Marsha-Week 1

I finally made it to Summer Immersion this week after a two week delay in Ithaca from an unexpected illness. At 7 am on Monday morning I met Dr. Spector for the first time and got off to a quick start immersing myself into the clinical world. Dr. Spector is a plastic and reconstructive surgeon at New York Presbyterian, which means that he is involved in surgeries that cover the entire expanse of the body.

Mondays are when Dr. Spector typically has office visits—these are patients who have already undergone surgery and are returning for follow-up visits or those who are receiving consultations for anticipated surgeries. Previously, I had associated cosmetic appeal as the primary reason that a plastic surgeon would operate. This is not the case at all! During office hours, I realized that wound healing is a challenging and important part of any surgery. All too often we focus on the few hours the patient is physically on the operating table, and forget the weeks and months that are spent caring for the resulting wounds. This is a long process and can keep patients out of work for a significant amount of time. Pre-existing medical conditions such as diabetes or poor circulation can make wound healing even more challenging.

The operating room was an experience like no other: seeing the musculature and vasculature inside a living body is unbelievable, as well as knowing that in a matter of hours a procedure will be done to vastly improve someone’s quality of life. The common theme among Dr. Spector’s cases was “healthy vascularized tissue.” In many cases a diseased state was persisting because there was no healthy vascularized tissue in the area. This led to stagnation in healing from a previous procedure and was often accompanied by infection. In these situations, a muscle, such as the pectoralis muscle, that does not play a necessary role in everyday functionality is moved into the area of injury while still remaining connected to its original blood supply. This is called a flap procedure and solves the problem of no “healthy vascularized tissue” in the area. I saw flap procedures moving a muscle from the chest to the throat, from the calf to the ankle, and across the abdomen.

The other procedure that really excited me was a skin graft. In several situations, after moving a muscle in a flap procedure, there simply would not be enough skin to cover the wound; therefore, a skin graft was necessary. I always thought a graft meant a thick slab of skin being transferred from one area of the body to another. In essence, it is, minus the thick part. To perform a graft, the uppermost layer of skin from the thigh or butt area is shaved off in  a single continuous strip. The thickness of skin removed is no deeper than what you might encounter with a common scrape. The skin is then put through a meshing device which increases the area a graft can cover by converting it from a solid sheet of skin to a mesh. The meshed layer of skin is then stitched into place to provide a new source of epithelial cells to the area, and the graft is complete.

This week I also had a brief introduction to the lab but that will be discussed in a later entry once my project gets off the ground. There was so much excitement in Week 1, I cannot wait to see what is in store for next week and beyond.

Week 3 - Julie

In my third week I had the chance to observe very unique departments in the hospital: the emergency department and the pediatric ICU. On my first day at the ER, I shadowed the head resident from 7:30am until 4pm. This was a good time to start with because around 11am the ER was in full swing and very busy. I attended the morning report, where the residents and interns played a matching game to learn about the top symptoms of each medication commonly prescribed in the department. Now I know not to take too much Ibuprofin. The second day I spent in the ER was from 3:30pm until 11:30pm, in which I shadowed nurses and doctors in the walk-in and ambulance triage areas. It was amazing to see them work with such alacrity during the busy 4-6pm time period, and I was even able to help organize charts with them.

The major issue in the emergency department reminded me of a key issue of the hospital in Tanzania. First, they simply do not have enough space. There were points when the number of patients in the hallway about equaled those who were in rooms. However, the patients were more varied. In Tanzania, patients and their families happily sit 2 or 3 patients per bed and quietly await the doctor’s attention. Here some family members would run around searching for a doctor or nurse in order to get their attention or ask to be discharged quicker. One patient during the night shift came in with alcohol and cocaine use, and he would not stop screaming “help” at the top of his lungs. This made the other patients nervous and the staff annoyed. It’s amazing to think of the patience and strength of the staff who not only deal with difficult medical decisions, but also have to handle the more “human” side of their patients.

What I learned in triage was the variety of afflictions that people can come in with. The doctor was able to discern not only what the patient was most likely suffering from, but how much of a stability risk they presented. But most of the cases were not as dramatic as we see on tv. There were only 2 or 3 key traumas who came in and had to be resuscitated immediately. Otherwise, the EMTs were able to stabilize the patient or they had not suffered as a dramatic injury. The psychiatric patients were sometimes difficult to handle emotionally. This is where I wish I was trained on what to say, when people were speaking of suicide or depression. There was also a man who kept yelling at me that he needed to be seen right away and we were ignoring him. We needed to get security to remove him from the building. In fact, I saw many patients escorted by security who just wanted pain medication or food and became belligerent to the staff. When I return to the ER I will try to speak to a member of social work to learn how their department fits in, since I see they could have a difficult job managing the array of patients who come in.

The pediatric ICU was interesting because while the patients were all very sick, there was a palpable positive attitude. I shadowed the blue team and red team on rounds, which allowed me to learn about the care for cardiac patients as well as other disorders. One patient has congenital heart disease, and a probable genetic disorder that causes her to develop more slowly. We spent most of our time on rounds reviewing this patient because she is a difficult case. They were unsure of possible liver failure due to electrolyte imbalances, but since her main issue was cardiac, they focused on her recovery from multiple heart valve surgeries. In a bigger picture, this patient was unique to me because I saw how a group of doctors worked together in a brainstorming session to try to determine her key problems and different methods to combat these. It was similar to how engineers are taught to brainstorm, with each person presenting ideas and no one disputing them right away. As a group they would talk through the different possibilities until they came up with the day’s treatments and noted what to keep track of during the day. I am looking forward to similar experiences in the PICU later in July.

For my lab project I began to produce the tools necessary for my research. I learned how to create fibers for my scaffolds. These fibers will be embedded in collagen with a co-culture of cells. Then the fibers will be dissolved, leaving a microchannel, representing microvasculature. Now that I have the fibers and the mold, next week I can add the collagen with the co-culture.

Week 3 - Chih-Yun Hsia

This week was a bit different from the last two weeks. I focused more on my research project compared to the clinical aspect. My primarily project is to go through the database of bladder cancer patients who have cystectomy surgeries. My job is to compile the information such as: TURB ( Transurethral resection of the bladder) results, surgery pathology results ( tumor grade/stage, present of CIS, STSM..etc) and the current status of the patients ( whether there are local/distant recurrence of the cancer). Initially, I thought it would only take me no more than 1 week to finish the work since it didn't sound very hard and time-consuming. However, it is more complicate than I expect due to the lack of understanding of the treatment process of bladder cancer. For example, why some patients got converted cystectomy not robotic cystectomy? Why we care the presence of CIS, STSM?  Why doctor still wants to operate cystectomy even thought patients already got chemotherapy and their tumor were under T1? I need to keep asking the fellow in Dr. Scherr's team lots of questions while working, and I think I definitely learned a lot from this work.

Beside the project, I also attended some meetings/lecture this week. On Monday, I went to Urology department grand run. Two residents presented two difficult clinical cases they had recently. They described the case, presented

literature relevant, and showed the ideas how they can improve it if the same thing happens next time. On Thursday, Dr. Prince also gave us a lecture on medical imaging and diagnostics. He taught us the procedures and methods to read images, such as X-ray, CT or MRI. It was my first time to read these images and I had really limited knowledge of it, but Dr. Prince used case studies to get everyone involved. I really enjoyed his lecture and be more familiar with these intimidating images. 

  

Jonathan-Week 3

I had a very interesting last week. Since my mentor, Dr. Bostrom, was away for the week, I spent a day shadowing Dr. Jerabeck in the clinic, a additional day shadowing him in the OR, and three days working on my summer research project. In the clinic, Dr. Jerabeck had two cases I found particularly interesting. In the first case, a young woman came in experiencing severe knee pain with some swelling. She had been battling cancer for years and appears to be in remission. The cancer damaged the bone quality in both her femur and tibia, leaving necrotic bone voids in each. These bone voids have the potential to cause her tibio-femoral joint to collapse. The case was complicated because the young woman did not want to have new X-rays taken due to all of the radiation exposure she experienced during her cancer treatments. Dr. Jerabeck could not know how bad the situation was without up to date X-rays. If the severity of the bone voids was still low, she could be helped with bone filling surgical techniques from Dr. Joseph Lane, but if the situation had worsened to joint collapse, she would need a knee replacement. The patient was recommended to Dr. Lane and encouraged to receive up to date X-rays.

For the next case, a elderly woman with a hip replacement came in with severe pain. Her previous doctors could not explain the pain. Dr. Jerabeck identified that her pain likely was a result of problems associated with metal-on-metal total hip replacement. The problem with these hip replacement designs is the generation of metallic wear. All hip and knee replacement systems wear; however, in most designs, the wear in polyethylene wear, which is much less harmful to the body. Cobalt of chromium wear causes a more severe inflammatory and allergic response from the body. The previous doctor likely did not know what was wrong with her because he did not run thorough enough tests on her to determine the metal content in her blood. Dr. Jerabeck prescribed her to have additional tests; based on the outcomes of those tests, Dr. Jerabeck will decide if a revision THR is necessary.

In the OR, the case I found most interesting was the use of the MAKO-plasty robotic assistant device in a unicondylar knee replacement. Uniconylar knee replacements (UKRs) are sometimes used in place of TKRs because their kinematic behavior more closely resembles the natural knee joint or only one of the sides of the knee is experiencing arthritis. For the MAKO-plasty robot, the surgeon first uses a specially designed set of tools and a camera to recreate the 3D position of femur and tibia in the computer. To do this, the surgeon places a fine-tipped tool only approximately 100 points across the tibia and femur matching points on the computer. Using these coordinates, the computer can recreate the two bone surfaces with an accuracy around 0.5 mm. A microscopic cutting tool equipped to the robot is then used to cut away the cartilage for the tibia and femur of the side of the knee they are installing the UKR. The cartilage must be cut away so that the implant can be fixated with bone and so that the new implant surface is properly aligned with the cartilage surfaces of the other side of the knee. Using this system, Dr. Jerabeck was able to install the UKR with precise alignment and with minimal destruction of the surrounding bone.

My research project is going very well. I am researching about why cementless knee replacements are not more widely used and about how recent technological developments (trabecular metal, bioactive coatings) may make cementless TKRs a more attractive design option in the future. I am planning to present my findings to the Bostrom lab near near the end of my summer immersion term.

Weeks 1 and 2 - Jean C. Cruz

Week 1:

On Tuesday morning, I met with Dr. Gupta. He is a neuro-radiologist at the Weill Hall Neuro Radiology Department. We talked about my research for a while before deciding on a possible topic which should be my focus for the summer. He immediately got me involved by introducing me to his colleagues and staff members. 

Due to the fact that the nature of my thesis (elucidation of the triggers and progression of Alzheimer’s disease) and his day to day work, (interpretations of radiographs, CT, and MRI involving the brain, spine, and the head & neck) don’t have anything in common, we decided that during these next two weeks I should shadow some of his colleagues before we decided on a specific topic for the summer project. We opted shadowing Dr. Bradley Pua, an intervention radiologist at Weill Hall Cornell Medical School. In addition of the general procedures (biopsies, insertions of catheters and IVC filters, etc.), I had the opportunity to watch a thrombolysis and balloon angioplasty/stent procedure. During this procedure Dr. Pua was able to remove the most recent clots using the Trellis System and for the old ones he used the balloon angioplasty system. 

                                                       

                                                        Figure 1. Trellis Peripheral Infusion System

The Trellis Peripheral Infusion System is an isolated thrombolysis catheter with two occluding balloons, drug infusion holes between the balloons, and mechanical drug dispersion capabilities. This pharmaco-mechanical combination provides focused treatment of thrombus within vessel.                    

  Figure 2. Balloon angioplasty mechanism

The balloon angioplasty procedure can open blocked arteries by expanding the inner diameter with a balloon mounted on a thin tube.  

Week 2: 

For the second week, I kept shadowing Dr. Pua and Dr. Sista in the intervention radiology department. Similar to the first week, in addition to watching general procedures, I was able to watch additional uncommon and interesting procedures. During this week we can highlight the tumor embolization procedure. 

                                                         Figure 3. Tumor embolization procedure

Tumor embolization is a procedure that can be performed prior to a planned surgical resection. Embolization shuts down the blood supply to a tumor reducing blood loss during surgical resection. A secondary benefit from embolization can be that tumor margins are more easily identified and a tumor can be removed more completely and with less effort.

In addition to being able to observe some medical interventions during these past two weeks, I was able to attend some of the MD classes, some general meetings, conferences, tumor board discussions, and social events with Dr. Pua. Of all the above activities, the tumor board discussions were probably the most insane ones. In this meeting the physicians were able to go through 20-30 patient records per hour; they were able to identify and determine the tumor type and decide the most convenient treatment for the patients.  

Week 3 - Marie

An 8-hour shift in the Emergency Department (ED)was definitely the highlight of my week. I shadowed Dr. Joe Rella, an attending physician in the ED. What was most interesting about this experience to me was seeing the process of taking a patient's history and peformin a physical exam-- most of my experiences in the hospital so far have occurred after the patient's health concerns are well-known, but in the ED this is often not the case. For example, one woman came in to the ED complaining of chest pain. Dr. Rella's line of questioning included her medical history, her parents' medical histories, her lifestyle and diet, her work and associaed stress, etc. From this we learned she was a middle-aged woman with a high-stress job in social work who smokes and drinks 6+ cups of coffee a day, and has a history of lupus and high choleserol. This led Dr. Rella to consider both cardiac and gastrointesinal sources for chest pain, which he assessed with serial blood work. This case demonstrates a few other challenges of the ED: triage means that some patients can wait for a long time, high occupancy means many patients are in beds in the hallway, serial tests (often necessary to look at changes in serum levels) mean patients are at minimum frustrated (and sometimes irate). I was impressed, however, with the continued professionalism of the ED staff, and greatly appreciated how much time Dr. Rella made to explain the various x-rays, MRIs, and EKGs that he had ordered for his patients. I plan on spending more time in the ED this summer, both in the A section and with the triage nurses.

Another interesting part of my week was the imaging seminar given by Dr. Prince. Dr. Prince used case studies to teach us how to read medical images--for example, the first slide featured an x-ray of an arm demonstrating a "nightstick fracture", which is an isolated ulna fracture. This slide was fairly easy to identify, but the images became increasingly difficult, ending with two fetal MRIs. These seemed quite challenging at first, but we were to discern health concerns such as previa and encephalocele. These MRIs were follow-ups to concerning ultrasounds and are used to determine the type of birth and to prepare the medical team to quickly act.

I attended the gynecologic oncology tumor board meeting this week, which is where the team of gynecologic oncologists, pathologistics, etc. meet to discuss common patients and determine courses of treatment. I also attended the pediatric grand rounds on Tuesday as well as part of my Pediatric ICU rounds, during which fellows presened their research.

Week 1 - Sung Ji

Summer immersion has been exciting so far. I am paired with Dr. Pannullo in the Department of Neurological Surgery at NYPH. In the first week, I was able to attend an IRB (Institutional Review Board) meeting. In the IRB meeting board committees reviewed various clinical researches. Mostly, the studies were phase 1,2,3 trials about testing the efficacy of the drugs, new equipment, methods of various treatment regimes. Mainly the discussions were about blind control of the study candidates, the contents of informed consent and whether insurance or research funding can cover those clinical studies. The committee went through list of clinical trials and decided to defer or approve. During 5 hours of IRB meeting, I was able to get some scope on clinical research.

With Dr. Pua in the interventional radiology department, I shadowed some biopsies and surgeries. I was very fortunate to attend a class with third year medical students about interventional radiology before I get to shadow the real procedure, since Dr. Pua had to give lecture in the morning I went.  It was very interesting to see liver biopsy done with a needle under a CT scan. In order to confirm a biopsied tissue, histologists came and examined the tissue under the bright field microscope in the surgery room right next to the patient. Surgery in the interventional radiology department was very interesting. A guide catheter was placed to find the exact location and catheters with different size and shape was placed to perform certain tasks such as application of drug, blow a balloon to stanch, adhere, change direction, and so on. A real-time x-ray scan was done to monitor where catheter was placed. I was very surprised to see how the advances of those devices enable doctors to simplify the procedure and minimize the damage of the surrounding tissue. One thing I noticed that needs amendment was moving the table where patients were lying on, since the x-ray scanners were fixed at one position. In most cases, patient doesn’t receive general anesthesia, and thus it would be a pain for them to lye on the moving bed for 5~10 hours.

I was able to shadow some of Dr. Pannullo’s clinic. Patients were mostly diagnosed with a malignant brain tumor. Since Dr. Pannullo use irradiation therapy to get rid of brain tumor instead of open head surgery, most of her patients have small tumor and are eligible for irradiation therapy (tumor that had diameter greater than 3cm cannot receive irradiation therapy because of their high dose). Although I could only see patients in the clinic, I hope I get to see brain surgeries in the following weeks.