Week 3: OR-ed Out - Kaminski

This week was similar to the others - I spent tons of time in the CT OR. I am finally getting comfortable with the CT lingo, what tests they order and why, what the results mean, how to identify issues on a TEE, blood pressure monitor, and how they fix them. This in and of itself is really exciting. To be able to really follow a procedure, from multiple view points is so much fun. I'm also just really tired. Although I now have some level of communication with the fellows and doctors I am shadowing, and have been able to ask some more questions, it's not as much as I would have hoped. But more so, I have yet to be exposed to the steps leading someone to having their chest/heart cut open. The clinic was what I was most looking forward to experiencing and that has so far been more or less completely absent. But, I have met some pediatric cardiologists who I think I am going to reach out to and try to follow in the coming weeks.

Last week I saw a lot of pediatric cases which I enjoy much more than the adult cases. The cases of note were a Tetrology of Fallot full repair and a procedure to connect the superior vena cava (SVC) to the pulmonary arteries that seemed to be a modified Glenn Shunt procedure because the child's anatomy was far from normal. The first case had complications, mainly turbidity and non-physiological flow, discovered by the TEE after the pulmonary artery was connected directly to the RV because an outflow tract never developed. The pericardium that had been harvested to make the pulmonary artery wasn't sufficient due to pulling from the PDA and the repositioning to connect the the RV. They had to go back and add a second piece of biomaterial (core matrix) to the site to extend the newly made pulmonary artery. In the second case was the first of a series of two procedures where they would later connect the inferior vena cava to the pulmonary artery to completely bypass the right heart. This kid had a very strange anatomy, the left and right atrium were confused as to their identity, there were two SVCs, and ASD and then a lot of other non-heart related issues. Hopefully the kid will be able to live a normal life, but they are at least lined up for one more major open heart surgery and it sounds like many other surgeries on top of that.

The other interesting case was a man with an aortic root abcess that required the reconstruction of almost his entire left heart. They replaced the mitral and aortic valves and had to rebuild the atrium using a ECM product. This case was not only intense and really interesting (the whole thing was an engineering challenge) but it also brought a new sensation to the OR. The smell of infection and necrotic tissue. Adding to the blood and burning flesh, this really took things to a different level.

In summary, I'm looking forward to getting out of the OR because I think it will help me to appreciate more what happens in the OR - and vice versa! I'm also hoping to observe more in the pediatric floors and will be in the PICU after 4th of July.

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.

My third week in NYC

My main goal this week was to set up all the equipment for the experiments I'm running in collaboration with the Goldring lab. This required a significant amount of troubleshooting because the equipment hasn't been used in two years, but I was able to get everything up and working. Next week, I plan to begin my experiments and learn new skills with some cartilage experts in the Goldring lab. I also completed all of my microCT scans for analysis back up in Ithaca this week.

Besides my lab work, I experienced two new things in the hospital: cardiothoracic surgery and the pediatric intensive care unit (PICU). I observed an aortic valve replacement and the beginning of a mitral valve replacement. The fellow working the echocardiogram was very helpful and I learned a lot from him on how to diagnose heart problems. Seeing an open heart surgery for the first time was pretty intense, but overall, I enjoyed it a lot. In the PICU, I saw a bunch of different cases with patients varying from a few months old to their teens. A lot of the terminology the team used was very difficult for me to understand, but hearing them discuss what their plans were based on the patients' conditions and X-rays was awesome, as I learned how some doctors have to think like engineers on a regular basis.

Week Three

Dr. Sista is the coolest physician that I have met to date. We actually discussed engineering issues from an interventional radiology perspective. I will consider Dr. Sista as a primary contact for future design of fiber delivered light as a laser surgical source. This type of device would be useful for removing intravenous filters engulfed by endothelial tissue, and for cutting other forms of water containing tissues (especially where coagulation is not necessary).

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 3 What Happened (No pun included) (Guss)

This week had some high points for sure. Finally got into the OR this week and let me tell you it was a quite a doozy seeing the cardiothoracic surgery as my first OR experience. Being very tall I was able to stand near the anesthesiologists and peer over to see what was happening easily. I had to take a step back the first time I saw the patient's chest open and their heart beating right in front of me.  It was truly an incredible experience and showed me I really had no appreciation for what happens in the OR.  It was very interesting seeing how diseased the heart could become with fatty deposits and how failure in one chamber can lead to pressure changes that lead to hypertrophy on the other side. One side was nearly twice as big as the other. I also was surprised that the smell of burning flesh is common place in the OR due to the surgical tool. The organization in the OR was very impressive and how all the team members know what is going and what the next step is for the procedure to go effectively.

Another procedure I saw was an arthroscopic knee surgery.  This really did not compare in the "coolness" factor after what I had witnessed in the OR the other day.

I also did rounds in the pediatric ICU this week which was very interesting yet very depressing.   I saw babies hooked up to IV's and ventilators, as well as a teenager that had a massive blood vessel burst in his brain and will be left paralyzed.  It was nice to see the children however that were recovering and were starting to smile again which is always refreshing.

The rest of my week was very similar to the other ones as I shadowed fellows in rheumatology.

THATS ALL FOLKS

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).