University of Illinois at Chicago
Instead of just sitting around reading the EEGs we were actually able to see some being preformed!
While watching the setup of the EEG, it was clear that patients don’t often know what the EEG does to them and how it works in general. The technician told us that first time patients often were very nervous about what was going to happen to them. They would ask things like “Are you going to be zapping my brain” and “Can you read my mind”.
For the most part this week has been a continuation of last week. By this I mean that the days mostly consisted of inpatients and clinic. However we were also able to spend some time with radiology seeing that in neuro the physicians commonly need to use multiple imaging techniques to help with their diagnosis.
During our time with radiology, we mainly focused on the different types of MR Imaging and on how the machine actually functioned. We then were able to spend some time with one of the techs that actually take the images. During this time we learned about the different precautionary measures that were taken due the high risk of injury that comes with using these machines. The MRI magnet is always on, and produces a magnetic field that is ~50000 times stronger than that of the earth. If a person were to enter the room with a piece of metal on them, it would quickly accelerate towards the center of the MRI machine reaching bullet like speeds.
During the rest of the week we continued the same basic schedule, stroke ICU inpatients in the morning and then clinic in the afternoon. The specific type of patients at the clinic varied from day to day, one day it was epilepsy patients and the other was neuromuscular patients. We also got the chance to look at some EEG recordings and learned the very basics on how to read them and what physicians are commonly looking for in these graphs.
During the time that we spent going through rounds with the stroke team, the physician commonly preformed a series of quick reflex and physical exams. These exams had very little quantification and the score given was also subjective. The patient’s physical exams are rated on a scale of 0 – 5, zero being unable to preform the task and five being preforms the task normally. For the reflex tests it was a bit more complicated since there is a possibility of the reflex being hypo-reflexive, hyper-reflexive, or some other potentially abnormal variation.
The EEG readings were, in my opinion, one of the more interesting things we have seen so far; mainly because it has alot of potential for growth.
Making it to week 4 means that I am in Neurology now!
It also means that I am no longer on a two person squad, but now in a four person team and I get to work with the IMED students. This is defiantly going to be different than the last rotation for sooo many reasons, but they are also all reasons to be excited.
We started the rotation off in the ICU in the mornings and in the neurology clinic in the afternoon working with all kinds of patents.
I was with the stroke team specifically, during rounds in the ICU. The patents that they commonly saw were patients who were at risk of stroke (i.e patient who has suffered from some kind of aneurysm or hemorrhage) or had recently had a stroke. The interactions between the patients and the attendings were very different from those in GI. In Neuro, the attending commonly experienced some difficulty while trying to communicate with the patients; at times compliance was the issue, but it could also be due to aphasia.
This was not the only difficulties in communication with patients that physicians ran into; the reliability of some of the patients was questionable at best sometimes. Because specific details and patient history is so important, physicians need to track down family members and/or witnesses.
This is clearly not something that can easily be resolved, but it is a very prevalent problem.
In the last days of the GI rotation, we spent most of the time with the inpatients, however we were also able to finally actually take a very close look at some of the instruments and devices that are used during some of the procedures.
Most notably I was able to see how all of the scopes get cleaned; during this time I also got the opportunity to hold a scope and actually feel what it is like to control it. The knobs used to control the tip of the scope actually had a higher resistance than what I had originally expected, but they also didn’t slip back to its original position if I let go for a second. After a bit of using it I also noticed that I was actually holding it backwards in my hand…I’m sure this doesn’t happen to real doctors though. Holding it properly made it more comfortable to move around, as it should, however, it still felt like it required a large set of hands to turn the knobs with ease.
For the final week at GI, we mainly shadowed Dr Skef during his inpatient rounds and consults. The mornings always started off the same. Rounds. This was where the residents, the fellow, and the med students all presented on their patents to the attending and then everyone discussed in order to create a preliminary plan of action. With all the talk of LFTs and sodium levels, I quickly got relatively lost. These presentations lasted quite a while, because of all the patients that were admitted into GI or were being consulted by GI.
After the presentations we went from patient to patient to review exactly what we had just talked about. The attending reviewed the questions for the patent that had already been asked to verify the status once again, and then they would explain the plan that had been discussed previously.
Having the attending, the fellow, and all the residents going around from room to room, sometimes stopping right in the middle of the hallway outside a patents room to discuss, seemed pretty overwhelming and many times cluttered. The residents were each assigned a small amount of patents so they didn’t necessarily need to pay attention when it wasn’t their patient, but it did give them greater exposure by being there.
During the madness of shuffling around, I was able to notice that the inpatient beds where larger than the ones we had seen in the GI lab. These beds were also more difficult to move around, especially because patents are almost always hooked up to IVs.
For the rest of the week we spent it in the GI lab, observing more procedures. Although we had already seen some of the procedures being preformed, watching them for a second, third, or even fourth time still revealed different insight on the procedures. Another benefit of watching a procedure more than one was the ability to verify if a previous observation is consistent though out a greater amount of samples. They also had the added benefit of being pretty cool to watch as well.
After looking at a couple of colonoscopies again, there were a couple of extra details that I noticed. For one thing the doctor preforming the procedure commonly holds the hose part of the scope with a small washcloth. This is done in order to get a better grip of the scope and to not get lube on the gloves. Another little trick that I saw was that if the doctor is having trouble around a difficult bend the nurse will apply pressure onto the patients belly so that the scope has something to push back on; making it easier to ride the colon, as described by one of the attendings. There was also the fact that when removing a polyp it is completely up to the doctors best judgment whether or not it has been sufficiently removed. If the polyp was not completely removed it can easily grow back making this part more delicate.
I actually didn’t see any more basic endoscopies, instead I was able to observe a couple of more advanced procedures like another EUS, a double balloon endoscopy, and an EGD dilation.
During each of these procedures a different endoscope was used. They all basically looked and functioned the same, but they each had a extra little thing that was vital for each specific procedure.
In many of the procedures, most noticeably in the double balloon endoscopy, the physician preforming the procedure ran into a good amount of obstacles. For example, it was common that a second person would need to hold/insert/operate an extra tool that was placed into the scope. This made things difficult because the physician would need to tell the second person exactly what to do and when to do it. At times the people would not be in sync and the procedure took longer to preform.
Another thing was the difficulty of manipulating the scope around difficult areas. In the double balloon endoscopy there was visible bruising to the walls of the small intestine where the scope commonly got stuck. Luckily the patient cannot feel any pain in that area, but it will take some time to heal.
For the first half of this past week, were in the Endoscopy Lab basically the whole time. The Endoscopy Lab is were all the GI related procedures happen, for both inpatients and outpatients. During an average day there were approximately 20 patients. Even though there were that many patents I commonly was only able to see about 6 each day depending on what the procedures were.
Instead of going through each of the patients that I met, I am going to talk about each procedure separately in hopes of making this more organized.
Starting off, the colonoscopy is by far the most common procedure that patients needed. This is because it is recommended that everyone gets a colonoscopy at the age of 50. After that, depending on their findings another colonoscopy is recommended. If everything was healthy another one is not necessary for 10 years. If some polyps are found they often say 5 years. Beyond that it is usually a couple of months to keep a close watch. During the colonoscopy the patient is placed under twilight sedation, so they are pretty out of it, but they can sometimes follow simple directions from the doctor or nurse. The patients also experiences retrograde amnesia, which makes them forget their experience during the procedure.
The biggest difficulties that I noticed during the colonoscopy were actually knowing what part of the colon the end of the scope was at and having full control over scope. Just so everyone is aware the colon basically looks exactly the same regardless of what part of it you are in. To make it even harder, there is often a great deal of back and forth in order to get past some of the more complicated bits. In order to get around this problem the doctor makes his/her way to the cecum (i.e. the end bit of the colon that connects to the small bowel) and then they look closely for polyps, among other things, on their way out. This allows them to take their time and focus, while easily keeping track of their position inside of the colon; after all going out is much smoother than going in. While observing one of the colonoscopy procedures the patient suddenly exclaimed that he was feeling pain in his abdomen. This went on for a bit while the doctor tried to figure out the cause. On the way out of the colon we noticed “skid marks” caused by the scope on one of the walls of the colon. After the procedure was completed the doctor explained that from time to time when moving deeper into the colon the hose like part of the scope can twist on a sharp turn in such a way that it forms an alpha-loop. Now if the doctor tries to push forward once this loop is formed this alpha-loop just gets bigger, causing the patient pain, and the tip of the scope does not move forward as much. Pulling the scope out would also cause the patient pain because of the way the loop would unfold. The doctor mentioned that there was a maneuver that was used in order to minimize the size of the loop and then you could undo it with the least amount of damage to the patient.
I was also able to observe multiple endoscopy procedures. This procedure was much simpler than the previous because there are much less curves involved. The hardest part of it, for both the patient and the doctor in actually getting the scope into the esophagus. The patient commonly gags on the scope and puts in a good amount of effort to take it out even though they are under twilight sedation. Once that part was over, the rest of the procedure goes pretty smoothly. One of the patients we saw previously had a gastrectomy, which thoroughly confused me while I was trying to follow where we were. This cut down the procedure to about 10 min or less, the bulk of which was getting in the scope. The only other thing that I noticed was that if the doctor needed to take biopsies for whatever reason they inserted biopsy forceps into the scope and took their samples; while they were inserting the forceps into scope, the doctor kept inserting the wire until they saw it on the screen, which lead to an overshot making the tool hit the wall in front of the camera. This was also consistent when taking biopsies in the colon as well.
Another trait that both the colonoscopy and endoscopy have in common is that the nurses need to be paying attention to the level of the fluids that were sucked out of the patient. These fluids go to a canister that can hold about 1200 mL, if it were to overflow the fluids would go into the suction system and would damage it. I haven’t seen it get to the level that it needs to be replaced, but there have been a few cases that the level got high enough (about 1000 mL) that it made me ask the question of what could happen and if there was any indicator of its fill level .
Just to be clear, these canisters are replaced for each patient.
From time to time a patient would need both colonoscopy and endoscopy. When this happens, the endoscopy is always preformed first because it requires more anesthesia. The room is set up with two scopes from the very beginning in order to save some time. After the endoscopy in complete, the nurses quickly turn the bed around to that the patient in now facing the other direction. It is important to note that these rooms are tiny and turning the bed around is very difficult especially when trying to work around all of the tubes and wires. While this is happening the doctor hooks up the second scope and does some quick checks to make sure all the features of the scope are working.
I was also able to observe another ERCP, which was just as intense as the first one. This time I were able to talk to the doctor a bit more before the procedure started so I found out a bit more about the procedure itself and about the tools that they use. For instance, a special scope is needed for this procedure because in order to find the papilla that lead to the bile duct we need to be able to see sideways, so this scope has its camera on the side of the tip instead of right in the front, as shown in the diagram below.
It also has an extra knob that controls the elevator adding more sensitivity to the movement of the catheter when it is used. While all of this is fine and dandy, it also makes it harder to get to that point because you cant easily see where you are going.
This specific patient also had the added challenge of having a couple of tubes coming out of his chest for a multitude of reasons. I didn’t mention this in the last post because it was not that relevant, but during the procedure the patient is lying on their chest. In order to protect those tubes and therefore the patient, these foam doughnuts were taped over the tubes, this just seemed kinda weird to me and very improvised. During the procedure I also noticed that it was very focused on trial and error. The doctor literally tried more or less the same movement over and over again in order to get the catheter around a bend until it worked. There is very limited control over the catheter, at one point it buckled and made a U shape while inside the bile duct. This was clearly very frustrating because it got stuck. The doctor inserted a stiffer wire into the catheter, which ended up fixing the problem. This patient needed a stent to make sure that stones didn’t get stuck in that area. The stents were inside a normal sterilized package, but that package was also inside its own box. This stuck out to me because everything else in the room didn’t come in this extra box casing.
The only other procedure that I was able to observe was an endoscopic ultrasound (EUS). This procedure is usually preformed in order to take a close look at the pancreas. Again this procedure needs its own special scope which has an ultrasound probe at the end of it right before the camera. Now this is where I really got lost, I could not make out most of what was on the small ultrasound screen. It looked a bit like a mess to me. The only thing I can say about this procedure is that in order to properly see the image a balloon at the tip of the scope needs to be filled with water because ultrasound does not work with air. When this balloon is inflated for the first time, it is filled mostly with air because even though the water line is hooked up, there is still air in the pipes of the scope from before it was connected. Removing the air takes some time and is an annoying process for the doctor.
Besides observing the procedures, I was able to talk to the doctors a good amount, mainly about anatomy in order to get a good understanding of what was going on in the procedures. I also learned about a procedure that doctors didn’t particularly like, Dr. Boulay was at the VA in the morning and he had to insert a rectal stent. The reason that this procedure isn’t very well liked is that there is no way for the patient to prep for it, so once the rectum is opened everything comes out. Needless to say it can get pretty messy.
I am almost certain that I learned more about the anatomy of the GI tract in those two days, than I ever have before. Initial exploration was clearly a success.
For the rest of the short week I found myself mainly at the GI/Liver clinic going from patient to patient.
On day 2, I was shadowing a Hepatology fellow named Dr Martis in the morning. We met with 4 different patients; each of them at the clinic for different reasons. The length of the appointment varied depending on the reason for the visit, the questions that the patient had, and the availability of the attending physician, Dr Naveed at the time.
Every day I was with a new fellow and attending, but the process was still the same. When we met with a new patient, the fellow asked them a few pretty general questions. Regardless of the point of their visit these questions did not change much from patient to patient. The first thing that the fellow needed to know about was the patient’s stool, the shape, color, texture, and the number of bowel movements a day. The color and form of the stool is really important because it can indicate bleeding in the upper or lower GI, celiac disease, chronic pancreatitis, or bile duct obstructions. From these questions the physician may want to take some scans or upper/lower endoscopies to verify any problems in order to properly diagnose the patient.
Many of the patients expressed dissatisfaction towards the wait time, and this was consistent throughout the week as well. When looking at their waiting time, it mainly accumulated when the fellow needed to confirm his plan with the attending, but they are busy with another patient.
After asking one of the patient what one of the most difficult/annoying parts of visiting the clinic was, she let me know that she thought that simply talking about what specifically was wrong was the hardest part. She went on to explain the the topic itself is very private and hard to open up about.
Another difficulty that I saw was the patients compliance with their medicine and more importantly their diet. The patients diet was such a big deal for the patients that some patients were there specifically because they no longer wanted to stay with it and wanted to ask the doctor if they could do something else. Depending on the case some patients had to deal with it and others could try different foods, but with caution.
There was another patient that I met had a very interesting case. He was a prisoner. I hadn’t originally noticed this until I went to shake his hand and saw that he was wearing handcuffs that were attached to a chain belt around his waist. This really limited his area of mobility making it difficult for him to gesture to the area where he had pain. It also made it more difficult to examine his abdominal area.
The times that we weren’t in the clinic we were able to see two endoscopy procedures with Dr Khan and Dr Nannegari and an endoscopic retrograde cholangiopancreatography (ERCP) with Dr Boulay.
During the endoscopy procedures there were a couple of things that I noticed. First off, the scope and all of its features are tested to make sure it is functioning properly before the procedure starts. There are two knobs that control the movement of the end of the scope (approximately 4 cm) making it flex up, down, left, and right. The scope also has a flush feature, which means that it shoots out water from the tip in order to clean up the view if it gets too messy. It also lets out air at the tip in order to inflate the stomach/intestine to get a better view. During the procedure there were times where the doctor had to not only turn both knobs, but turn their entire body in order to twist the scope in order to maneuver throughout the duodenum. It took a couple of attempts from the attending to explain it with words and for the fellow to properly execute. There were times in the procedure where the patient would begin to drool so like in the dentist office the nurse had to suction it out. The difference that I saw was that the nurse put the suction back into its packaging and then placed it either behind the patient’s pillow or below the mattress.
The ERCP was very similar to the endoscopy at the beginning, however once the end of the scope got to the duodenum the Dr Boulay began to look for the major and minor duodenal papillas. Using live x-ray images Dr Boulay then needed to insert a catheter into the bile duct in order to remove and gull stones that were present. Once the stones were out a stent was placed in order to keep the duct open. Now all this doesn’t sound all that bad, but the hole was approximately the size of the tip of a ball point pen making any movement seem very large. The condition of this patient made the procedure much more difficult than normal. The whole procedure took over 2 hrs and all the people in the room had to be wearing lead the whole time, even though the x-ray machine was only on once the catheter tip was inside the duct, making standing there quite a challenge.
It may have been a short week for us, but we saw alot of patients, but no matter what we always started off with their stool.
The first day…WOW
Walking in to the Outpatient Care Center was definitely an adrenaline filled moment.
Not knowing exactly what to expect, tired from waking up waaayyy too early for the first time in months, and standing in front of the GI and Liver Clinic next to my partner, which I had only really just met earlier that day. It really gets your heart pumping.
Too bad that just a few moments after we enter the clinic my heart dropped to my stomach in a matter of seconds. After introducing ourselves to one of our listed primary contacts, she said the one thing that I absolutely did not want to hear. With a confused look on her face she let us know that she had no idea who we were, what this “Clinical Immersion” thing was, or what we were meant to do there. After a clearly needed much more detailed introduction and a bit of thinking. We figured out that the information that we were given was from the previous year. She then suggested that we pay a visit to a conference room next to the Endoscopy Lab.
More introductions, again with many puzzled looks. Luckily a new Fellow, Dr. Khan, and an Attending, Dr. Nannegari, went along with it and really helped us out. We were able to talk to them for some time while they were filling out some notes on patients. Dr. Khan gave us a brief overview of GI and some quick notes on how the hospital functions. Inpatients, outpatients, consults, pretty much the basics.
We accompanied Dr Khan on a few of his consults. This also served to give us a quick tour of the hospital, introduce us to the Residents, and to get to know him better. These consult visits were quick, mainly just to review the patient’s condition and ask them a series of basic questions. Once we did that, Dr Khan just had to give his assessment to their primary doctor at which point they would then decide on a course of action.
Alas, Dr Khan gave us a heads up that it had been a slow day and did not have much left to do besides writing up the notes about his patients. He did however invite us to go and watch him perform an endoscopy the next day. We said our goodbyes and since it would have felt way too unsatisfying to leave our first day at that, we went to talk to the residents again. We asked them some pretty general questions about the hospital and the patients. Because many of them had actually just started we did not get too much information from them besides the fact that tubes and wires were all over the place during procedures and that the infusion pumps were annoying to deal with; nurses often ignored their alarm because they went off so often. Ironically we were given both of those problems as examples earlier in the day before we even got to the hospital. Even though we did not actually get much, we were able to a good reading off of the residents and give them an idea of what to look out for.
Once we were done there we wanted to take another crack at the clinic again and ask a couple of questions there. As soon as we entered the office portion of the clinic, with all the doctors and computers, Dr Jong to our surprise immediately knew who we were, with no introduction needed. She quickly set us up with a fellow each and sent us on our marry way to meet some patients.
To say the least, the day picked up a bit.
I was paired with Dr Skef, a brand new fellow from Canada. The process at the clinic was pretty simple. First, Dr Skef got a patient and looked up previous information in their record. We then went to go see said patient and asked a couple of routine questions to properly assess the nature of the visit and to develop a proper plan for the patient. Once that was done we went back to the office and reviewed the plan with Dr Jong, the attending physician at the time. After the plan was verified in a somewhat verbal exam type manner, we paid a visit to the patient, this time with Dr Jong as the main point person. Finally, Dr Skef put in his notes of the patient into the computer and once again the process starts from the very beginning.
The most obvious problem that emerged was difficulty in using the hospitals program to see all the patient’s information and to order medicine/tests. Dr Skef mentioned that he was still learning how to use it, however after a while I noticed that even Dr Jong had some difficulties and was not fully aware on how to use it. Beyond that the layout has many tabs and is very saturated with text.
Another problem was the difficulty to communicate with the attending in the narrow hallway of the office; especially if another doctor had to pass through as well. Trying to not be in the way of someone is clearly not easy.
To sum it all up, it was a bit of a roller coaster.
None the less, I could not be more excited.