken were not sufficient to determine whether or not the shoulder was simply dislocated or if in fact there was a fracture so they needed to take another set. While having her arm positioned in multiple angles for the x-ray, there was a loud pop and the patient felt an immediate sense of relief.

The color that had originally been drained from her face was quickly coming back and we could all sense her relief. Although the resident physician following her case was happy to see his patient transition so quickly to a more comfortable state and that his initial diagnosis of shoulder dislocation was correct, it was clear regardless of the new x-ray results they had already decided they could not put the shoulder back in place themselves and would need to wait for someone from orthopedics had her shoulder not accidentally popped back into place on it’s own during the second set of x-rays. I learned that even within a medical team of certified doctors, there are still limitations and regulations as to what one can or can not do which if not followed could then result in a serious malpractice lawsuit.

Week 3: I think, therefore I...must have a brain?

I work with Dr. Susan Gauthier in Neurology and her specialty is in dealing with multiple sclerosis patients. Since immersion term started, we have looked at multiple examples of brain MRIs containing legions, and I thought it would be interesting to get a chance to learn how to operate an MRI machine as well as participate as a test subject in an MRI based study. Thanks to Dr. Prince and one of our peers working with him, Zhe, a few of us had the opportunity to do this. Greg, Chris, and I met with Zhe and one of Dr. Prince's current graduate students, Alexi. We discussed the process required for taking MRIs of patients and the amount of paperwork generally involved. It was interesting to be on the other side of the table (patient) being studied rather than the one doing the study (researcher). In my excitement to get started, I started to skim through the documents only to find myself actually reading in detail all the specifics and being concerned about what would happen with my brain scans later and what some of the terms and conditions actually meant. That was when I realized that getting test subjects for studies could in fact sometimes be difficult especially if the patient has to undergo further testing and prolonged exposure to a specific drug therapy. 

Alexi took a standard set of scans that is typical of those taken for patients with MS. Although the longest scan period was no more than 5 minutes, and I was only in the scanner for a total of nearly 10 minutes, it felt much longer. I can not imagine being in the scanner for an hour or more at a time as is required for doing some lesion enhancement studies for MS patients. In the process of doing a scan of Greg's brain and abdominal regions, Dr. Prince came by to see how things were going and for starters, it was confirmed that I HAVE A BRAIN! He said it was a young, healthy, normal brain so I was fairly relieved as Dr. Prince went through the anatomy of my brain and spewed off names of important regions in different image slices. For a while, I was actually concerned something wrong would appear in the MRI so you can imagine what a relief that was! I recommend that when you do get your shot at playing around with the MRI machine that you ask to actually take the scans yourselves. No need to read through Dr. Prince's online book in advance (might be useful to skim and get a sense for what you will be doing, though), but be sure to work through Chapter 1 with the phantom object as a group and then Chapter 4 with one of your peer's brain. Anyway, below are slices of my brain for any of you doubters.

        

Back to working with MS patients in the clinic! I have been attending clinical rounds with Dr. Gauthier and watching as she interacts with many of her regular patients. It is interesting the level of loss of function seen in patients of all ages. In particular, a 37 year old patient and her mother stood out to me. Mostly the interaction between the mother and the daughter really threw me for a loop. The mom insisted that Dr. Gautheir was depriving them of a stronger medication that would essentially allow her daughter to start walking again not understanding that it was physically impossible for her to regain that lost strength in her legs in order to even support weight. The daughter understood and seemed content working on small things; she had accepted the fact that she was now trying to maintain current motor functions rather than attempt to regain loss of function. The mother kept insisting that Dr. Gauthier was for some reason not giving her daughter the strongest form of drug therapy that would help her daughter recover and demanded that she try radiation therapy (I am still unclear how that would help at all with preventing myelin degeneration) but after confirming that things seemed stable and that the patients condition had not worsened over the course of the past year, Dr. Gauthier was firm in her decision to have the patient remain on the current drug therapy.

Clinical observations aside, research has been progressing along. I've had multiple meetings with physicians and researchers throughout the medical campus that collaborate with Dr. Gauthier on a regular basis, and I am blown away by how well she seems to manage meeting after meeting on top of her responsibilities to her patients as a physician. Sometimes I wonder when she actually has time to do research between all the meetings, clinic duties, and hospital rounds not to mention having a kid and husband to go home to! It's been great exposure for me to see a clinical researcher in action. I am still contemplating going down that path eventually, but for the time being, I'll be content if I can manage one thing at a time at this stage in my life. 

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.