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!

Week 6 of Immersion

My 6th week started out well. Dr. Goodman and I went on clinical rounds in the morning on Monday. I was able to see quite a few interesting patients. The second case I saw was a patient that had seropositive rheumatoid arthritis that was diagnosed quite a few years ago. She was first given some methotrexate (the gold standard for RA) and told to come back a few months later. However, she hadn't been back for about a year, so quite a few doctors were concerned about her. To everyone's surprise, the patient had stopped taking almost all of her prescribed medications for her RA. The patient claimed that she was feeling much better and had almost no physical signs of having RA. This was a good sign for the patient, but the doctor was concerned that the RA would come back very aggressively since she stopped her medications; RA very rarely remits completely in the long run. They decided to keep a close eye on her for the next few months, but did not decide for her to continue to take the RA medications, at least right away. The doctor just cautioned her to start taking the methotrexate again immediately if she had any more future RA flareups. This sort of stuff always surprises me; it confirms that patient compliance is a very real issue for RA and other types of arthritis because of personal, religious, fear related reasons.

Another case I saw was with a patient that exhibited many types of diseases at once, including diabetes, RA, OA, as well as a few others. The diabetes was causing her nerve pain that was complicating things somewhat. The patient was originally diagnosed with just OA in the past, instead of RA, but the doctor was convinced that the patient exhibited some sort of combination of the two. The doctor saw some tell tale signs that pointed to inflammatory arthritis (RA) in her wrists (synovial thickening, inflammation, swelling) and feet (same). He decided to prescribe her some RA meds to help with the pain and inflammation. For personal reasons, the patient refused to take prednisone (a steroid) so the doctor had to prescribe methotrexate instead. The prednisone would have had almost immediate effects if there was RA present, and it also leaves the body fairly quickly. This would have helped confirm RA without any side effects. However, methotrexate  (as well as most other RA drugs) takes weeks to take effect and last for relatively long periods of time in the body, which leave patients susceptible to side effects if not managed properly. Hopefully she really does have RA so the methotrexate will be able to help her in the long run. 

I went to the CAP clinic again this week but nothing really happened because the patient did not show up. There was a presentation about various inflammatory diseases though which was pretty cool. 

On Wednesday, Greg (my surgery buddy) and I went to the burn unit on the 8th floor, and by chance, ran into residents on their rounds. We joined them and saw some interesting things. One of the first things we noticed that most of the burns were caused from spilling hot/boiling water on themselves, or by playing with fireworks/fire. We also ran into a very belligerent patient that was busy cursing everyone off because he wanted to leave the hospital really badly. That was interesting. Greg and I were able to go into the wound dressing room and see a patient badly burned on her stomach and legs. It was rather scary to see someone with very little skin left in that area, but it was also very interesting how they treat such wounds. Most of the times, they soak the wounds in saline to keep the wounds from drying out (they heal better wet). If the burn is bad enough, the patient will have to get a skin graft. Another medicine that they use periodically is Silver sulfadiazine, a sulfa drug, is used to prevent and treat infections of second- and third-degree burns. It kills a wide variety of bacteria. Many of the patients that have severe burns suffer from "burn shock" which is a systemic reaction to a traumatic injury (the burn). It causes widespread vasodilation and neutrophil exudation, as well as increased blood pressure. Burn shock is serious and can lead to a wide array of systemic organ problems if not treated properly. 

Greg and I also went to a brain surgery (craniotomy with a brain tumor removal) on Wednesday. Overall the procedure seemed straight-forward: the surgeon (Dr Schwartz in Neurology) made an incision in the skull, then used a dremel tool like instrument to remove a circular piece of the skull so that they could access the brain easily. Once the skull was open, they used a bipolar forceps to cut through the dura mater of the brain to get to the tumor. This instrument was vital because they needed to cauterize the brain tissue (and the tissue around the brain so they wouldn't have any bleeding). Residual bleeding in/around the brain would be very bad. They used some imaging devices (including ultrasound to locate the tumor), which was very close to the base of the skull. This was very lucky because surgery deeper in the brain would have been very risky/fatal. They kept using the bipolar forceps to cut through actual brain tissue around the tumor to remove it and it was successful. The coolest part was seeing the brain pulse every time there was a heartbeat.  

5th Week of Immersion: Will It Blend? (Human Spine Version)

Spine Surgery
ED Department

Let's start off with some of the more boring things I did this week. Regarding my research, here is a brief summary of what I aim to do before the summer ends. Mike Wei, a MD student who is working on the project with me, is looking into how using Methotrexate affects inflammatory markers in hip replacement patients with rheumatoid arthritis (RA). The hypothesis is that using Methotrexate decreases the inflammatory markers because of its anti-inflammatory properties, allowing for less degradation of the hip replacement, which extends its lifetime. So far, we have not been able to see any significant differences between patients on Methotrexate and those not on it. We primarily have been looking at medical reports and pathology reports, but not at actual pathology slices (currently working on doing this). We think that the study is underpowered and confounded by other factors such as patients that have both RA and OA. I have been working on separating patients with OA and RA recently so that the analysis can be rerun without the OA patients. This includes looking at the pathology and comparing inflammatory markers and the medical records. Getting access to the pathology is slow going and may not be possible with the time I have left. Will keep you posted.

As in the past weeks, I have attended the CAP clinic and it was enjoyable. The patient was an ex-baseball pitcher and had severe limited motion of his throwing shoulder. The doctors suspected that he had some RA going on, but he also had some disfiguring of the shoulder and elbow ligaments, as well as some bone spurs, which made him painful to move his shoulder. The doctors thought about doing a total shoulder replacement, but they couldn't decide if they should treat the elbow problems or the shoulder problems first. Apparently, the shoulder surgeries have better outcomes and actually may help elbow alignment problems. Through shadowing Dr. Goodman this week, another random thing that I learned this week was that patient compliance for many types of hardcore drugs (such as steroids, Humira, etc) for RA and OA is not as high as you would think. Many patients are very concerned with the side effects and some do not like taking drugs at all. It is a big problem that doctors have to deal with.

I also shadowed in the Emergency department this week, and it was pretty interesting. A lot of patients were brought in by means of chest pain scares, but there were a couple of cases that were more serious. One of the most ridiculous things I saw was with one of the older patients. He came into the ER after a serious fall, and had some bad problems that he was also dealing with at the time. He had late stage Parkinson's disease, and at times he was shaking uncontrollably. The doctor had a very hard time getting an IV into his arm to take blood work, and even needed help holding him down. His speech was very slurred and it was very hard to understand what he was saying. Overall, it was a scary experience.

Now for the most interesting part of the week: seeing a spine surgery. Greg and I saw a laminectomy with a full facetotomy of the L4-L5 vertebrae. This was to remove part of the spine that was causing spinal cord compression and also to stabilize the IVD of the patient. First, they had to make an incision in the back and use a chisel to remove portions of the lamina (bone that protects the spinal cord) to remove the compression problem. Then, they needed to work around the spinal cord to get the the IVD. They made an incision of IVD and began scraping out some of the IVD's center to place a metal cage to help stabilize the area so that the IVD would not impinge on the spinal cord again. The whole process was pretty gruesome as they had to continuously scrape the endplates of the vertebrae to get good adhesion between the metal cage and endplates. After the insertion of the cage, the surgeon (Dr. Elowitz) had to remove the facet joints that connected the L4-L5 vertebrae to place some stabilizing rods in their place (for added stability of the spine and area). This involved some more chiseling and scaping. Once they were removed, he had to use a drill and a hammer to place screw holes for the posts (perpendicular to the spine) where the rods would lay across (parallel to the spine). This involved using X-rays to continuously locate the screw bits and other instruments to make sure they didn't go to far into the spine (or not far enough).  Once the screws were input, they screwed the rod post into the place around the screws they already input. After securing the posts using a torque wrench, they inserted the rods in a slot in the posts and tightened everything up.

By far the best part: they blended the lamina of the patient and placed the ground bone into the IVD space of the patient to stimulate bone adhesion of the cage and endplates. So yes, lamina does blend (if anyone was wondering).

4th Week of Immersion

This week was pretty good overall. I continue to work on my research project, although not much has materialized so far. Right now, I am just looking at medical records to see where a RA patient cohort got their primary hip implant. Requesting for medical records is fast enough, but the other side of the project had not gotten started yet. I will be more aggressive this week in trying to see how I can help with examining the pathology of tissue slices from these RA patients. However, requesting for the pathology samples is just slow in general so hopefully everything works out.

I saw an open heart surgery this week through rotations in the CT set up by Cornell. The surgery that I saw was an aortic valve replacement. They started the procedure by cutting open a hole slightly to the left of the sternum of a 69 year old male. Once they got through the skin and muscle, they needed to use a bone saw to cut through several of the ribs around the heart. Then, they used metal clamps to open up the chest and keep it open. I was standing right near the anesthesiologist so I was able to see a beating heart up close! After, they hooked up a heart and lung machine to reroute the blood around the aorta. Once complete, they shut down the heart by pumping a potassium dense liquid through the heart (called Cardioplegic solution); this caused the heart to stop beating but protected the heart from cell death while the procedure continued. Once the heart was stopped and cooled down (to 10C), the surgeon (Dr. Girardi) continued to cut open the aorta and remove the defective valve. Once the valve was removed, they had to sew up the aorta with the new bovine replacement valve. They finished up the surgery by starting up the heart again and reconnecting everything once the heart was up to full strength. It took about 4 hours to complete.

Another surgery that I saw this week was a C-section. I went to the NICU and asked if they had any surgeries that I could watch and luckily, they brought me to the OR with a soon-to-be mother. She was 30 years old and this was her second C-section. It was a pretty straightforward procedure where they made an incision through the abdomen and cut through till they got to the uterus. They carefully cut through that to reveal the baby's head; after which he was quickly pulled out. Overall, the surgery was more bloody than I was expecting. It was probably because they didn't want to cauterize much around the uterus in fear of fetal or nerve damage. It was a very cool thing to see. The baby seemed to be fine and everything went smoothly. 

Other than that, I was shadowing Dr. Goodman and did some little things with other doctors. I went to the CAP clinic again (see previous posts) but this case was not nearly as interesting as the last few have been. Looking forward to more things in the future.

Week Three of Immersion

This week was pretty interesting overall. One of the first things I saw was with Greg Fedorchak. We witnessed a 1 year old male being transferred from cardiac surgery to the pediatric intensive care unit. He had just had surgery trying to fix his several heart conditions, including Tetrology of Fallot (ToF). However, several things were going wrong right from the get go. The patient was losing quite a lot of blood from the wounds induced from the surgery, his blood pressure was way too low (50/25), and they were having problems with his breathing, as well as having problems getting his IV lines up and running to administer the proper drugs. In the end, they only had one subcutaneous IV working so they had to perform emergency surgery on the hospital bed to open up another IV line in his femoral artery. They called this a "central line," since it has better blood flow, but it is harder to get to and is generally a more desperate attempt to administer treatments, as well as carries extensive bleeding risks. In the end, this attempt worked, so they were able to better monitor and administer treatments to help this kid survive. While this was all happening, several nurses were desperately giving the kid morphine and other drugs to keep him sedated as well as try to reduce his heart rate (about 200 bpm) and increase his blood pressure. The nurses had to go through several hundred cc's of frozen fresh plasma (FFP), platelets to help stop the bleeding, as well as administer saline through one of the IVs. They also had the kid hooked up to a ventilator to prevent labored breathing, but even this had its problems. In the end, the kid was stabilized in about 24 hours. The increase in fluid intake helped increase his blood pressure enough so that his heart could calm down.

I also went to the PICU this week, and it was sad to see so many sick children, but it seems like they were all in better shape than the previously mentioned kid was in the other day. One of the interesting cases was when I heard about Maple Syrup Urine disease, which is a very rare disease where the body is not able to process a couple amino acids, which leads to many problems down the line. The doctors said that there is not much they could do to help the kid, other than keep her diet restricted as well as give her medications to help prevent her body from building up too many of these amino acids (which apparently is hard).

Other than that, I shadowed my mentor, Dr Goodman, around to see some of her patients this week because she is finally back from her conference/vacation. She allowed me to see some of her private patients this week and it was very cool seeing her see many patients. Overall, none of the cases really stood out. Also, we are getting the research project underway. I am currently looking into see how methotrexate affects the pathology of hip replacement patients with RA (and potentially OA as well). I am going to be learning about the pathology of these samples as well as other factors that could contribute to the study (more details to come).

Frustration and Awe in the 2nd Week of Immersion

The beginning of this week was pretty dull overall. The majority of the first half of this week was just like the last week, with me going to the CAP clinic (see previous post) and shadowing some rheumatologists in the hospital or in the office doing physical examinations. The CAP clinic was interesting as usual; the 16 year old female patient had a rare bone disease where some of her bones were actually being resorbed by her body at a fast pace. They called this "vanishing bone syndrome." It was eating away at her hip socket so that she walked with a severe limb and had her left leg be a full 2 cm shorter than her right (due to the way the bone sat in the disintegrating hip socket). Performing a full hip replacement was an option, but due to the instability of the hip socket and the surrounding bone, it might have future complications. Lengthening the bone might be an option as well, but would complicate any future joint replacements. Due to the rarity of the disease, it was hard to tell what the doctors should do, as there is only one treatment on the market today that has been shown to help stop her excessive bone resorption, but it had severe side effects, and would jeopardize her ability to have children in the future. The patient surprisingly did not have any pain, so this confused the doctors. Should they treat something that caused the patient no pain, and risk bad complications due to the treatment? Or should they see how the patient's condition progresses down the line and make a decision then? Both have their pros and cons, obviously. I thought it was very interesting that a patient's pain level significantly influences a doctor's decision in this case. It was obvious that she needed treatment, and that her hip would eventually fail catastrophically, but since she had no pain, the doctors had to think twice about the mode of future treatment.

On a less related note, I was very frustrated with the Immersion program this week. One of my biggest complaints is its apparent disorganization overall. Yi Wang and Shannon have been helpful overall, but they did not know how people should go about getting IDs for HSS access, did not know how to get scrub access for watching surgeries in the OR (for both HSS or Presbyterian), did not inform people that choosing a non-surgeon mentor would complicate seeing surgeries overall, and did not get things rolling with seeing surgeries in the CT field until the beginning of the third week. I believe that most of this stuff should have been taken care of ahead of time and that more information be given to the students before we get here. For the first two weeks, most of us have been running with our heads chopped off trying to get access to the OR, get our HSS IDs, find a way to get scrubs, and to find things to do overall. I have spent dozens of hours trying to find out how to do the aforementioned things, with no apparent guidance from the administration. I have contacted Yi and Shannon multiple times regarding these topics (among others) and although they have been working hard at figuring this stuff out, they did not have any good answers. In fact, I (as well as the rest of us, for the most part) have been able to solve most of these issues ourselves, with no outside help. The worst part about it, was the ease at which most of these issues could have been solved, only if they were looked into BEFORE we got here in the summer. It is very frustrating knowing I wasted many hours of my time trying to solve these programs when we only have a short 7 weeks here in the first place. On a good note, it seems like will be able to rotate with a lot of the ER and ICU units around the hospital in the coming weeks (thanks to the Cornell admins).  

Another big problem I have with this program so far is the lack of communication about ANYTHING. I was under the impression that we would be seeing lots of surgeries just like the last year's group, but it seems like that will not be the case (at least not according to Yi or Shannon), but let me explain more about that later. Again, it would have been a great help to get some handouts about expectations from the program (such as how much time we should be spending doing research etc), potential problems we would be facing (scrub access etc), and just general contacts (to help us get scrubs, connect with surgeons, etc) that we could have to help us find our way with our time here. It would have been helpful to just have MORE information about just about anything, but I get the impression that Cornell doesn't care about the program enough or just can't be bothered with finding out information about logistical issues before students arrive here. Everyone involved with the Immersion program could have done better in this regard.

On a more happy note, many of us now have OR access and have seen a surgery or two at least. It seems like all we had to do was to contact a surgeon, get him to fill out an OR access form, then scrubs and OR access would be granted to us. It was fairly simple to begin with, and will get even simpler. Once we have scrubs and OR access, it seems like we can just come and go to the OR as we please, as long as we get the OK from the surgeon first. I now plan on seeing as many procedures as possible. 

On Friday, Greg and I went to see a prostate get removed from someone who has cancer. The surgery was performed by Dr. Scherr (a Urologist) and he specializes in using the Da Vinci Robot surgical system in his procedures. It was truly a sight to behold, and was one of the most amazing things I have ever seen in my life. The Da Vinci allows a surgeon to perform tasks with unprecedented precision and speed and allows for the surgery to be as quick and painless as possible. Before the surgery began, they inserted a catheter up the man's penis (which we found out why later). For the surgery, they first had to open up a couple of "ports" on the patient's stomach so that the robot would have access to the abdominal cavity of the patient. Once inside, the surgeon uses a 3D reconstructed image from a camera on the robot. He controls the robot's instruments using video-game like controls (I believe the instruments on the robot included a harmonic scalpel and a electrified bipolar clamping device). Dr Scherr was able to cut effortlessly through the tissue of the stomach to the prostate using the robots scalpel and cauterization tools. Nurses were able to access the cavity as well through the side ports; they were busy sucking out residual blood and clamping any blood vessels they decided not to cauterize (see below). There was very minimal bleeding as well, until they got to the prostate and bladder. Since the prostate and bladder are attached, they had to bisect the two as well as the ureter which ran through both organs (which took a while). After they were bisected, they pulled the bladder down to access the prostate. Next, they had to clamp and cut the vessels that fed the prostate, but they could not rely on cauterization to stop the bleeding this time, because this might have damaged some of the sensitive nerves in that area. Overall, they did an excellent job in clamping all of the vessels and removing the prostate, but there was a tense moment or two when the suction device stopped working for a minute (which caused the cavity to start filling with blood). This is one of only cons to this type of surgery; once the cavity starts filling with blood, the only way to remove the blood is with a suction device. If that stops working for some reason for long periods of time, then the only way to stop the bleeding is to remove the robot and open up the patient (which is much more risky surgery). They removed the prostate through the hole on the stomach and were able to reconnect the ureter to the bladder and sew the catheter to the wall of the bladder with dissolvable stitches (from the man's penis). The man would have to have that removed in a couple weeks. It was truly amazing, and I cannot wait to see some more cool surgeries. Also, my mentor will be back next week so I will be able to get underway with my research project as well. 

1st Week of Immersion

Sorry for posting my first week's post as a comment, but I copied everything over to this page. Not much happened for me this week but I was able to shadow some rheumatologists with Jason. I was also able to attend the comprehensive arthritis program (CAP) clinic as well, where they examined a patient and as a group discussed what they thought was the best course of action for him. At this clinic, the patient had a valgus deformation with her left leg because of a prior car accident. He also suffered from some genetic deformities. It was definitely a hard case and it led to some good discussion.

I would say that my favorite part of the week was the CAP clinic. I found it very cool how the doctors assessed the patient and there was some very good discussion points that they all addressed. It was nice to see how they thought through the process and came to a consensus about the patient. The more experienced doctors were able to coax the fellows in the right direction if they thought a course of action was not as good as it could have been.

I also liked seeing patients in the exam rooms as well as visiting patients in their hospital beds. The exams that the doctors gave were very thorough because a lot of patients exhibit many symptoms from several conditions, which made it more difficult to discern what was actually going on. It seems like the default solution to everything in rheumatology is to apply some sort of steroids to calm down the inflammation in the joints or in other areas, and the long term solution depends on how they respond to the initial steroid treatments. The most interesting case was was with an older woman with rheumatoid arthritis. She had taken many different medications hoping for one that did not have significant side effects. Some of the drugs were very effective, but she stopped using them because of the side effects. Now, she refuses to take almost anything because of the thought of side effects. This made it very difficult for the doctors to treat her problem, which lead to frustration on the doctor's part. It seems like patients in general are very wary of a lot of side effects of some of the more powerful drugs out there.

I look forward to being in the OR next week, as well as exploring some other areas of medicine.