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.

DB Week 6

MICU

The MICU was a nice change from the CCU especially because the staff was exceptionally friendly.
I usually avoid patients on contact isolation but since most patients were on, I gowned up with the team. I realized that I felt much more comfortable gowned and gloved because I look like less of an outlier to the patient. One of the Interns was very nice and let me and Lina listen to patient's hearts and feel for pitting edema (when a patient has so much swelling that pressing on the skin leaves a dent which takes time to resolve). Interacting with patients makes rounds much more immersive.

Lina and I saw a patient who survived the holocaust and who received a pacemaker on Friday.

Patients with heart problems in the MICU are interesting. It's clear that the MICU staff isn't as comfortable as the CCU. Makes sense, but it's still funny to see someone looking up basic info on heparin. There was actually an issue where a patient didn't get the proper heparin dosage because someone on the night shift didn't know to bolus in addition to continuous delivery, probably an extreme example.

CCU

I continue to learn from CCU even though I've been there many times. However, I've noticed that the skill of the person presenting a case makes all the difference in terms of following the patient and being interested.

One case this week, a women in her 40s with tachycardia. When we rounded on her, she seemed okay, but 30 minutes later she was throwing up and in ventricular tachycardia. Vtac is basically when the ventricles start pumping quickly while the rest of the heart is like slowww downnn.  It's usually a prelude to vfib, at which point your blood flow has basically stopped and your heart is about to arrest. (My 4x CABG patient was a good example of this progression after his surgery.) A fellow and a PA cardioinverted her, a procedure in which the patient is shocked with electricity, essentially "defibrillated,"  but to prevent fibrillation, not terminate it.

DB week 5

ER

This week I went to the ER. While there, things sped up and slowed down constantly, making for a very different pace than at the CCU. Every spare second, doctors were doing a ton of documentation and paperwork. It was most interesting to see the docs interview patients that had just been sent from triage. One woman was refusing further treatment and I acted as a witness.

Surgical VSD closure

I also got myself back into the OR for a pediatric CT procedure. This patient, age 18, had a congenital VSD, which is unusual since these are normally fixed early in life. The VSD was appreciated on TEE to be about 2.5cm, quite a large hole, at the base of his heart. There was also a piece of muscular tissue that had grown between the right side of his septum and his RV wall which was probably messing with hemodynamic flows out of his tricuspid and through his PA.

The most interesting part was the behavior of the ventricles after the surgery.

The VSD was causing a L to R shunt, causing oxygenated blood to return back to the right side of the heart.

You’d be tempted to think that the LV has been working harder to accommodate this inefficiency, but the contrary is actually true. The shunt acted like a pressure relief valve such that the LV never had to work very hard to contract. In other words, there’s a healthy EF (ejection fraction) with less work from the heart, but some percentage is leaking back across the heart. The patient has been able to live normally but did not exercise, which wasn’t a surprise. To my understanding, this is the same way a patient with mitral regurgitation would present, in which case the MV is the pressure release valve.

The RV on the other hand has been working exceptionally hard to push blood not only across the PA but also against the L to R shunt. There was also a low to mild grade tricuspid regurgitation which you might attribute to this extra RV function (in this case a healthy TV will function as a pressure release valve but only at abnormally high pressures).

After sealing the shunt, EF dropped from around 70% to around 25%, which implies a very weak LV. As the fellow said “the LV is squeezing and then it realizes ****, why is it so hard to pump now?” in case you needed another reiteration. Meanwhile the RV was strong. I don’t remember if the TR was gone, but it was more important to get the LV pumping harder. To encourage the LV to pump, the patient was given epinephrine and probably some dobutamine. His LV function improved but was still terrible. It’s weird to see (on TEE as always) an 18yo with the same LV as you’d find in an elderly patient pre CABG. His LV will probably make a full recovery with time. On the same note, his heart was unusually fatty for such a young patient.

DB week 4

4H

This week I was back in Ithaca co-coordinating outreach with Dan. 

I like to teach so the experience was good overall.

Research Project: Discrimination of MR etiologies by biomechanical analysis 

Leah and I have been stuck due to an inability to run code given to us for the project.

This week, I got the code to work by hacking. Meaning, I still don't know why it wasn't working, and simply found a way to make it work.

In this retrospective project, we will use patient echos (and maybe MRIs) to quantify the structural states of healthy and regurgitating mitrial valves.

We will first need to discover mechanical parameters that are useful in discriminating between healthy and diseased valves. Ultimately, our goal is to be able to show differences within disease states by discriminating MR of different etiologies using the mechanical properties of valves. This is an idea JW was specifically interested in pursing.

DB Week 3

VSD patient

As I mentioned last week, her occulder install didn't go well. There was no way to plug the remaining hole.

I saw her every day on rounds, during the attempt to patch her VSD, during her diagnostics, and through multiple TTEs and TEEs. I saw her suffer from being intubated and from being stuck in the hospital. I saw her family many times, seeing how they became understandably more distraught as things progressed.

On Thursday they were consulted and agreed that she should not be kept on support. Examining her documentation at a computer terminal, one of the items was a DNR, a do not resuscitate order.

The family’s decision was consistent with my thinking, but seeing the DNR made it real.

She was taken off balloon pump support Friday afternoon and passed away early the next morning, according to the night watch nurse.

The doctors and the cath lab would like to have an autopsy done. Indeed it would be amazing to have seen the occulder placed, located on echo, and then to physically see it in place and finally know the topology of her septum.

CT surgery

(AVR) My first open heart surgery was an aortic valve replacement. Seeing the open heart for the first time was awesome, as well as seeing a bypass machine in the flesh. It was hard to watch the details because so many students were around.

To remove the old valve, they simply ripped the calcified leaflets off the valve bit by bit. They used a large number of sutures used to install the prosthetic valve, attaching one end of each suture to the prosthetic and the other to the aortic root (I’m guessing, couldn’t see).

I also was able to observe the patient’s atrial fibrillation. It’s amazing to see something that you would only ever see on an EKG as a different wave form. EKGs usually make me feel detached from the reality of a beating heart, but now I can actually visualize the data on a real heart.

(4xCABG) My next surgery was a quadruple coronary artery bypass graft. At the start, one doctor was sticking a scope up the patient’s leg. There was a pink rope looking thing dangling in side of the patient, which she proceeded to clip it and pull it out. I quickly realized that this was one of the veins they were using to acquire the grafts. The doctor injected them with saline to make them expand (they are super contracted without any pressure inside of them). Simultaneously chest cavity was prepped.

Two surgeons, one a fellow, began identifying the anatomy of the patient’s heart to locate the bypass areas. Some of these were inconveniently located such that a helper had to come and pull/hold the heart at the right angle for access. Fortunately, I was able to see the more straightforward graft in detail. The surgeons carefully placed sutures into the vein and the bypass sites. The fellow made a few mistakes, but the doctor calmly/frustratingly tell the fellow how to either fix an error or to just move on and avoid repeating it. It was very interesting to see someone make a mistake during open heart surgery and see the doctors keep their cool. At one point the fellow was getting yelled at after a mistake. I could notice her hands shaking, but she quickly continued the procedure. The doc also switched back to a calm mode immediately. Lucky for me, this let me learn a bit about suturing techniques.

Before the procedure, the patient’s left ventricle appeared very weak on TEE. The LV was only displacing slightly and was not contracting in most directions EF~=30%. Afterward, the LV was displacing and contracting on all axes EF~70%. It was a reassuring to see a dramatic, quantifiable improvement after such an involved procedure.

More Rounds

I also visited the NICU and PICU this week. I found discussions with the parents to be the most interesting.

DB Week 2

The part you might want to read

If people are interesting in seeing caths, EP or ccu rounds, let me know. I've already taken Danielle and Aniqua, and joined up w/ Jason, so pairs work in cardiology.

Tracking the VSD case

As you all remember from last week, I have been tracking a patient who has a ventricular septal defect. This week, the patient went in for her cath to place an occluder device in the defect. On echo, there was a clear defect near the apex of the heart, so at the time it seemed like it would be straightforward. What I didn't know at the time was that it took 3 echo techs and many tries to actually locate a hole. The only reason they kept trying was because her mermer was drastic.

At the start, the doctors realized that extra permission from her family was needed to perform a balloon angioplasty of her stenoic aortic valve. After the BA, contrast agent was injected near the site detected on the echo. It didn't show up. If anything, it looked like there was a hole more central in the septum. They were able to interrogate a hole after about an hour of poking and calling in a trans-esophogial echo. Upon injecting contrast, there was obviously still a leak, in fact the leak was more obvious than before! Ultimately, in terms of heart efficiency, the procedure did seem to help. She was removed from balloon pump support and appeared to be stable. However, that night she became hypotensive (~70/20) and went in to afib right when I went to rounds in the morning.

I watched her post op echo live. Again, the tech had a very hard time visualizing the defect and the occulder. It was great to witness the occuder in place, seeing the results of the cath first hand. There was still a clear leak around the apical side of the occulder. She was put back on the balloon pump and continues to need support. If she does not stabalize soon, the doctors will need to inform the family that they will not be able to stabilize her.

Mapping Cardiac Electrophysiology (EP)

Patients require EP mapping when they have dead heart tissue that creates abhorrent electrical circuits. The heart is mapped to find the tissue, which can then be burned using radiofrequency ablation.

The EP lab looks like the cath lab 100yrs in the future. They use a technique called stereotaxis where two large magnets are used to guide a metal catheter inside the patient's heart. The doctor need simply control the vector of the magnetic field with a mouse pointer, and the insertion and withdrawal of the catheter with the mouse wheel. Stereotaxis allows the EP lab to map the electrical properties of the heart point by point onto the patient's heart geometry, which can be initially be obtained by echo slices and is refined as the doctor probes the heart.

Interestingly, the EP lab has the ability to induce arrhythmias by pacing (shocking) the patient's heart. Before cath insertion, the patient demonstrated several PVCs, indicating that there were several possible sources of arrhythmia. At one point, they induced a ventricular tachycardia that caused the heart to completely destabilize. The doc asked "is he out?" and before the nurses could answer, he proceeded to say "Shock him." The patient was defibrillated. Jason Jones and I thought this was insane, to be euphemistic.

This happened 3 times in the procedure, which took 5 hours. While his VT was harder to induce by the end of the surgery, he was sent back the next day to have an ICD (intracardiac defibrillator).

I saw the ICD implant, finally getting into a surgical room (not quite an OR). At the end of the install, a VT was induced and the patient's new ICD dutifully shocked his heart back to normal.

DB Immersion Week 1

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

Catheterization 1 6/10

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

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

Cath 2 6/12

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

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

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

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

Rounds 6/13

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

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

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