Students

Nada Abdelrahim
Nada Abdelrahim

Bioe extrodinaire: A student with an increasing interest in surgical procedures.This blog will cover my experiences shadowing the transplant surgery and orthopedics departments at UI Hospital in Chicago Illinois.

July 9, 2014
Expectation
    It’s not very difficult for a person who has never seen a live operating room to make assumptions about its atmosphere. Dramas and movies depicting such settings are quite common and those standards seem to be the expectation that most people, including me, would have. Though I am sure in times of distress or difficult operations the atmosphere would surely turn towards the serious, I find myself surprised that the OR can also have some not so serious moments. On my first day, a few transplant surgeons were reconstructing a pancreas that by the same day would be placed in a matched patient. As the doctors worked to ensure the pancreas had no leaks the surgeon in charge was willing to have a conversation with me and my partner. I was surprised to be given any attention at all while the surgeon was working. All others not working on the pancreas were not very rushed as they worked to prepare the room for the awaited operation. It might have to do with the fact that there was no actual patient under the knife as of yet or maybe that the surgeon in charge was skilled in multi-tasking; nonetheless it was an interesting deviation from the expectation.
    Later on we moved into another operating room where a patient had fluid building up in his stomach. Holes in his abdomen and neck were made to allow pressure mediated flow to drain the fluid via Denver shunt. I only witnessed the first forty-five minutes, and the strangest part to me was the way the surgeons prepared the patient. The sheets used to visualize the area were stapled to the man’s stomach. In retrospect it makes some sense though at the time I was slightly taken aback. They used quite a few staples.
    On non-OR days I found myself in the hospital ICU very early morning making rounds with the surgeon and his posse of residents, fellows, medical students and other physicians.  Afternoons are spent in the transplant unit clinic, where possible patients, current patients, and recovering patients of transplants (mostly kidney or pancreas) receive examinations and answer questions. These three areas all have different atmospheres as well.
    The OR has a very strict policy to keep sterility and it is carefully enforced. The ICU boasts many signs telling doctors and all staff to constantly wash their hands. Typically the doctor will use hand sanitizer each time he enters and exits a patient’s room. At the end of his rounds he will then wash his hands. This is similar to the behavior in the clinic as well. I did not have much of an expectation of this simple action, but it was interesting to note the emphasis surrounding the subject on the walls and the practice by staff in these areas.
I would like to note how many different posters of reminders for the staff in the ICU there were. As an outsider these wall adornments seem to stand out, but for those who see them everyday they might be less and less noticeable.
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July 12, 2014
Clinic
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Though the most exciting days are in my opinion the OR days, patients cannot enter surgery without going through the clinic first. A waiting room, seven patient rooms, and a very tight hallway houses multiple “clinics” at the same time. These clinics include pre-surgery and post-surgery patients. Inside where an MD, nurse, nutritionist, pharmD, financial adviser and social worker all work together, is where patients for potential transplants, organ donations, and dialysis port consultations come to see the transplant staff. Most of the patients are older and come to the clinic to become listed for a new kidney or kidney/pancreas combination. Also because this means their kidneys are approaching failure, they also need to receive a surgery to start dialysis until a kidney becomes available.  Usually these patients are not only suffering from kidney failure but have had many operations in the past or currently have a number of ailments.

The fact is the people coming to this clinic are not healthy. I feel guilty at times that I am witnessing their private news alongside them. The doctor reveals the truth in a manner that is both direct and kind. I wonder how that can be done. The specific doctor I have been shadowing has a very amusing approach to dealing with her patients. She has a tendency to raise her eyebrows and joke with her patients. More importantly she never takes her actions to an inappropriate level and it is easy to tell she does not sugarcoat the issues of her patients to make sure they understand their options and what they are fighting against. This is an appreciative quality and I haven’t seen a patient become angry with the doctor as of yet.

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Patient reactions/interactions are not all created equal however. One older gentlemen who came along with his wife would lightly banter with the doctor about his various surgeries and illnesses; he did not seem upset but more so used to his declining health. While the doctor was going about her procedure there was conversation and a more relaxed atmosphere. Another patient, a middle aged woman, came alone, and for every question the doctor asked she would give a stoic response. She did seem uncomfortable but not with answering the questions; it just seemed like the clinic was the last place she wanted to be. All the patients I followed the doctor to see gave off different body language and looks to us being there, but I believe that their desire to be healthy glossed over the fact that there were students to tag along for the ride.

July 17, 2014

Live Donor Transplant Surgery

 

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All roads in transplant eventually lead to the operating room. Because most transplant patients rely on cadaver donated organs, a surgery can never be planned too much in advance. There are times however when a patient will receive an organ from a live donor and that is a case I witnessed today. A woman donated one of her healthy kidneys to her sister who was suffering from end stage renal disease caused by an unknown source. The donor was placed under general anesthesia and this particular kidney excavation made use of robot technology, the da Vinci robot. A physician made a 3 inch length incision in the lower abdomen of the patient along with several quarter sized incisions. The arms of the da Vinci and tools used during surgery were placed in these small incisions while the larger incision was used by the physician to remove the kidney after it was successfully separated from the donor. Tools used in surgery included trocars and cauterize-able metal hooks and hands that the main surgeon controlled via the da Vinci. Once the kidney was removed, it was placed into a bag of ice and transported to the operating room with the patient receiving the donation.
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    Kidney placement was more traditional, with a larger incision in the abdomen opening the perineum and allowing the attending surgeon to attach the kidney to the patient. Interestingly, the patient’s old kidneys were not removed and the patient now has three kidneys. During these joint surgical procedures specifically while the da Vinci was in use, the surgeon would need to pause and wait for her assisting physicians to clip an organ or suction excess blood. Despite its advanced technology, it seems the robot can still benefit from improvement. Conversely, looking at the more traditional kidney placement, there is more risk because of the invasive nature of the operation. The patient’s abdomen is cut open and stretched outwards to open up the cavity. Though this method is sufficient enough for the time being, it would be beneficial to develop less invasive and effective ways to donate kidneys and other potential organs. Though the da Vinci might be considered as an option for this operation, it seems too restrictive at its current level to give surgeons the capacity to complete a donation with absolute efficacy and safety.

July 18, 2014

Nurse Talk
Despite the ever evolving technologies of a hospital there is always room for improvement, especially when it comes to patient care. Who is the right person to go to when looking for direct answers, specifically of device use in the ICU? RN’s (registered nurse) and NT’s (nurse tech); these are the workers who spend their entire shifts interacting with the patient. Most importantly however they are the ones who are interacting with the technology used for patient care. One surprising piece of information I heard from a resident was that residents are not allowed to administer drugs to patients. They can prescribe any medicine they see fit, but they are disallowed from physically giving it to the patient. MD’s at any level therefore have little interaction with the devices used in patient care units which leads us to the only link to patient-device use: nurses.
    Armed with a bag of Dove chocolates my partner and I made our way around the transplant ICU and coerced the nurses to give us their opinions of the devices they use on a daily basis. Collective complaints came from a device known as the PCA (patient controlled administration) device. These had been recently updated in the last year and for the most part had improved user interface experience when it comes to labeling drugs in the device. The change however introduced a heavier device (complaint) which the nurses almost collectively agreed upon. Another problem with the current design of the PCA is that it has the capacity to only administer one drug to a patient. Therefore, more drugs means more PCA’s and transport of the patient becomes a much more difficult affair. More comments about the layout of the ICU rooms and  size of newly renovated elevators were also made; they were mostly negative in nature and claimed that it made the job of the nurse in keeping a patient comfortable more difficult.
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    One nurse I did speak to, who happened to be a male RN, had much less severe opinions than many of the other nurses. He did not find the weight of the PCA too much of a problem. Also, when I asked him about the layout of the patient rooms he just shrugged and said that it is something that was designed a while ago-he had that you learn to work around it sort of attitude. He also seemed confused as to why I would ask him these sort of questions as well. I followed him into a room as he was adding a new drug for a patient. The patient needed five drugs in total and there were five PCA pumps for each drug. He showed me how it was an easy task to label the pump and emphasized the improvement. I had noticed the tubing looked very disorganized and tangled. So I asked the nurse if he had issues about the tubing; his response was that tubing didn’t really give him a hard time and having these pumps that could be programmed to administer drugs in a much more interactive way was what mattered. He could deal with tubing issues.
    These varied nurse reactions was an interesting look at how different people deal with a certain situation. Some nurses would list every complaint they could think of while nurses like the RN above would talk about the improvements and how they were accepting of the small inconveniences. Watching nurses interacting with the devices more so than hearing their complaints gave me a much clearer look at issues that could possibly be solved with simple design changes.
July 23, 2014
Healing Wounds
    Surgery is no trivial matter. There are risks, ones serious enough that warrant the signing of release papers, and side-effects. The day before, a pancreas was successfully implanted into a middle aged man via a long incision down from his stomach to lower abdomen (side note: this incision was very large). One side effect in some patients post-transplant is excessive blood clotting around the abdominal area and this was the case for the above pancreas. Indications leading to diagnosis: the patient was 5 liters positive. Also, initial ultra sound on the patient’s abdomen did not conclude much and eventually the patient did need to visit the operating room once again. This surgery was unplanned and did affect doctors’ schedules; the attending taking care of this case did have other surgeries to perform, and handed off a biopsy to another attending surgeon. This also affected planned meetings and obligations for the attending surgeons; it was interesting to watch how the surgeons juggled the tasks they needed to complete and how they were willing to change their schedules so surgery and office work could get done as needed. The clotting was resolved successfully for the pancreas case as well. Two surgeries followed, a kidney biopsy and a cholecystectomy.
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    The next two procedures were laparoscopic ones (i.e. via camera). These were done by two different surgeons, so it was interesting to see the way each surgeon performed using the same devices. I also wonder why laparoscopic methods do not always make use of the da Vinci robot. During surgery, a representative from applied medical was present because the hospital was in the process of using their newly developed trocars. Obviously this person was there to promote their product, and they would interject with tips to the surgeon tech while they were prepping for surgery. What a strange position to be in, especially when using a product that does not perform as the surgeon desires would be hard to promote. The surgeon did like the idea of the trocar, minimal invasion and therefore better vision in the surgery site, though he did say it would be better if the length was improved, especially for larger patients.
    I’d like to point out a large part of the OR that hasn’t been discussed very much. For every procedure, in order to maintain sterility, there is so much waste product. It is quite boggling to realize that most of the tools used throughout the entire operation will just be dumped. In my opinion, developing devices, materials and other OR products that can reduce the waste and cost of hospitals is very important. What exactly is the reason companies create products that are mostly one time use and expensive? A small fraction of the tools are sent to a company to be refurbished, but I see everything else go into the garbage that has the potential to be refurbished or should at least be re-designed to optimize refurbishment or recycling of the product. Gowns both in and out of the OR are used so frequently, and are supposedly quite expensive, that I feel it is such a waste. We need to reconsider the reasons we design products. I do not feel that these products are designed for the benefit of health care, but instead for the benefit of the company. There needs to be a middle ground, and I believe even simple solutions can be found that could have a great impact on the future of hospital care. A way to really make use of design driven innovation.
July 25, 2014
Moving Forward
    The final surgery I was able to observe in transplant Friday morning was the bloodiest I’ve experienced; the best way to leave with a bang I suppose. It was an excision of an infected dialysis access graft on the upper arm. Infection is a large complication that results from the use of foreign substances in the human body. Typically a dialysis access of the preferred method is an arterial venous (av) fistula. A graft is necessary when a patient’s veins are not large enough to allow for the use of a traditional av fistula. If we think about the user experience, it would be optimal to reduce risk of infection even when grafts are used in surgery. A graft that is both biocompatible and has low rate of infection would lead to more successful surgeries. Graft technology has the potential to be expanded and integrated into other surgeries, with most impact in the transplant field.
    Three short weeks spent in transplant has been an eye opening experience. I have become well versed in the language of the operating room and it is funny how by observing an operation a few times (coupled with many questions and wiki searches) can give you an understanding of that procedure.
    What I found most surprising (pleasantly) is the relationships between the attending surgeons, residents, and medical students in transplant. Despite the obvious hierarchy stemming from the experience gap, there was a lot of teaching going around. The attending, mid surgery, would stop and draw out a diagram on paper to explain some concept to his assisting students. The residents would give pointers to the med students as they helped stitch small incisions. A med student would give me (bottom feeder) explanations about each surgery. The environment is accepting, and if a person is willing, a place where you can feed your curiosity.I found that I had a spot right alongside the team in a department that was just so open and compassionate. In a place where I thought I knew nothing, I came to learn much I will find invaluable.
August 15, 2014
Final Days
Three weeks of clinic, hand surgeries, joint surgeries, and casts has flown by. In one word Orthopaedics is structure. There is a set schedule and not much variation. One of the many things that I have learned from my time here is that pain, no matter how little it threatens the life of a patient, hinders the quality of a patient’s life. Is that not in the end equivalent to not having a life at all? Orthopedics may not be as serious as transplant surgery, but it contains a larger set of people, all who in some way cannot live comfortably in their daily lives. As an engineer it is my responsibility to design devices to improve the experience of the surgeon or patient using my product. There is a great many avenues to tackle as an engineer and I have been lucky enough to have a front row seat to the world I hope to one day change for the better.
August 8, 2014
No surgery, No problem
    When it comes to the bones and joints of our body, surgery is not always the answer. There is a whole world of injections, casts, and braces that may be the better solution. Fractures or sprains that are fresh can be righted easily with a cast. Cast making had traditionally used plaster of paris until the introduction of fiberglass came along. Plaster is still used but it takes much longer to fully dry. Holding a dried plaster section and a dried fiberglass cast section also proved that fiberglass is a much lighter alternative. When it comes to cost, plaster is a quarter of the price. Nevertheless, fiberglass is the main material used in casting at the moment, and there have been ideas to improve efficiency of putting a cast on. Fiberglass sleeves that come in three sizes have been popping up as a possible innovation. The orthopaedic tech I spoke to however was not sold on the idea. The human body he said is one that is too variable for three fixed sizes. I do agree with him on that. I think the innovation should come in increasing drying speed of the cast material, or a material that is potentially allows for the skin to breathe.
    Braces for the hand, knee or foot can be the stepping stone between a cast and full recovery. These tools put pressures on certain areas to reduce pain that is not caused from any serious injury, or to keep the area that was recently healed from fracturing again from using it too soon. I am not sure yet how braces can be improved specifically, but in general giving the most mobility and comfort for the patient user is the best route to take.
August 6, 2014
Knee Problems
    Knees take on five times the weight of the person when they are being used (walking, running etc.). This important joint can come to wear down for a number of reasons and this wear can introduce pain that can decrease mobility. Solutions can range from non-invasive and very invasive. Two knee related operations are the total knee arthroplasty and the knee arthroscopy.

    Indications for an arthoplasty include cartilage loss on the knee, severe arthritis, and generally includes severe pain associated with the entire knee. Pain is the root of the problem and this pain makes moblilty limited or even impossible. Some patients who came in for post operative examinations for the total knee were overall satisfied with some patients saying their prosthetic knee was being slowed down by their other knee. The total knee is pretty routine but it is a major surgery that requires involvement of the patient to ensure the healing process is complete to an optimal level. The actual surgery requires drills and buzzsaws to shave the femur and tibia bones to fit the prosthetic. Surgeons must be aggresive when conducting this operation to make holes in the bone and insert the knee prosthetic successfully. Also important is the angles they are the cutting the bones. A healthy knee should have a five to seven degree valgus of the knee. This means that the load bearing axis in the knee is not putting too much much pressure on the outside of the knee. If alignement is done correctly the surgeon will have successfuly replaced the bad knee and allow the patient to regain their comfort. If not done correctly the pressure from the forces on this joint will eventually lead to the prosthetic cracking. Needless to say, despite the routine nature of this operation, risks are high and infection is too prevalent. Understanding and designing prosthetics in a way to withstand infection would greatly reduce the risk associated with this operation.

    The less invasive cousin of the arthoplasty is the arthroscopy method, using a scope to visualize the knee in a minimally invasive procedure. This procedure is done when only a part of the knee is causing issue for the patient. The example I observed was the cutting of the meniscus tendon of the knee which was getting caught on a bone and causing pain. The rest of the patient’s knee is not causing any problems and so total knee replacement would be an excessive solution especially given its risks. Probably the best way to improve this surgery is to allow for better visualization of the knee via the scope. This particular scope surgery was an interesting watch and it does make me wonder if surgeries utilizing the scope is the way for the future.
August 3, 2014
Drilling out the Infection
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Power tools in the operating room? Just another surgery day at the orthopaedics department. Bones, which are thick and strong, need such tools to be repaired. Or broken apart. One surgery where a total hip replacement prosthetic was infected for eight years is one example. The prosthetic stem had grown into the bone. To remove it, cracking the thigh bone was necessary. Hammers and saws are used to get the prosthetic out of the bone and then to repair it. A cracked wrist bone is also repaired this way, with plates to keep the bone together and screws until the bone is able to repair properly.
    Infection of a prosthetic placed inside the bone, despite being made from what is considered biocompatible material, is still prevalent. Finding a way to decrease infections in prosthetics that are so rooted within the body can reduce surgeries needed to take the prosthetic out.
    Breaks and fractures in the bone are often times repaired with screws and plates. Placing these parts on wrists or ankles where fractures often times take place limits full rotation. It would be worth while to consider a design that can help repair bones but at the same time can keep the most function of the limb or joint. What is most important in my opinion when it comes to parts being placed into the body is that it does not disrupt the life of the user as much as possible.
July 31, 2014
Clinic vs. Clinic & First Impressions
    Orthopaedics has turned out to be one of the larger departments at the UI hospital. Compared to my experiences in transplant, the UI ortho clinic is spacious and sees much more patients in a day. The doctor I shadow also has a clinic located on North Michigan Avenue. Despite the UI clinic’s upgraded look compared to transplant, the Michigan Ave. clinic is much nicer- fourteenth floor views of Millennium Park and the lakefront of Chicago. Different patients come to each clinic respectively.
    When it comes to each clinic, there are similarities and differences. The MA clinic does not have any nurses, and the volume of patients is much smaller. Mainly the residents or attending physician make use of needles for steroid injection and the beds for patients to lay on during the examination. There is a cast room, which contains splints or casting tools, as well as an ex-ray room. In the UI clinic there is a cast room, and an ex-ray room and the examination rooms are pretty spacious. Physicians can give injections here as well and set casts or splints for patients. The volume in this clinic is much larger, probably three times more patients come to the UI clinic than to the MA clinic.
    I’ve noticed that splints used for the hand after surgery, either on the tendon or the bone, are wrapped large and bulky. The cast seems in the way, making use of the hand minimal or non-existent. The main reason seems to be that the doctors want to keep the splint tight and just end up using many layers to do so. It would be nice if a splint that was not so inconvenient was available. I also saw an interesting surgical workaround with a button. This shirt button was sewn to a graft in the finger for a surgery to heal a tendon in the hand. The stitches go into the finger and wrap around the button to keep it in place. It is interesting to wonder how long this method has been in use and how universal it is.
    Patients would come to the clinic to have stitches removed from various surgeries, or as a follow up for a surgery they had previously. Many patients, more so in the MA clinic, came to see the doctor because of some pain in their hand or joints. Pain seemed to be the biggest reason patients were coming in for and why they were having surgery. Many of the patients at the MA clinic had minor issues mostly on their hands.
    Considering the previous rotation I participated in, these issues, though I’m sure are not fun to live with, seem almost trivial compared to a patient who is receiving dialysis and needs a new kidney. I cannot write away these problems though it is a very different feeling being here versus being somewhere like transplant. The most important tool a doctor has in an orthopaedics clinic is their hands from what I have observed up to now.
Haroon Papa
Haroon Papa
Hello! I am Haroon Papa and I am a student in BioEngineering at UIC! Under the guidance of Dr. Kotche and Susan Sterling I am a part of the first BioE Clinical Immersion Internship. I am excited and honored to share spaces with clinicians that work everyday to improve the health of their patients.

The Bioengineering Clinical Immersion internship aims to produce engineering students with a greater understanding of the clinical domain . This is accomplished by placing students next to the physicians and patients in order to understand what they go through on a daily basis.

My own experiences will detail the G.I. Department, and Transplant Surgery. I will talk to both the recipients of care, and the caregivers themselves in order to facilitate a dialogue that may someday improve the clinical environment for everyone.

Entry 1: Week of 7/07/2014

posted Jul 9, 2014, 8:38 PM by Unknown user

The first day of the Bioengineering Clinical Internship begins! As customary, the first day began with a meeting to discuss the intern’s role in the clinical environment and what sort of thoughts should be running through our heads. We received nifty notebooks, and were told to go forth and document what we see, hear, and feel.

So, I trekked uncertainly to the G.I. lab for my first rotation and met the attending physician Dr. Robert Carrol, quoted by one nurse to be the resident genius. There may have been a little miscommunication as my contact, a Medical Fellow by the name of Dr. Vineel Kankanala, was not in the G.I. lab for my first day. Nevertheless, the nurses and another fellow, Dr. Sugir, in the lab graciously showed me around and got me acquainted with the lab. Without further ado, I was plunged into a procedure room in the middle of a routine colonoscopy.

Before setting my sights on the procedure I made sure to take a good look all around the room. What I noticed was a plethora of notes posted on walls, and little labels all over cabinets and drawers. Yet, most nurses and doctors hardly paid any attention to this information, and almost never used the drawers. Most of the equipment/gear that they used was already out and easily within reach. I came to the conclusion that the majority of unused medical equipment was for emergencies, which I came to realize were uncommon in G.I. procedures.

Finally I set my eyes on the operation itself, the climactic act of excising polyps from the colon. I almost passed out. Lead by a nurse I stumbled into the bathroom with a bag of ice around my neck, my eyes like plates. My body weighed an extra 100 lbs, and I wasn’t all too sure what had happened. Additionally, I had an ominous feeling about undertaking a medical career. When I came around, I found the nurse who helped me and profusely apologized for what happened. She warmly told me that it was not a big deal, and its not an infrequent occurrence. My response was something called a vasovagal response. After my experience, the attending physician and tech assistant laughed and told me they’ve seen responses such as mine commonly and it’s something many people deal with and overcome.

My experience with this phenomenon called the vasovagal response showed me the empathy the nurses and doctors have. I was blown away by how quickly and kindly the helped me, and I now have tremendous respect for the G.I. lab department.

 

Entry 2: Week of 7/07/2014

posted Jul 9, 2014, 8:41 PM by Unknown user   [ updated Jul 12, 2014, 9:24 AM ]

AS A FOREWARD:

The length of the following post is directly related to how much information I learned in my week in the GI Lab. There is much more raw data that I observed but could find no spot in the post.
My next few days in the GI Lab were fairly routine, I watched several different procedures and observed the lab in 2 different aspects. I rotated between technical descriptions/problems, and humanistic occurrences and problems.
The main problem faced by people in this lab was organizational chaos. Each day it grew more apparent that the system of organization was not well understood. I determined that the information for patients came from the UI Health online system, which is organized, advanced and usually up to date. But this information is transferred to paper for easier accessibility and then transcribed onto a white board to further disseminate information. Though the system appears to be working, at times it is not understood why certain hiccups occur. These include when a certain “Dr. ?” is assigned to cases and at times this simply means the nearest attending physician. It is worrying that patients care can so easily be mismanaged simply from a lack of knowing which Doctor is assigned to what patient. Furthermore, there are times when the OR simply arrives at a standstill with patients waiting for their turn and all of the operating rooms open. These intermittent stops increase the odds that every single day is behind schedule, and increase patient stays in the hospital. Although routine colonoscopy or EDG procedures are outpatient, these wait times cause a 8:00 am patient to wait until 8:45 or even later, simply waiting for a procedure to begin.
Though these sort of problems happen frequently they are dismissed by staff, and are usually expected. Everyone shrugs when it comes down to organization claiming whoever is at the top clearly doesn’t know what is happening. Additionally, most residents seem to carry around sheafs of paper and notebooks during their rounds to take notes. Often these can be seen as a large cluttered mess sitting around in their pocket which grows larger each day. I’m sure a more profoundly simple system for note taking could be used to eliminate the bundles of paper they carry. Disorganization of information is not something new here, and it has been adapted by the system and several work arounds exist that somehow get the right papers to the right room, and the right procedure on the correct patient (thankfully).
Another issue that I was privy to was the endoscopy prep. Every colonoscopy patient is to undergo a preparation which involves drinking a large amount of laxatives the night before and day of the operation. This would flush out the colon and make it easier to visualize the colon walls and excise any abnormal growths. Usually, some patients would neglect to prep themselves properly and in turn would have stool/liquid stool in their bowels. This ultimately makes the colonoscopy harder, as the scope would need to navigate through this in order to make to the end. Somehow a way to improve prep adherence might be beneficial to the staff as well as the patients.
It is also worth noting that the physicians and nurses frequently wash their hands. Although they do wash hands pre and post operation, the older physicians tend to make mistakes such as touching the faucet’s handle, or doing procedures without wearing a mask/gown due to seniority.  Also, hand washing is not prompted when a gloved and gowned nurse who participated in the procedure would hand a pen and paper to the physician who might not have been gloved, and the physician does not wash their hands afterwards. This sort of culture is prevalent here because GI work hardly involves risk of infection here in the lab, and I fear that someday that the laxity could cause a patient more discomfort.
Now that I’ve explored a little bit of the human side of the GI Lab, I will enter a discussion of the more technical aspects. The two major procedures that occur in the GI lab are colonoscopy and EDGs which is for the upper digestive tract. Both procedures are done using a colonoscope which can illuminate, move up/down and torque left/right, it can spray water, air, and suction air and water, it can also deploy a clamp and take high resolution images with 17x magnification. The manufacturer is Pentax and the GI department has a good relationship with them. These devices, in a trained hand, can navigate the colon or upper digestive tract and take images, biopsies, and diagnose illnesses. It not a intuitive device, but can be learned and requires experience to improve. Though when it is in a untrained hand, it is possible to damage walls of the colon or stomach through repeated hits which is incidentally referred to as “skidding”. Though the damage is very minimal, it could be a potentially threatening problem in some cases. It was explained during patient consent that less than 1/1000 patients end up with a perforated colon due to this procedure, which is still large number of patients. I mused that a simulation of an endoscopy might be worthwhile to improve skills without lengthening colonoscopys with new trainees.
The operative spaces themselves are equipped with high tech monitors and visualization devices. For example, there are monitors that display the colonoscopes pictures in high definition on a main screen for the physicians. Furthermore, there is a computer in every room for documentation, and to record duration of each operation. However, it is common that the recording times are rather haphazardly kept and sometimes completely made up. This could be solved with a reminder system or by incorporating this job more fervently to the nurses (as if they didn’t have enough work). Another issue that caught my attention were the piles of wire in every room. All though the GI lab is touted to have state of the art equipment, the electrical wires for equipment run all over the floor and posit a hazard to anyone who isn’t looking directly at them. The possible consequences of this would include stopping the procedure, and stopping data collection if any wires specific to the colonoscope/computer were pulled. This could be handled by creating a casing for the wires, or by looking into wireless devices that could replace current equipment. Additionally, the operative spaces are rather cramped, and the position of the door has a high probability of hitting anyone near it. It would be worthwhile to look into light doors that would swing with less force, and they could be equipped with a blind window to improve communication outside of the room. Another point I would like to make is that the GI lab does not have dedicated stethoscopes for each operation space. This should be corrected, and more stethoscopes should be introduced to further drive down chances for infection.
The non-operative spaces on the other hand are spacious, and conveniently located near all sorts of device that are necessary. For example, thermometers are simply steps away, there are cavi wipes next to beds, gloves next to beds and handsanitizer dispensers in every direction 10 ft or less away. There is an easily drawn curtain that goes around the beds, and the location of the beds is a few feet away from the nurses desk, so it is likely that any patients in distress would be noticed. Each bed has disposal for bio hazardous waste, and linens roughly 5 feet away with a foot pedal to avoid touching anything.
In conclusion, regarding the GI lab, it is a working environment with state of the art equipment and highly trained attending physicians, bubbly hardworking nurses,  and capable (but tired) fellows. Each person has their role and does it to the best of their ability using their skills.
Entry 3: Week of 7/14/2014

posted Jul 16, 2014, 8:40 PM by Unknown user

My week in the GI lab had come to a close, and I transitioned on to the G.I. and Liver clinic. Though I moved forward to a new department, I felt like I moved a step back in the clinical process. I moved to the point in time where I saw the diagnosis that lead to the procedures I witnessed last week. I gained a greater appreciation of the process that doctors use to treat their patients.
The attending physician was Dr. Halline, and I was his shadow. Before walking into patient consultation rooms he stopped outside, explained the patients’ history and informed me of his ideas and plunged in. He systematically approached each case with a collected demeanor that was assuring. His process was to describe what he knows about his patient, verify the info with them and then asks about their complaint. He listens and notes down anything important, then he offers treatment options and explains his views. He leaves the decisions entirely with his patient after giving his advice. He works quickly and patients trust him. Despite his ability for medicine, he does have a weak point so to speak. He is not fond of typing out large quantities of information, and this can sometimes occupy much of his thought especially when attending with a patient. Unbeknownst to him he might miss a vital part of a patients question or be unable to answer due to his occupation with typing out some bit of info. As a result, he uses pen and paper with most patients and keeps vigilant air of attention in order to obtain each piece of information in order to process it.
Something else I would like to discuss is not the human environment, but the physical environment itself. The actual clinic is separated into an interior office, and surrounding hallways that have patient consultation rooms. Each room is box like and small, 3 people can be crowding in the room, and there is almost no space to move without bumping into anyone. Additionally, the diagram of the liver is right above the patients head when they sit in the room, thus preventing them from reading important information. Even though each room is equipped with a computer, it is pointed in a direction that makes it hard for the patient to see. It would help if a patient could see what a doctor is seeing on screen to better understand what is happening. The very layout of the room impedes patients from becoming more knowledgeable about their health. It can be noted that the very aesthetics of the room are plain and uninviting.
In my next blog post I will detail some interactions I saw with patients and possible work arounds for the problems mentioned.
Entry 4: Week of 7/14/2014

posted Jul 18, 2014, 7:50 PM by Unknown user

My next few days in the clinic were enlightening as I saw numerous different patients, and the method of interaction that physicians engaged in. The usual procedure I saw for each patient is as follows:
1. A patient history is submitted to the physician and they look it over.
2. The patient’s previous medical reports and seen by the physician.
3. A general purpose for the clinic visit is developed.
4. The doctor and patient meet, and the history is reviewed again with the patient in order to identify anything incorrect, or to further update information.
5. The doctor asks a patient a series of questions about their chief complaints.
6. The doctor delivers the principal idea they have on the patient, and communicates it using pictures/diagrams.
7. They ask if the patient has any questions and understands their diagnosis.
A few notable patients I saw were detailed below:
Patient 1: Caucasian Male, older gentleman
He was diagnosed with inflammation of the pancreas and had a high degree of bruising. Non-compliant with stopping alcohol use for several months. Was asked to undergo the EUG procedure.
The patient was quiet and seemed overwhelmed by the number of people in the room. He understood that his health issues were critical, and was told by Dr. Halline he needed to make sure that he would not continue his alcohol use. The patient understood, and said that he stopped drinking for 2 months. The atmosphere was intense, and the patient knew that he was not doing his best in getting better.
Patient 2: African American woman, middle-aged
The patient came in to schedule a screening for a colonoscopy after significant weight loss. She was previously diagnosed with seizures and was under disability. She expressed her living situation was not ideal, and did not have a home/occupation. She also previously expressed having suicidal thoughts.
Dr. Carroll began the patient meeting by taking notes about family history, and noted that the patient did not look at the history form. He later told me that it is possible she could not read. The doctor was primarily concerned with her living situation and wanted to make sure that she had access to a bathroom in order to properly prep and flush out her colon. He also thought that the weight loss could be due to poor dietary habits rather than any colon cancer issues. Despite this, he did note that her family of 14 brothers/sisters had several cases of cancer. Dr. Carroll also made sure to inform her of the various homeless shelters nearby, and made an appointment for her to a social worker.
Dr. Carroll informed me that many cases of weight loss and stomach pain are due to living conditions rather than disease. The actual problem lies in economic/social hardship.
Patient 3: Caucasian female (older)
This patient came in to discuss her throat stricture and pain she is experiencing daily. Her demeanor was stoic, yet upbeat and hopeful. Dr. Stewart was the attending physician in this case. Of all the clinicians I have met, she is the most understanding, empathetic, and listens the most. She works with her patients rather than “on” them. She rarely used the computer during the visit, and made it a habit to hold out her hand to her patient in order to emphasize that she is there for them. Dr. Stewart also made an effort in keeping me in the loop while explaining the issues that the patient was undergoing.
The principal problem was that the patient could not eat without experiencing mild to severe pain. She previously had a dilation of her esophagus which allowed her to eat, but the stricture in her throat made it difficult for even liquids to pass. In the past, Dr. Stewart was unable to prescribe a powder form of the medication that was only in capsule form because the patient could not swallow solids. This situation produced a work around where both physician and patient worked together and came up with an ingenious solution. The patient opened the pill capsule and put the powder in yogurt and ate it. The idea worked marvelously and the patient recovered some of her weight.
In the end, Dr. Stewart decided that another ct scan was necessary and comforted her, she told her that she would do everything she could to reduce the pain. The experience seeing this clinician-patient interaction was exceptionally moving.
In reference to the common problems I saw in the clinic I will propose some solutions.
First I will start with the edification of patients on their own liver and GI system in general. The posters kept in the room should be moved away their location, and perhaps placed behind the door. So a doctor can stand up and actively teach the patient about the liver and the progression of Hep C. Furthermore, the computer system in each room should be entirely removed and replaced. A tablet note taking system would promote higher interaction with the patient and efficiently allow the physician to get every detail. I would also posit that a large lcd screen could be placed on the wall which would display relevant information about the patient’s health. I noticed that many patients felt distant and uninformed about their own health information. Perhaps in the future providing a patient with their information would speed up treatment and give them a better understanding at what their doctor is trying to do.
Alternatively, if a patient does have access to their labs it could cause a patient to self-diagnose and come to incorrect conclusions about their own health. Some sort of compromise must be reached with holding patient information, and granting them access to it.
Entry 5: Week of 7/21/2014

posted Jul 23, 2014, 4:26 PM by Unknown user

My week at the G.I. Clinic came to a close, and I moved to working with Dr. Sugir and my partner in G.I. Matt Dela Cruz back at the G.I. Lab 🙂 The purpose of the next bit of shadowing is to see inpatient consults, and get a better sense for what happens on rounds. Interestingly, rounds don’t seem to have a set schedule and happen at irregular time intervals.
My first few days back in the lab were marked with the hectic hustle and bustle of a newly implemented Doctor’s note taking system, Provation 5.0. Staff, including doctors and nurses, were in the middle of getting trained by software engineers within the hospital for this new system. The reason for the switch is for an upgrade, and to prevent unauthorized personnel from accessing patient information/files. The change causes doctors to log in for every patient that they see, rather than leaving the computer logged in all day (which is against the law, and much more efficient). The second day in the week, the engineers were still available post-op to help with inputting doctor’s notes and other vital information. Though the new software seems to be slightly inefficient, the software engineers tout its reliability and work hard to teach the doctors how to use the system.
Matt and I ventured onwards to watch a very different procedure on a patient with a colostomy bag. We spectated an ileostomy, a procedure where an endoscope is inserted where a colostomy back is to visualize the small intestine. I noted that the colostomy bag was removed, and the patient had a hole on their side. The endoscope was inserted, not delicately, into the stoma. Despite previous sterilization procedures, the endoscope could’ve easily transferred a large number of foreign microbes into the body. The doctor took various biopsies to be sent to pathology. The biopsies according to the physician looked fairly healthy, and displayed large villi.
Today, Matt and I watched a procedure called a bronchoscopy. Though similar in procedure to a colonoscopy, a bronchoscopy is much harder on the patient and requires great skill as a physician. The preparation for the procedure is as follows; the patient recieves a lidocane wash for their mouth, and is required to inhale lidocane in order to permeate the numbing effects throughout the trachea. In addition, patients are given fentanyl to reduce discomfort. Simply the degree of anaesthetic used in this procedure speaks volumes on how uncomfortable it is.  The premise of the procedure is to visualize the lungs with a bronchoscope that is inserted down the nasal cavity in order to obtain biopsies and rule out other abnormalities. The scope continues and goes in between the vocal chords (a highly unpleasant feeling that induces intermittent coughing). The scope explores the bronchus, and some larger bronchioles but predictably cannot fit into alveoli. In order to obtain biopsies of the lungs a clamp is extended to the chest wall, then retracted 2 cm and extended 1 cm, the biopsy is then collected. The purpose of these seemingly random steps is to prevent puncture of the lungs. That is a terrifying outcome. The risk that is incurred from this procedure is heavy, and any miscalculations could have dire consequences for the patient. Thankfully an x-ray machine is used to supplement the camera on the bronchoscope to make sure the scope never pierces through the chest wall.
Lives are truly held in the hands of physicians who rely on bio-instruments.

Entry 6: Week of 7/21/2014

posted Jul 23, 2014, 4:28 PM by Unknown user   [ updated Jul 26, 2014, 2:44 PM ]

The final week in G.I. has concluded, and many valuable observations and insights have been made. These last few days were marked with a couple of unusual cases, and disdain from the a anesthesiology department.
I was lucky enough to witness 3 unusual cases in GI which push the abilities and often patience of the attending physicians. The first case was an ERCP/EUS procedure which was done to access the bile duct. Unfortunately, the procedure was NOT successful because of the difficulty in maneuvering a thin piece of wire from an artificial hole in the colon. The patient was older and under anesthesia during the procedure, additionally  an X-ray machine was in use during the procedure with a high contrast dye. Though the visualization and equipment was sufficient, the difficulty of the procedure was high. The second case was an EDG patient with no stomach. Essentially, the esophagus was connected to the small bowel with a suture. According to Vineel, the stomach does do a small portion of protein breakdown, but the small intestines do the majority. Therefore, the stomach is really only necessary for acid degradation prior to the intestines.   The endoscope could not go far enough during this procedure, and there was difficulty in locating a specific component for the operation. The component was a foreign body scissor, which was only found when Dr. Boulay lay physically went to search for it during the procedure. When the component was retrieved Dr. Boulay snipped a small piece of offending suture which had not degraded in the body. The final procedure was a routine colonoscopy done by Dr.Carrol, a senior attending physician. Though it was a routine check it was not possible to reach the cecum, and the patient was in extreme discomfort. This was because of the patient’s obesity coupled with a sharp turn around the first bend of the colon. Ultimately, these cases showcase that despite superior technology and technique there are shortcomings and each can only be met with a personal solution.
Interestingly, the anesthesiology department for the last two days were slightly critical of the GI department. In the first case, the anesthetists equipment had a hard time fitting through the doors in the GI lab, and the anesthesiology nurse complained loudly to Dr. Halline about how awful the conditions (room size and layout) were. He quickly explained he understood, but made to return to the procedure at once. Subsequently, an attending physician from anesthesiology gathered the GI staff and loudly complained that the patient ought not be late, and that waiting for them say past the time appointment time was not okay. Despite the bittersweet ending of that situation, the GI physicians and nurses were unfazed and continued onwards to improve the lot of their patients.
Entry 7: Week of 7/28/2014

posted Aug 3, 2014, 7:58 AM by Unknown user

This week Justin and I rotated into Transplant Surgery under Dr. Ivo Tsvetnov. We found ourselves on the 7th Floor of the Hospital where many patients in the Transplant unit are in critical care.

Each morning on the 7th floor extensive rounds are conducted under the tutelage of Dr. Ivo from 7:30 AM to 10:00 AM. Medical students, residents, and a pharmacist present various cases, and discuss the current stage of each patient in a comprehensive manner. The discourse includes methods of treatment, and Dr. Ivo’s startling revelations regarding each case. In one particularly interesting account, Dr. Ivo mentioned that he preferred a patient to be hypertensive rather than hypotensive. His rationale was that it was much easier to lower blood pressure with 20 or so medications available, but not easy to raise it. Another bit of info he talked about was that when a line was contaminated, a whole new line/pathway into the body must be done due to bacteremia. This was in response to a resident who simply tried to change the line. Additionally, Dr. Ivo discussed the difference between peripheral and central lines, where only certain concentrations of medication can be used. A peripheral line can infuse up to 10% of a medication before toxicity happens in the body, while a central line in the venous system has higher flow and greater dilution that can handle a medicine concentration greater than 10%. Rounds act as an essential part of the students medical education as Dr. Ivo is able to easily impart his experience and regularly test students on their knowledge.
Despite the fact that rounds does in fact manage to address the needs of every patient there were noticeable problems. For instance, during rounds was that handwashing/hand sanitizer use had less than 50% compliance for every room visited. Although it would be inefficient to wash hands at every juncture before and after meeting a patient, somehow a system should be developed to counter the accidental spread of pathogens. Interestingly, rounds have an air of intimidation towards patients, because the doctor is discussing them a few feet away to the medical students. I can imagine it would be unnerving to see a doctor and a large gaggle of medical students gawking at me if I were a patient. Another issue that occurred was a patient shouting for help repeatedly with no immediate response. Justin and I stood waiting for somebody to acknowledge a patient who was in pain for whatever reason. It turns out that the patient into question was actually just complaining and had no real issue, but the fact stands that sometimes the patients are simply not believed.
After observations, some of the technology and design in the Transplant Unit was phenomenal. For example, a room had a special pulmonary ventilator that supplied oxygen to a sedated patient. The ventilator has a variety of options ranging from pressure, volume, and duration ventilation. Yet, the ventilator acts dynamically to measure how much more oxygen it should pass to the lungs in a way to prevent the patient on being wholly dependent on the machine. The patient rooms themselves had clear sliding doors equipped with blinds. This simple bit of design is efficient in that it provides a glimpse of the patient while being able to block out sounds to aid their rest. Other novel bit of design was to place an electronic chart displaying all the physiological signals of patients in the middle of the resident’s desk. This type of design is optimized to quickly understand when patients are in trouble, and get them the appropriate care.
Unfortunately on Monday, Tuesday and much of Wednesday were marked with no cases in the ER.
Entry 8: Week of 7/28/2014

posted Aug 3, 2014, 8:42 AM by Unknown user

At the instruction of residents and the medical students Justin and I spent time in the OR and the Transplant clinic in the Eye and Ear infirmary for the remainder of the week.

The OR lies at the heart of the hospital, with many important surgical procedures taking place there. In order to be in the OR you must obtain a set of scrubs, a hair net and shoe covers. Actual procedures require you to wear a face mask at all times. The first procedure that was seen was a hysterectomy; not a transplant procedure but one to see while waiting for a Transplant surgery to start. A hysterectomy is the surgical removal of the uterus. The surgery requires several trocar, a scope for viewing, and sets of scissors and cauterizers. The procedure was slow and took a long time as cutting through every muscle fiber was tedious and inefficient. I posited that a scissor-cauterizer combination could speed up the procedure greatly instead of having each physician snip and cauterize cyclically.  The setup for the procedure was highly interesting where a set of 3 monitors were placed in a configuration that allowed you turn in any direction to see the progress of the procedure. Furthermore, the arrangement of each nurse was to improve efficiency and sterility. This is evidenced by the circulating nurse who prevented any contamination, and watched the team from outside of the procedure. Despite this, it would be rather easy for any incoming bystanders to brush up against the sterile cart holding tools, therefore better signage or brighter colors than blue could be used to signify the difference between each cart.
Next, I went on to witness the removal of a fistula for a patient. A fistula is an abnormal connection from a vessel to another part of the body. Transplant surgery deals with many fistulas due to the fact that kidney transplant patients often need to undergo dialysis, and a fistula can occur due to regular connection to a blood vessel which experiences a flow that is too large. The fistula was found in the upper forearm of the patient, and it was removed by first opening up the patient’s arm. The fistula was excised from the blood vessel to prevent the formation of clots, and to keep the patient safe. The primary tools for this operation were blades, a cauterizer, and sutures. The operation was relatively simple, although the patient continually complained of pain from their central line until they received enough medication to put them to sleep.
The Transplant clinic in the Ear and Eye Infirmary was also explored. The clinic is a simple area where patients are met in extremely small rooms, and are given a diagnosis and explanation of their treatment. The resident nurse, Carl, discussed the various cases that come in ranging from fistulas to kidney and liver transplants. Furthermore, Dr. Ivo talked about laminar flow rate in a fistula and why it is problematic. According to him, a fistula causes turbulent flow in a blood vessel which is often too fast which can cause damage and platelet accumulation. These two factors combined are dangerous for a blood vessel as a blockage could happen at any point and cause patient mortality. Though the clinic was cramped and small it did bring all the physicians together to discuss patients, and had a homely feel (an odd thing for a physician’s clinic).
Entry 9: Week of 8/03/14

posted Aug 7, 2014, 10:36 PM by Unknown user

Slow. That is really the only way I can describe the first half of this week at Transplant. I slowly grew to realize that much of the residents and medical student’s work is waiting, watching, and writing notes. Once again my days began with rounds roughly at 7:30 in the morning to 10:30 am, and we went bedside to bedside listening to medical students and residents present cases on patients while Dr. Ivo added his recommendations. The rest of the day was dominated by note taking and reception/recording of patient tests by physicians. In addition, there weren’t very many surgeries at the beginning of the week.
In the meanwhile the attention of the transplant unit was turned to patients in their ICU. The transplant unit had several patients who were currently healing, one of which had taken a turn for the worse. This patient had GI tract bleeding, a blood infection, his transplanted kidney was failing and he had atrial fibrillation. Between these conditions his body was dying, it was a painful state for the patient who was receiving platelets, blood and various medicines. Unfortunately, all of these fluids were not helping much to increase blood pressure. Surprisingly, the nurse and the doctor were undaunted despite the grim nature of the situation.
When asked about the different measurement devices in the room Dr. Ivo gave an in-depth explanation of their various uses and the theory behind them. The devices according to him made it possible to perfectly deliver a certain concentration of a drug over time. I noticed that the room he was in was filled with IV poles and infusion pumps which made it increasingly difficult to maneuver around. Furthermore, it looked confusing to identify the several different bags of medicine and IV fluids around the patient.
Entry 10: Week of 8/03/2014

posted Aug 11, 2014, 12:57 AM by Unknown user   [ updated Aug 15, 2014, 7:32 PM ]

My final week in transplant was bittersweet, but packed with unforgettable experiences. The second half of my week encompassed a few major operations and in-depth rounds. Furthermore, I got the experience to talk with Jurgis, a medical student, and a resident, Dr. Arun, about what I saw, heard, and felt.

A sobering and humbling experience in medicine is the inevitability of death. Despite the best efforts of the transplant physicians on staff and nurses, patients can die. The patient mentioned in blog post 9 passed away. His passing was chosen by his family, because he had reached a critical state where he would only survive with the constant infusion of blood, IV fluids, and oxygen. When I had last seen this patient he was gasping for air, hooked up to 6 infusion pumps, and had a heart rate above 120 consistently. In all honesty, I feel slightly relieved that the patient’s suffering did not continue. At the same time, I was dissatisfied with the technology that the man relied on, as it did not heal him but only just kept him alive. I was also musing that the patient’s family’s perception of the number of infusion pumps, IVs and monitoring equipment hooked up to the patient could have influenced their decision in removing the aforementioned systems. Although I have my own fascination with medicine, life, and healing the enormity of death will always oppose the efforts of physicians.

The major operation that I was privy to see was a nephrectomy; the surgical removal of the kidneys. This operation is only done when the kidneys become non-functional and are a detriment to a patient’s well-being. The patient in question had kidneys that had become non-functional and filled with cysts. The left kidney had broken through the peritoneum and had deformed the small bowel. The procedure required the kidneys to be tied off and removed surgically. The major tools used were scissors, a clamp to open up the cavity, and a cauterizer. Though these were relatively simple tools to conduct the surgery, it was done successfully. Prior to the surgical procedure, the patient was undergoing constant pain, and did not have a high quality of life. The surgery was a step towards restoring this patient back to health, and presumably a life with less pain. Ultimately, the patient will undergo dialysis 2 times per week until they can receive a transplanted organ.

These two experiences showed me vastly different sides of medicine. The human aspects as well as the technological aspects that we were meant to focus on. From this I now place more importance in human perception of healthcare along side the efficacy of the involved technologies. Between these two ideas design can emerge and create a common point of intersection that understands the issues of both a physicians and a patient with an engineering edge.

 

Final Blog — Friday, August 15th, 2014

posted Aug 15, 2014, 8:02 PM by Unknown user   [ updated Aug 18, 2014, 12:45 AM ]

Whirlwind, experiential, unbelievable, beautiful, and downright fun. Those adjectives barely begin to describe the Clinical Immersion Internship under the guidance of Professor Sterling, and Dr. Kotche. The purpose of this internship was to guide students toward empathizing, and understanding the feelings of both patients, and clinicians in a healthcare setting. This experience was truly eye-opening.

I began my first day at the internship by nearly passing out in the middle of a routine colonoscopy in the UIC Hospital G.I. Lab. I remember the tunnel vision forming around my eyes, the sounds of the G.I. lab becoming more and more distant, and the sudden shock of an ice pack hitting the back my neck and bringing me back to reality. Thankfully, a nurse had been paying attention to me and made sure to sit me down in a bathroom and talk me through the frightening experience I was undergoing. This experience showed me the kind of care that nurses and doctors provide in the hospital; despite the enormous amount of bureaucratic shuffling they do, and filing of papers, at the end of the day they are there to take care of people.

Past the human standpoint, I went to analyze the tools/layout/procedures of the physicians in order to identify some sort of need. Now that leads one to question, what exactly is a need? A need is something that must be had, or something that is essential. The essentials that I witnessed were: extra training for colonoscopies, a more intuitive colonoscope, and a colonoscope with a larger visual field. My general experience in the G.I. Lab was that of EGDs (esophagogastroduodenoscopy) and colonoscopies. Though these procedures were typically outpatient, and not difficult in a skilled hand, new fellows and medical students would have difficulties in maneuvering and obtaining the correct positioning without causing some ramming of the intestinal wall. This observation founded my interest in extra training for G.I. fellows/students. Furthermore, the colonoscope has an incredible number of functions which range from taking HD pictures, clamping polyps for biopsies, deploying a net, spraying air or water, suction of air/water, and even cauterizing biopsied areas. It’s no wonder that 2 people, the attending physician and nurse, are required to operate the numerous different functions of the colonoscope by using a footpedal, a controller, and by literally pushing and pulling the colonoscope in and out of the colon. A more intuitive colonoscope would hopefully give all the control to 1 person, as well as be easily manageable in control by centralizing controls. In addition to this, I noticed that the colonoscope had to take several different camera angle shots, many of which required tricky maneuvering and extensive pushing and pulling of the scope for proper bending. Perhaps additional cameras with a wider scope/visual field would reduce the necessity of all these movements. In essence, these solutions seek to streamline the colonoscopy/EDG procedures because ultimately they are embarrassing, sometimes painful, and somewhat of a hassle (though they are HIGHLY necessary).

Next, I found myself in the Transplant Surgery rotation in the hospital. The main areas I frequented were the transplant ICU, the transplant clinic, and the OR. Between these three areas, the OR happened to have much of the advanced technology and techniques for surgical operations. For example, the da vinci robot for minimally invasive transplant surgeries is a tool that empowers surgeons to make incisions and cuts with higher precision and maneuverability than a human can normally do. While the transplant ICU featured ventilators, ultrasound equipment, infusion pumps, and ECG machines. Much of the equipment used in the ICU was typical in most ICUs in the hospital. The clinic on the other hand had little to no technology, for the most part it was meeting space for patients and physicians. Furthermore, the clinic was rather cramped and little adornment; the walls were largely blank and dull. Ultimately, many of the proposed improvements in technology for Transplant would be involved with the ICU. This is because the largest problems are not exactly health related, rather they are centered on the ergonomics of patient comfort. For example, infusion pumps are sometimes stack upon each other, up to 5, in case a patient needs multiple different intravenous medicines at once. This can lead to very heavy IV poles, and decreased patient mobility. Another issue noted was that the beds and infusion pump had no point of attachment. Some solutions for these issues would revolve around having 1 infusion pump do multiple medicines at once, rather than separate infusion pumps for each medicine. Also, the infusion pump device could be incorporated into the bed for increased mobility, or even a backpack apparatus for increased portability among younger patients/older patients.

What was most surprising about the Transplant surgical rotation was the human aspect. I learned that Transplant surgery was much more stressful than I anticipated. The rotation had medical students and residents working around the clock for 10 hours for multiple days, and many of them were running on minimal sleep. Between deciding medications and conducting surgeries that would determine the difference between life and death, the sleep deprived surgeons seem to have adapted to this high stress environment. In response to that conjecture, I feel that it would be highly appropriate to design tools that are easy to use at all times, and require little forethought before putting them into operation. I have reconsidered my interest in being a surgeon, as it calls for a greater sacrifice of personal time and life than I might want to give. I believe in living a balanced life, and in some ways the lives that are lived by the people I saw were undoubtedly one-sided (though I believe their work is necessary and incredibly important).

Once again, I would like to thank Dr. Kotche and Professor Sterling for allowing me to foray into these once alien subspecialties in medicine. I have learned incalculably important information, and I feel like I have developed a new design engineering mindset that will allow me to approach bioengineering problems in a new light.

 

Image 1

Image 1: A typical bedside for patients awaiting their procedure, or recuperating post-op.

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Image 2: Pictorial representation of the digestive system.

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Image 3: Fluoroscopy Room, where high contrast dyes are used for imaging.

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Image 4: Fluoro room continued…
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Image 5: Procedure room 1.
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Image 6: Procedure room 2.

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Image 7: Procedure room 3.

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Image 8: Procedure room 4.

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Image 9: A colonoscope!!

Martin Gannon
Martin Gannon

 

Week 1 Ophthalmology

Wednesday July 9th
I rotated between four different subspecialties in the ophthalmology department the first two days. I spent time in glaucoma, cornea, pediatrics, and neuro ophthalmology.
I notice problems or workarounds in three categories: communication, equipment, and floor plan.
Communication
Each subspecialty has its own system for record keeping. Most of these centered around writing paper notes. In glaucoma and cornea scans of the notes are used during follow up. In pediatrics doctors are strictly paper for everything but ordering prescriptions.
In neuro ophthalmology the resident and attending physician record notes on a continually updated Word Document on a Windows 98 laptop. The technician takes notes using a different computer and a specialized software. Finally all images from previous visits are stored on a UIC website system. These images are pulled up using Internet Explorer on a third computer.
I felt like sometimes patents did not understand the next step they were supposed to take. E.G. “Come back for a yearly check up. But you can’t schedule an appointment a year in advance. Do it in 6 months.” To someone who is elderly or with non-native-English skills that statement sounds like the patient should schedule an visit for 6 months from now.
Referrals from generalist can also be tricky. The patient is required to provide most of the information regarding their medical history and reason for being referred. This is because most information sent from the referring doctor is stored on multiple non-searchable PDFs. If patients are not familiar with the exact medical terminology this can lead to poor diagnosis and lost time. Patients bringing paper from their referring doctor helps, but seems demanding on patient and far from ideal for medical professionals in 2014.
Equipment
Two medical equipment related problems.
1) Pulling eyelashes. Doctors have a hard time pulling tiny eyelashes. The tweezers used to pull eye lashes are sometimes not fine enough to attach to the eyelash.
2) When testing peripheral vision on young people the Octopus 900 is great, however for the equipment refreshes to fast for the reaction time of old people. Old people use the Goldman Perimeter which requires a technician to operate. It seems like the Octopus just needs a simple software fix.
Floor Plan
The building was opened in 1965 and has major layout issues regarding the location and size of waiting rooms, reception desks, and patient rooms. I will tackle this in Episode 2 of Week 1.

Week 1 Ophthalmology

Saturday July 12th
On Thursday we observed cornea and retina surgery. On Friday I observed contact lens in the morning and retina in the afternoon.
The Building and Floor Plan
Patients have to take an elevator to get to the eye care departments on the second and third floor of the Eye and Ear Infirmity.
The elevator on the second floor lands in a vacant hall way. On the third floor the elevator lands in the footpath of a waiting room. It is not obvious where to check in, often patients go to the cornea area to the left, instead of the general check-in area to the right.
There has been little remodeling or maintenance for the specialty patient rooms in the Southwest of the third floor. For some reason there is a bathroom in each visiting room and the paint on the walls is from the Reagan Administration.
The Ophthalmology Department is spread out between the second and third floor of the Eye and Ear Infirmary and the first floor of a building next door.
Information Flow
Retina is the only clinic that has an exit form for the physician to fill out. This helps with organizing next apartments.
Redundancy in patient interviews from physicians and nurses is efficient as the patient is more willing to reveal symptoms as the exam unfolds, especially if the different people are directing the interview.
Patients spend a lot of time sitting when they could be checking basic information, such as making sure their cell phone number is up to date.
Patients rely on the color of eye drop caps in order to identify which medicine is which. Drop companies may want to invest in simpler names and unique cap colors (combination colors). The department may want to create a one-page-cheat sheet that identifies cap colors and medication. Possibly make individualized sheets for physicians and patients.
Equipment
In clinic, physicians have to remove very fine and very short eye lashes with tweezers. Tweezers that have any dents or gaps fail to remove fine eye lashes. Basically, tweezers that have been used for many cycles are incapable of performing the job of eye lashes removal. Some times doctors go through three sanitized tweezers and many attempts before they can remove the eye lash. Each additional attempt is wasted time and another chance for the patients cornea to be damaged.

Week 2 Ophthalmology

Saturday July 19th

Instruments for testing eye pressure
There are many ways of testing eye pressure in a clinical setting. The most common way I saw in practice was to use a device called a Goldman tonometer. The Goldman tonometer is part of the split-lamp microscope set up, which is in every room. The Goldman tonometer is a lever. The working end of the lever touches the patient’s cornea and the lever’s fulcrum has a set level of tension or resistance. The tension is adjustable by the physician. The level of resistance is set based on the thickness of the cornea. The thickness of a patient’s cornea is typically not known with great precision, leading to one cause of imprecise measurements. However this imprecision is not necessarily the leading cause of concern in this area of practice. If a reason seems out of bounds there are more pressure ways of measuring eye pressure.
A patient’s pressure is only measured during office hours. But eye pressure varies day to day and fluctuates over a single day. For patients with diabetes variability in eye pressure is particularly important. Currently researchers are testing contact lens tonometers (CLT). CLTs can be warn by patients through out the day allowing tests to occur at many times during a day without having to be in a clinic. Without CLTs there is no practical way to measure a patients eye pressure throughout the day. CLTs have been shown to have a high correlation (0.98) with Goldman tonometer readings (http://www.iovs.org/content/38/12/2447.full.pdf).

Week 2 Ophthalmology

Sunday July 20th

Full Immersion
As I shadow ophthalmologist I wear glasses. On Tuesday a doctor correctly guessed my glass prescription just by looking at the glasses on my face. On Thursday I was in surgery with the same doctor. During an end of the day conversation she mention I should see a retina specialist. She explained that I have a long eye, which causes nearsightedness. My prescription is strong which means I have very long eye. The irregularity of the length of my eye is causing extra pressure and distortion my retina. This conversation took place in a hurdle that included a medical student, a fellow, and two fellow engineering immersion students. All of whom where making eye contact with me as I was getting a medical diagnosis. Mean while the doctor was throwing in words like myopic. So while I’m going through the emotional ride of suddenly being told I might go blind randomly at some point I am trying to remember strange words to look up later and I have to make eye contact with people that know more about my medical health then I do. In addition to all of that I’m asking myself when can I fit in an appointment, will my insurance cover such a visit, and can I get this all done before I have to switch insurance providers in a few months. And luckily I speak English naively and have some education in medicine and science unlike many patients I have seen.
I think the biggest take away from all of this is too have a friend or family member with you on your visit. The other interns where able to remember the medical terms for me. Someone who is not directly effected by the medical advice is in a better position to remember what exactly happened, what medical advice was given, and what next steps where given and implied.
From a clinical observation perceptive I think it would be a good idea to give patients a hand out that explains their medical condition. I also think patients should leave writing down the diagnosis, next step, and where they are at within the overall diagnoses-treatment time line. Even within the Ophthalmology Department each specialist office and doctor have their own system. Some doctors walk the patients to the receptionist, say what the next step is to the receptionist with the patient present, and then leave. Others write down on a form all of that information and let the patient bring it to the receptionist. Still others verbally tell the patient what the next step is and hope that the patient can internalize the information and then communicate the next step to the receptionist.
I see potential for an app would help organize, store, translate, and communicate patient information. The patient is currently responsible for knowing most of their medical history and diagnosis. Making it easer for them to carry this information would ease patients anxieties and allow for better medial care. However the patients who would most benefit from such an app seem like late adaptors to technology. I still think such an app would have value for the assertive-tech-savvy-native-English-speaking-science-educated individual.

Week 3 Ophthalmology

Monday July 21st

Cornea Clinic
I shadowed a cornea specialist in the afternoon. As part a patient’s cornea visit they also examined her retina with an ultrasound machine. The doctor explained that the machine they have in the Cornea Clinic was the least refined ultrasound machine in use.
Another patient was prescribed a few different medications. Some of the medications treated eye problems not related to the cornea. And other medications did not treat eye problems but caused side effects which damaged the patient’s eyes. Additionally the patient was not using some of the eye mediations because the patients insurance was removing benefits randomly. The doctor had to write a letter for the patient. The doctor wrote the letter by calling a number and dictating the letter to a voice mail service. The dictation was done in front of the patient. All of this made a decision to preform cornea surgery on the patient’s better eye harder.
To Cut or Not To Cut
In every department doctors go over risk-benefit evaluations several times before scheduling a surgery. Doctors try to avoid operating on a patients “good eye”. If a doctor does not preform surgery they are even more wary to refer patients to an outside surgeon for fear of recommending a surgery that will damage the patient.
Doctors also make sure patients can fully articulate why not having surgery is damaging to the their quality of life. “Can you drive?” , “Do you drive?”, “Where do you work?”, “What do you do for fun?”, “Theoretically could you live your life with just your left eye?”, etc.
Often doctors require second visits before even scheduling surgery for a patient. This is especially true in pediatric strabismus. In pediatrics doctors have to explain to patient’s parents why not having surgery (or not keeping up with treatments at home) will negatively effect their child’s quality of life. This is especially hard when parents do not speak English.

Week 3 Ophthalmology

Tuesday July 22nd

Differential Tear Buckets
Eyes are buckets that hold tears. Tears come into the eye from one set of ducts and leave through another set of ducts. And the eye acts as a bucket that holds tears.
Case 1:
There is an ideal level of tear volume in the bucket, lets call this Videal. Nothing more to say about this.
Case 2:
An individual with dry eyes has a tear volume that is less than ideal, Vdry < Videal.
Cause 1: To much drainage from ducts. Solution: Block some ducts with plastic plugs.
Cause 2: Not enough tears coming in. A possible cause: stimulus system broken. The nervous system is not telling eyes to produce tears. Nervous system does not sense stimulus on cornea. Current Solution: Take eye drops every three hours.
Case 3:
Individual who cries (non-emotionally, no irritating object, etc) has a tear volume that is more than ideal, Vcry < Videal.
Cause 1: To little drainage from ducts. Many possible reasons: inflation from infection causing skin problems… Solution: Depends on what the problem is. Treat inflammation with medication. Implant plastic tubes to open duct work.
Cause 2: To much tear production. Possible cause: overly sensitive nervous system.
Solution: Depends on what the problem is.
The controlling the nervous system at some point in the response cycle  is one area for an engineering solution.

Week 3 Ophthalmology

Wednesday July 23rd

Differential Tear Buckets The Saga Continues
Current State
To much tear production due only to poor signaling in the nervous system is uncommon.
However poor drainage is a problem. The current solution is to implant a plastic tube that starts at the bottom corner of a patient’s eye and runs into the patient’s noise. The problem with the eye to noise tear drainage is that the tube acts as a noise to eye snot pipe when a patient blows there noise. It is also uncomfortable.
Dryness is sometimes caused by to much drainage. When this happens physicians insert a plastic plug; for some patients the plugs come out between visits. Another solution is to cauterize some of the drainage ducts. Cauterization usually requires a few treatment visits before it is effective.
Future Research
Dryness is sometimes caused by an inability to control the eye lid. Usually related to a damaged cranial nerve V.
Things that have been tried but are not great solutions: springs to keep the eye shut, sewing the eye shut, sewing the eye almost all the way shut and then adding cream constantly, gold or platinum weights in eye lid.
Observations
Today I saw a topographical mapping of patient’s eye. The patient had cornea transplantation surgery recently. The topographical map showed how tight the stitches in the cornea were. This helped the doctor know which stitches he should remove.

Week 4 Anesthesiology 

Monday July 28th

Closing Time
In the morning the old groups went over the last three weeks of their accumulated knowledge. We then presented them to the class. We did this in order to prepare for our final presentation and report. It was a helpful exercise to unlock new information via information we all ready gathered. I particularly like the 2×2 matrix (side note: it should be called ‘the Cartesian plain’). I broke matrix in to high tech vs low tech and common usage in a typical visit vs uncommon usage. This helped me frame the medical equipment in a new way.
Knockout Introductions
We meet with our mentor at 1pm. He gave us more reading material, about the general history and categories of anesthesiology . Showed us the basics of surgery etiquette: how avoid nurses yelling at you. Showed how to get our scrubs in the day before we use them.

Week 4 Anesthesiology 

Tuesday July 29th

Brain Stuff
At 6:30 am there were two half hour meetings: one small group listened to a presentation on a neurological disease and a larger group went over titration. It was a resident student that gave the presentation on moyamoya disease. UIC sees a moyamoya case about twice a year, this makes UIC a high rate hospital for treatment of moyamoya. Most of the people in the room had more experience treating moyamoya than the resident giving the presentation had.
We observed two operating rooms and saw two and a half operations. From 7-730 people got ready for the day, meet the patient in the holding pen. One patient required a MRI before the operation, we saw them as they left for the MRI. Another patient was having a tumor then were pushing the patient to the or by 7:30. Preparing the tumor patient for the neurosurgeons took the anesthesiologist  over an hour. The anesthesiologist have to consider every thing from a patients medical history to their posture during the surgery to neurological interactions that could bother the neurosurgeons when treating the patient. It took the anesthesiologist about 40 minutes after the surgeons where finished to get the patient awake and prepared for recovery. The patient didn’t leave the operating room until 2:40pm.
In the other operating room a patient was being treated for Parkinson’s disease by injecting an electrode into the correct place within their brain. The patient only received local anesthesia. The anesthesiology resident mostly check vital signs.
Alternative Careers
We meet a neuroengineering graduate student in one operating room; she was an intraoperative neurophysiology technician. She monitored the patient’s nervous system throughout the operation. There are two in-house IONT at UIC. When they need a third an outside vendor. During the third operation of the day I meet an outside vendor. He was a biology pre-med student. While shadowing he discovered the IONT career. It’s actually a prefect job someone with a neuroengineering background because the technician has to know when an ‘odd thing’ is the technology’s failure or the patient is having a serious neurological issue.

Week 5 Anesthesiology 

Tuesday August 5th

Vendors
For many operations vendors from outside companies are present. The vendors are easy to identify because they wear red hair nets, while everyone else wears blue hair nets. (Sidenote: because everyone has the same uniform in the OR suite its difficult at first glance to tell if someone is a world renown surgeon or a janitor.)
The outside vendors are not just sales people dropping off an implant for a surgeon. They provide mechanical sterilized tools to implant devices, in orthopedics. In neurosurgery a vendor took pre-op monitoring information from an electrical stimulus device, before a replacement surgery happened. He programed the reading device for the surgeon and prepared the new implant before it entered the sterile field. This vendor had a background in law.
Another vendor spend the day monitoring the use of his companies equipment in three operating rooms.  Still another vendor was a clinical medical worker. He did neuro-monitoring when people the hospital was understaffed.
Except for the neuro-monitoring vendor none had degrees in  science or engineering; instead they had degrees in law, finance, and business.

Week 5 Anesthesiology 

Wendsday August 6th

Residents Meeting

Oximetry

uses light monitoring(spectra), safer than leads that can shock;
Causes of false readings:
methylene blue causes problems, xenon lamps, montion, nail polish
Beer-lambert law:
Arterial Pressure:
Small changes in artery diameter cause large pressure changes
Have to rest transducer everytime patient moves, bed with head up or down
Resperation:
Pulsus parox
Arterial catheter:
0.1 percent problem, invasive monitoring,
CVP venous catheter:
What is it: volume status: volume of what: preload of heart, inter vascular volume, It is a ratio capacitance to volume assumeing capacitance stays the same, frank star lying curve
Makes a lot of assumptions, volume, nutrients
Damage of tissue?
PA catheter (swan-ganz):
Cardiac output
Mixed venous oxygen partial pressures
Noninvasive cardiac output:
Impedance monitoring
Something
Stroke volume variation svv
Gas Analysis:
Ramon standard worse
Mass spectontor to big too expensive
Photo acoustic spectrograph blueRay beta
Capnigraphs:
Safety in children?
Works in awake people
ETCO2
Hypothermia?: 36 degrees core,
Brain function monitoring:
Recall of surgery 1:500
Bis. awareness optimal monitoring 60
Asa on evidence: not required and not harmful
Disposable cost of $.5 billion annually
Is it really worth the extra cost?
Echocardiography:
Ultrasound,
Trans a surgical echo
Behind the heart, mostly benign, can damage small patients(Pedactrics), mostly not that bad
Askimiea monitoring? YES
Dopler, phase shift of blood movement BART blue is away red is towards
Evoked potentials:
Electrical responds to stimulus, response time, amplitude,
Somatosensory evoked potentials: spine case, dorsal root, postal columns, up neck to sensory cortex. Most drugs that ano gives makes these things hard to measure for neuro monitoring.
Finding baseline
Motor evoked potentials
Pain Clinic Post-Op surgery rounds
Ice bag rests on IV pump.
Nurses personal bug is by the door, near foot peddles
I am writing this in my iPhone’s Evernote app. This is how I take notes as I shadow. I pull these notes into a word doc and then narrow it down to a few topics and make sentences.

Week 5 Anesthesiology 

Wednesday August 6th

Pain Clinic
First procedure was an epideral to the back for leg pain. X-rays were used to find the correct placement in the spine. The patient was obese so the 9 cm needle was not quite long enough. The physian needed to press in an extra 0.5 cm to reach the correct location. Normally a needle can be left standing in a patients back, allowing the physican to have two free hands. But in this case the he needed to always keep a hand holding the needle. There is a 13cm needle option but physicans don’t want to acciently push to far into the spine, so they avoid using the 13cm. Maybe a 10cm option should be made. (This might lead to miss readings, and hence spinal punctures for the smaller patients.)
Second procedure was an ultrasound aided heat injection. The location near the ribs was found using ultrasound. Heat was radially injected to cut off nerve sensation in the mid area of the body that was damaged in another procedure. The tempature was 80C. The patient was very in great pain during the enter procedure: finding the needle location, injecting a numbing agent, and having the hear treatment for 90 seconds.
Third procedure: Another epidural injection. Using an X-ray device a physican can zoom in on an injection area after initial general location is established. This is done for two reasons1) to increase contrast on screen, which leads to better locating needle and vertebra anatomy and 2) to reduce radation exposer to everyone in the room.

Week 5 Anesthesiology

Thursday August 7th
Pictures
Martin Gannon Blog

This is a neuro-radiology room. In the foreground you can see the patients brain vascular on the screen in the monitoring room. In the other room you can see the anesthesiology monitoring equipment and in the background is the radiology machines. They are able to obtain a 3D view of a patient’s vascular system.

Week 6 Immersion Review

Monday August 11th
Part One of Reviewing the Immersion Program

Three Weeks:

I think rotations lasting three weeks can seem long. However I found that I was not really able to appreciate the nuance of a medical specialty until I had adjusted to everything. On the first day of ophthalmology I showed up cold at the glaucoma department. I didn’t know the first thing about how to examine someone’s eyes, how to looking into a teaching side scope, or how to interact with patients and staff. By the end of the ophthalmology rotation I was able to diagnose people with cataracts in 2 seconds. And felt comfortable in my role as a suede medical student when interacting with staff and patients. Similarly in anesthesiology, I spent the first few days going: “that’s really cool”, “that’s really sad”, ‘that’s really disgusting”, and “those are a lot of words I don’t understand”. But after I got used to all of that stuff I was able to understand the typical workflow that an anesthesiologist goes through for each patient. Towards the end of both rotations I felt like I knew how to ask more relevant questions concerning what doctors would like from engineers and also what are their top worries were during a procedure.

Week 6 Anesthesiology

Wednesday August 13th
How Products Get Bought

By complete serendipity we had an opportunity to observe a meeting of OR nurses. They happened to be reviewing a spreadsheet of which products they want to buy. The following is a lightly edited version of my notes I took down on Evernote:

Senior nurses sit together deciding what equipment they need. They are mid career people, experienced but also young enough to not be counting the days till retirement.

Packaged deals get you a discount from Strykr. The hospital did not go with that option, unclear why.
Have to consider marginal costs (battery replacement, how cheap is to fix, how quickly do we need a replacement)

“How many times does this break…Has that effected patient care.”

Doctor XYZ is complaining about ABC. The squeaky wheel got greased.
At conferences world renown doctor lies to other doctors about having 3D vision microscope. 3D is not for patient care; it’s for educational and research reasons. (Nurses discuss whose budget this device falls under.)

They use combined experience of how the office works, how devices get used. The third floor ORs will be remodeling in a few months.

Excel spread sheet:
Service, ranking preferences for each category, Manufacture, Notes (links to brochures and pricing).

Brochure links are ignored

Renting rectal probe for $1,000 per operation was considered a good deal. No need to buy.

Synframe in spine curette tray removed from list while laughing.

$3k for spine fusion is cheap. But they are not needed; enough are lying around. There is a department at the hospital that figures out how much inventory waste vs the cheap cost.

Parts are out of date on some equipment in the OR. Once the device breaks “SOL”

Old device makes noise. “Is it supposed to do that?”

Device Blank is good for 5 years. We keep Device Blank for 7 years.

The goal of the meeting was too rank preferences for each medical device requested by group LMNO in each category. And then send that out to QRS.

Matt de la Cruz
Matt de la Cruz

Join me on this crazy awesome clinical journey!

First Clinical Post (Week 1 – First Post)

It’s only the first few days of this internship, but I’m already having a blast! The clinical environment is honestly quite new to me and it gets really hectic at times. The first few days I got to observe some physicians and nurse practitioners in the clinic. One of the nurses introduced me to the works of JJ Collins and gave me a little bit more background info about the Gastroenterology and Hepatology Clinic. I was informed of some of the procedures that patients have to undergo to see the problems in the GI Tract. I’ve noticed that patients are really hesitant to receive a liver biopsy, or really anything invasive. In my opinion, I don’t blame them. You can’t be on any blood thinners like Aspirin and it takes up the whole day. A few patients have had bad experiences with it. That is why I am excited for the clinic to receive a machine called FibroScan. Basically, it is able to non-invasively test for fibrosis in the kidney! I still have a lot to learn and I learn more every day that I spend in the clinic! Tomorrow, I plan to talk about the types of people that I’ve seen and the interactions I’ve observed.

 

First Week Recap (Week 1 – Second Post)

First Day

After we had given our introduction to the experience, I went to the GI Clinic with my heart racing and my mind ready for observation. I walked into the clinic and was received with friendly greetings from the receptionists. I then met my point person and we went into the infusion room. The infusion room was dark, mostly to the preference of the patients. My point person gave me a little background information about what goes on GI Clinic. I learned a little about Esophagogastroduodenoscopy (EGD), Diverticulitis, and Helicobacter Pylori. After a while, a practitioner arrived and I began to shadow him while he saw patients. The first patient was an older fellow, healthy too, discussing his condition of Primary Biliary Cirrhosis with the practitioner. When a biopsy was mentioned, he cringed because the last biopsy apparently did not go well. He and his wife seemed resigned, stating that his “clock’s ticking down.”  The third patient had neurofibromatosis. She was remarkably insistent on some sort of pill to get her bowels moving, but the practitioner was stalwart that Miralax would be sufficient. A lot of people seem to want the “latest and greatest” in medicine, but the desire seems to blind them to methods that work just as well. Another patient came in for a check up on her carceroma, and contrary to that patient earlier, she just decided to not do anything because she is 77 years old. Not even a biopsy. She told us that she’s tired and that her kids already know her decision. I’ve never seen anything like that. In general, the practitioners try to be as personable as possible and make sure the patients know exactly what is going on. Practitioners answer only what they know is certain so that there is no room for confusion or misunderstanding. The clinical environment does not seek to leave people in the dark, it seeks to educate the people that come in.  There were a few patients that required a Spanish translator and unfortunately I was not able to help with that.

Second Day
I had the immense pleasure of shadowing a practitioner of Hepatology. Prior to seeing patients, I was instructed to read up on FibroScan. FibroScan induces a 50 Hz Mechanical Shear wave in the liver. The velocity of the wave is measured and converted into a liver stiffness value in KPa. The greater the KPa, the more extensive of fibrosis. I learned about the Asterixis test. The patient is asked to hold his or her hands out and if there is any shaking impulses in the hands it is a sign of confusion. Confusion can be a result of Hepatic Encephalopathy which can be caused by toxic substances in the blood. One of the patients had a blood clot restricting the liver flow caused by new aneurysm near the spleen. The proposed solution was a shunting of blood from liver using something called TIPS. It is pretty much a straw redirecting flow. I noticed that patients often ask about the length and frequency of drug consumption. While it may be intuitive that people don’t want to take things forever, that was certainly reinforced through my observations. One of the patients got sick of waiting for the primary practitioner so he just got up and left! The audacity! Although all that was needed was to convey the message of aggressively checking up on the multiple adenomas to make sure that it isn’t cancer. A patient came in and had a condition known as Achalasia, where the esophagus has difficulty moving food to the stomach. I ended up having to help the patient with her things because her son just up and vanished. The next patient had anemia and burning sensation in her throat along with abdominal pains, but something I noticed was her book “Comfort For the Wounded Christian.” I thought to myself, “as if it wasn’t hard enough to deal with these physical problems, she has to deal with spiritual problems as well.” When my day finished, I saw her in the waiting room. I approached her and told her that I’m praying for her to get better. She thanked me and I went on my way. In general, family interaction is very crucial for the clinical environment. Whether that is making sure that they are informed, asking them about certain habits/clarification, or even about history, family is essential for all aspects of the clinical process. Also, I apparently can’t say “Today is slower than yesterday.” I came to eat those words later in the day.
Third Day
The first patient of the third day had four pregnancies with hemorrhoids occurring on the second child and constipation caused by diet pills after birthing the fourth child. A cream was prescribed, but it had no effect and she also has to go every time she eats. When she does go, the stool is wet. Strangely enough, another patient that had four kids came in. She was dealing with a burning in the chest as well as an asphyxiating spasm at night. The next patient that came in was a kid that was diagnosed with Juvenile Polyposis Syndrome. The patient himself spoke English, but the father who accompanied him only spoke Spanish. The practitioner decided to bring in an interpreter so that the father could fully understand what was happening. Once again, transparency is something that stressed very heavily in the clinic. The following patient spoke only Spanish so yet again I felt like I couldn’t really assist. Though I did not have to take another language because of my engineering background, I now understand that I should probably know another language to be more accessible to a wider variety of people. The practitioner spoke Spanish, but she was really worried about giving “sub-optimal” service because she doesn’t speak Spanish fluently. The next one spoke Spanish (surprise) and this time an interpreter came in virtually to facilitate the process. This day I also became more informed about insurance. Everything requires a referral for insurance and that referral takes a long time. The main observation of this day was that even though the practitioner knows a little bit of another language, she was still very insistent on having an interpreter. It goes to show how much the clinic values the quality of the information given to the patients.
Fourth Day
There was this patient that swore to high heaven that someone was tampering with his MRI, it was very interesting. The patient kept saying that “he has credibility in this institution.” There were these words that stuck out to me on this day. A woman said, “The only part I don’t like is that the procedure is in a hospital” and she goes on to request an ambulatory site to reduce infection. I found that very interesting and honestly I don’t know how to process it. Today was a shorter day, because I was not feeling very well.
Fifth Day
I could go on and on about all of the patients I got to see, which would be extensive since there were nineteen of them. I’ve noticed that the practitioners try to establish a personal connection with the patients. They truly want to make the environment as friendly as possible. There is apparently a new medication for HCV (Hepatitis C Virus) but it costs upwards of $150,000 and the state will only help with the cost unless the patient is in full cirrhosis. I saw a great deal of patients that spoke another language today. With this one patient, a doctor that wasn’t even supposed to come in, came in to see this patient and the consultation took nearly an hour. There was a lot of information that needed to be covered. I want to say the most shocking thing I learned that day. Sexual abuse and assault is common in patients who are constipated. When I heard this, I didn’t have an initial reaction. I needed time to process it. My words left me and my gaze went sullen. I couldn’t believe what I heard. That’s when it hit me. There’s so much more that goes on in a clinic than being the bearer of bad news. Often it seems like these people are the only ones these patients can talk to. The practitioners are the ones who save lives on a twofold level. That is why it is so important for the clinic as a whole to be kind, empathetic, and patient.

Endoscopy-ception! (Week 2 – First Post)

This week I had the pleasure of being in the GI Lab. After a week talking about the procedures that happen, I would finally see it for myself. I meandered in to begin my second week of immersion.

First Day
A few starting observations were that all of the procedure rooms in the lab are slightly different. There is a room specialized for ERCP since that requires X-Rays, but even further than that, all the rooms seem to be different. For example, there are two rooms connected by a screen door, but it is only those two. The equipment that is used are accompanied by stickers to identify it and also to send a report to the database. The first case I attended was a EUS and an therapeutic ERCP. The purpose of the EUS, or Endoscopic Ultrasound, is to examine the stomach and the pancreas. The patient was anesthetized, bandages (or tape) was placed over the eyes, and a green mouthpiece that allows the endoscope to go through was placed on the patient. The endoscope was then administered through the esophagus. The endoscope is truly incredible as it has many functions such as freezing, suction, and biopsies. The patient had a pancreatic mass that needed to be biopsied and investigated by pathology, so a needle with a serrated edge was put through the endoscope and suctioned a sample. After that finished, the ERCP was next on the list. The patient had jaundice, a discoloration of the skin, so these two procedures were necessary to find out the cause of it. The ERCP found a stricture caused by the aforementioned pancreatic mass. The stricture was brushed and sampled to send to cytology. I had also met a person from Boston Scientific, who obliged to provide information about the technologies they have. A few, and definitely not all, are stents, biopsy forceps, and hemastasis clips. The two procedures took up quite a bit of time, so I decided to call it a day.
Second Day
I saw a person that I knew from the clinic. A medical student recognized me and shadowed along with me. She was incredibly helpful with any general questions that I had and she also gave me insight on how patients are presented to the physicians. The first case we observed was a GI Lab Double, which is an EGD and a colonoscopy. The colonoscopy went off without any problems, but the EGD was not tolerated by the patient. There was certainly a challenge about whether to give the patient more anesthesia because of the danger of aspirating, but it was decided to just go ahead and not go through with the EGD. I got to observe more procedures and also got to read up on some terminology. A code pink happened while in the lab, so that was interesting. After a few procedures, it had been time to call it a day.
Third day
There were other procedures but I wanted to remark on two AMAZING things that I got to witness. The first was a double balloon enteroscopy. This utilizes a series of balloons inflated by CO2 to advance in to the areas of the GI tract that are missed by EGDs and Colonoscopies. Once the endoscope has reached its limit, ink is injected as a permanent tattoo to landmark the progress of the procedure. The procedure itself is very risky and requires a Gastroenterologist of considerable skill. As a result, if the EGD and Colonoscopy do not return solid results, this procedure is an option to see what’s wrong. The second amazing thing was essentially an endoscope in an endoscope! Hence, “endoscope-ception.” The endoscope inside the endoscope is referred to as Spyglass, a product by Boston Scientific. The purpose is to have a camera inside places that normally can’t have a camera, such as the bile duct! The procedure that utilized the Spyglass was an ERCP to take out a gall stone. Many methods were attempted such as utilizing the basket to break and pull the stone, prodding the stone to try to break it down, and flushing the stone out with saline. The stone had many complications since it was quite large, but the position of it was also quite bothersome. The procedure ended up taking 2.5 hours, but it was an incredible learning experience. The third day in general was just an amazing day to observe as a BioE!

Rise and Shine for a Radiology Conference! (Week 2 – Second Post)

The fourth day of the second week was observing more procedures. I started to understand just how difficult it is to move the endoscope through the GI tract. My colleague Haroon has a good a idea with creating a simulation of sorts so that not only fellows could get additional training, but maybe patients can understand more of the body. When procedures begin, a time out is done. That is simply name, date of birth, and the procedure. Prior to that, the attending physician comes in and informs the patient about the procedure whether it is a colonoscopy, EGD, or anything else. The standard of medicine has truly changed because now it is more of a let me help you understand what’s wrong and let me fix that. A technology that I was informed about was a pill camera. It is swallowed and then takes pictures of the entire GI tract! Amazing!

The fifth day was quite a treat. I started my day off by attending the Multidisciplinary Radiology Liver Conference. It was so confusing and I was so tired, that I need to go again to try to get a better understanding. After grabbing some breakfast, I had the opportunity to go into the Medical Intensive Care Unit to see an upper endoscopy done there. The amazing thing about GI is that everything they need can be brought on a cart! It is a very portable department if it needs to be. I had a little bit of bonus because I got to witness TWO bronchoscopies! It’s a little out of the scope (ha) of the department but still an excellent, excellent experience.

Provation 5.0? More Provation 5 point NO (Week 3 – First Post)

So starts the third week of my rotation in GI. The program said “inpatient consults,” so I was very interested to see what was going to happen. As soon as Haroon and I arrive at the lab to begin, we notice something different about the computers, specifically the records. Over the weekend, the lab changed to Provation 5.0. We were informed that it was in phase 2. Basically, all lab staff must log in with each new patient and out after every patient. This was not the case before as the records allowed doctors to freely examine the notes. Overall this is a change that should be implemented, but it is a bit of a hindrance in regards to acquiring information to reflect on. Before we started inpatient consult, we got to witness an Ileoscopy. The colostomy bag (a bag of waste) was removed and the endoscope was placed inside the Ileum. The patient had a small bowel transplant and was following up. After that we had went back to clinic to start the consults. Unfortunately, we were not able to keep up with the students that had the information. The consult is medical students and a fellow presenting cases to an attending physician and the physician talks through what’s happening and what’s going to happen with the patient. Once those had concluded, we took our leave.

GI Wrap Up (Week 3 – Second Post)

It’s been a little slow with inpatient consults for GI. It isn’t as involved and without prior information, it is very easy to get lost. However, we decided to make the most of observing procedures in the lab. We got to witness another Bronchoscopy, this time with X rays! The reason for the X rays is to be able to biopsy tissue from the lungs without collapsing it. Obviously, it is a very delicate procedure. A prior observation of the Bronchoscope was that it only moves in one plane. Perhaps that is because navigation through the bronchial tubes is easier in one plane so it might be to ease navigation. The bronchial tubes are indeed different from the colon or the esophagus, so a different design may be considered for it. One final interesting thing is the pill camera often gets stuck in the GI Tract. I wonder if there is a good way to get around that?

Onto Orthopedic Clinic! (Week 4 – First Post)

The time has come for the second rotation. This time, I am in Orthopedics. I will be recounting the events from Monday through Wednesday.

Monday
I had begun my adventure in the department of Orthopedic Clinic. After receiving a new badge and getting oriented of what was going to happen, I went to the clinic. I was met by Dr. Chmell, a lighthearted, hilarious human being. As soon as I entered, we went right into looking at X rays and seeing patients. The Ortho Clinic is much different from the GI Clinic. The number of patients is greatly increased and there was often no time to rest. I found myself increasing my pace to just keep up with Dr. Chmell. “Who’s next? Are you good to go?” I would hear Dr. Chmell say to the residents. I wouldn’t say the cases are more trivial in Orthopedics since the pain is definitely a problem for some patients, but I would say that there was more of a common trend. Dr. Chmell specializes in the knee, so many of the patients I saw received knee injections. An injection is lidocaine and cortisone, which helps alleviate the pain. After a hectic day, I decided to leave.
Tuesday
This time we had ventured to the clinic on Michigan Avenue. It had quite the view and the patients and the clinic were much different. These people had insurance and frequently had more jobs. The clinic felt a little more… stifled? At any rate, Nada and I had met with Dr. Gonzalez, an MD/PhD in Mechanical Engineering and quite the genius. Seriously, he’s incredibly brilliant. The environment seemed to be a little more lax, even though Dr. Gonzalez wasted no time in his walk of haste. It is interesting to note that the clinic on Michigan Avenue was not digitized. All the records were kept in the X Ray room. It could be because it’s a private clinic, but I still found it strange. How would patients coming in get their records successfully transferred? With the exception of that, nearly everything seemed… nicer? The patient beds were really soft, some rooms had a view. The environment is very different too. We were not given the same freedom to wander and investigate as we pleased. We saw a lot fewer injections. Dr. Gonzalez was kind enough to take us out to lunch at the park! It seems that Orthopedics really enjoy talking about baseball, well sports in general. After shadowing a few more patients, we decided to take our leave.
Wednesday
We were in the clinic, this time with Dr. Gonzalez. The difference in the demeanor of Dr. Gonzalez at UIC and at Michigan Avenue was like night and day. He had to see 60 patients! Here I thought 20 patients was a lot… No effort was wasted with Dr. Gonzalez or his residents. They worked hard to expedite consults and procedures. We tried to keep up, but it was difficult. I’ve noticed that the common suggestion given to the patients is to lose weight and to continue with therapy. It’s definitely focused around those two things. Which makes sense because we are talking about the joints that support the weight of the body. Surgery is generally avoided, unless absolutely necessary. With these observations in mind, we depart from the clinic.

These Scrubs Are Awesome! (Week 4 – Second Post)

Thursday

The time has come! I got to put on scrubs and head to the OR! Finally, we get to see the technologies and the respective procedures. As expected, the OR is very strict. You’re not allowed to touch certain things like the surgery table and you must have the appropriate attire. The most noteworthy thing was witnessing the replacement of an infected prosthesis. I definitely have to update more on this with pictures, but they basically had to break the femur to access the infected prothesis. They did so with this rotating blade, a buzzsaw, and some good ol’ elbow grease with a chisel! Orthopedic surgery is some pretty physical stuff! The surgery tech was kind enough to let me take pictures of the removed prosthesis. It was overall very cool! I had stayed for a little longer, but once we had to wait for the cement on the new prosthesis to dry I decided that I had saw the best of it.
Friday
We had returned to clinic to observe once again. I asked the people in the procedure yesterday how long it took after I left. It turns out that they were there for three more hours waiting for the cement to dry and closing up the patient! When an infected prosthesis occurs, the cement needs to be made with antibiotics. However, the antibiotic cement takes longer to dry. I wonder if there is a good way around something like this. We had started to brainstorm of an idea to get around the stiffness of screws in prostheses and plates, but nothing substantial yet. One of the most noteworthy things was one patient got shot and had nerves damaged in his arm. Dr. Gonzalez said we can definitely do something about that. That is honestly so incredible. Orthopedics has some really amazing individuals and procedures for its patients. I can’t wait to see what the next week holds!

Casting With Frank (Week 5 – First Post)

Frank in the casting room of the Orthopedic Clinic was kind enough to take Nada and me under his wing for the majority of the day. There, we got to witness cast removal and cast applications. Casts are either made up of Plaster of Paris or Fiberglass. Plaster of Paris takes longer to dry, is heavier, is more moldable and is also stronger. Fiberglass, in contrast, is lighter and it dries faster. Fiberglass is the material that is typically used, but Plaster of Paris is used occasionally for the instances where molding is necessary. Both materials must be dipped in water to start the hardening by removing the polyurethane resin. The cast is then applied over bandages and wraps. After the cast has been fully wrapped, it is rubbed down to facilitate drying and hardening.  The cast removal is an oscillating blade hooked up to a vacuum to suck up the fiberglass shards. I had thought that maybe we could invent a way to make the cast removal mobile, but maybe it’s not such a good idea.

Here, We Observe a Hand Procedure – Oh, It’s Done Already. (Week 5 – Second Post)

We were fortunate to spend another day in the OR shadowing Dr. Mejia. Every doctor has their own specific way of doing things, seems obvious but there is quite a contrast between the three doctors we’ve followed. Mejia has shown in both surgery and clinic that he is very technical. He knows exactly what he wants, though I shouldn’t expect any less from the Director of the Residency Program. The most noteworthy thing we witnessed was a fracture surgery. The procedure was putting wires through the area of fracture to support the area while the bones heal. The wires were administered using a drill of sorts and were guided by X Ray so naturally we had to wear lead. The X Ray technician had to be ready to take an X Ray at the surgeon’s request. Most likely this was done to reduce the amount of radiation administered.

On a side note, we got to witness a bronchoscopy in the OR. Really, the only difference was that this time I was wearing scrubs and the patient was anesthetized. The procedure was first going through with a general bronchoscope and getting aspirations, biopsies, and lavages. Then the scope was withdrawn to use another scope aided by ultrasound. The ultrasound scope was used to get aspirations of things like the lymph nodes, which are dangerous to access without guidance.
This day certainly was different, the procedures were on the hands/wrists so they tended to be shorter in nature. The three cases for the day just seemed to fly by. As I mentioned in the title, it seemed that we left as soon as we walked in. That’s just how fast it was. It’s certainly a difference from the 3 hour observation of the knee replacement!

Wrap It Up (Week 6 – Last Post)

The last week of Orthopaedics just seemed to fly by. We followed the same schedule as the first week of the Ortho rotation, with the exception of Friday presentations of course. One remarkable thing about the week happened in the OR of course. Dr. Gonzalez performed a knee replacement on a patient, but the method seemed completely different from Dr. Chmell. Gonzalez uses cement to secure the joint, but Chmell does not use cement. It shouldn’t come as a surprise, but it’s kind of refreshing to see that even within the department, there is a great amount of diversity. Frank explained to us that even for a simple stabilization of the finger, the physicians do completely different things. One more thing, Frank Radja is an amazing human being that really made Ortho a wonderful, fantastic experience. He even invited us to a wrapping class! Thanks to Frank, Dr. Gonzalez, Dr. Chmell, Dr. Mejia, and all of the residents, we ended up having a wonderful time in Ortho! I learned to re-evaluate my knowledge and put forth a greater effort to develop my expertise. I leave the department with higher spirits and a determination to do the best I can do!

 

 

 

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Ryan Orda
Ryan Orda

 

 

First Day

posted Jul 10, 2014, 1:31 PM by Unknown user

To begin, my experience at the Orthopedic Clinic was a very brief but eventful first day. When we arrived at the clinic we were introduced to Dr. Chmell, who was constantly being bombarded with questions by med students. We proceeded to shadow Dr. Chmell as he saw patients and watch as new residents gave knee injections. We even had the opportunity in assisting in putting a knee brace on a patient (pictured below). The doctor’s office was always very busy and crowded, with doctors coming in and out to view X-rays and assess patients. In the hall, red and green flags hung outside each patient door. If a green flag was raised up, it meant the patient needed to be seen. If both green and red flags were raised, then the patient was in the process of being seen. Lastly, a raised red flag meant the patient had already been seen and was awaiting further assistance (such as putting on a knee brace). One important thing to take away from this experience is the importance of hand hygiene, as evident from the various signs hanging around the office reminding doctors to wash their hands and the hand sanitizer dispensers located in the halls.

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Surgery

posted Jul 10, 2014, 2:18 PM by Unknown user   [ updated Aug 4, 2014, 4:15 PM ]

The first week of our clinical immersion has passed, and boy do I have a lot to share. I didn’t think I would have seen this much right away and in such a short period of time. On our second day, we were already changing into scrubs and observing surgery in the OR. One procedure that I found really interesting and also had a really good view of was the total knee replacement. I didn’t get any actual pictures in the OR, but this picture (below) from the company OrthAlign is pretty close to what I saw. The vendor from OrthAlign was actually in the OR as well, where he essentially walked the surgeons through which equipment to use. The surgeons wore body exhaust systems or “space suits” which include helmets with battery operated fans (also pictured below). After the operation, the vendor showed us how his device, KneeAlign, works. The device utilizes accelerometers for both tibal and femoral alignment.

When we weren’t in the OR, we were shadowing Dr. Gonzalez as he saw patients in the clinic. Dr. Gonzalez specialized in hand, hip, and knee replacements. The system at the clinic was very organized, especially considering how hectic things can get. Dr. Gonzalez told us he typically sees around 90 patients a day! The process begins by the nurse first bringing in a patient to a room and putting up a green flag outside the door (to inform the residents the patient is ready to be seen). A resident or med student then comes in (raising both red and green flags) to meet with the patient and gather information, which he or she then bring to the attending physician (Dr. Gonzalez) to be further assessed. The attending goes back to see the patient and gives his final consultation. In some cases, a red flag is then raised meaning the patient needs further assistance. For example, a knee brace or cast. One concern I noticed while observing in the clinic is the doctor’s office is fairly small and can get really crowded and difficult to maneuver around.
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Surgery?

posted Jul 14, 2014, 2:59 PM by Unknown user   [ updated Jul 17, 2014, 1:54 PM ]

“We operate on people, not X-Rays,” Dr. Chmell told a patient. He later elaborated to me, in some situations: X-Rays may not look bad, but the patient can be in extreme pain. In this case, surgery may be required. The situation may also be that the X-Ray looks bad, but the patient isn’t experiencing that much pain and is still manageable. The patient may then require a cast or more physical therapy. A shocking new statistic I found, was that one out of three knee replacement surgeries are completely unnecessary. In these cases, patients may be more susceptible to further complications that can occur during surgery.

When surgery is required, Dr. Chmell showed us the hip joint he gives patients when they require a total hip replacement. The Stryker: MDMX3 is a dual mobility system composed of an outer metal shell and polyethylene insert. The X3 represents the device’s process of being annealed three times. Annealing, as opposed to melting, allows for greater stability and longevity of the device. Stryker is currently the only company to offer this process on hip systems.

Clinics

posted Jul 19, 2014, 2:53 PM by Unknown user   [ updated Aug 4, 2014, 4:11 PM ]

On Tuesday, we had the opportunity to visit Dr. Gonzalez’s clinic at the Illinois Bone & Joint Institute on Michigan Avenue. I included a few pictures just to compare the clinic to the one at UIC. At first glance, the clinic was obviously much nicer and had an amazing view overlooking Millennium Park. Although, both clinics had a very similar system. Compared to the UIC clinic, this clinic was much slower. Dr. Gonzalez normally sees 20-25 patients, compared to the 90 at UIC. The clinic still used a similar flag system as UIC, with additional flags for specific cases such as injections or X-Rays.
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In between seeing patients, Dr. Gonzalez told us more about the different companies that design the prosthesis he uses. Specifically, calling out Stryker and how Dr. Chmell just believed everything the vendor told him (also why my last post ended up sounding like a sales pitch…). Different doctors will go with different companies. It all depends on what that doctor is comfortable with and believes is best suited for their patients.
Some new medical devices we got to see were the SonoSite X-Porte Ultrasound Kiosk and Applied Medical Simsei Laparoscopic Training System. The X-Porte gives doctors an easier way of giving injections, by allowing them to locate tendons and guide the path of the needle. When we were talking to the vendor from Applied Medical he told us how most older doctors won’t even touch the new equipment. They figure the way they have been doing things for years has worked, so why bother changing that. On the other hand, younger doctors will be more willing to try something new. If it could potentially make surgery easier and even more precise, they would want to try it out. Plus it can get pretty boring doing the same operations every week, I saw doctors who seemed excited to try new devices. Some even made a game out of the Training System by moving the colored rings from one side to the other.
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SonoSite X-Porte Ultrasound Kiosk

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Top Display (showing path of injection)

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Bottom Display (user interface)

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Applied Medical Simsei Laparoscopic Training System with different size Trocars

 

Engineering

posted Jul 23, 2014, 7:42 PM by Unknown user

Yesterday we went back to Dr. Gonzalez’s clinic at the Illinois Bone & Joint Institute, where he gave us several presentations on his research and studies on hip and knee implants. A big concern when designing implants is wear. Cross linking decreases plastic deformations. A study determined large metal heads of hip implants caused corrosion. This led to research in switching from metal on metal joints to ceramic on metal. Another concern is sub-micron particles as a result of friction. Sub-micron particles, as opposed to micron particles, can be phagocytized by macrophages and cause osteolysis.

Today we returned to the U of I clinic. One problem I noticed was when the nurses would check which patient rooms were available. Nurses would get frustrated when the doctors forgot to either put the red/green flags back down or switch the “in use” sign to “available.” It seemed a little redundant to have the signs in addition to the flags, and this caused uncertainty to whether or not the rooms were available or not. Other times, a sling or documents would be left in the room and appeared the room was still in use.

Knee Revision

posted Jul 25, 2014, 12:13 PM by Unknown user

Ryan Orda Blog

On Thursday, we were back in the OR observing a knee revision surgery. The patient’s knee (pictured above) had gotten an infection and the implant needed to be replaced. This surgery is more complicated than a regular total knee replacement, since the implant that needs to be replaced has begun to grow into the bone. One complication to arise from this surgery was actually due to the vendor’s equipment. Smith & Nephew was the vendor and typically use the same trial spacers every time. These trial spacers are used in place of the actual spacer to test for sizing as necessary. The problem that occurred was that the trial spacers’ screw holes had been stripped due to prolonged use. Dr. Gonzalez got frustrated with this and made sure the vendor knew that by telling him that they need to have new ones next time and assure this does not happen again.

Once that problem was resolved, the surgeons continued with the surgery by replacing the knee implant. Another thing I noticed was all the surgeons wore multiple layers of gloves (3 or 4 layers). The gloves are usually made of latex or vinyl material, but sometimes they wear a middle layer made out of Kevlar (pictured below). I understand the extra precaution when dealing with tools like screwdrivers and hammers, but it almost seems like a lot of precision is lost when the gloves are so thick.
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Several work-arounds I noted were resting small tools on the patient’s body at times and one surgeon flipped a clear face mask to shield his eyes.

Last Day

posted Jul 28, 2014, 5:17 PM by Unknown user

Today was our last day in the Orthopaedic Clinic. These past three weeks have gone by so fast. We met so many different people and saw a lot of med students come and go through different rotations. Several random facts that I jotted down, but just got left out of my other entries are:

1) The University of Illinois Hospital is the only hospital in Chicago to accept public aid

2) Don’t give a patient a steroid injection if they have uncontrolled diabetes

3) The KneeAlign device works for tibial, but not femoral alignment (according to Dr. Gonzalez)

4) Orthopedic and Orthopaedic are both correct

First Day Again

posted Jul 31, 2014, 12:24 AM by Unknown user   [ updated Jul 31, 2014, 12:29 AM ]

This week I began my rotation through the Hematology/Oncology department. We first met with Dr. Rondelli, who helped us plan our tentative schedule for the next three weeks. We will be observing three different settings, one each week. These are clinics, inpatient center, and stem cell lab. We began by shadowing the nurses by the chemotherapy rooms. These rooms had a much different feeling than the typical patient rooms we had been observing. Patients would be paired based on common language spoken or even by request. There were four private rooms reserved for patients who prefer to be alone or for more severe cases. Unfortunately, most of the private rooms go to inmates since they need to be kept away from other patients.
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Chemotherapy room
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Private room
When we weren’t observing the nurses, we shadowed the doctors around the clinic. One meeting we sat in on was about Stem Cell Transplants. These meetings tend to be mainly paperwork and scheduling transplants. The doctors discuss patients and assess if they have found qualifying donors. I never though of all the different complexities involved in donor matching. For example, a donor’s immune system may be “too aggressive” towards the patient’s immune system. This is known as Graft-Versus Host Disease (GVHD). When patients seek a related donor, there isn’t a guaranteed chance they will be a match. Siblings have only a 25% of being a match, due to genetic variation. Three methods for harvesting bone marrow (stem cells) are through the bone – using a needle pictured below, peripheral blood – drug mobilizes stem cells to blood and is detected by flow cytometry, and umbilical cord.
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Afraid to be Bored

posted Jul 31, 2014, 9:55 PM by Unknown user   [ updated Jul 31, 2014, 10:16 PM ]

Today we met with Dr. Mahmud in the Stem Cell Laboratory. The technologist, Youngmin, showed us the various equipment they use.
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Stem Cell Storage Tanks

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Automated Hematology Analyzer

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CD34 Reagent System

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Temperature Monitoring

 

Afterwards Dr. Mahmud shared with us his very inspiring outlook on life. He began by telling us to think like children. He does this because he believes little kids can see things adults cannot. Nowadays, people are too preoccupied with technology, keeping a social presence online, and in general not being in the moment. Dr. Mahmud explained to us how everyone just wants to act busy all the time. People are “afraid to be bored.” They shouldn’t be scared to reflect more. If people took a moment to stop worrying about their Facebook status or Instagramming what they’re eating for dinner, they could think like a child and question the way things works. It was this mentality that Dr. Mahmud instilled in me today. I could start asking myself, why don’t they try doing it this way or what if they changed this part of the device.

After we visited the Stem Cell Lab, we returned to the clinic where we had the opportunity to observe a bone marrow aspiration and biopsy. I was surprised how quickly this procedure was and how it was all done in the patient room. The bone marrow kit used was from Hospital Service and is identical to the picture I included in my last post.

An alternative to the bone marrow kit used in the clinic is a “gun-shaped” device that takes care of the biopsy procedure in one shot. However, a few down sides to this device are its cost and noise, due to drilling. Dr. Rondelli brought up an interesting idea for a Bone Marrow Catheter. The device would need to be thin and flexible and could hypothetically transfer stem cells through the blood system.

 

Inpatient Center

posted Aug 6, 2014, 2:23 PM by Unknown user   [ updated Aug 7, 2014, 6:44 PM ]

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Otoscopes hanging on wall

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Wall mounted vital machine & multiple outlets

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Transfusion machines

 

On Tuesday, we followed Dr. Rondelli as he held rounds at the Inpatient Center. The center is located on the eighth floor of the hospital. The entire floor was remodeled thanks to a $1.5 million donation. It is easily the nicest floor in the hospital with its hardwood floors and yellow painted walls. Dr. Rondelli hand picked pictures of various cities to be placed in each patient rooms. His favorite is the one pictured above, which features pictures from his home: Venice, Italy. Included in each patient room is a TV, computer, wireless keyboard, and webcam. Also, in each room is a fridge (the only hospital to include one). Dr. Rondelli believes patients should be as comfortable as possible in the hospital and still maintain connection with friends and family. There is even a bench that pulls out to be a bed for family members to stay overnight.

When seeing patients, everyone must use hand sanitizer before entering the room and after leaving. In certain situations, extra precaution is required. Yellow gowns, gloves, and masks are worn when seeing patients under chemotherapy where their white blood cell count is close to or is zero.

Several areas of possible improvement are the bathroom tubs could be changed to standing showers for easier patient access and X-Ray equipment could be mounted from the wall to take standing X-Rays.

 

Stem Cells

posted Aug 6, 2014, 11:03 PM by Unknown user   [ updated Aug 7, 2014, 7:57 PM ]

Today, we returned to the stem cell lab where we saw a stem cell cryopreservation.  The first step was in the Donor Center, where the stem cells were being collected from matching donors. The Apheresis System separated the donor blood, which was then sealed in a sterile bag and closed with a heat sealer. The Photopheresis System is a similar machine, only it uses ultraviolet rays to treat and separate the blood. Kits for the COBE Spectra Apheresis System can run around $100, while the Therakos CellEx Photopheresis System costs $1400-$1500. Although, the Therakos CellEx System has only been approved for CTCL (Cutaneous T Cell Lymphoma), not for GVHD (Graft Versus Host Disease).
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COBE Spectra Apheresis System

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Flow path for COBE Spectra System

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Therakos CellEx Photopheresis System

Once the collected stem cells are brought back to the lab, CD-Chex CD34 is used as quality control for enumerating CD34 cells by flow cytometry. One interesting fact I found about the sterile bags was, Baxter used to sell 20 packs of the bags costing approximately $400 ($20/bag). Unfortunately the bags were discontinued due to a low profit. Which makes me wonder how much it cost Baxter to produce the bags that caused such a small return.
One workaround I noticed was when the lab technologist, Youngmin, would transfer the bone marrow samples to a tube. Instead of using a centrifuge, she would quickly drag the tubes across the pipette tip holder rack. She said it saves time and centrifuging may damage the cells.
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SCD 312 Sterile Tubing Welder

Radiation

posted Aug 7, 2014, 8:22 PM by Unknown user   [ updated Aug 10, 2014, 5:54 PM ]

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Linear Accelerator

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Remote Control

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Console Control

 

Today we visited the Radiation Oncology department, where they use radiation therapy as a cancer treatment and to prevent tumor recurrence. The main device that is used is the linear accelerator. This machine uses electrons traveling nearly at the speed of light to kill cancer cells. The device is controlled from a console outside the room. The console includes camera control to see inside the X-Ray room. The machine moves precisely by entering in coordinate dimensions and automatically adjusting to the settings. A CT scan is initially taken by the device to acquire an image to determine a target setting. An individual plan is created for each patient, by studying their CT scan and movement of the tumor based on bodily movements. A margin is then created to account for that movement. Treatment can last from 5-6 weeks and 15-20 minutes a day. A mold is created to keep the patient in the same position each day and reduce error. When we talked to the radiologist about how he creates the patient’s plans he told us, “Words will confuse you, just look at the pictures.” It’s true that it is much easier to show someone how something needs to be done as opposed to telling them. The linear accelerator machine we saw was actually a new device (Varian TrueBeam STX costing approximately $4million) that was still being set up. Side effects of radiation therapy include nausea and complications that can arise from improper target alignment

 

End

posted Aug 15, 2014, 2:14 PM by Unknown user   [ updated Aug 15, 2014, 11:06 PM ]

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The final week of our rotation saw the conclusion of the stem cell transplant procedure. We previously followed the technologists retrieve the bone marrow from the donor bank and then to the stem cell lab for the stem cells to be frozen. Which brings us to the final step of giving the new donor stem cells to the patient. The stem cells were brought up to the inpatient center from the lab, where they had to be defrosted to a “slushy” consistency before being given to the patient. The one side effect that patients experienced from the procedure was a sour taste left in their mouth. Some patients have worse experiences than others, and can cause nausea and vomiting in some cases. The nurses give the patients hard candy to help with this problem.

All in all, this clinical immersion experience has gone by incredibly fast and there is so much insight and knowledge I have gained from my time in both Orthopaedics and Hematology/Oncology. I want to thank Dr. Kotche and Prof. Sterling for giving me this opportunity; as well as Dr. Gonzalez, Dr. Rondelli, and all of the hospital staff for letting us observe them and teaching us all about medicine and how it incorporates engineering.

Nadia Crawley

Nadia Crawley

My name is Nadia Crawley. I am a senior Bioengineering student at the University of Illinois at Chicago, with a concentration in Cell & Tissue. I am an intern in the Bioengineering Clinical Immersion Program. I will use this blog to document my experiences while in the clinical environments: Transplant Surgery and Anesthesiology. This blog will help centralize my “raw data” and better help me analyze the dynamics of a clinical environment, and how the products and protocols of engineers impact the atmospheres in which they are implemented.

First Day July 7th, 2014

posted Jul 7, 2014, 4:33 PM by Unknown user   [ updated Jul 7, 2014, 5:11 PM ]

Nadia Crawley Blog

Talk about immersion! No more than an hour into my first day, I found myself in scrubs and in the “middle of action” in the operating department of the University of Illinois Medical Center. The foot traffic was hectic, nurses were walking back and forth, the phone kept ringing off the hook, and the charge nurse seemed rather stressed. Soon I found myself walking into an operating room where two surgeons were reconstructing the arteries of a pancreas in preparation for surgery. I couldn’t believe what I was seeing! And to top it off, the lead surgeon seemed more than happy to explain what exactly he was doing, and even encouraged my partner and I to come behind and watch! Just when I thought my day couldn’t get any better my shadow doctor, Dr. Jeon, allowed my partner and I to come into his operating room where he was removing fluid from a patient. To witness the prep, incision, and operation of a patient in such close proximity was exciting, yet slightly nerve wracking as I was constantly moving to get out of the way. Nevertheless, I witnessed some pretty amazing things today.

 

Friday July 11th, 2014

posted Jul 13, 2014, 8:39 PM by Unknown user

At the end of the first week I was relieved and exhausted, but most importantly, I was excited for the coming week. I really didn’t know what to expect, but the experiences that I’ve had in just  short days were incredible. I was able to see surgery, in which a HERO catheter was placed in a man’s arm. I also shadowed a doctor as she did her rounds in the Transplant Clinic. Most of my time last week was spent in the clinic, and while it was interesting to hear patient’s stories, it was also very sad. I wasn’t really prepared to hear of patient’s tumultuous health history, their struggles as they wait to be put on the “list”, a patient being notified he may have cancer, and the list goes on and on. Those type of encounters were pretty tough to hear, and it made me more aware of my own mortality. Many patients were diabetic and suffering from kidney failure. Many patients were on dialysis, and the toll it takes on the human body was exposed through each pair of enlarged veins I witnessed. It made me wonder, in what ways could the process be improved to not damage the human body in such a manner; or further more, in what ways can we develop practices in which we prevent the use of dialysis machines?

While the patient interactions were memorable, I’m still yearning for a chance to get more acquainted with the equipment in the hospital rooms and OR. I had very littler interaction with the actual hospital rooms. However, I spoke with a nurse who will allow my partner and I to interview the other nurses and potentially follow them around the Transplant/ICU unit, so we can gain a better understanding of how the equipment works, how it impacts the environment and users, and potential obstacles, if any, when using the equipment. I’m also looking forward to seeing more surgeries. My favorite part of this experience so far has to be my time spent in the OR. Watching live surgery is amazing, and it gives me an opportunity to see many devices in use.

Week 2 Recap July 14th – July 18th, 2014

posted Jul 21, 2014, 6:48 AM by Unknown user

Some really great things happened this past week! First, I noticed that I felt more comfortable coming into this second week of Transplant Surgery. I knew my way around the hospital more, I had developed a nice relationship with the fellows, and I was really excited to see more surgery. On Monday, while there was no procedures going on to observe, I was able to play with the Da Vinci surgical robot! In a cold and sterile “large animal procedure room,” I experience, first hand, what it felt like to use a device as an extension of my own hands. It turned out that the device was quite easy to use. After speaking with Dr. Jeon, I grew to understand the benefits and disadvantages of the robot. While it is great to use on overweight patients, there are a few factors that could be improved. The arms could be a bit slimmer as to not bump in each other when multiple arms are being used. And the robot lacks tactile feedback. So there were times when I gripped the testing board too hard. Had that been human tissue or flesh, that could have been very painful. The only issue with designing improvements to the device, or any device for that matter, is patent laws. We learned, to the irritation of our doctor, that improvements or ideas are no longer based solely on the advancement of medicine and science, but business. And so the company that makes the Da Vinci robot and patented so much of the technology that they use, that it would almost impossible to design an improvement to the device without selling it to them. That was very interesting to hear.

Tuesday was beneficial because after our morning rounds, I was able to speak with a number a nurses about their experiences in the hospital, with the equipment, and with patient care. They were very opinionated and had a lot to say about the PCA pumps that are heavy and the lack of consideration for nurses in terms of room design. The following day, I was able to shadow a nurse for about 15 minutes to see how he interacts with the equipment. Wednesday and Friday were the typical clinic days.
But Thursday was amazing! I was able to see an actual kidney transplant. In the first room, I witnessed Dr. Garcia use the Da Vinci robot to remove a kidney from a live donor. Afterwards, I followed her to another operating room where Dr. Jeon placed the kidney in the recipient. It was an awesome procedure to witness. Right after that procedure, there was a fistula case which I saw the beginning stages of. Overall, I was very pleased with this week.

Week 2 Concerns July 14th – July 18th, 2014

posted Jul 21, 2014, 6:54 AM by Unknown user

While some great things happened this past week, a few things concerned me. Our doctor was very much absent and non-responsive to us. When were attempting to locate him or figure out where to go next, we were pretty much left to our own devices. We took the initiative, at times, to speak with the residents and nurses. However, we were also aware that this is a busy running hospital with busy employees. So sometimes there wasn’t an opportunity to “bother” anyone at the moment. We did our best to quietly observe or shadow, but there was often downtime when were wondering what we should do or where we should go. We know it is not the responsibility of the nurses or residents to accommodate us, but we were shocked with the great distinction we discovered in our doctor from the first week to this one.

We’ve discovered that our favorite place is the OR. And so on this last week, we will attempt to spend more time there as it seems some of the other doctors recognize us and are a bit more comfortable with our presence in the OR. While the time spent in the clinic is good and it impacts our empathy towards the patients who use the devices, we would like to see more use of the devices.

Pancreas Transplant July 22th – July 23rd

posted Jul 23, 2014, 10:58 AM by Unknown user   [ updated Jul 23, 2014, 10:58 AM ]

During our last week in the transplant department, Nada and I have decided to commit as much time in the OR as possible. While it seemed apparent that the doctor we intended to shadow no longer had a desire to accommodate us, we used our resources and cordial relationships with the other attending physicians and residents to our benefit. We were able to see one of our favorite doctors, Dr. Garcia-Roca, dissect a cadaver pancreas that was shipped from Texas, in preparation for transplantation of a 68-year old patient. We watched as she inspected the work that had already been done on it, and then began to cut away some of the fat and remove the spleen. While she was doing this, three medical students were present in the room, so she took the time to thoroughly explain the process, the pancreas, and educate us on issues regarding why someone would need a pancreas. Our conversation delved into the world of islet transplantation, instead of the entire pancreas. It was very interesting to hear because I have some knowledge of that process from taking BioE 455: Intro to Cell & Tissue Engineering. While she was discussing the process of islet transplantation, I asked her opinion of placing the islets in biocompatible capsules to prevent rejection, an idea we had previously discussed with Dr. Jeon. She expressed that experimentation is very premature, but it would be interesting to see what results from it in the future.
A second attending physician, Dr. Ivo (can’t remember how to spell his last name) came to assist Dr. Garcia-Roca in preparing the pancreas. Both doctors would be performing the actual procedure. Watching them work together was awesome. In contrast to Dr. Garcia-Roca working with a third-year medical student thirty minutes prior, the cohesiveness and fluidity of the two attendings showed not only their skill, but also their years of working together. There was an accompanying vessel that needed to be attached to the organ, so both Dr. Ivo and Dr. Garcia attached the vessel. Once everything was connected, what I thought to be saline was pumped through the organ to check that there weren’t any leaks in the pancreas and that the water was flowing all the way through. Once that was confirmed, the doctors called for the patient.
When the patient came in, the doctors were still working on the pancreas. But there was still a lot of chaos and foot traffic in the room as nurses prepped the patient and anesthesiologists began to monitor him and put him to sleep. Once sleep, we watched a medical student insert a Foley catheter, which proved to be a lot quicker and simpler than I had ever imagined. Once the patient was sedated and prepped, Dr. Ivo and Dr. Ying (resident) began the procedure by making a large incision down his stomach. The cut was much larger than I had expected for such a small organ. They then had to cut through all of the fascia to get to the abdomen. One thing that was kind of hard for me to watch was the placing of the clamps on the exterior walls. They use metal rods and clamps to pull back the open skin to provide a large cavity to be able to work within the body. While I know it’s necessary, seeing the doctors yank, pull, and tug and the skin was sort of….creepy. Anyway, once everything was in place the doctors began to work. But because the work was being down so deep into the stomach, we weren’t able to see much.
Not too long into the procedure, Dr. Garcia-Roca came and began to take over for Dr. Ying. Time was ticking down, in terms of our work shift, but I was able to stay long enough to witness them place the pancreas inside the patient. Although I didn’t finish the procedure, I was able to see the patient this morning in the Transplant/ICU unit during rounds. He seemed ok, but there looked to be excessive bleeding, which may cause clots. So he’s been brought back to the OR to find the source of the bleeding.
Something that stood out to me about this case was the impact of transplantation. Unlike the kidney, no living human being can donate an entire pancreas. A live donor can give a pancreas segment. However, if it’s full pancreas, then that means that the donor is dead. And in this case, that donor was a 10 year old. I don’t know the full details of the story, however the resident briefly told us the sad story of how that young boy came to become a donor so early in his life. Despite that boy’s unfortunate death, his organ is now sustaining the life of a 68-year old man. Interestingly enough, when the patient was first brought into the OR, I overheard him asking the nurse how he could become a donor. He wanted to donate his body to science. Since I’ve been in transplant, that’s the second time I’ve heard of that request. But this man was asking it on the operation table! It’s an amazing thing: the process of transplantation. And the recipients of organs seem to not only appreciate what they’re being given, but want to contribute. Even if their health doesn’t allow them to donate to other people, they want to donate their bodies to science. I think that shows the power of medicine and the power of surgery.

Goodbye Transplant July 25th, 2014

posted Jul 27, 2014, 1:18 PM by Unknown user   [ updated Jul 27, 2014, 1:19 PM ]

It was bittersweet Friday afternoon. While I was, and still am, excited to go to Anesthesiology to experience a new department, I was sad to leave the Transplant unit. The doctors were amazing, the surgeries we saw in OR were amazing, and my partner was amazing. In just three short weeks we had developed relationships with the attending doctors, the residents, even the nurses in the OR. We had asked them tons of questions, followed them around everywhere, and still they always made us feel welcome. So, because of the amazing generosity of the Transplant Department, we decided to give them thank you cards.
Nadia Crawley Blog
We got cards for the two residents that helped us out the most and allowed to ask them anything and everything. At times, they even encouraged us to ask questions. We also got cards for Dr. Jeon, our shadow doctor, and Dr. Garcia-Roca. I truly feel that Dr. Garcia-Roca’s card was the most important one of all. She turned out be our favorite doctor and she is not even apart of this program. She allowed us to follow her incessantly. If anything, she was more helpful than our shadow doctor during the last 2 weeks of this rotation. And for her generosity, I will always be grateful.
In terms of our last day in transplant, I must say it was pretty eventful. We watched a bloody procedure in which doctors were assessing a graft in a woman’s arm. Part of the arm was infected, which made it difficult to determine how and in what direction the doctors would have to loop the tube. The infected mass on her arm had dark tissue inside, but was full of blood. So Dr. Garcia-Roca continued to drain it using the suction tube. And many times the doctors just pushed down on the mass to push out the blood. It was apparent that the doctors were getting frustrated, so another attending was called to get his opinion on what should be done. After he scrubbed in, he forcefully removed as much of the tube out of her arm as he could. That was pretty gross to watch. But it seemed to remedy the situation, at least somewhat.
Nadia Crawley Blog

Image

Nadia Crawley Blog

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Nadia Crawley Blog

All in all, I really enjoyed my time in transplant. I feel I have obtained a better understanding of the clinical environment. I was able to identify common issues within the hospital, in terms of medical devices, that need further development. I gained a very strong sense of empathy for the patients that need these medical devices or procedures done. I also gained a sense of empathy for the users of the devices, such as the medical staff. I believe that I now have the first-hand knowledge and experience to explore better options, to explain was obstacles within a clinical environments, and the motivation to be apart of the advancement of medical practice. Although I will miss the Transplant unit deeply, I’m looking forward to see what lies ahead in Anesthesiology.

 

Anesthesiology!!! July 29th, 2014

posted Aug 3, 2014, 8:20 PM by Unknown user   [ updated Aug 3, 2014, 8:37 PM ]

Can I just start off by saying that I love the anesthesiology department! Not only is this rotation much more organized; but our doctor is amazing and the number of engineering related applications in this department help me better conceptualize the true purpose of this program. On our second day, but first day in the OR, we saw two neuro cases: a brain tumor resection and deep brain stimulation for Parkinson’s disease.

1) Brain tumor resection:
This case was extremely interesting to watch. We were able to see this case from start to finish. When the patient was initially put to sleep, the resident anesthesiologist was searching for her radial vein to place the A-line (fig. A). However, he had difficulty finding it. He was essentially “poking blindly”. After some time, he decided to go for a central line instead. The central line also proved to be difficult. The attending anesthesiologist, our Dr. Edelman, was also frustrated because he believed the patient should have had an x-ray beforehand to avoid all of the hassle. He explained that trying to place a central line is also “poking blindly” because they have to find the subclavian vein. Often times an ultrasound can be used to look for veins, however the subclavian vein is hard to detect because it lies under the clavicle. That means the deeper the vein, the lower ultrasound resolution because of the lower frequency. If advanced technology were developed to overcome such obstacles, prep time for surgery could be cut down significantly. And ultimately, the well being of the patient, so doctors aren’t “poking blindly.”
Something very interesting about this procedure was the patient’s posture. Due to the nature of her tumor, she was placed in an upright position (fig. B). Her tumor was located directly in the center of her head (fig. C). So the surgeon had to enter her brain behind her ear in the suboccipital region of her head. This position posed a major risk, as it increased the chance of air traveling into the vessels and causing an embolism. Additional precaution was given to avoid such a tragedy.
Ultimately, the procedure was a success. We were able to see the procedure clearly due cameras being used for the procedure. The operation took our entire shift, however we saw the patient wake up. And while she rather disoriented, she seemed to be ok.
Nadia Crawley Blog

fig. A

Nadia Crawley Blog

fig. B

Nadia Crawley Blog

fig. C

2) Deep Brain Stimulation for Parkinson’s Disease
The true gift of anesthesia was personified in this case, as the patient was wide awake as micro-electrodes was placed into her brain! A small part of her scalp removed and a whole was drilled into her skull, all the while she was cognitive on the other side of the plastic drape (fig. A). Since the procedure was to examine her brain activity in terms of muscle movement related to her disease, she couldn’t be under full anesthetic, as those drugs impact neural activity.
So electrodes were placed in her brain and we were able to see muscle activity and movement through a signal wave on a DBS monitor: Alpha Omega (radio frequency). After the signal was established, her neurologist moved her muscles to test brain activity. She was also asked to repeat certain words from him. It was amazing to watch her speak and be fully conscious through this procedure. The device showed certain movements resulted in a high and rhythmic amplitude.
Nadia Crawley Blog

fig. A

The use of different medical devices in this single day proved to me to advantages of engineering concepts in the medical field. And it has already got the wheels in my brain turning of certain improvements. Little did I know the amount of work that went into an anesthesiologist’s job, nor how engineering intensive these operations are. But I’m excited for the rest of this rotation.

What do Anesthesiologists Want

posted Aug 3, 2014, 8:56 PM by Unknown user

 

My first week of Anesthesiology has been absolutely amazing. I’ve seen multiple neuro cases, lumbar back cases, robotic gastric bypass, laryngectomy cases, and the list goes on and on. I’ve gotten so used to the procedures that seeing blood and guts doesn’t even phase me anymore. I find myself asking soon afterwards, “So when’s lunch?” But although each case may be completely different, with different body parts and surgeons and complications; there are a few universal problems that I’ve found in all operating rooms.

1) Too many cords/tubes!!!
I was quite shocked when I saw the amount of clutter. Each and every operating room deals with this large amount of tangled tubes. The anesthesiologists use 4 types of drugs, and each drug has its own PCA pump and tubes. There is also a tube for pain medication. Other tubes included are breathing tubes, gas tubes, IV’s, EKG leads, etc. All of these tubes have to be hooked up to the patient in some way, yet there is no product to consolidate the tubes. Such a clutter poses serious risks! How can the doctors know which cord is which if it needs to be changed immediately? If the patient’s position needs to be altered in the procedure, how could they? What if someone tripped over these tubes? The questions are endless. And anesthesiologists aren’t very happy with the set up either. This issue seemed to be the number one problems for many doctors.

 

Nadia Crawley Blog
2) Equipment like a “car”
New technology appears in hospitals through a revolving door. While tons of new equipment comes in, medical staff have to be re-trained to use them. This appears to cause some frustration with the anesthesiologists. They desired equipment that was all intuitive. They compared their ideas to that of renting a new car or buying a new phone. You don’t have to re-learn how to use a new or different car; they all work the same. The similar though process goes for buying a new phone. All the devices function the same, despite their different brand or model. So doctors desire equipment that functions on the same principle. With that idea in mind, time and money could be cut down and medical staff could effectively use the equipment without of fear of misusing a new device.

Interventional Radiology (IR)

posted Aug 24, 2014, 5:22 PM by Unknown user

I really enjoyed going to the IR department. I must admit I was a bit biased, because my mother is an IR nurse. So I was very intrigued to finally the devices and procedures I heard her speak of so often. On this particular day I witnessed a biliary tube exchange. A man suffering from cancer of the bile duct had to come in every 6-8 weeks to have the tubes in the bile duct replaced. The tubes hung outside of his body, on the side of his abdomen. After so long, the tubes become obstructed due to the thickness of the bile, which causes build up. The procedure was very straight forward. Guide wires were placed inside the old tubes as place holders. The old tubes were removed and the new tubes were inserted where guide wires were. The procedure took all of thirty minutes. But I wondered if there was a way to prolong the life of the tubes a bit longer than just the 6-8 weeks. I thought of different tubing material or a better porting system to drain the bile, but keep the tubes intact. But there already seemed to be a plethora of devices in the IR department. In fact, it resembled a grocery store in the main hall. I noticed tons of catheter systems and tubing from Abbott, Boston Scientific, Kimberly-Clark, Cook Medical, etc. The number of different medical device manufactures in the department was astonishing. I did not have nearly enough time to try and distinguish between the multiple devices to determine their difference. Nonetheless, it seemed each tool had a purpose and was there for a reason.

Unfortunately, there weren’t any “interesting” cases to view in the IR department, other than the biliary tube exchange, which the attending referred to as their “bread and butter” cases. But it was an enjoyable experience. The department seemed to use a large amount of medical devices and imaging tools. It would be awesome for there to be an IR rotation next year.

Blog Posts and Saving Lives…

posted Aug 24, 2014, 4:46 PM by Unknown user

My immersion in the Anesthesiology department really made me think of how I budget my own time and priorities. I seemed to really struggle with updating my blog regularly. I always felt that by the time I got home from a long work day and an even longer commute, that I was way too tired to write a blog post. I would push the blog to the next day, then the next day, and then before I knew it…it was Sunday night. I must admit, initially I felt quite justified in my excuse for not completing my required posts. But I soon became rather disgusted with myself for two reasons.

1) My excuse for not keeping up with my blog posts was just that, an excuse.
2) The doctors I had the pleasure of shadowing were working 3x harder and longer than I was, yet still had to arrive at work at the same hour every morning because people’s lives depended on them. They couldn’t forget a patient just because they had a long day/night.
Some anesthesiologists had to spread their weeks between multiple departments. One such doctor was Dr. Rakic, who also worked in the Pain Clinic. So not only did he work in the OR, but on certain days, he had to make rounds within multiple departs to check on the pain of recovering patients and then go to the Pain Clinic to consult with outpatients. I got to witness the treatment of a misplaced epidural pump, nerve burning, and simple one-on-one doctor patient consultations. The most interesting part, however, had to be the nerve burning procedures.
The nerve burning procedures, or Medium Branch Block, are performed on patients who are experiencing pain due to damaged nerves. An ultrasound is used to locate the area, and then a needle with radio-frequency capabilities at the tip is inserted into the patient’s skin and the nerves are burned. The pain can remain gone anywhere between 3 months to 1 year. The procedure is relatively quick, yet it was very painful for the patient.
One thing to note was the use of the ultrasound during the procedure. It seemed as though Dr. Rakic had a love-hate relationship with the device. While the ultrasound is dynamic, it shows only a small portion of the image. Therefore, every time you replace the probe on the skin, you have to start from square one to find your position again. In contrast, the X-ray shows a much larger image.The con of the X-ray, however, is that it is only 2-D. It would be very beneficial is the ultrasound could display a larger image. I’m not sure if that would mean a probe with a larger surface area, or not. But it seemed like a larger radius could be to the benefit of the doctor and the patient.

Saying Goodbye to Anesthesiology

posted Aug 24, 2014, 5:50 PM by Unknown user

I loved this department. I truly enjoyed Dr. Edelman, the entire department, and the awesome people we got to meet along the way. What I took away from shadowing the anesthesiologists was sheer respect for what they do. Their job far exceeds what I ever thought. They hold one of the most important positions in the hospital. They allow for surgery to take place. They assess a patient’s status to determine what drugs are appropriate. They alleviate pain. They consult the patient before and after surgery. They serve as doctors, confidants, and therapists. And though they carry so much responsibility, their working situations are less than ideal.  While their technology is advanced, they still lack many advancements, namely wireless connections, which could really alleviate the stress of their jobs. However, even with all of the stress, the staff still welcomed us with open arms and were happy to teach.

Dr. Edelman took so much time to explain to us procedures, tools, devices, doctors, etc. He allowed us the opportunity to see multiple types of procedures. We traveled to other departments and labs. And we sat it on daily workshops for the residents. This was more than an immersion, but a dynamic educational experience. The staff that he introduced us to were also very welcoming. We were able to shadow doctors in the pain clinic, the IR department, and travel to an anesthesiology lab. No question was a stupid question! And in the end, I wanted to stay longer! I hope that next year Dr. Edelman will do this program again and that other students will be fortunate enough to experience what we got to experience.
This program was truly a blessing. I can never thank Dr. Kotche and Susan enough for choosing me to be apart of this wonderful immersion program. The lessons that I learned could not be taught in the classroom. I have so many ideas flowing for my upcoming senior design class and I can’t wait to tell my peers of the opportunity I was awarded.
Martin Strama

Martin Strama

In my opinion, a bioengineer advances human health by producing medical breakthroughs that improve the quality of human life. Originally, I thought that bioengineers need only to balance their knowledge of engineering, human anatomy and the life sciences to produce and maintain systems and equipment used to assist health-care professionals. However, humans are complex, dynamic systems in themselves, and are often omitted from the center of the story when converting medical need into demand.

Being accepted into the UIC Bioengineering Clinical Immersion Program, I will be able to learn from the lives of patients by spending six weeks immersed in the clinical environments at the University of Illinois Medical Center. Therefore, this blog will serve as a detailed account of my experiences within the program in an attempt to document the actual experiences of people as they improvise through their daily lives in a clinical environment. I will begin my immersion at the Ophthalmology department. After three weeks, I will rotate into the Anesthesiology department for the remainder of the program.

Uncharted Territory

posted Jul 9, 2014, 9:11 PM by Unknown user   [ updated Aug 1, 2014, 5:14 PM ]

Observations

To grow and prosper as a bioengineer, I decided to completely get outside of my natural engineering mindset and see the world through the eyes of the patients coming to the Illinois Eye and Ear Infirmary from the very beginning. What I soon came to realize was that solving differential equations seemed to be easier than watching what patients don’t do, and listening to what they don’t say.

After entering the building and taking the elevator to the third floor, I encountered rows of chairs inhabited by patients and medical technicians running about. As I stepped out of the elevator, I soon learned that I was in the wild. The air was stuffy, the lighting was bright, and there was no clear sign to direct patient flow. After turning my head left and right a couple of times to decide where I should go, I noticed that by the ceiling hung a dark sign with white letters that read “Reception.” Approaching the reception area, I noticed numerous documents taped on the sliding panels above the counter. The patients neglected the taped documents and instead went directly to the desk receptionist. I then spotted another sign attached to the far left wall that gave directions to the different services located on this floor. A typical patient with visual problems would not have been able to read such a sign from the elevator area. Above the sign, on the ceiling, hung another sign indicating the service that is provided in this area. Apparently, dark signs with white letters are the basic template in this building. Luckily, the sign read “Cornea,” the service I was looking for. The Cornea Service houses Dr. Joel Sugar, a renowned Cornea specialist who has received numerous of awards including “Best Doctors in America.” Dr. Sugar is to serve as my clinical mentor during my rotation in the Ophthalmology department. After brief introductions and a tour of the department, Dr. Sugar assigned me to the Oculoplastics & Reconstructive Surgery Service under Dr. Pete Setabutr for the morning, and to the Glaucoma Service in the afternoon under Dr. Ketki Soin.

Although I was fortunate enough to observe two completely different services, both have similar patient-centered approaches. Ocuplastics did not have a dedicated waiting room for the patients, and as a result, the patients would stand in the halls and block traffic. Patient check-in and check-out occurred over the same counter, so patients who are checking out have to wait until new patients are done checking in. Furthermore, the counter was dirty, cluttered and contained unnecessary medical equipment such as gloves. Similar observations were seen in Glaucoma with the exception that this service provided a waiting area, or at least chairs that formed rows to resemble a waiting area. In the waiting area hung a muted HDTV that caught the eye of none of the patients. Most of the patients were on their cellphones or tablet devices playing games. There were no accessible outlets for the patients to charge their devices after waiting 1-2 hours to see a doctor. Attached to some of the walls were magazine racks that were untouched by the patients. There was no vibrant colors to brighten the room either.

In the patient rooms, desks were cluttered with unnecessary diagrams/objects, leftover medication bottles/droplets, disorganized paperwork, and bulky equipment. The doctor barely had a place to do paperwork. Meanwhile, cables from the equipment were exposed and scattered all across the floor. Walls were chipped, scratched and dirty. In addition, meaningless screensavers about the new UIC Medical Logo were being displayed to the patient in the background. Furthermore, the windows always had their blinds down and made the patient feel like he/she was in prison. While sitting in the patient chair, the patient keeps to himself/herself as tightly as possible, and holds onto personal items because there is no place to put them besides on the floor next to the chair. The patient chair is relatively close to the doctor’s chair, but additional chairs for family and friends are located far off into the distance. In a sense, the patient was isolated from loved ones and was left to face the doctor by themselves. When explaining a condition to a patient, the doctor uses multiple hand gestures to convey their point across to the patient. The patient usually does not comprehend the doctor until the third iteration. After the patient understands what the doctor has said, the patient is left to wonder in silence with any questions he/she may have because the doctor is filling out paperwork. Non-English patients rely on relatives to adequately translate between the doctor and themselves. During initial measurements, the doctor loads the patient’s medical history over the internet and displays it on the monitor. The software utilized in not coherent and relies on additional programs to open up image files that take time to load. While the doctor is looking for the desired files, silence fills the room. Hence, the information flow and exchange between patient and doctor is insufficient, and varies from service to service.

Soon the clock struck 5 PM, and it was time to regroup with Dr. Sugar. This immersion experience is going to be harder than I thought. Suddenly I am missing equations. However, I did get to review ocular anatomy in vivo using a Slit Lamp! At the end of the day I realized that no matter what patient room I entered, two basic and critical medical instruments were always waiting to be utilized: the Phoropter and Slit Lamp / Biomicroscopy.

Equipment

  1. Phoropter – an instrument that contains various lenses to determine the refraction of the eye during vision testing and prescribe eyeglass lenses. Cons: easy to dislodge from place, manually set -> easy to forget to change lens settings, patient can’t recall previous options when lenses are switched, hard to record lens numbers in dark.
  2. Slit Lamp – a thin sheet of light is illuminated into the eye from a high-intensity light source. Cons: handheld lenses are utilized to examine the retina, huge learning curve, head and chin rest need to be constantly sterilized from patient to patient, pressure sensor stick out to the side. 

Barriers

  1. Floor Layout – The layout of the patient rooms are tight and next to each other, the location and size of the waiting areas vary considerably from service to service, reception desks are detached from service of interest, and their is no clear signals to direct patients sufficiently.
  2. Communication / Information Flow / Patient History
  3. Interior design / décor
  4. Privacy

Connect the Dots

posted Jul 11, 2014, 8:46 PM by Unknown user   [ updated Aug 1, 2014, 5:14 PM ]

Emotional Connections

On Wednesday, I had the privilege to observe Dr. Sugar in Cornea for my morning shift. I knew he was good, but I just didn’t expect him to be flawless. Dr. Sugar approached patients with respect and conversed with them before engaging into business. In essence, Dr. Sugar was inviting patients into his home. At the front door, Dr. Sugar personally greeted the patients, guided them down a narrow corridor, into his room, and seated the patient. The patients did not feel lost or misplaced, but comfortable, relaxed, and human. Then it hit me, Dr. Sugar never forgot that he, himself, is also human. He was modest and humble when patients complemented him and his abilities. He did not let his status define him. Instead, his hospitality and actions made him memorable to his patients. Such qualities create loyal patients coming back to see him, even one who had received a Castroviejo square corneal graft back in the 1950’s, a rare graft that I had got to see first-hand. Just as friends shake hands before saying good-bye, Dr. Sugar walks the patient out of his house after every visit. Not once did a patient leave him without a smile on their face. Dr. Sugar did not learn this behavior from any textbook, but from his personal experiences. Dr. Sugar treats patients, and in turn, the patients teach him. Such a connection is priceless. Initially, I thought I would just be observing Dr. Sugar as he evaluated his patients. I was dead wrong. Dr. Sugar immersed me into the process by allowing me to view patients through the teaching scope of the slit lamp. Furthermore, Dr. Sugar did not tell me what ailment was bestowed on a given patient. Instead, he gave me clues from the observations I saw through the teaching scope and made me put the pieces together. He genuinely wanted me to learn, and I couldn’t have been more grateful. I mean to be in the presence of Dr. Sugar is one thing, but to be personally taught by him is like meeting a celebrity and getting their autograph.

In the afternoon, I was taken in by Dr. Azar in Pediatric Ophthalmology & Adult Service. Dr. Azar exposed me to a world of muscles located around the eye. I learned about various cases that fall under strabismus such as esotropia and exotropia. Like Dr. Sugar, Dr. Azar engaged with the patients before proceeding with examinations and after, and that makes all the difference.

Overall, Wednesday was an amazing day. I got to observe the mental state of patients in a completely different perspective, a perspective based on personal care.

On Thursday, I also got to observe patients in a different perspective, a perspective based on extreme care.

(To be continued… Surgical Connections)

Surgical Connections

posted Jul 13, 2014, 7:23 PM by Unknown user   [ updated Jul 13, 2014, 8:08 PM ]

The operating room, the OR, or the panic room is a daunting place for anyone who has never set foot in the place. As I entered the main OR entrance, I noticed that everyone had hair nets on, foot slippers, and scrubs. It was like being inside an ant hill, except the ants were trained OR personnel. Each person had their own job, was rushing about, and seemed overworked. Before entering the OR, I had to put a mouth mask on for sterilization purposes. I looked great! Entering the OR room, I encountered the main staff: a circulating nurse, an anesthesiologist, and a surgical technician. This trio was prepping the room for the upcoming operation to music played from an iHome docking station. Each person had their own corner workstation in a sense. The room seemed cluttered with equipment and loose, unlabeled cables/tubes. The surgical technician sterilizes the room by placing sterile, blue sheets onto medical equipment and instrument trays. These areas are considered sterile and cannot be touched by unauthorized personnel. The surgical technician told me that everything used in the operation is labeled with a pre-printed label prior to the operation. If a label is missing, the technician must hand-write a label with a marker that can smudge. Also, the technician and nurse must exchange verbal confirmations before exchanging fluids/medication between each other. The technician also mentioned that the chairs utilized by the doctors are uncomfortable. After sterilizing the room, the patient was wheeled in on a stretcher and placed in the center of the room. Upon entry, the patient was exposed to bright lights and a chaotic atmosphere. When positioned in the center of the room, everyone cluttered around the patient. I was beginning to feel claustrophobic for the patient. In addition, the patient was not put to sleep and was able to communicate with the doctors and personnel. The team performed a quick verbal debrief before starting the operation. The patient’s file was placed beneath the patient’s feet on the stretcher. There was no dedicated place for personal items or desk space for paperwork. I observed Dr. Tu, a cornea specialist, perform multiple cataract surgeries and corneal transplants. Observing the beginning, middle, and ending of these surgeries was a great experience. I saw how the donor corneas were packaged, extracted, and modified for the patients. While trying to find weak points in these surgeries, I could not. These surgeries were so elegantly performed and averaged half an hour. I asked Dr. Sugar if he knew of any weak points, or places that can be improved upon. Dr. Sugar told me that there is no standard protocol/procedure for these operations. It was up to the doctor to use whichever technique he pleased. Furthermore, Dr. Sugar told me that the standards for these operations would be changing soon to techniques that are currently used in Europe. Currently, an aspirator and image inverting microscope with two teaching scopes are the two main instruments used by the doctor to perform the surgical procedures. The aspirator contains several functions that sculpt and irrigate the eye during the operation. Dr. Sugar said that the current medical equipment utilized are outdated, but do not constrain the operations in any significant way. New instruments utilize a cloud-like service that allow the doctors to prep for the operation in their offices beforehand. The doctor must be comfortable using two feet pedals at the same time to operate these machines while performing the operation. I got to operate the foot pedal for the inverting microscope, and it was extremely difficult. Dr. Sugar pointed out that most doctors wear only socks to operate the foot pedal because they need the freedom of motion. The skill needed to be comfortable using these foot pedals while operating is unbelievable. Aside, I was astonished to see how steady the doctor’s hands were when performing these operations. In addition, there was no place for the doctor’s hands to rest. Furthermore, the patient’s chest was utilized to hold medical sponges and forceps. Also, folded sheets were used to comfort the patient’s neck. In addition, a holding sac was creating by the side of the patients head to hold the liquid oozing out of the patient’s eye. After the operation, the patient was comforted and taken away into the ant hill. The OR was then turned over for the next patient, and the process repeated. After four operations, I could only image how tired Dr. Tu’s arms were. I definitely enjoyed the thrill and rush of being in the OR.

Furthermore, on Friday I got to shadow Dr. Shorter in Contact Lenses and Dr. Chau in Retina. In Contact Lenses, I learned that the PROSE contact lenses are like a six month long surgery. The patients need to constantly make appointments to come back and refit/reshape their contact lenses for comfort or for more refractive power. In Retina, an indirect ophthalmoscope is used in conjunction with magnifying lens to view the retina. Another machine emits ultrasound wavelengths from a probe onto the patient’s eyelid. This instrument is non-invasive, provides high resolution pictures and videos of the retina. In addition, optical coherence tomography (OCT) is another method used to get the cross-section of the retina to view gross cell layers. Both of these services utilize drops to treat the patients. Patients primarily identify their medication using the cap color of the bottle if they do not recall the name of their medication. Patients are also asked the same questions by the nurse and doctor regarding their medical history. This redundancy allows the patient to extend his/her responses, but may not always be to the doctor. When interviewing the patients, the doctor asks the patient for personal contact information to update their records so that the patient can receive messages from the doctor’s office. The patient could be updating their personal information/medical history while waiting for the doctor in the waiting room instead of sitting idly by doing nothing productive. I underestimated how much a barrier information flow is in a clinical setting.

 

All in all, an awesome, eventful week. I am looking forward to learning more in the coming two weeks!

 

Fire the Laser!

posted Jul 16, 2014, 7:41 PM by Unknown user   [ updated Aug 1, 2014, 5:13 PM ]

I began the week observing doctor/patient encounters and patient testing in more detail. When conducting the basic visual examinations, many of the technicians and doctors had to squint their eyes to read the small numbers on the phoropter. The difficulty of reading the numbers increased when the lighting was dimmed to perform a visual acuity test – a test to determine the smallest letters a patient can read from a standardized chart given a certain distance. The visual acuity tests were performed on electronic monitors or displayed on a wall/door. The electronic monitors are controlled via remote or tablet. When using the remote, many of the doctors selected the wrong option because they could not read the font on the remote in the dark. When using the tablet, the screen would go to sleep due to inactivity and would have to be woken up constantly. At times, the phoropter had to be adjusted several times for a given patient because the patient was leaning forward and not making use of the chair.  Before the patient is positioned into the phoropter or slit lamp, the head/chin rests are sanitized. Some doctors use the paper sheets on the chin rest to sanitize. In addition, only the chin rest of the slit lamp can be adjusted for patient comfort, not the headrest. Adults are usually able to comprehend and follow the doctor’s instructions when positioned into these instruments. In contrast, doctors use visual aids on children to get their attention such as stickers, movies, and hand-held devices. I saw a sticker attached to an indirect ophthalmoscope to help a child focus their attention onto the doctor during a retina examination. After the examinations, the doctor would give verbal instructions to the patient / patient’s parents regarding treatment procedures and medication usage. Some doctors utilized a “Return Appointment Form” that contained the patient’s barcode. On that note, each patient receives a sheet of sticker barcodes in their file. The barcodes are peeled and placed onto various forms that relate to the patient. The barcodes help organize patient data electronically. The electronic cloud service/software contains various tabs that help categorize vital information including chief complaints, illness history, health status, symptoms, and physical examinations. Although the service organizes patient data, the service is limited by human input. Recent tests and examinations on patients were not readily available to doctors because the files were not scanned into the system over the week period.
    I never realized how much physical contact ophthalmologists had with their patients. The doctors have to almost always physically pull their patient’s eyelids apart. The doctors also position their patient’s head into a certain orientation/direction. Furthermore, doctors often have to hold loose lenses in one hand while holding a torch light in another. The doctor would place their fingers on the patient’s forehead to stabilize the lens to a desired position. This also occurred when using loose lenses with the slit lamp.

    Towards the middle of the week I observed several retinal detachment and vitrectomy procedures performed by Dr. Lim. These procedures utilized a more complex aspirator/visual system that powered a laser to patch the retina. The system was color-coded in order to correctly attach various tubes to the machine. In addition, the machine verbally confirmed any modifications performed by the surgical technician. Furthermore, these operations came with their own tray that contained the necessary instruments for the procedure. The tray also included the labels for the instruments and provided the technician with an overview of the required instruments/medication for the operation. Dr. Sugar mentioned that some of the microscopes contain a light source defect that only supply 20% of the light from the source to a head. Ideally, all three of the microscope heads would have full illumination and stereopsis/depth perception in case the doctor required additional help during surgery. In addition, Dr. Dela Cruz demonstrated a laser surgery using a LenSx Laser System. The system was the first femtosecond laser cleared for cataract surgery. Essentially, the doctor creates a template on a monitor, follows a series of steps to modify settings and ensure safety, and clicks a button. The laser makes the desired incisions, and the doctor aspirates the left-overs. The technology is so advanced that the hospital actually loses money when using the machine on most patients (approx. $300 per use of the docking station and $50,000 per contract)! On the bright side, the surgery time is drastically shortened. I love to see bioengineering at work! I just wish it could be more affordable to the general public.

    As a side note, younger doctors seemed to use more newer technologies when performing visual examinations as opposed to senior doctors who preferred the more traditional technologies.

Second Week Down

posted Jul 18, 2014, 2:55 PM by Unknown user

 On Thursday, I had the privilege of observing Dr. Azar in the OR. The OR room was different compared to the other rooms in terms of layout and equipment. Upon entry, one could tell the room was grounded to prevent electric shock hazards. Various cables terminated into the walls from doors and windows around the room. Towards the bottom of the room were green and red outlets. Anything plugged into the red outlets will be powered by a back-up generator in case the power goes out. Thus, the operation would continue and the equipment would still maintain functionality. The OR room had no three-head microscope or a visual monitor to view the procedure. I was a little discouraged by the lack of a visual monitor because I thought I wouldn’t be able to observe the operations in detail. I soon found out that a monitor wasn’t needed because the operations were macroscopic when compared to cornea/retina surgeries. In other words, one didn’t have to utilize a microscope in order to view the extraocular muscles around the eye.  Instead, Dr. Azar and Dr. Namavari utilized magnifying headsets. In addition, fiber optic headlights were utilized in order to increase the intensity of light around the eye; the lighting required varied from operation to operation. The room temperature was manually controlled and was often deceased to temperatures in the fifties. As a result, lots of blankets were wrapped around the patients in order to maintain normal body temperatures. The operations always began by cleaning the eye areas, especially the eyelashes since they carry the most bacteria. After cleaning, the eyes were isolated with transparent sheets from 3M. During the operation, swabs were often utilized to absorb blood from the vessels. Visualization is critical for any operation. Except for the use of the cauterizer, the operations were manually performed by hand. When in use, the cauterizer generated loud noise pulsations. Frequently, chunks of fat/tissue would stay on the forceps and were dislodged manually by hand. The doctors manually twisted suture threads to create square knots. The best part was hearing Dr. Azar sing to the Pandora radio playing on the computer in the background.
    On Friday, I had the opportunity to observe a visual field test. The test can be electronically or manually administered depending on the severity of the condition of the patient. The technician informed me that the manual visual test is administered to patients who need a more thorough examination or who cannot react quickly to the visual cues. In a manual visual field test, a patient uses a buzzer to signal that he/she saw a light at a particular location. The examiner then records the location where the patient had buzzed in. The buzzer is loud, frequent, and annoying. Furthermore, most of the equipment squeak loudly when positioning/moving them.
    Two-thirds done with my rotation in ophthalmology. I have learned so much about anatomy and physiology of the eye. I only have one problem. I might be considering an MD, PhD. Oh. My. Goodness.

A Balancing Act

posted Jul 23, 2014, 6:17 PM by Unknown user   [ updated Aug 1, 2014, 5:12 PM ]

Patients are verbally summoned and guided from the waiting area to a patient room by a technician/resident. During the trip, the technician communicates with the patient on a personal level in order to provide a sense of comfort to the patient. The patient is then guided into an illuminated room. Upon entry, a patient always encounters a chair that is located towards the end of the room. Attached to the chair are the phoropter and slip lamp. These two instruments are relatively large and can be intimidating to children and adults alike. When not in use, these instruments hover to the side and often get in the doctor’s way during visual examinations. The chair also contains a foot pedal that repositions the patient to a comfortable level prior to using the phoropter or slit lamp. The foot pedal is often mistakenly utilized by the patients before sitting down. When the patient takes a seat, they look right and left for a place to put their personal belongings. Often the patients put their personal belongings on the floor, in their lap, on the phoropter arm, or on a chair located on the other side of the room. Furthermore, patients often have to get up and walk over to their personal belongings to get their glasses, medications, or documents. Rising from the patient chair and walking across the room may seem like a trivial task but it can be dangerous given the design of the patient chair. The patient chair contains a foot holder, which many patients forget about when standing up. As a result, many patients seem to “slip” off the foot rest.

The whole introductory process could be streamlined with technology to better manage traffic flow, but would such technology be necessary? For instance, at Panera Bread, a buzzer is given to a customer after placing an order. The patient then finds an available seat in the “waiting area.” Next, the buzzer goes off when the food is ready to be picked up. This type of system can be easily implemented into the hospital setting, but instead of the buzzer going off, the buzzer would indicate to the patient that they are ready to be seen and could direct the patient to their room by displaying a room number. If such a system were to be implemented, personal interaction between patient and technician/doctor would be delayed. As a result, the patient could feel isolated, nervous, or even scared. In contrast, the technician/doctor could utilize the additional time to better acquaint themselves with the patient file to better communicate with the patient.

After the patient is seated, the technician/doctor goes over their medical history. The patient file is either in electronic or paper format. Electronic medical records (EMR) are convenient for accessing a patient’s medical history, but lack flexibility in regards to data/figure entry. In contrast, paper records are convenient for data/figure entry, but lack the ability to view the patient’s entire medical history. Furthermore, both methods take time for the technician/doctor. Usually the technician/doctor asks a patient a question and writes/types the response. During this time, the technician/doctor has their back to the patient and silence fills the room. Instead of waiting until the technician/doctor sees the patient to ask basic questions regarding their medical history, patients should be proactive in the waiting room. Patients could be handed a tablet containing forms/documents that help gather necessary data regarding their personal and medical history. The data could then be instantly linked to the technician/doctor at their office to review before visiting the patient. This would give the technician/doctor an opportunity to personalize patient care beforehand. Furthermore, the technician/doctor could then directly communicate with the patient right off the bat. Patients prefer to see the technician’s/doctor’s eyes instead of their backs. Thus, technicians/doctors could be equipped with tablets to record examination results, etc. while keeping their faces visible to their patients. Since tablets allow the use of a pen, technicians/doctors do not need a keyboard and can “write” their notes directly into electronic format. Again, the question arises whether such technology is needed?

I feel as doctors try to maintain a balance between technology and personal contact with patients. Many of the instruments utilized by ophthalmologists call for patient cooperation and patient contact such as light torches and loose lenses. However, such instruments require manual operation. As a result, the doctor’s hands often get tired. Nevertheless, patients are engaged in their examinations and are not just visitors.

This post was mainly to address the balance between technology and personal care in regards to servicing a patient. My next post will try to be more geared towards observations relating to pathologies/conditions.

Variables

posted Jul 25, 2014, 2:36 PM by Unknown user   [ updated Aug 1, 2014, 5:12 PM ]

In a sense, doctors function as MISO (multiple input, single output) control systems. For a given patient, the doctor must extract vital information and piece the inputs together in order to form a coherent diagnosis. The information can be obtained verbally from a patient, electronically via EMRs, or physically from several different examinations. Patients are not alike, and so, the inputs vary from patient to patient. As a result, the constraints differ from patient to patient too. Furthermore, a trial-and-error process in often taken to refine the diagnosis, similar to a negative feedback loop. The process a doctor undertakes is almost analogous to the process an engineer takes when solving a problem. However, doctors can’t change their inputs while engineers can’t change their constraints.

In addition, disturbances are dispersed throughout the system. One prominent disturbance is scheduling. Typically, the front desk schedules 50 consultations for a given day. However, the doctor can usually handle 35 consultations. Of the 50 scheduled consultations, approximately only 25 actually show up. Doctors have no control over such disturbances. If a patient does not show up, the doctor stands idle. Another prominent disturbance is language. A large portion of the patient clientele is Hispanic and speak Spanish. If the doctor doesn’t speak the patient’s native language, the doctor tries to overcome this disturbance by seeking the help of office employees who do. A translator hotline service is available, but doctors prefer in-person translations. The in-person translations allow the doctor to display hand and facial gestures to the patients while speaking to the translator. Thus, the patient observes the doctor’s gestures while listening to the translator.

Medical instruments/equipment pose another disturbance for doctors. Doctors operate the phoropter and slit lamp in the dark or very dim light. Doctors must read and interpret the data from these instruments in the dark. A majority of the equipment is loose and hand-held. While performing retinoscopy, doctors manually maneuver a light torch horizontally and vertically. In addition, doctors must be familiar with many different instruments that cross different specialties. Children pose another disturbance for doctors. When observing children in pediatrics, a majority of children are uncooperative. To overcome this disturbance, the doctor asks the child’s mom/dad to sit in the chair with them and constrain them. Children get bored easily and have short attention spans. As a result, performing thorough eye examinations is very difficult. In addition, checking a child’s eye pressure is nearly impossible. Children who receive drops become scared of the doctor and environment. In essence, the child becomes emotionally disturbed. In such cases, the disturbances disrupt the system entirely.

Today wraps up my rotation in the Ophthalmology department. I can’t believe it’s already the third week. Time is flying! I learned so much about eye care, anatomy, and the medical instruments currently utilized by the doctors to keep vision alive. This has been a rewarding experience. I am definitely looking forward to my next rotation in Anesthesiology!

Wires and the Concept of Breathing

posted Jul 30, 2014, 6:03 PM by Unknown user   [ updated Aug 8, 2014, 3:59 PM ]

This week I began my exciting adventure in Anesthesiology under Dr. Edelman. When I first met Dr. Edelman, I could immediately tell that he was going to be a great mentor from his Squidward sticker ID badge. Dr. Edelman stated that no individual really knows what anesthesiology is because no one has completely identified the chemical pathways triggered by anesthetics. As a result, there is no standard protocol for anesthesiologists. Instead, there are suggestive studies that indicate ranges of anesthetics for given operations. Thus, each patient receives individualized care based on their medical background. In essence, anesthesiologists are the jack of all trades. There are neural anesthesiologists, cardio, ophtho, etc. Each area requires specialization and has their own constraints regarding anesthetics. Right off the bat I was immersed into two highly specialized neurosurgical procedures: a craniectomy involving the removal of a brain tumor in the pineal body (the center of the head) and a deep brain stimulation (DBS) operation to treat Parkinson’s. In the craniectomy operation, Dr. Edelman explained that the patient was put under local anesthesia as opposed to inhaled anesthesia so that the intraoperative neurophysiological monitoring technician could acquire meaningful invoked signals. These technicians monitor the neural integrity of sensory and motor functions. This is another example of how an anesthesiologist must consider all aspects of a given operation, from the staff to the actual procedure. It definitely feels like the weight of the world is on their shoulders at the beginning of any operation. To make matters worse, the patient was oriented in a sitting position. When under anesthetics, positioning of the patient is a critical consideration. Since the brainstem goes to sleep, a patient loses hemodynamic abilities resulting in lower blood pressure. Thus, a war wages on to keep blood pressure up to normal ranges. In addition, nerves need to be padded and tissues need to be relaxed. All the things sentient humans take for granted are what anesthesiologists need to monitor/regulate.

When a patient enters the OR room, the anesthesiology team springs into action. They attach a pulse oximeter to a finger to monitor oxygen concentration; a blood pressure cuff on the bicep to monitor blood pressure; electrodes on the chest to monitor heart rate (EKG), an endotracheal tube via CCD video endoscope to allow respiratory functions and monitor CO2, and a bispectral index (BIS) strip on the forehead to monitor neural activity (analyzes an EEG and EMG signal and returns a number). The electrodes are oriented across the chest and transversely across the body. The CCD cable serves as a guidewire for the endotracheal tube and is utilized for patients with stiff necks or for patients with spine injuries. The cable is equipped with an oxygen port to blast away barriers and a camera that produces colored video onto a monitor. The anesthesiologist slips the tube onto the cable and tapes the end of the tube onto the cable. The anesthesiologist then proceeds to navigate the cable into the trachea via handheld controller by looking at a monitor. The CCD allows the anesthesiologist to look around corners. Once the cable has reached the desired position, as indicated by the markings on the cable, the anesthesiologist detaches the tube and manually shoves the tube along the cable. The BIS strip is based on an imperfect science where a number between 40-60 is usually accepted as indicating that a patient is under general anesthesia. In more fragile cases, real-time blood pressure monitoring is utilized via IV catheter. Thus, the anesthesiologist does not have to wait for the blood pressure cuff. To insert the IV catheter, the anesthesiologist has to locate a radial artery by palpating the artery. In essence, the anesthesiologist is blindly poking around until blood leaks.

Each sensor is attached via cable to a machine with analyzers for the various physiological parameters. One popular machine located in many of the ORs is the Dragus-Fabius Tiro. In addition, the machine contains ventilators and vaporizers. The monitors on the machine are touch-sensitive. In addition, the machine can be programmed to emit audible alerts for a given physiological variable. Thus, during the operation the anesthesiologist does not have to look at the screen to know which parameter needs attention because the alerts can be customized to emit different sounds. Based on the sound heard, the anesthesiologist knows which parameter needs attention.

Given the amount of physiological parameters an anesthesiologist needs to monitor, one could guess that a lot of cables are involved. Indeed, a labyrinth of cables is formed on the floor. Everyone in the OR needs to watch their step at all times and navigate their way through this complex labyrinth. One would think that these connections would be wireless in this day of age given wi-fi, Bluetooth, or IR technology. I must say, the labyrinth is quite deadly.

 

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Jackpot (Case Studies: Pt. 1)

posted Aug 1, 2014, 7:08 PM by Unknown user

The best part of being in the anesthesiology rotation is that I am not confined to a single department in the OR. Anesthesiologist are everywhere. Thus, I am exposed to many different surgeries, and consequently, many different medical devices! How amazing. This is a jackpot for any bioengineer. As a result, I will be posting many different case studies along with significant medical devices utilized by both anesthesiologists and the surgeons.

Deep Brain Stimulation to treat Parkinson’s

In DBS, the patient was awake and under local anesthetics. The surgeon targeted the subthalamic nucleus with electrodes. These electrodes emit a radio frequency that correlate to the brain activity at their positioned location. Essentially, the radio frequency mimics brain responses and the brain waves are picked up on a monitor. The patient is awake in order for the neurologist to examine the patient during stimulation. The neurologist directs the patients with verbal and physical cues. For example, the neurologist would move the patient’s arm and listen for the electrode response. In addition, the surgeon would increase the current in the electrode to assess the maximum pain threshold the patient can perceive before muscle spasms occur.

Spine Lumbar Laminectomy

In this operation, the anesthesiologists were concerned about the patient’s blood pressure because the patient had a weak heart. The two main medical devices/instruments utilized were an echocardiogram and a pulmonary artery catheter. The echocardiogram is positioned in the esophagus and uses Doppler ultrasound to produce images of the back of the heart. The images allow the anesthesiologist to assess the heart muscle, valves, contractility, pumping capacity, and tissue damage. The pulmonary artery catheter is used to monitor pressures in the heart chambers. To insert the catheter, the anesthesiologist created a central line across the patient’s chest using ultrasound. The anesthesiologist then looks at the EKG to make sure there is no irregular heartbeat as a result of the central line. The central line is then sutured to the patient’s skin for stability. During the operation, anesthesiologists are also concerned with cardiac output and cardiac index parameters. To obtain these parameters, a separate machine performs calculations on the EKG trace to obtain the cardiac output, and another requires the patient’s height and weight in order to obtain the patient’s body surface area, which is required to calculate the cardiac index. Thus, machines do the math for the anesthesiologists, which makes sense since they should be more focused on the patient instead of calculations.

Right Ventriculoperitoneal Shunt

In this procedure, a small hole is drilled into the skull to allow a catheter to pass into a ventricle in the brain. The surgeon used an infrared pen to position and guide the catheter to the ventricle. Another catheter was guided in a similar manner down the neck, chest, and into the belly area. Excess cerebrospinal fluid drains down this catheter network in order to reduce intracranial pressure.

 

Anesthesiologists’ Complaints

During my lunch break in the anesthesiology break room, I engaged with some anesthesiologists to inquire if they experienced any problems with the medical devices. One anesthesiologist enthusiastically wanted all medical devices to be like a car in the sense that one would not have to read a user manual in order to operate the device. In essence, devices should be more intuitive with simple knobs and no icons. Make signals be straight to the point with words. Another anesthesiologist mentioned that placing the various EKG leads onto patients takes too much time. Additionally, the leads are attached to cables that clump together and create a mess.

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Terminator: Rise of the Robots (Case Studies: Pt.2)

posted Aug 6, 2014, 3:44 PM by Martin Strama

Robotic devices are fully functional and operational in the OR. More specifically, the da Vinci robotic system is the dominant robotic platform. Such procedures that utilize the da Vinci Surgical System include laparoscopic cholecystectomies, gastric bypass surgeries and laryngectomies. Robotic platforms offer smaller incisions for major surgeries, more precision, and faster recovery times. In these operations, miniature wristed instruments along with a HD 3D camera are inserted and controlled externally by the surgeon at a console. The surgeon’s hand capabilities are expanded into micromovements of the wristed instruments. Although an incredible step forward, the wristed instruments of the da Vinci Surgical System lack tactile feedback. The incorporation of tactile feedback would allow surgeons to better assess their surroundings inside the patient, increase precision, and minimize errors in severing tissues. To address this issue, haptic technology should be implanted into robotic platforms. In addition, robotic platforms have no indication for which cables are which and where the cables are connected. For such a sophisticated system, there are no indications for malfunctioning equipment, which prolongs the troubleshooting procedures.

 

Anesthesiologists’ Complaints

Patient-controlled analgesia (PCA) infusion pumps allow a patient to self-administer opiates at the click of a button for pain relief. Patients feel empowered and experience immediate results. However, one main problem is monitoring and recording the injections. Most of the time, someone other than the patient administer the pain medication in a situation known as PCA by proxy. PCAs are programmed to reject additional injections requested by patients who are oversedated. However, such safety features are overridden in PCA by proxy. Thus, physicians need to be able to monitor when the injections are occurring as well as who is facilitating such injections. Such information needs to be recorded electronically to EMRs so physicians can have immediate access to such information from their office.

Currently used infusion pumps are bulky, brick-like, and not emergency-friendly. The pumps are stacked on top of each other on a pole and can be easily dislodged from position. The interface for the pumps are difficult to navigate and exhibit delayed response times. Many times, the IV pumps are unplugged and replugged for a quick restart. The drug library for each pump varies for each department. As such, the selection process becomes a hassle and causes delays. Infusions need to be seamlessly integrated into one system to drive IV standardization. Infusion pumps need to be compact, lightweight, and infuse a wide range of fluids. The pumps should include dose rate calculators, convenient drug libraries, and perform titrations of drugs. In addition, the exterior should feature a user-friendly interface with durable buttons. Furthermore, IV injections should be barcoded and scanned directly into EMRs with dosage.

 

Mission Aborted (Case Studies: Pt. 3)

posted Aug 8, 2014, 3:55 PM by Unknown user

During a robotic airway laryngeal tumor operation, the attending anesthesiologist expected the operation to last for several hours and so, front loaded the patient with large doses of anesthetics, which is a common tactic for long operations. The anesthesiologist then proceeded to attach all the various physiological monitoring sensors and then intubated the patient. In this procedure, the endotracheal tube was wrapped with a laser absorbent tape. The tape served to protect the tube from catching fire from a laser that was going to be used during the operation. As an additional safety precaution, a special dye was injected into the tube. If the dye was seen during the operation, the surgeon knows that the tube had been breached by the laser. During intubation, the anesthesiologist had difficulty inserting the tube into the trachea, a red flag. After 20 minutes or so, once everything was prepped and the sterile field was up, the surgeons approached the patient and proceeded to examine the patient’s throat. After examining the throat for less than a minute, they knew the operation was in peril for the tumor had progressed to the back of the throat. The case was cancelled, all the prep work and open instruments had gone to waste. However, a war was then raging between the anesthesiologist and the extubation process. The anesthesiologist had to extubate the patient hours ahead of time after a heavy preload. The anesthesiologist needed to reverse muscle paralysis, relax the muscles and reactivate the respiratory system. The whole crisis could have been adverted if the surgeons just glanced at the throat to begin with. Instead, the patient’s health was at risk, money went down the drain, and valuable time was wasted.

Pain is a highly subjective topic. On a scale of 1 to 10, how much pain are you in? Has your pain decreased or increased overnight? What more can we do for you? These questions are often asked by the pain clinic anesthesiologists who administer various narcotics to patients for pain management. When not administering narcotics from IV pumps, the anesthesiologists treat pain by burning nerves inside a patient. In a lumbar pineal shunt case, after applying anesthetics to the nerves, a needle that emits radiofrequency is guided via ultrasound to the area. Ultrasound is utilized instead of X-rays because X-rays can’t show depth. However, while ultrasound can show depth, it cannot show detailed anatomic structures. For example, a rib is a rib, but which rib is it? An experienced anesthesiologist who is familiar with the ultrasound can navigate such difficult paths. In addition, the anesthesiologist does not have binocular vision and can’t look at the ultrasound monitor while guiding the needle at the same time. Instead, the anesthesiologist relies on tactile feedback while looking at the monitor. Furthermore, the anesthesiologist cannot modify the ultrasound machine by himself/herself when inserting the needle. Once positioned properly, the needle emits radiofrequency to burn the sensory nerves. During this process, the patient experiences painful heating sensations. In addition, the pain relief generally lasts from 3 months to a year.

Carry On My Wayward Son

posted Aug 15, 2014, 6:26 PM by Unknown user

Ophthalmology
    My time in the ophthalmology department has been a rewarding and constant learning experience. I am truly grateful to all the doctors who took the time to incorporate us bioengineers into their challenging daily routines. Being able to rotate into different specialties within the department allowed me to gain a deeper appreciation for the wide range of medical devices utilized to examine and treat vision deficiencies. The clinical setting allowed me to understand how doctors and patients perceive different medical devices to address the various needs. Not all medical equipment is new and state-of-the-art, and as a result, doctors and patients must function as a team. To persevere past these obstacles, a balance needs to be established between device usage and patient service. I envision to design medical devices that strengthen such a delicate balance. One approach would be to research Possible design projects include advancing keratoprostheses, advancing multifocal and accommodative intraocular lenses, and developing smart contact lenses that monitor physiological properties such as blood sugar and intraocular pressure. As biomedical imaging and optical technology advance, ophthalmologists will be better equipped to treat patients in a more effective and accurate manner. As an aspiring bioengineer, I plan to be apart of that mission.
Anesthesiology

My experience in the anesthesiology department has been nothing less than spectacular. Everyday we were faced with new opportunities for advancement. Before my rotation in anesthesiology, I believed that anesthesiologists only had to view a monitor and inject medication into a patient at various stages during a procedure. How wrong I was to imagine such a simple and calm environment for anesthesiologists. These specialists are essentially engineers in the sense that they must analyze various inputs and constraints in order to determine the most optimal treatment for their patients in real-time. In addition, they must be proficient in comprehending and utilizing a wide array of sophisticated medical devices in chaotic and congested environments. Current technological advancements aim to reduce the risk an anesthesiologist experiences during surgery, but fail to integrate seamlessly into existing procedures and work areas. As a result, anesthesiologists require additional training, and are forced to love the addition of cables and tubes. This immersion helped me understand that physicians need to be able to do more with less. I envision to design medical devices that are multi-dimensional in terms of functionality and efficiency. Possible design projects include wireless telemetry systems that integrate various physiological sensors and communicate the data to external peripheral devices, as well as a syringe auto-injector for constant pressure IV injections.

Thank you Dr. Sugar, Dr. Edelman, the Ophthalmology department, the Anesthesiology department, and last but definitely not least, Dr. Kotche and Professor Sterling, all of which have made this immersion experience a once in a lifetime opportunity that I won’t soon forget!

Justin Thomas
Justin Thomas

 

July 7th, 2014

posted Jul 13, 2014, 9:50 PM by Unknown user   [ updated Jul 26, 2014, 7:28 PM ]

It was the first day of the clinical immersion program, and I was a little nervous but mostly excited. I’ve never been to an orthopaedic department, so I had no idea what to expect. For our first day, Ryan and I were sent to the orthopaedic clinic at the outpatient care center. We walked in to the waiting room and saw a lot of people. Some were waiting in line at the front desk, and others were sitting down. We were told to meet Dr. Chmell, so the front desk clerk guided us to a room called the “Attending Office.” There we saw many people with white lab coats. They all looked busy. A few of them were on computers looking at X-ray images or filling out paperwork. There were others walking around while reading papers. Finally, we found Dr. Chmell with residents and medical students all around him presenting their patients to him. Dr. Chmell was happy to see us and greeted us. He seemed like a very kind person. He honestly didn’t know what he was supposed to do with us, but he did his best to keep us entertained. Since he knew we were engineering students, he thought it would be interesting for us to check out a new knee brace that a patient was receiving. The knee brace that the patient received was an Ossur Innovator DLX which was a post-operative knee brace to help rehabilitate the knee. The doctor sets an angle that the patient can bend his or her leg, so the knee can improve. Ryan and I helped put the knee brace on the patient. During our first day, we also observed a knee tap. This is basically removing fluid from the knee for testing. Ryan and I then walked around the clinic. We noticed a few hand sanitizer dispensers in the hallways right outside patient rooms. The attending office was in the center of the clinic with doors on both sides of the room. This allowed doctors to quickly move around the clinic to see patients in either hallway. The patient rooms were like ordinary patient rooms we see at any clinic. There is a bed, a few chairs for the patient, a computer for the physician, cabinets filled with medical supplies, a garbage bin for the paper used on the beds, a red bio-hazard bin, a regular garbage bin, and a bin for used injection needles located on the wall. Something that was interesting was that there were green and red flags outside of each patient room. A single green flag meant there is a new patient that needs to be seen. A green and red flag meant that the patient is currently being seen by a doctor. A single red flag meant that the patient needs further assistance such as having a knee brace put on. When the flags are crossed, it means that the patient needs paperwork filled out. When there are no flags, the room is being unused. Our first day at the clinic was a little scary because we were not familiar with the place and how things were done, but we definitely enjoyed our time there.

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July 8th, 2014

posted Jul 13, 2014, 9:54 PM by Unknown user   [ updated Jul 20, 2014, 5:20 PM ]

Today was an exciting day for me because it was going to be my first time watching a live surgery. I’ve been to an operating room before, but I never seen the environment when a surgery or operation was going on. Ryan and I went to the Main OR on the third floor, and had to change into scrubs. We had to pick up the scrubs at a scrub vending machine. After changing into the scrubs, we put on hair nets and shoe covers. This was all needed to prevent the spread of germs. We then headed to OR 3 where we met a medical student who gave us instructions. Since an x-ray was being used during the operation, we had to wear a lead apron and collar. We also had to put on a surgical face mask. Now we were ready to enter the OR. As soon as we stepped into the room, we saw a lot of people in the room. The anesthesiologist was at her machine teaching a student how it works. There were people in red hats, and they were the specialists for the tools used. One of them was a vendor from Stryker, and he gave advice to the surgeon throughout the operation. There was a scrub nurse handing the surgical tools to the surgeon. There was also a circulating nurse who made sure the operation follows hospital policy and safety guidelines. There were also a few residents and medical students watching the surgeon’s every move. The patient that was being operated on was an elderly women who fractured her hip, so the plan was to put a rod down her leg and use screws to secure it. The surgeon used the Stryker Gamma3 IM Nailing System. The surgeon used a drill to put the rod down the patient’s leg. He had to be precise when placing the rod, so he took x-ray images of the leg every time he moved the rod. When he finally placed it at the location he wanted, he then used a tool that helped the surgeon guide the screws into the leg. When it was ready to close the patient, the surgeon used a technique what i believe is called the buried suture. This is a type of suture where the surgeon only sews inside the walls of the incision without ever sewing above the skin. It results with no suturing scars and no need to take out the suture because it would dissolve in the body with some time. After the operation, the patient is woken up and brought to the post-op room. Then, a few people come in to clean up the room. We then went to another OR to watch another operation. There were less people in this room because there wasn’t residents and medical students observing. The surgery that was being performed was an arthroscopic shoulder surgery. The surgeon made two holes on the shoulder and placed a trocar for each hole. The trocar is used to keep the hole open while the surgeon inserts tools inside the hole. The surgeon inserted an arthroscope into one hole and a shaver into the other. An arthroscope is a camera with a light source used to view the joints. There is also a lumen so salt water or saline solution can flow into the arm. The shaver is used to clear up tissue. The surgeon made several holes to place the tools at different locations on the arm. Then, the tools were removed and the holes were closed. Throughout the second surgery, Ryan and I were extremely tired of standing for so long. I don’t understand how the surgeons can do this when there are surgeries back to back. Also, the room was very cold.

July 10, 2014

posted Jul 20, 2014, 5:35 PM by Unknown user   [ updated Jul 20, 2014, 7:19 PM ]

Today was another day at the OR. The first surgery we watched was a total knee replacement. The surgeons were wearing a big suit that covered there entire body. It looked like a space suit. The suits were needed to protect the surgeons from bone and tissue fragments. We arrived in the middle of the surgery, so it was a little confusing what was going on. I saw a metal cap on top of the knee, and the surgeons were using a sagittal saw to cut the bone. After cutting, they removed the metal cap. Then there was a plastic object that they kept inserting into the knee. I think they were trying to make sure the plastic object fits nicely in the knee. It seemed like the plastic piece wasn’t fitting nicely, so they continued to use the sagittal saw. Once the adjustments were made, the surgeon made a white cement by mixing a liquid and a powder together. The cement had a very strong smell. They then put the cement on the knee and hammered the prosthesis to the knee. There was a vendor from Orthalign named John. He took us outside to explain the device that was being used in the surgery before me and Ryan came. It was a device used to make sure the surgeons were correctly placing the prosthesis. The device works by using an accelerometer. There was also a LCD on the device that gave the surgeon simple instructions on what to do. The device was only used for the first part of the surgery because the surgeon wanted to use his way for the second part. Next, Ryan and I watched a total hip replacement. This time we couldn’t see anything except a huge hole, so the experience was not that great. We tried getting a better view, but we didn’t have any luck. The surgery was over two hours, so we were really tired of standing for so long.

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July 16, 2014

posted Jul 20, 2014, 8:45 PM by Unknown user   [ updated Jul 20, 2014, 9:39 PM ]

So far this week, we haven’t been to the OR. On Monday, we were at the clinic, and saw a lot of patients. When a doctor sees a green flag, they go to the patient’s door and pulls out the patient’s papers from the door. The papers tell the doctor the patient’s history and the reason for their visit. Before entering the room, the doctor puts the red flag up so that both green and red flags are up. When the doctor enters the room, they greet the patient and sit close to the patient. They try to get the patient comfortable before actually evaluating them. When a doctor sees a patient with hand pain, I noticed the doctors use the same tests to evaluate the hand. They tell the patient to squeeze their hand to test the patients strength. They also touch the tip of the patients fingers to see if the patient has any tingling sensation. They then tell the patient to spread their fingers and try to resist when the doctor tries to squeeze them together. They also tell the patient to bend their hand forward and backward to see the joints mobility. If the patients never had surgery before and their problem isn’t too bad, then the doctor would advise physical therapy. If the patient has severe pain, then they would give the patient an injection of steroids. The injection is performed first by applying iodine and alcohol pad. Then they inject the needle. Patients have a lot of pain when they get the injection, so the doctors sometimes apply a spray while giving the injection. The spray is supposed to ease the pain. If the injections and physical therapy don’t work then the doctor advises surgery. Another thing I noticed is that the doctors didn’t really use many tools. One tool they use is a goniometer, and it is used to measure angles such as the angle when someone bends their hands. Another device they use is an x-ray which is really important when evaluating a patient. We also saw patients who needed their cast removed. Normally people who work at the cast room would remove the cast, but when we were there the medical students wanted to remove the cast. They used a cast remover to remove the cast. The device has an oscillating blade that only cuts through hard material. It can’t cut through skin because the skin moves with the oscillating blade. A hard object like the cast doesn’t move with the blade, so the blade can cut through it. The clinic at the UIC medical center is usually busy, and the doctors don’t really have a break. The clinic downtown is totally different. It is more like an office environment with a great view of Millennium park. The layout of the clinic was different too. The doctor’s office was far away from the patient’s room. The center of the clinic was the x-ray machine and the cast room. I think the clinic was designed this way because there is not a lot of patients at the clinic at one time, so the doctors don;t really need to rush over to the patients. The downtown clinic also had flags, but they weren’t used often. I also think it’s because there is not a lot of patients to see at one time. I noticed there wasn’t any hand sanitizer dispensers anywhere. There was only one anti-septic container in the hallway. They were also in every patient room. One thing that was interesting was that there was a room that was latex free. I don’t think there was a room like this at the UIC medical center. The patients were also different. All of the patients downtown were all Caucasian and seemed pretty wealthy. They also took care of themselves, so there cases weren’t that serious. The UIC medical center had a lot of minorities and poorer people. They did not really take care of themselves and were normally overweight. I think it was great going to the clinic downtown because we can compare the two clinics.

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July 17, 2014

posted Jul 21, 2014, 5:21 AM by Unknown user   [ updated Aug 10, 2014, 1:34 PM ]

Today was another day at the OR. This time we were able to watch a total knee replacement from start to end. This made it much easier to understand what was going on. The first thing that happened when the patient entered the OR was putting the patient to sleep. This job was done by the anesthesiologist. Then the patient had a urinary catheter inserted. The patient was also hooked up to a Zimmer automatic tourniquet machine. The tourniquet is important because it controls bleeding. Then, the surgeons applied iodine and alcohol pad all over the patients leg to get rid of any bacteria on the surface of the skin. Then, the patient’s whole body except one of his or her leg was covered by blue sterile drapes. This was done to prevent the spread of infection. If a surgeon touches skin that isn’t properly cleaned and then touches the surgical area, then bacteria can go inside the patient and cause infection. The drapes also prevents the patient from getting blood all over their body. Next, a bandage was tightly wounded around the leg and then removed to decrease blood flow. Then they put an orange film over to prevent bacteria to go into the body. I also noticed that a DVT pump was used. It was cool seeing the DVT pumps in surgery because I was familiar with them. I had to repair them a lot at Northwestern. The surgeons and scrub nurse go outside the OR and properly wash their hands. Then they return wearing a helmet called the Stryker T5. The helmet is light and has a fan at the back for airflow. Then they put on their “spacesuits” and layers of gloves with the assistance of the scrub nurse and the circulating nurse. Once it was time to make an incision, the circulating nurse called timeout and stated the patient’s name, age, operation, and any allergies. The first thing the surgeons did was cut through the skin until they reached the kneecap using a scalpel. They also used retractors to keep the surgical wound open, and they also used suction to get rid of any fluid. Then a tool was placed on the joint of the femur. It was secured on the joint by having pins hammered into it. There are slots in the tool, so a sagittal saw can be used to shave off bone. Next, the Orthalign system was being used. The system was placed over the shin, and pins were used again to keep the device in place. The surgeon followed the instructions on the screen of the device. This allowed precise tibial resection. The orthalign system was then removed and put aside. Another device was placed over the joint of the femur. It also had slots, so that a sagittal saw can be used to shave off bone. The joint was sculpted, so that the prosthesis would fit. There were test prosthesis, so that the surgeon can keep checking if the final prosthesis will fit nicely. Once the sculpting was done, the surgeon made cement and applied it to the joint. Then the prosthesis was hammered into the patient. Now the surgeon was ready to close up the knee.

Justin Thomas Blog

July 23 2014

posted Jul 27, 2014, 6:09 PM by Unknown user

The past few days, Ryan and I were at the UIC clinic and the downtown clinic. At the UIC clinic, I sparked a conversation with Dr. Schmell and the other residents about their opinion on Orthalign. They were saying that the system is very precise, but there wasn’t any proven fact that patients do better. They were talking about a study on Orthalign and that the patients who had the Orthalign system used on them actually had a worse recovery than patients who didn’t use Orthalign. The reason is because there isn’t a good ligament balance when using Orthalign. Another problem with the device is that it causes the operation to be longer. I noticed that orthopaedic surgeons like things quick and easy, so the device increasing the time of the operation is not great. However, Dr. Schmell said that the device does work in getting the correct angle or tibial resection. Dr. Schmell doesn’t use the device at all during surgery, but Dr. Gonzalez uses it for the tibial resection. I asked Dr. Gonzalez for his opinion on Orthalign, and he said the same thing. It is good for tibial resection and that is why he uses it. He said he would like to use the device for the second part of the surgery, but the device isn’t effective then. I found this orthalign issue interesting. At the UIC clinic, we saw patient and physician conflict for the first time. One issue was that a patient was behaving immaturely and made the doctors feel uncomfortable and think their lives were in danger. The patient’s behavior led her to be kicked out of the spine clinic. Dr. Gonzalez talked to the patient and told her that their are rules in the clinic and the patient’s behavior was unacceptable for the clinic and in general. Since he knew the patient for a while, he did not throw her out from the orthopaedic clinic. Later that day, there was another patient-physician conflict. A patient was very mad that she could not have surgery. Dr. Gonzalez kept telling her that there is an increase risk of infection and blood cots if the patient had the surgery done because she was overweight. The patient could not let this go and things escalated. The two kept yelling at each other until Dr. Gonzalez couldn’t take it anymore and called security to kick her out the clinic. I’ve never seen patients and doctors getting into serious conflicts to the point that a patient is banished from the clinic. I never knew a patient could even be banished. I noticed that all of the residents and medical students talked about what happened in a low voice when Dr. Gonzalez wasn’t around, but they didn’t mention the situation when he was around. This was a very strange experience for me.

July 24, 2014

posted Jul 27, 2014, 6:29 PM by Unknown user

Today was the last day going to the OR for the orthopaedic department. It was a great day because there were a lot of surgeries scheduled today. One surgery in particular was very interesting. It was a total knee revision. The patient’s knee replacement became infected, so she needed a new prosthesis. From the start, the surgery was a complicating surgery, but there were more complications during the surgery. One major complication was when the test for the femoral component wasn’t working properly. Dr. Gonzalez tried to attach a piece to the test device, but the device was so worn out from being used multiple times that he wasn’t able to properly attach the piece. This made him furious because he was spending a lot of time trying to fix the test device and also the implant may not fit correctly. Since he wasn’t able to properly screw the piece to the test device, he just put them together without screwing them together and placed it into the knee. He then continued the surgery. One thing that was interesting was that the surgeons and the scrub nurse had to wear special gloves since the patient had HIV and hepatitis C. The gloves were to protect the surgeons and scrub nurse from getting infected. I thought this was interesting because they are already wearing layers of gloves, so I wondered how also wearing this special glove can make such an impact. I then remembered my gloves breaking many times when I worked at Northwestern. I also looked up why layers of gloves are needed, and it is because there is a a lot of defects in gloves.

July 30, 2014

posted Aug 3, 2014, 10:48 PM by Unknown user   [ updated Aug 8, 2014, 12:01 PM ]

The first few days with the transplant department were spent at the ICU. During the morning, the residents and medical students present the patients to Dr. Ivo Tsvetnov. The reason they do this is to make sure everyone is up to date with the patient, and so that everyone can discuss on what further actions can be done for the patient. One of the residents said they do this, so that they can figure out how to discharge the patients as fast as possible. The presentations or rounds take a few hours. I noticed most of the doctors talked in a low voice. I think they do this so that the patients can’t hear what the doctors are saying about them. Since the doctors are discussing and making speculations, they probably don’t want to scare the patients. However, it still seems uncomfortable for the patient because a group of residents, medical students, and pharmacists stand outside their room and talk about them. The patients look scared and curious of what the physicians are talking about. What I liked about the ICU was that there were a lot of medical devices. For example, there is a few Braun infusion pumps, a DVT pump, a GE patient monitor, urinary catheter, urine drainage bag, a glucose testing machine called the ACCU CHEK Inform II, an endotracheal tube, a ventilator, and many more. The ventilator was very interesting because the machine has many modes when assisting a patient. The ventilator can have full control and breathe for the patient. The machine basically pushes in air to the lungs. The volume and pressure can be adjusted by the physician. The person who sets up the ventilator is the respiratory therapist. We’ve also went to the Interventional Radiology (IR) room where minimally invasive procedures were done. The procedure that Haroon and I observed was the placement of a central line. The setting of the room where the procedure was performed was similar to an OR. Everything in the room was sterile. The patient was properly cleaned with iodine and had drapes over their bodies. The radiologist who performs the procedure also wears gloves and surgical aprons, but they also wear lead glasses, lead apron, and lead cuffs. The radiologist also used an ultrasound to see where to place the central line, and they also used an x-ray to see where the central line, which was coated with radiopaque, was when it was inside the patient. I’ve never heard of an IR so this was an interesting experience for me.

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August 1, 2014

posted Aug 3, 2014, 10:58 PM by Unknown user   [ updated Aug 19, 2014, 9:33 AM ]

Haroon and I went to the OR on Thursday and Friday. I saw a vendor from Applied Medical that I met a couple weeks before, and he asked us if we wanted to see his new trocars in action. We agreed and watched a hysterectomy. The surgery was interesting because the surgeon used a minimally invasive method to remove a whole organ (the uterus). The surgeon made a few holes over the patients stomach and pushed the trocars through the skin. What was special about these trocars is that they have a camera at the tip, so the surgeon can safely insert the trocar through the patients body without damaging any organs. Also, the trocar has a balloon, so the trocar doesn’t move around. The trocar is important for minimally invasive surgery because it keeps the surgical hole open, and it allows surgeons to put tools inside the patient. The procedure took a while because the surgeon was carefully cutting away tissue with an Ethicon laproscopic tool. The tool was similar to a cauterizer but it’s end looked like scissors. I was thinking that laproscopic surgery is great because it’s minimally invasive and there is a less chance of developing infection, but it causes surgeries to take much longer.

 

In the transplant department, there are a lot of surgeries related to the fistula. When Haroon and I were at the Transplant clinic, we saw many patients that had a fistula. A fistula is a substitute for a catheter for dialysis patients. Catheters are not great because they increase the chance of infection, so fistula’s are recommended. The fistula is a pathway created by a surgeon. A fistula is needed because dialysis takes blood out of the body at a fast rate which causes veins to collapse. Thus, the fistula prevents the vein from collapsing. However, when the fistula does not work, then a graft is used. Haroon and I saw a procedure done in the OR, that inserted a HeRO graft into a patient. This was done by making an incision at the left shoulder and above the elbow. The graft is then tunneled through the skin using a device shaped like a hook.

 

Justin Thomas Blog

August 6, 2014

posted Aug 9, 2014, 9:39 PM by Unknown user

The past few days have been very slow. There were no procedures at the OR, so Haroon and I were at the ICU and transplant clinic. We attended rounds in the morning as usual. Then we walked around the ICU, and observed the staff. There wasn’t really anything interesting going on. The residents and medical students were taking notes and talking on the phone. They also just sat there and talked to each other about their days. Every now and then they would check up on their patients. Most of the cases there were also not interesting. They were mostly patients recovering from surgery. While walking around the ICU, I noticed a device that I wasn’t familiar with, so I asked Dr. Tzvetanov what it does. The device was an Edwards Lifesciences Vigileo monitor. He explained that the device gives hemodynamic information to doctors. There is a catheter placed into a patient’s artery, and then the device can display the volume of blood and oxygen saturation. Dr. Tzetanov was telling us that engineers build these deices, so that doctors can obtain more information about their patient and try to figure out what is wrong with their patient. He then told us that creating infusion pumps with pressure sensors have helped medicine. He said that doctors had to do calculations when using IV, so making a better infusion pump has made their lives easier. He then talked about how machines can be wrong, so a doctor needs to understand machines to verify if what is being displayed by the machine makes sense.

Justin Thomas Blog

The patient that was hooked up to the Vigileo monitor was having many health problems after his surgery. He was continuously bleeding, and the doctors could not stop the bleeding. The patient was in need of blood, so the nurses got blood for him. However, the patient’s name tag was not on the blood, so the nurse refused to give him blood until she was sure it was okay to give the patient the blood. The resident in charge was very calm about the situation, but the nurse was not calm. She did not want to give the patient blood because she was scared of losing her nursing license. Once the blood was verified, the nurse gave the blood to the patient.

August 7, 2014

posted Aug 10, 2014, 2:27 PM by Unknown user   [ updated Aug 19, 2014, 9:31 AM ]

Today, Haroon and I were finally at the OR. The first procedure was the removal of both kidneys. The kidneys were very large and looked deformed. After removing the kidneys, they were placed on a table. It was a profound scene. We then watched a fistula creation. It was a simple surgery where the surgeon made an incision by the brachial artery. They then use a cauterizer to continue cutting through the skin and stop small bleeders. The surgeon then used a retractor to keep the surgical hole open. The surgeon then cuts the cephalic vein and attaches it to the brachial artery with sutures. I noticed the surgeon had trouble keeping the surgical hole open with just one retractor, so he added another retractor that crossed the first retractor. It seemed like the surgeon had difficulty placing the two retractors, but he eventually got it. After attaching the vein to the artery, the surgeon closed up the patient.

 

 

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The next procedure I observed was a kidney transplant. The surgeon made an incision at the lower right side of the patient. She then used a big device called an omni retractor to keep the surgical hole open. The surgeon seemed like she was having difficulty setting up the omni retractor. She then made some incisions inside the patient, and then attached the new kidney to the patient.

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August 14, 2014

posted Aug 19, 2014, 10:02 AM by Unknown user

The last week of this rotation was spent at the ICU and the OR. There was nothing new this week at the ICU. I attended rounds, walked around the patient rooms, and talked to the doctors. The OR, on the other hand, was very interesting. I was able to finally see the Da Vinci in action. There were two procedures going on for a patient. The first procedure was a nephrectomy. The patient was donating her kidney to her mom. The Da Vinci has three main components: the surgical console, the actual robotic arms, and the monitors. During the surgery, the attending is at the surgical console. The surgeon looks into a screen and has controllers to control the robotic arms. The surgeon also has a mic, so he can talk to the other doctors and assistants. The robotic arms are over the patient and they are very big. The residents attached tools on each arm. It is very easy to put tools on and off each arm. Since the robot was really big, there was little room for the residents to help out. There were three monitors around the patient, so that the doctors and assistants can see what is going on.
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I have really enjoyed the bioengineering clinical immersion. From my first day at the Orthopaedics department to the Transplant department, I have learned a lot about what kind of devices are needed in each environment. This experience also allowed me to learn about what current medical devices are being used and what flaws there are. I am glad that I was able to partake in this internship because now I have some future projects I want to work on.

Victoria Way
Victoria Way

 

Week 1-7/13

The later half of the week began with OR. I was able to observe several cornea transplants from donor tissue. What stood out to me as most interesting was donor cornea tissue is only viable for 2 weeks after it is retrieved. Even though this appears to be a restriction, donor corneas exceed the patient need for transplants. My first thoughts into entering the OR were more lighting could be installed, A Dr. complained about the chairs not always working properly while they are in the middle of a surgery and not staying in place. The microscope used during surgery had two teaching scopes attached for residents and fellows. Attached to the microscope is a foot pedal, where the Dr. often removes his shoe to control the movement of the microscope. During an operation the Dr. voiced that the microscope would “flinch” once in a while, minimally affecting vision, but affecting it none the less. In the OR, blue sterile papers are laid over any environment which is sterile and not to be touched by anyone who did not scrub in. Music is played in the room. My assumptions for this is for the patients, because they are awake during these procedures. Patients are calmed with a mild sedative. For each procedure performed they have designated sterile trays containing all the necessary instruments to perform the surgery. Once the patient is ready for the cornea tissue to be stitched in, the doctor or fellow will cut around the cornea with a device that has sizable tips to correlate with the size of the patients eye, it is used every time and is very effective. I also notice they have a “drainage bag” on the side of the patients head. Everything is labeled in the OR, from air to water. One of the nurses mentioned that often times it will smudge (They hand write it) my thought for this is to already have multiple labels printed for ease, or introduction a small printer into the OR where they can quickly obtain labels. In making the patient comfortable they roll a sheet and place it under the patients neck, my thoughts are that a long thin pillow would be useful and more comfortable, especially for longer procedures. a workaround- the Anesthesiologist cut the O2 tubing that was going into the patients nose because it didn’t fit properly, once she did that the patient was able consume more oxygen and the procedure could begin. The equipment used was very intimidating, I assumed it was the most advanced but then found out there is already a newer model out, but isn’t an urgent necessity. The most interesting tool is the machine they use to get the eye ready for a transplant, it sculpts, polishes, vacuums etc while providing irrigation to the eye. It was beneficial to observe the equipment being used in the OR and how everyone worked together as an organized team. The last day of the week involved observing doctors with patients. An interesting thing I enjoyed was the Dr.used a specific dye that turns green in the eye to show epithelial deformities. A doctor from another country was also observing, he explained that america is one of the only countries to use the 20/20 vision system, most everyone else uses the 6/6. In speaking with a Dr, I learned that cornea transplants have a low rejection rate when the patients continually uses steroids. This is often due to abrasions or infections occurring. I observed a patient who had an infection and waited a very long time to come see the doctor, they then proceeded to heat a metal rod under a small burner in the patient room and scrape along the eye to begin a culture. The patient appeared to be very unsure of their process. What I found interesting was they actually have a fridge filled with corneas for teaching. One patient found it to be awkward to have us there observing, which in turn made me feel a little uncomfortable. One of the machines i observed was an ultra sound for the eye, it was a small probe that could view the fluid (sub-retina fluid) in the eye at a high resolution. Some doctors will use the ophthalmic scope on their head vs. the one attached to the patient chair and will use handheld lenses that provide extra magnification because you need a certain length between the light and magnification which can be controlled by the doctor. Overall it was an intense week, but very incredible.

Week 1-7/9

At first arriving to the ophthalmology clinic, there were patients everywhere, long lines of them. Most were unsure of where to check in for their appointment, There were many signs up, but at first glance they appear very cluttered, some could have been enlarged for better visibility. There is a distinct room in the cornea department with several instruments for measuring and documenting various attributes of the eye. To continue with my time in the cornea department, the exam rooms were compact four rooms in a small hallway, it seems optimal for doctors to quickly move to new patients, however when there are multiple people assisting the doctor it can feel very cramped. In each exam room there is a large piece of equipment containing scopes for doctors to view the patients eyes using the slit lamp. In most rooms there was a ‘teaching scope’ attached, which was extremely helpful in observing what the doctor is looking at. It would be beneficial to have them implemented into all of the exam rooms. Some general observations – doctors were incredibly diligent with cleanliness, as expected. Residents, students, and fellows also did the same. Majority of patients I observed were very friendly and open to allowing me to observe the Dr. examine them and watch how he uses various tools. In the exam rooms, patients and optometrists seems to have limited leg room when the doctor closely examines them with the scope because of the device placements on the patients, no one seemed to be bothered but it could have been improved. One of the most interesting devices was the field of vision. As the technician physically marked where the patient could view the light (they buzzed when it appeared in their field), my first thought is, instead of the technician having to stop every time the patient buzzes, a device could be implemented onto the equipment to mark the sheet simultaneously while the patient indicates light in their vision. In taking in more basics about the office setting, each room contained a desk close to the patients chair for easy examining and additional chairs for family, etc. After many patients I observed a minor surgery where all that was required were tweezers and forced to remove a cyst on the eyelid. This may be considered a work around, a patient could not understand English so the doctor then learned the terms for “up” “down” “left” and “right” from a family member in Spanish so she could examine the patient with ease. One of my favorite things was observing the contact lenses department. In this department, I was most familiar with the terminology. Having taken cell and tissue engineering classes, we learned a lot about the “kpro” created by UIC. I observed many patients with this sutured onto their lens. following that, they would be fitted with either soft or hard lenses, or even hybrids which contained hard lenses in the center followed by different skirt lengths of soft lenses. In this department patients seemed most relaxed. One thing i would change about the equipment is that most rooms now have a tv screen where doctors can put various letter sizes up on the screen for patients to read, not all rooms possessed this however. some had boards, or projectors, it would be beneficial to upgrade them all. Also, patient files are scanned into the computer instead of directly entered. this could be upgraded, but in speaking to the department head this would cost around 500 million to update the entire hospital and health systems to an online system, such as Epic. Another great instrument I observed in action was an infra red laser which vaporized unwanted tissue. I also got to use it on a kleenex box. An interesting case I enjoyed was someone who had a stem cell transplant in his cornea, improving his vision to 20/15. Overall, the doctors were very informative and welcoming, they even provided me with a list of permeable membrane materials used for lenses which helped put the process into perspective, since proper oxygen flow is crucial.

Week 2-7/16

During the beginning of this week I shadowed a Dr. in the contact lenses department. I observed several patients with large gas permeable lenses – large, hard, and rigid. One thing that stood out to me was the cost of the prosthetic, $2,000 per eye! However, the Dr. always personalizes a letter to the insurance company to help pay for the cost so the patient can have the best lens possible to improve their vision. An interesting conversation I got to be a part of involved limbal stem cells. They are trying to be able to induce the natural production of them around the cornea to aid in vision repair. An apparatus I found intriguing was another way they check a patients prescription. They have a large draw filled with a huge amount of interchangeable lenses they can pop in and out of what appeared to be a set of large bulky glasses. With this, patients were able to walk around and become comfortable in what would be their new prescription. I found the rooms to be more spacious than the previous cornea department. The equipment was the same as described before in each room, although they did not have a teaching scope which would have been very beneficial. Following contact lenses, I spent the next day in the OR. I observed several vitrectomys which cleaned up scarring, and cleaned the aqueous and vitreous membranes. Through out this procedure I gained a better understanding of the anatomy of the eye. I saw the membrane of the eye being peeled to improve vision and the repair of a torn retina. What stood out the most was the advanced tools being implemented. A machine called “constellation vision system” supported majority of the tools required for the procedure. It had color coded tools for the cutter, laser, polisher, etc. Anytime the doctor asked for a setting to be changed on the machine, the system would verbally confirm the change, reducing room for error. Before each surgery the machine is checked for defects. Some nurses found the verbal confirmation to be annoying at times, I was mostly fascinated with it. Its almost hard not to look for problems in any situation presented to me, I feel as though the engineering side of me continually wants to solve problems. A fascinating device we got to observe was a laser that could do majority of the procedure for the doctors so less time was spent in the eye during the operation. However, there was one slight issue, the machine doesn’t make the hospital money so it is primarily used in self pay patients, because then it would be a price reduction for them. There is a lot of room for technological strides in this procedure but the reimbursement in health care prevents doctors from facilitating advancements. Continuing with the procedure it was intriguing to learn about the type of gas they use to keep the retina held back C3F8 or SF6. Patients are not allowed on airplanes for a few weeks after the procedure, one patient actually went against this and his eye ruptured. I never understood why some patients choose not to listen to their doctor. I noticed that through out the OR’s different music is played in each of them, must be doctor preference. Although the surgery techs only went to school for 2 years they are required to know all the names of the medications and how each machine operations. Training must be exhausting. Moving through the week, I sat in on an interesting lecture about using the eye for translational research, and studying graft vs host disease. despite some of the knowledge being beyond my scope it was interesting to see the results of them using in vivo to track T cells within the eye. They performed cornea transplants on mice and experienced high rejection rates, increased graft survival was found using chemokines and receptors to block anti-recruitment therapy. One thing I understood the most was using an anti-VEGF to prevent the build up of blood vessels within the eye in diabetic patients. Lastly, I spent some time in pediatric ophthalmology. Some observations I made were that the rooms were much larger, and had brighter colors. There was plenty of room for family and students to observe. The standard equipment was the same in pediatrics, also without the teaching scope. Movies are played for the kids in the rooms so they can focus on something while the doctor examines them. Or the dr would allow the child to sit on the parents lab as well during the examination. The overall appearance was very bright, it felt friendly like you wanted to be there. In pediatrics you observe a lot of children with crossed or drifting eyes. A tool I thought to be interesting was the prism blocks to see how much correction is needed to be done to the muscle to straighten the eye in surgery. One diaper equaled a 1/2 degree. With these they could bend the light to the fovia to document the correction needed. One thing I found to be challenging is that in the ophthalmology department there are larger numbers on the doors, for example 3143, then also on that door was “exam room 1” or a variation of that with more room numbers, it became a little confusing when directing patients or searching for a room. Overall, the first half of the week was very informative.

Week 2-7/18

The second half of the week began in the OR. I noticed the room was grounded for safety, I’ve learned about it briefly in class, but to actually see it was fascinating! I was able to observe strabismus surgery. With this I was able to get up close with the pediatric surgeon and see the muscles they were working with and how they measure the diameter length needed for correction so the eye could be straight. An interesting technique the Dr. talked about was how she leaves an exposed stitch so she can fine tune the adjustment of the eyes when the patients wake up and focus on a fixed object. I noticed that all of the rooms had red outlets, this indicates that even if the power were to go out they would be connected to the generator. I found that to be extremely beneficial, I hadn’t thought about how hospitals operated during a power outage. Moreover, during this procedure the doctor places a microscope on her head where the lenses can rest over her eyes, versus the large microscope in prior operating rooms, visibility was great for students to watch the operation. I observed them cauterizing parts of the eye to stop the bleeding, the room feels much more relaxed than the previous OR’s. Something I found most interesting while observing a resident do the surgery is that they practice on pig eyes before being able to operate. An interesting case I observed was twins who needed the same surgery for correction, they needed the same exact millimeter correction to straighten their eyes, it was fascinating. Moving back into patient cares, I noticed a machine called a pupilometer, it measures how much the pupil reacts to light and had a large “bioengineering” stamp engraved on it, it was neat to see that. I experienced a patient that did not allow students to observe her, patients are typically very welcoming to us observing, even though some appear overwhelmed to the amount of us there are (fellows, residents, med students, and engineers). I’ve been finding that through this shadowing process I am gaining a lot of knowledge applying to the eye and its anatomy, it makes each day more intriguing because I can understand more of the diagnosis and typical patient/doctor reactions. An interesting conversation I got to be a part of was how they are creating contact lenses that can monitor your blood pressure through out the day and even your eye pressure. This seems ideal for those with high pressures to minimize the risk of the condition worsening. In a few of the rooms I noticed domestic violence signs, I found that to be odd seeing as it is an ophthalmology clinic. One of the doctors actually let me use some of the instruments she uses to treat patients, that made the experience even more like a clinical immersion. Rotating in the neurological ophthalmology  department allowed me to observe patients with underlying conditions that cause eye related problems, one of the most fascinating causes was a patient whose autoimmune system began to attack the healthy cells in the eye. The patient appeared to be calm and understanding, although you would think a different reaction would arise. Overall, the week was filled with new clinical experiences and interesting patient cases.

 

Week 3-7/23

During this week I listened to some of the doctor’s voice their opinions on issues within the clinic. One that arises often is patients in wheelchairs; it’s hard to examine them without inconveniencing the doctor. A solution we discussed would be to have the room chairs slide back; allowing the wheelchair to come in its place so the doctor can better evaluate the patient. An interesting conversation I took part in involved tissue glue, which acts as a clotting factor. As a future tissue engineer this grabbed my interest. It’s made up of proteins that cause clotting without the cells often used in glaucoma patients. It’s rewarding to hear them discuss a case that you fully understand, such as them referring to the material PMMA. In class we learned it to be an option in hybrid lenses, but in actuality it is only used in trials because it isn’t O2 permeable. Moreover, I have gotten different reactions to EMR when discussing it with the doctors, some really want it while others have to make sketches of the patient’s eye and find that it would be difficult and time consuming to perform that on an online system. In spending more time in pediatrics I’ve learned that children have a higher rejection rate of transplants because their eyes change more drastically. Parents often try to self-medicate their children, by googling, WebMD, etc. I noticed a doctor wishing the public was better educated about the risks of not treating a child’s problem correctly or avoiding an immediate doctor visit. Doctors are incredible at multitasking, nothing seems to slip by them, and it’s very admirable. The amount of patience they possess is incredible, especially in pediatrics where children are very timid to doctors and often screaming while receiving eye drops. Something I found interesting was a patient was taking a diuretic to reduce eye swelling; it never occurred to me how simple over the counter medicine can apply to more global problems. I observed a patient who had no sensation what so ever, it was very hard for the doctor to work with them; it’s very difficult to know if there is a problem within the eye because they don’t perceive an issue. There is no sensory system, so even an eye lash that may be in the eye wouldn’t be detected. An intriguing case I observed was a patient who got a chemical burn in their eye. The surgeon took tissue from this lip and reconstructed his eyelid. It looked absolutely perfect. That patient was extremely grateful. Seeing patients like this make me better understand why doctors find this so rewarding. In viewing a glaucoma patient, they compared their screenings to a “normal Caucasian” because that’s all they have for comparison. It would prove to be more beneficial to have multiple races included. Moreover, I spend majority of my time in the lenses department where they work with k-pro’s and prose. What I find most intriguing is the hybrid lenses. They are composed of a soft lens and a rigid lens within the center. The lens should not touch the cornea; therefore there is a base curve within the hard lens. I had a discussion with the doctor about room for improvement. I noticed in patients that have these are often uncomfortable at some point. The material they are constructed with could be made moister so less deposits form which cause irritation in the patient. A major issue is keeping them moist.  As the patient wears them throughout the day they become tight on the eye, a moister surface would prevent this. The shape of the soft lens can often contour and suction to the eye, which is very unhealthy. This generated my interest as a possible project to look into new material options with optimal permeability for ultimate patient comfort. A lot of the constraint is that the material needs to be bio-compatible to the eye. I observed patients complain about the pain of removing a suctioned lens. As I continue more closely within one department it opens my eyes to more of how the patient feels and how the doctor adapts to each individual case putting their best knowledge forth for minimal error.

Week 3-7/25

The second half of the week was spent talking a lot about innovation and design, reflecting on the various departments we have visited. In the previous post, I discussed working with hybrid lenses, and how I would improve them. Going further into innovation, the Dr. and I discussed bio-integratable K-pros. It would be an excellent idea to use a porous material, so the tissue can grow into the pores and secure the implant. Another issue we discussed was cornea banks. There is not enough for the world; however there is plenty for the United States. We obtain about 60,000 corneas a year, and export around 15,000 of them to places around the world. If we could come up with a bio-engineered cornea, this would completely eliminate the need for donor tissue. Another interesting point was that there is always a demand for higher resolution imaging to see through cloudy media. Most of the instruments I observed used ultra sound to take imaging, which most doctors appeared to be content with. I spent majority of the rest of the week in pediatrics. They try to make most tasks a game with the children; they become engaged and seem to forget they are even being examined. The movies they play for the kids make them feel much more comfortable as well. The technician will often times let the child sit on the parents lap in the exam chair. One thing I noticed was they use a small device to check the patients eye pressure, it is described to the child as it just “tickles their eyelashes” which proved to be effective and true. The only issue with the device is that there is only one of them for the whole clinic; technicians are often going from room to room looking for it. It would become a faster process if they had more than one circulating. It takes such a great amount of patience to work with children every day. I experienced a few children that had quite the attitude! The parents didn’t really do anything about it, maybe they were used to it. I felt bad for the technicians trying to examine them. I observed an adult patient who had 4 compression’s done. That entails the bones being broken around their eye four times to make room for swelling of the eye. The patient had thyroid eye disease following breast cancer. Seeing patients every day really makes me fortunate for my good health. I noticed it takes much longer to dilate children, they need to wait about 40-45 min, while an adult only waits about 15 min. This is due to the doctors needing to completely paralyze the accommodation in children otherwise it can result in too high of a prescription and cause headaches. Parents often get irritated because they don’t understand why it takes so much longer for their kids to dilate when it hardly takes any time for them. I think a lot of the issues in the clinic arise from people being uneducated and having language barriers. One of the highlights of my week was the other interns and I got to give each other eye exams with the instruments! It was a great experience, I found out I see 20/15 which is really fascinating. We became familiar with some of the equipment without feeling the pressure of having patients around. Most importantly we had a lot of fun testing each other and understanding what we were looking for within the eye. Overall my last week in ophthalmology was filled with great doctors that really took the time to explain to me what was happening with each patient. I was approached with the question of “what surprised you the most about being here?” My answer was simply, the willingness of all the doctors, fellows, residents, and students wanting to help us. It made me feel much more welcome and less in the way especially when I got to participate in diagnosis discussions. At times it felt a little crowded to be there, but overall I had a great experience in ophthalmology and am looking forward to starting a new rotation where I can partake in a new environment and view a different setting.

 

Week 4-7/30

This week I began a rotation through the hematology/oncology department. All the staff was very open and friendly to having us there. The week began with a stem cell transplant meeting, in this they discussed upcoming stem cell transplants and identified donors as well. It was a very open discussion of what was appropriate for the patient.  Each doctor knew their patients very well in heavy detail which astonished me.  They discussed presenting risks and benefits before anything is taken from the donor to avoid any confusion. I became educated on the difference between autologous and allogeneic donors. What I found most interesting was that autologous means the cells are coming from the patient. The benefit of this is that, they take the patients cells before chemotherapy. Since chemotherapy kills majority of bone marrow, they can inject the cells into the patient once chemotherapy is complete to revive their immune system. On the other hand, those who use an allogeneic donor have a difference role. This does not replace the bone marrow; it serves as a genetic match where the new immune system is transplanted to the attack the cancer cells. At the same time, the current immune system needs to be suppressed for long periods of time.  I found this information incredibly beneficial because seeing patients in the clinic I can better understand the type of transplant they went through. Some interesting facts I learned were that your family only has a 25% chance of being a donor match. There is actually a large donor bank where unrelated donors donate stem cells and patients can be matched to them on the DNA level. A discussion I found interesting was involving cord and placenta blood stem cells after birth. This was interesting to me because I have actually been asked my opinion on this topic before and was not able to give adequate advice. I learned that it can be extremely beneficial but there is a very microscopic chance it will need to be used, an alternative is to donate the stem cells after birth. In my opinion that would be very beneficial, even just for research purposes. I was hoping to get a look at a bone marrow harvest in the OR. Unfortunately they only do 4 or 5 a year. It usually takes about 1-2 hours and they take barrow from flat bones, like the back of pelvic bone they puncture 30 to 40 different areas so they don’t drain the same spot. I spoke to a physician about this and they mentioned a device that would be extremely beneficial – a device that takes bone marrow painlessly, they seemed to laugh it off however seeing the difficulty. Moving into the clinics, the facility was very nice, the hallways were bright and the rooms were well spaced out so that there was minimal traffic. Nurses seemed to wear their own scrubs as well, seemed to be anything they liked. In the chemotherapy section, rooms are typically shared by patients – two in a room. And there are a few private rooms. It arose that inmates often get the private rooms even though you would think a frequent patient would be first in line for it. A nurse commented it didn’t seem right prisoners got special treatment seeing as there are limited private rooms. The rooms all have TV’s bathrooms and recliners. This seems like a problem could arise if you are paired with a patient whom you share no interests with, nurses try to pre-place patients to accommodate for this. The lighting in the rooms could be a little brighter. The department uses Cerner for EMR. Most like it, however I have encountered complaints of having to click too many times to get somewhere and they cope and paste everything for each visit and just add a few new notes, you would think there would be a better way to update the patient records other than continual copy and pasting. Chemotherapy seems to be all about patient comfort, which is good! There isn’t a whole lot of activity besides making sure patients are feeling their best. Moving more into the clinical side, I observed patients coming in for check-ups. A lot of what is done is making sure patients remain in remission or they are either working to prolong their life. A lot of it is also trying to improve the quality of life for the patients, even though it may be ending soon. I feel very out of place at times, its such personal news for family that I think I shouldn’t be involved. If I was in their place I wouldn’t allow extra people in the room, but that is just how I feel. I am grateful to be there regardless I just hope I am not making anyone feel uncomfortable. The patient rooms are very tight; I think this adds to the fact of me being slightly uncomfortable. Patients are very open to us being there, which surprised me. I witnessed a patient emergency where one fainted, apparently it happens enough to where their approach of the system could be updated. There are so many cables and lines in these situations that it makes a situation where you need to act fast potentially difficult. Overall the patient experience was beneficial, I will be spending this week in clinical, the next in the stem cell lab, and the last week in inpatient.

 

Week 4-8/1

The second half of the week was also spent in clinical. I found it interesting that they specify each day of the week for a certain cancer, for instance, Wednesdays are for lung cancers and Fridays are for breast cancers and so on. I think that is most effective, especially for the doctors that specialize in a certain type of oncology to be on rotation with one another on the same day.  When the patients medication is not working for them, or they don’t see improvement doctors try to enroll patients in clinical trials. They have trials in all types of cancers including brain, gastrointestinal, lung, head and neck, gynecologic, genitourinary, breast and hematologic. An issue I noticed is that nurses have a hard time finding veins on heavier set people, the doctors will flat out tell them they are fat or need to lose weight. That seems like it would almost be uncomfortable for the patient and the doctor, but physicians seem to have no problem saying it out right. The oncology department not only aims to cure cancers, but in patients that are terminally ill or have little chance of recovery physicians try to improve the quality of life. Patients are often faced with the decision of quality or quantity. Either to continue chemo and live longer, but not feel as great or stop chemo and enjoy what time you do have. Two people in my family have passed of cancer actually and they both chose quality or quantity, as much as families want them to live longer you also want them to be able to enjoy what time they do have. We got a chance to visit the stem cell laboratory. It made the BioE 456 lab look very low quality! The lab was incredible, the technologies astonished me. They have a cell count machine that takes seconds to count cells in a vial, it’s amazing. In the lab they harvest stem cells from donors that get called in. They store them in large tanks using cryopreservation, controlled by liquid nitrogen. They got through about 4 tanks of liquid nitrogen a week. I spoke to the doctor who controlled the lab; he had a great outlook on life. He emphasized the fact that it is in fact good to be bored.  People often do not take enough time to reflect and be innovative. You need to find a learning style; teaching only goes so far, individually you need to develop your own way of thinking. The new generation these days relies very heavily on technology. Kids often have the best ideas, they are very simple minded. Things that adults often miss, kids easily pick up. Engineers often over think, myself included. His overall point is that, we don’t take enough time to reflect and question why things perform the way they do. His outlook was incredibly motivating and made me want to go be innovative! Following that, we observed a bone marrow biopsy. They aspirate the marrow and take a sample. When the physician is numbing the area, you can hear the needle continually hitting the bone and they try to numb the fibers on the bone as well. This process is not done in the OR which ultimately surprised me. They drape sterile clothes in the patient room and work from there. The patient did not feel the procedure until they began aspirating. The change in pressure causes excruciating pain and the patient often screams. It’s very quick though. The device they used to extract the sample is very simple. They penetrate the skin with the needle and remove it while keep the rest of the device in the body, they then turn the tool 360 degrees several times to obtain the sample. Another part is inserted to remove the section and the procedure is over within 10-15 minutes.  The week ended in the breast cancer clinic, we almost felt uncomfortable because they cancer is much more intimate. The physician welcomed us to observe. They would pull a curtain around the patient when it came time for the examination, which we were thankful for. I don’t want to ever make the patient uncomfortable. For breast cancer, they actually have an online tool called “Adjuvant” it processes all the patient information and looks at all parameters to assist the doctor in deciding the best chemotherapy route.  Those who have overcome breast cancer are then placed into categories: low, intermediate, and high. These assess their risk for the cancer returning based on clinical trials that are occurring. Patients in the intermediate and high category often receive chemo even though for now they are cancer free. Doctors try to do all they can to eliminate the return of the cancer. Overall the week went by very quickly and was filled with a lot of great experiences!

 

Week 5-8/6

This week started off with a bone marrow transplant meeting. They discuss on going cases and their status for transplant, as well as the possible donors. They discussed an interesting case were the patient would not accept cells from her sister because they were feuding. When it comes to something that could save your life you would think the feud would be put aside. In their instance they are going to look for an unrelated donor but that could take time. A lab technician expressed her concern of how hard it is to find an unrelated donor, especially with mixed races today. We then went to the stem cell laboratory where they used a two-way syringe to extract the plasma from the cell plus plasma collection. Additional plasma is added if a higher volume is needed for the transplant. For cryopreservation of the sample, they freeze it to -90 then to -150 C. This halts all the chemical reactions in the cell, and essentially put the process on “pause.” The following day was spent in inpatient. These are typically patients with cancer that cannot go home because their stage is too far along. This is the newest wing of the hospital, it looks incredible. The rooms are spacious, the hospital beds appear comfortable and large, and there are chairs and a couch that folds out into a bed for patients staying overnight. The hospital received a 1.5 million dollar donation to create this wing. The room also includes its own private patient bathroom, as well as a TV that doubles as a computer. The colors throughout the wing are bright yellow; they make you feel happy when you walk through. Patients appear to be very comfortable there. The nurse’s stand is very open; they have their own area with glass walls to view patient hallways. A group of doctors, residents, and pharmacologists discuss each patient before they enter the room to update the patient on their status. The doctor quizzes the resident, before entering their input. We saw a patient that developed another cancer from getting treatment for another cancer. I didn’t get a chance to ask the physician how rare that was, but I can imagine it’s a small percentage. In observing the infusion pumps we noticed how beneficial it would be to have an infusion pump that could handle multiple drugs. Similar to what we discussed in class Monday, having codes for each drug to control them. Shortly after the inpatient area, we visited the hemapheresis center. Here they perform collection of stem cells; they use a 17 gage needle in the patient’s vein. If that doesn’t fit they have to put a port into an artery. The apparatus they use entails four pumps – anticoagulant, blood outlet, replacement, and plasma pump. The nurses stressed the importance of collecting the thin band produced by the centrifuge. They try to collect between 3% and 2% HCT. The patient seems to struggle during the hours they remain there, and feel pain when the needle is pulled out. The nurses discussed that when the FDA approves something the products become more expensive; the reagents cost up to 5,000 and are typically one time use. This enlightens me, seeing as how much health care cost these days. The last part of the day was spent observing the stem cell lab and how they extract the plasma from the red blood cells. The machines they use are incredible and extremely exact when they perform cell counts. We are always astonished at the technology in the lab.

 

Week 5-8/8

The last half of the week was spent in radiation oncology and continuing clinic observations. Radiation oncology is incredible! Not only do the devices astonish, but the programs are very intimidating. 30-35 patients can come a day from treatments ranging from 15-30 minutes. The clinic is smaller, and a little outdated except for the equipment. The radiation clinic consists of physicists, doctors, an engineer, and many technicians. The flow of patients seems to be on time and is thoroughly planned out several times. The newest machine they are in the process of implementing is the linear accelerator. This device is huge, and takes up a large amount of space. It operates by accelerating photons and electrons to the speed of light to the desired tumor location. Radiation is often received for 5-6 weeks. Tumor location is determined very precisely. They have an individual plan for each patient; they start from scratch each time for a precise plan. This plan creates a target location where the tumor needs to be hit with radiation. With each area of the body they use different margins to spare surrounding tissue. For instance, tumors in the brain have a very small margin of the area around the desired spot. For these patients their skulls are held in place during the procedure because even the slightest move can create many problems and damage healthy tissues. In majority of tumor locations they can spare the surrounding tissues. For cancers like prostate in the pelvic area the surrounding tissues are compromised, such as the bladder, because there is no other way to fully reach the infected area without damage to a larger margin. They use different levels of energy depending on tumor depth and sensitivity of the area. The deeper the tumor is the higher level of energy required. They can manipulate the radiation as “sliding windows” to zero in on one spot and not harm anywhere else. Another interesting feature is that they can layer pet scans or CT scans over the 3D plan to compare and contrast. All measures of accuracy are taken before the process even begins. Before the patient comes in, an exact plan is made for the tumor location. When the patient is actually in the machine they can take real time images to compare with the plan and make precise adjustments if necessary. The program prompts you with each step ‘are you sure you want to do this?’ and login and password must be entered. The machine will also stop if a problem is detected or the patient moves out of place. The staff agreed the program was very easy to navigate through while I found myself to be very lost. When asked if they would change anything, they replied with nothing. The machine is truly amazing with its capabilities. It costs 4 million dollars! You can easily see that. The technology is mind blowing. This has been my favorite part of the oncology experience so far. They showed us majority of all these features on a fake patient. The clinic has become a very routine environment for me. I am starting to observe many of the same issues, too many patients with appointments running hours behind waiting to talk to the doctor for sometimes 10 minutes and sometimes 45 minutes. It appears to be hard to determine patient times for oncology because family members often come, and many questions arise. It can take a lot of time to make patients feel comfortable and assure them of their progress or decline in treatment. I prefer to spend my time in the lab, radiation, and the donor bank. The clinic is such an intimate, personal space for most of these patients and I feel like I’m invading their privacy at most times even though this is a teaching hospital. I find myself empathizing more with patients in this department. Their expressions lead me to believe they feel intimidated having multiple people in the exam room. It seems to give off the impression of extremely bad news, which is not what you want a patient facing a life threatening illness to feel like when they are already vulnerable fighting for their life.

 

Week 6

The final week of the rotation was spent in various departments from radiation, to clinic, to the stem cell laboratory. In previous weeks we have seen the harvesting of bone marrow stem cells; this week we got to observe a patient being given the transplant. The stem cell mixture gets warmed to body temperature and fed through an IV into the patient. The technicians informed us that the media mixed in with the stem cells causes nausea in the patients. Nurses have them eat hard candy during the process. It was interesting to observe the whole transplant process, from the donation to the cryopreservation, ending with the recipient. The week went by very fast! I am very appreciative to have experienced a clinical immersion with such a welcoming department. The staff alone has made me feel comfortable in the clinic and the lab, enlightening me with stories and techniques. It’s always hard to end an internship, helping the staff and feeling like you’re making a difference makes it all worth it. In both of my rotations I have experienced incredible doctors and compassionate nurses and technicians. They seem to have a great amount of patience and such a drive to help people. Surrounding myself with such an astonishing group of individuals, with a passion for patient care, motivated me to want to do the same with medical devices. In previous school assignments where we were instructed to create a device or solve a problem, I never thought of the impact it would have on patients, and how they would perceive it. I am most grateful to have a new outlook on the design process. I’ve always found myself to be a very empathetic person, and working with patients brought that out in me even more.  Additionally, from this experience, I hope to bring the knowledge I’ve gained to IPD. I envision myself designing medical products not only from an engineering standpoint, but from an empathetic designers view as well. I would like to create medical devices that are comfortable to patients and easy to operate for doctors. I am very thankful for the opportunity to immerse myself in a clinical environment throughout one of the largest teaching hospitals. I’ve experience a lot of doctors and staff take interest in the path id like embark on after graduation. Many of them pushed me to try observing different specialties throughout the departments, which turned out to be another great learning experience. They were even interested in me as a person, and what I’d like to take away from this experience and where I’d like to apply it. It’s rewarding working with people who take the time to invest themselves in you, and make sure you gain the complete clinical and surgical experience. I think I would have preferred doing three, two week rotations and viewing another department, but I am thankful in general to have seen one, let alone two. Overall, I didn’t know what to expect when I walked into the clinical for the first day. Everything has surpassed my expectations, and I couldn’t be more excited to apply what I’ve learned to my future endeavors. Being immersed in the clinic has not only helped me to grow as an engineer but as an individual.