Week 4 - Julie

My fourth week at the hospital was different, because I focused mainly on obstentrics (OB). I got to attend morning rounds, and learn about the different complications pregnant women have, requiring them to remain in the hospital until the baby is delivered. It was interesting that hypertension is such an important vital to follow in pregnancy. After rounds I observed a cesarean section operation.  I had seen one in Tanzania, but this one was performed much quicker and with a smaller incision. The care for the baby when it first arrives into the world follows a very specific sequence. Ripping the muscle layer was pretty graphic, but I learned it is ripped and not cut so that breaks occur along fiber lines, making the healing process quicker. 

I also observed a natural delivery. This was even more exciting because the husband and mother of the patient were in the room. I was at first nervous about introducing myself and asking if I could observe, but they agreed and in the end I think I was helpful support for the mother. This birth was much more animated and exciting. When the baby was born the father was in tears and there was so much celebration. The patient was obviously in pain during the labor, but was able to control herself from screaming. Then after the birth she seemed to go back to normal without much pain, but was very cold from all of the hormones. Since the mother had a 101 degree fever while in labor they gave her antibiotics before the baby was born and then wanted to check the baby for a possible infection. I also learned that babies should not make a grunting sound, as this indicates they are having a harder time breathing. But in the end the baby was healthy.

One surgery I saw this week was a tracheotomy from a woman who had a cancer mass on her trachea. The ENT surgeons placed in a breathing tube, and then removed her trachea and the lymph nodes. It was the plastic surgeon’s job to take the pec muscle from under the breast, and reconstruct a trachea around the breathing tube. In a few weeks the tube will be removed and the pec flap tissue will serve as the woman’s trachea. I also got to see the pathology lab when the trachea was brought there. It’s amazing how quickly the pathologists can see a sample and determine if there is cancer or the type. I learned that they can quickly determine the cancer type by using cryo-frozen tissue histological sections and then tell the surgeon while the patient is still on the operating table. Since these samples did not require immediate attention, they will be done with H&E staining with normal fixation and take about one week. It was also interesting to see how they label the complex tissues: using tissue paint to orient each sample. Next week I hope to observe more surgeries, and also see patients in office hours. I would like to see the trachea tube removal.

For my project, I finished learning the skills for histology. I spent many hours becoming proficient in using a microtome. It was important to learn how varied the samples can be when they get to this step: some are much more fragile and the care of each sample also depends on the type of tissue. Now when my project requires this skill, I should be able to perform this step by myself and achieve good sample images. I also got to attend the lab’s 200^th lab meeting! Next week I will be making collagen scaffolds, embedding cells in them, and allowing them to culture for a week.

Week 3 - Amanda

This week was a whirlwind of activity. Due to my "I want to get the best bang for my buck" mentality, I signed up for as many shifts in other departments as I could between my time spent on research and shadowing Dr. Prince. My first shift was in the Emergency Department, starting at 7:30 am. When I arrived, I was quite surprised to see patients sitting on beds in the hallway. Apparently all of the ICUs were already full for the day (each resident is only allowed a certain number of patients, so they reach capacity quite quickly), so it was imperative that only patients who absolutely needed the care be admitted. The morning report, which appeared to be a learning opportunity for the residents, was a review of several case studies consisting of an EKG and syncopy (i.e. fainting). One of the most common patient complaints in the ER is that they fainted recently for no reason and now they feel fine, but their family members or friends encouraged them to go to the hospital. One of the routine tests is an EKG to check heart rhythm, so most ER doctors have to decide whether or not to admit the patient based on the EKG and a banal description like, "I was walking to the laundry room, and I suddenly felt hot and fainted. I got up right away though and now I feel great." The doctors have to pick up on small clues like irregular spacing or small bumps on the EKG printout. 

By the end of the morning report I felt semi-confident in my ability to examine an EKG and notice irregularities. One patient came in after having a few fainting episodes, and her EKG had very low signal. The resident automatically assumed the test leads were connected poorly, but the physician halted him and quizzed him on potential pathologies that could lead to low signal amplitude. He got stuck after a few guesses, but I came up with pericarditis, inflammation of the lining around the heart that would effectively muffle any of the electrical signals that the EKG picks up on. The resident looked pretty nervous since he was new, so I didn't dare say it out loud. However, the physician then named that as a very probable possibility. It was reassuring to know that my approach to solving engineering problems (i.e., why does this signal have such a low amplitude) works in medicine too! 

The rest of my time in the ER oscillated from incredibly busy to very slow. The doctors spent a lot of time updating patient records and ordering various tests and procedures. However, halfway through the day an older lady came in on the ambulance with a serious case of pneumonia, so I got to see a series of procedures ranging from the CT to diagnose the pneumonia, to intubation to bring her blood oxygen level up. I was very surprised at the risk involved with the insertion of a tube for the ventilator (in this case bilevel positive airway pressure). When the doctors decide a patient needs intubation to raise blood oxygenation, the patient already has a significantly low level. However, they need to remove the oxygen mask to insert the tube, which will further drop the oxygenation level. That means time is of the essence, and the procedure needs to be completed quickly and smoothly before the patient "crashes". This patient had oddly disproportionate mouth and throat anatomy, so a physician and two residents both initially failed to get a tube in. They were on the verge of giving up and performing an emergency tracheotomy when the head resident just managed to get a tube in. I didn't realize how dangerous the situation was for the patient until after the doctors succeeded and I noticed they began shaking from the adrenaline. I admire their ability to stay calm and focused under pressure and decided quite quickly that it takes a certain type of person to become an ER doctor.

My favorite thing during the week was my visit to the Pediatric ICU. There was such a variety of cases ranging from Duchenne Muscular Dystrophy to pneumonia. I only attended rounds for one morning, so I'm planning to go back so I can get a sense of how the doctors handle the wide range of cases and determine treatment options.

Week 3 and 4 - Mary Clare

Due to the shortened week 4, I have decided to combine week 3 and 4 summaries together. Week 3 was a highly eventful week, I was able to shadow Dr. Rodeo for patient appointmet, shadow a resident in the emergency department (ED), watch 5 different orthopaedic surgeries, attend a lecture on medical imaging, attend grand rounds, and work more on my research project.

Patient Appointments:

To my surprise, there is minimal redundancy in the patient cases that Dr. Rodeo sees. Although they all have a common underlying theme, each case has its own nuances that make it unique. A person could easily sum up Dr. Rodeo’s patients as a group of patient swith shoulder or knee joint problems related to damage to the tendon, ligament, or cartilage. Both the knee and the shoulder are highly complex joints, so one patient may have shoulder problems due to a torn rotator cuff, while another patient my have shoulder problems due to damage to the tendon that anchors at the elbow. This past week I saw patients with a range of issues from a torn hamstring to a dislocated clavicle. The most interesting thing that I saw in patient appointments this week was a synvisc injection.  As a biomedical engineer this is something that has come up in courses I have taken in the past and it was exciting to hear from patients that had used it previously and patients that were currently receiving arthritis treatment using synvisc.

Orthopaedic Operations:

The highlight of my week and perhaps the summer was in the operating room (OR) this week. I had the rare opportunity to see a meniscus allograft transplant. Meniscus allograft transplant is a procedure reserved for meniscus damage in which a partial meniscectomy (typical operation for meniscus damage) would be too extensive to serve the necessary biomechanical function in the knee. Shadowing Dr. Rodeo for knee and meniscus related surgeries has helped me understand the clinical problem I am seeking to address in my thesis. The meniscus allograft operation is a three to four hour procedure that is more invasive than most knee procedures. The waiting list to receive the allograft is at least one month and the patient often requires another transplant around seven years later. In Dr. Rodeo’s office you are able to see patients in each stage of joint degeneration. The patient I saw receive a meniscus transplant was 32 yrs old, which means his knees have a rather dismal future. Seeing meniscus operations has helped me understand the standard of care that motivates my research. However being in the clinic can be daunting in that you’re able to realize the full scope of the problem.

 On a different note, I learned a whole new aspect of the clinical world that I found to be rather exciting. While in the OR this week I met a vendor, Jude, from Smith and Nephew who told me the ins and outs of being a vendor at the hospital. Jude was there for a rotator cuff repair operation. Dr. Rodeo was using a new suture anchor product made my Smith and Nephew. When the operation happened vendors from other companies came into the OR to see what the new product was. Jude was telling me how competitive it is being a vendor and that often competing companies will purposefully sabotage a trail such as this to make the product look bad. If an influential surgeon such as Dr. Rodeo likes a company’s product it will boost sales and shift the preference of the industry. Aside from the competitive aspect of being a vendor, I was fascinated by the type of projects that these companies work on. I am really interested in working on clinically relevant research projects, so seeing a product that was related to some of the work I do for my thesis actually make it into the clinic was inspirational. Speaking with the Jude during surgery has further motivated my interest in pursuing industry after graduate school.

Emergency Department:

Last Wednesday I spent the evening shadowing a resident in the ED. I have always imagined the emergency room being a highly stressful environment. However for the most part I found the ED to be relatively calm. I realized that most of the stress occurs when a patient needs to be resuscitated which is somewhat rare and in general its stressful for the Attending Physician because he is in charge of monitoring all the cases of several residents combined.

From shadowing my resident, I learned that residents have the freedom to pick whatever case they choose and in a shift they probably only handle about 4-5 patients. The cases I saw with the resident were fairly ordinary; allergic reaction, high blood pressure, joint inflammation, and light headedness. One thing that surprised me in the ED was the essential role of social services. The light headedness case was rather strange in that there really was no reason for this patient to be in the ED. It was interesting to see how my doctor’s questions to the patient changed when he realized the patient had no job and was on welfare. This patient ended up being seen by social services to see if his “health issues” were related.

Research Project:

Over the past two weeks, I have been very active in the lab. My project involves characterization of genetic expression, therefore my time in the lab has been spent trying to obtain RNA and optimize primers for q PCR. At this point there are still several kinks to work out with the primers and the samples. We had originally planned to compare juvenile and mature explants, however since mature meniscus is relatively acellular we have had trouble obtaining enough RNA for the controls. This means it is unlikely that we would be able to get enough RNA for each of our samples. Therefore have decided to do the dynamic compression testing on juvenile explants. My postdoc and I conducted a test run last week on the bioreactor for mechanical loading. Today we will be obtaining explants to use for our official experiment starting Monday. Next week we will also try to do obtain a larger mature control sample to get enough RNA to use as a mature control genetic profile.

Week 3 - Hannah

Week three has been a smorgasboard of shadowing experiences…resulting in further affirmation that entering a PhD program was the right choice for me.  Monday, I shadowed plastic surgeon Dr. Spector during his office hours.  It was quite the contrast to my previous clinic experience with neurosurgeon Dr. Schwartz.   MRI scans are the stars of neurosurgery clinics.   The patient and his/her entourage sit fully clothed in ordinary chairs; the obligate examination bed just an obstacle to weave around when entering the room.  Much of the conversation involves comparing various anatomies of the brain on the charts and demonstrating how they have changed.  The plastic surgery office hours are much more intimate.  Body parts are palpated and photographed.  Botox is injected, sutures are removed.  The atmosphere is a bit flashier, a bit less somber.   

Wednesday was another change of pace as I shadowed members of the pediatric intensive care unit (PICU) on their morning rounds.  Surprisingly, the PICU cares for children who are only a few months old all the way up to age 22.  This was my first time going on rounds and I wasn’t quite sure what to expect.  The attending and additional rounding personnel spoke softly in low voices when discussing patients, making it difficult to hear the discussion through the ambient white noises filling the room.  I was extremely grateful to one of the physician assistants for answering my perpetual questions and summarizing discussions for me.  One sad case demonstrated how fixing one problem can result in another being created.  A toddler with leukemia had received a bone marrow transplant.  Unfortunately, graft vs. host disease had developed and a small hole had formed in his intestine.  Fortunately, the hole had fixed itself, but not before bacteria had been released.  A healthy baby might have been able to fight it off, but he was on drugs to suppress his immune system because of the transplant.  Thus, he needed strong antibiotics.  All of the drugs then led to him having renal failure and kidney problems.  Despite these problems, the baby was in fairly stable condition when I saw him.   I want to continue to follow this case and hopefully see the baby make it out of the hospital.  As we shuffled from room to room, a large cart with a computer containing electronic medical records was dragged along as well.  While electronic records have many benefits, I witnessed the hassle they can present.  Residents scrolled through long lists of possible medical procedures, only to find the specific one they wanted to record wasn’t there.  The software seemed like it had a ways to go before it would make their lives easier.   

Thursday and Friday were ER days.  The first day I spent in the ‘A bay,’ which is where patients with the most immediate problems are triaged.  The A bay contains the A1 bed, which is where patients go when they are pulled off the ambulance and in need of intense medical assistance.   The day started off with a meeting that went over some cases and also contained a teaching component.  The topic was on acetaminophen (Tylenol) overdoses.  Once of the reasons that acetaminophen overdose is so deadly is because there is an intermediate phase where the patient feels fine, yet his/her liver is rapidly being destroyed.  One of the patients in the PICU was there due to a Tylenol OD, so it was interesting to learn more about the biochemistry behind the treatment.  I spent the remainder of the day following around a resident as he tended to several patients.  The whole ER was crammed with patients; many were without a room and lay in beds lining the hallway.   The C bay was even crazier than the A bay (partly because it was a Friday evening).  The patients in C were more elderly and tended to have chronic medical problems in addition to the acute one that brought them into the ER.  When making rounds, one of the attendings commented on how tough an elderly lady was; despite taking a bad fall in the night, the patient had waited until the next afternoon to come in.  “Tough?” the patient snorted, “Chicken is more like it—I’m scared of the ER.” Personally, I was rather inclined to agree with the patient.  Incredible as the medicine is performed in the ER is, I prefer the calmer neurosurgery clinic and operating room and am looking forward to returning there next week. 

Week 3 - Tara

Every week at Weill seems to be unique and mentally stimulating in a different way. This week I spent the majority of my time becoming better acquainted with my research project. This involved learning and performing some initial experiments in the laboratory to optimize the conjugation efficiency of a particular hapten to a carrier protein for vaccination experiments for MS. As I'm sure most people would agree, it's rather interesting to become involved with a mini-research project over the summer as one must become familiar with the background and current lab methods in a very short amount of time. Therefore, I spent a significant amount of time reading papers related to MS as well as refreshing myself with microbiology. Although my background in microbiology is more generalized, I felt that it was necessary to have a better understanding of several bacterial species - in particular Clostridium perfringens, since the vaccination study is derived from understanding essential mechanisms within this microbe.

Also, as part of my research project, I have been on a "treasure" hunt to find a particular piece of equipment - a rotary evaporator that I need for some of my experiments. In the last week, I must have visited at least 20 different labs between Weill and Rockefeller....I thought I had some leads, but the equipment ended up being rendered nonfunctional. So, the search continues...I hope that early next week, I will find what I need. I have to say that walking around all the different laboratory departments at Weill, HSS and Rockefeller firsthand gave me an appreciation for how expansive the research facilities are here. 

I continued to shadow Dr. Gauthier this week during her neurology appointments. This week, Dr. Gauthier was also teaching a neurology resident how to make the diagnosis for MS, which relies on visual evidence (usually from MRI) as well as clinical symptoms. In one case, they were examining a patient with very large "characteristic" lesions for MS who also had some other more exterior cortical lesions that are not typically associated with MS - the net result, however, was surprising. The patient is completely asymptomatic - there are no signs of even early weakness or impairment associated with any CNS dysfunction. The decision, interestingly, then becomes whether or not to treat the patient based on the prediction of how long they can remain completely "healthy." This is the challenging part with MS treatment - it's entirely a preventative strategy to delay the onset of future neurodegeneration regardless of the patient's current symptoms (or lack of symptoms). In this case, the consensus was to start the patient on the first set of medications used to treat patients with mild MS.

This week, we all had the opportunity to learn how to read medical images from Dr. Prince, which was extremely valuable. He has a systematic method by which he approaches all types of images to help gain an understanding of how to interpret any pathology. I found this tremendously helpful - it's very nice to be able to apply his formula and watch an image transform from a sea of anatomical structures to pinpoint the exact place of deformation. 

I ended the week on Friday by shadowing the head resident in the ER during the morning shift. It's pretty astounding to see how the hospital is equipped to handle any range of cases, some minor and others more severe. The limiting factor seems to be space - since it almost seems like the ER is at capacity continuously. It was a long shift, but it was an interesting experience to see the resident perform the rounds and the diversity of patient cases. 

Week 3 - Ashley

The weeks here are flying by!

Dr. Lane has taken on two additional medical students as part of his team, and it has been great watching them get integrated. They have just finished their first year as medical students, and have already scrubbed into surgeries and assisted where they can.

One of the most interesting cases this week was concerning a patient who was in his mid 20's. Dr. Lane usually does not get younger patients, but sometimes it happens. This patient had been struggling with pain in his hip area, and his previous doctor referred him to the clinic to assist with his pain management. The patient was diagnosed with avascular necrosis (AVN) on his right hip. AVN is a disease of cell death in bone components, which can lead to the bone collapsing. Because the patient was having better pain management Dr. Lane gave him two options, a total hip replacement or managing his bone strength with a drug known as Forteo. The patient was most concerned with how at such a young age he contracted this disease. He had no previous use of steroids, and it is pretty rare to see in such a young adult. In  many cases, the cause is not known. Dr. Lane mentioned it could be his drinking habits (although normal)  that could have triggered the disease to occur, and his heightened exercise accelerated the process but did not cause AVN.

Overall, a great week and can't believe we are already into the month of July!