Week 7

This week was filled with babies! First, Lina and I together watched a preplanned Cesarean (C-section) surgery where an incredible cute 7 lb, 7 oz baby boy was born. The baby was in a breached position, meaning he was butt first rather than head first, and I suspected this is why the mother had to have a C-section. In the procedure they first made about a 6 inch incision into the woman’s lower stomach, cut through the tissues and linings of the uterus, cut into the uterus and removed the baby through an incision that looked only slightly bigger than the baby’s head. The doctor’s then pull out the placenta, sew the uterus shut, and close up the woman. Separately, the baby is cleaned up, they cut his umbilical cord, fingerprint his feet for identification, weigh him, and wrap in blankets for the parents to hold. The whole procedure takes under an hour, and the baby was out of the mother in only about 10 minutes.

Also this week I was able to go on rounds in the Neonatal ICU (NICU) with Dr. Jeffrey Perlman and a team of residents. Luckily, most of the babies in the NICU are not very sick and will have a healthy recovery. Most of them were born prematurely, and there are lots of twins. The doctors just want to watch them, help them gain weight, and make sure they are healthy before they are sent home. They teach the parents how to handle a preemie baby specifically. Unfortunately, there were two babies I saw in the NICU that did not fit this description. One full-term baby underwent a difficult delivery, so they doctors wanted to watch him for possible brain damage. Another baby was born with a heart defect and was in the NICU until she could have surgery.

This week I also had the chance to shadow doctors in the emergency department (ED). First, I went to the “Urgent Care” department which was very different from what its name implies. Here, I followed a 4^th year medical student who performed sutures on a woman’s cut wrist and identified a cornea scratch for a patient with eye redness and pain. For a woman coming in with tooth pain, the doctors prescribed antibiotics and pain medication, and arranged a dentist’s appointment for the next day. Overall, not the most interesting cases I’ve ever seen. After a few hours I went on to shadow a resident in Area A and observed the hustle and bustle of an ED that I expected. I was shocked at the significant number of patients they were able to accommodate at one time: two patients per room along with people on beds lining the walkway. However, it just seemed like everyone was running around crazy at all times. The patients I did see with my resident was an older man with ankle pain and edema and a woman who fell, possibly had a seizure, and needed to be examined for broken bones or internal injuries. The most interesting case was an older man with a history of bladder cancer and diabetes, had a recent kidney transplant, and now possibly has congestive heart failure or pneumonia, but no one could tell for sure what was wrong. They were worried about his high blood counts, glucose, potassium, creatinine, and urea. His stay in the ED was to simply take his counts and then admit him to an ICU within the hospital. 

Week 6

It is the week following the conference I attended and it pretty much went right back to same routine I had before I left. Monday afternoon I attended the weekly genitourinary tumor boards where radiologists and pathologists inform the doctors of their patients’ test and biopsy results. The doctors then propose what they think is the best treatment plan for the patient, or ask the other doctors for their advice on what to do. As long as everyone agrees on the plan they move on to the next case. As I attend more and more meetings I am starting to understand more of the details that the doctors are discussing, which is rewarding.

This week I also followed residents and Dr. Lindsay Lief on medical ICU (MICU) rounds. The rounds were a little slow paced; we only covered about 6 patients in 3 hours. Interestingly, the MICU hosts a wide variety of patient cases. The previous night a young 30 year old woman was admitted after overdosing on anti-depressants and was now experiencing seizures. The only treatment plan for her was to closely monitor and follow up with psychology and future therapy. Only right next door there was an older man with what was described as “explosive lymphoma.” Unfortunately, the cancer has spread all throughout his body and he is now in multiple organ failure.

As with every Wednesday, I spent the day in the clinic with Dr. Nanus seeing patients. I have now been able to see some of the same patients week after week and track their progress.

I was also able to get into the OR and see a robotic prostatectomy with Dr. Scherr on a patient with prostate cancer. First, the residents and PA made 5 small incisions all along the patient’s abdomen to insert the camera and robot tools. Once inside they cut around the bladder and fascia. They had to cut his urethra since it was attached to the prostate. Dr. Scherr then cut all the fat and tissue around the prostate to remove it whole. The prostate was put into a plastic bag to be removed later through an incision next to the belly button. The last step was to physically move the bladder and urethra close together, sew them together and to hold them in place within the abdomen. After all this was done the tools were pulled out and the incisions sewn closed.

Week 5

I spent the entire week at the World Congress of Biomechanics conference in Boston, MA. Since I wasn’t in the hospital I do not have any clinical experiences to share, but I will highlight some of the interesting points I learned at the conference:

• Cells spread more on stiffer substrates. This increases stress on the nucleus however.
• Increasing the ECM density (mostly collagen) of breast tissues increases a patient’s risk of cancer 4-6 times. Shown in mice, increasing the density increases stiffness, and also increases cell proliferation and metastasis.
• Obesity increases breast cancer incidence and prognosis via paracrine cell-cell signaling. Obesity is associated with increases collagen and fibronectin ECM deposition.
• One professor is using a microfluidic device with a VEGF gradient to study blood vessel morphogenesis and sprouting. Increasing the VEGF concentration increases sprouting. Interestingly, with flow there is a decrease in sprouting due to nitric oxide production. Flow also modulates endothelial cell morphogenesis.
• A change in cell spreading (by changing matrix stiffness) alters cytoskeletal tension, which affects the number and strength of focal adhesions. Increasing stiffness increases the force cells exert on micropillars. Different signaling pathways become activated based on cell morphology and the extent of spreading. Surprisingly, in 2D or 3D, increasing stiffness causes an increase or decrease, respectively, in cell spreading.

Week 4

On Monday I attended the pediatric ICU (PICU) rounds where I observed a wide variety of patient cases. Some of the patients were very young babies with heart defects, two with Tetrology of Fallot and one with a single atrium and ventricle and arteries/veins attached in the incorrect places, all recovering from complicated surgeries. There was also a 5 year old boy with a broken arm, and another 21 year old in organ rejection from a recent kidney transplant. One case was a mystery: a 15 month old boy having seizures with an unknown cause. An extremely sad case was a 12 year old girl previously with leukemia, suffered rare complications from a brain hemorrhage and is now a quadriplegic.

I was also giving the opportunity to observe Dr. Mark Schwartz, a plastic surgeon, in the OR where he replaced a faulty breast implant with a breast tissue expander. Here, his team cut an incision and first removed the old saline implant and the capsule formed from the implant. They inserted the new expander, filled it with saline to match the patient’s other breast, and then closed the wound. The patient will have the tissue expander for about a month and then will undergo another procedure to replace it with a more permanent implant.

Additionally, this week I was able to see cardiothoracic surgery with Dr. Leonard Girardi. The procedure was a triple bypass with at least one being a coronary artery bypass surgery (a “cabbage” procedure). This middle aged woman has suffered a heart attack and narrowing blood vessels, so the surgery was to restore and improve blood flow to the heart. A physician’s assistant removed a single vein from the patient’s left calf. A cardiothoracic fellow performed a lot of the other prep work until Dr. Girardi arrived. With all of the doctors and anesthesiologists in the room it became too hard to see anything inside the patient. I did hear that the patient’s mitral valve was experiencing regurgitation due to the injury in her heart, so the doctors placed a small white thing around the valve to help close it. Overall, it was a frustrating experience to not know what was happening in the surgery and also not being able to see much of anything.

Week 3

This week I finally got to observe surgery!

First I saw the removal of brain tumors with Nery and Dr. Schwartz. The first patient had a 1 inch left temporal mass, which they removed fully intact after fully opening up the patient’s skull. A second patient had a pituitary tumor which was removed through the nose. The doctor’s had to break up the mass into pieces in order to fit it through the nostril, making it a very non-invasive method.

Another day I spent with Dan and Dr. Spector to observe a skin graft. It seems like a rather quick and straightforward procedure. The doctors first removed a mass from the patient’s left inner ankle, and then grafted a large piece of skin from their upper thigh. They placed the graft over the wound, stapled it in place, and bandaged it to heal.

           

I think the most interesting surgery I saw last week was creating a neobladder and nephrectomy with Dr. Scherr via the robotic DaVinci machine. The patient was an older man with bladder cancer. First, the doctors removed old bladder with the DaVinci and put it in a bag. The machine was then disconnected, they made a small incision next to the belly button, and then literally yanked the bag with the bladder out of the patient. They then repositioned the patient on his side to remove his non-functional kidney, also with the DaVinci. The neobladder was then created from the large intestine by cutting out a piece and folding and sewing it many times. Next they reattached the native urethra, inserted a stent, and put the whole neobladder back into the body. The DaVinci machine was reattached to sew in a couple stitches to hold it in place. Overall, this was a long 9 hour procedure but it was extremely interesting to see!

Week 2

My week this week was actually quite similar to last week. I spent one day in the clinic with Dr. Nanus, a medical oncologist, for chemo patient follow-up visits. This week, we saw numerous patients with metastatic cancer. In particular, I learned that bone metastases are a likely location when prostate cancer is initially presented. Interestingly, I was able to see a visit between Dr. Nanus and a new patient, and all of the information and examination that goes into it. It turns out that this patient had quite the past history including: leukemia, a triple bypass heart surgery, kidney cancer, and diabetes. Unfortunately, he now also has metastatic bladder cancer invading into his muscle, and to avoid any further kidney damage caused by chemo and radiation, his only sensible treatment option is to replace his bladder in a neobladder reconstruction.

Again this week I went to the genitourinary (GU) tumor board meeting where many doctors from different departments meet to discuss a patient’s past results and decide what the next step to take is, collectively. I also attended the cardiac care unit (CCU) rounds with David. Here, we observed a transesophageal echocardiograph of an older woman with multiple holes in her septum between the ventricles in her heart. It was very interesting to be able to see blood flow through the heart, but it was a little hard to tell the different anatomy of the internal organs.

This week I also spent time observing in lab. I was able to see three different methods that they use to isolate circulating tumor cells (CTCs) from patient blood samples. The methods include (1) an FDA-approved machine with extremely high purity called CellSearch, (2) several rounds of centrifugation, that is easy, quick, inexpensive, but low purity, and (3) a microfluidic chip with antibodies attached to posts that specific to the type of cancer cell (ex. PSMA for prostate cancer). It is very interesting to see the tradeoffs between difficulty, expense, and purity of the different diagnostic methods.

Week 1

This summer I am matched with a medical oncologist, Dr. David Nanus, who specializes mainly in prostate cancer. I spent all day Wednesday with him in the clinic visiting his patients for follow up visits post-chemotherapy. It was interesting to see many patients in a wide range of stages of disease. A few had recently undergone a chemo cycle and were experiencing horrible side effects (nausea, body pains, mouth sores, etc). One man’s results revealed that his prostate cancer had unfortunately metastasized to his liver. Knowing that he might only live six months without treatment, Dr. Nanus created a new chemo regimen for him. Perhaps most interesting, we saw an extremely religious man with prostate cancer refusing chemo, believing that God will heal him. Although some of the cases can have sad outcomes, many other visits produced good news to the patients. MRI and CT scans showed that some tumors were reduced in size for some patients and their prostate-specific antigen (PSA) levels, a protein elevated during cancer, had decreased post-chemo. In particular, one woman’s scans showed that she was still in remission four years later after previously having bladder cancer.

Another highlight this week was attending the gastrointestinal tumor boards, where doctors from all departments gather to discuss individual patient cases and determine the best treatment plan for the patients from many different perspectives. During these meetings they show any scans and biopsy results that the patients have, which I found it extremely useful for me to be able see something in addition to hearing the doctors speak since frankly, most of their medical jargon and abbreviations are way over my head at this time.

I was also able to experience going on rounds in the cardiac ICU when I teamed up with David on Friday. His post describes the visits in more detail, but briefly, the residents are each assigned patients and discuss their status with the cardiologist on duty for the day. Two new patients had just been admitted the night before so their labs and symptoms were discussed in detail. For the other patients a routine was established: briefly discuss any new updates from the previous night and their current status, visit their room to check in and do a quick examination, determine a plan of tests/labs to run that day, and residents are left to implement that plan.

As for a research projects, unfortunately nothing has been decided yet. For now I have observed a post-doc in Dr. Paraskevi Giannakakou’s lab. He is working on isolating circulating tumor cells (CTCs) from patient’s blood samples and staining the cells for biomarkers of the specific cancer type. I will be helping him in some way for this.