University of Illinois at Chicago
This week in rehab we saw some amazing technology, including the hyperbaric oxygen chamber. Unfortunately there were no patients so we didn’t get a chance to see the chamber in action, but we did learn about its uses. The patient is placed in the chamber and it is pressurized to 30 ft below sea level and filled with 100% oxygen. This causes the patient’s plasma to become saturated with oxygen which helps them heal after surgical procedures.
This week we were also able to spend some time withthe Shceck and Siress prosthetics team at UIC. This was probably the highlight of my time during this program. The patients we spoke with were wonderful and very willing to answer any and all of our questions. In talking to them we learned a lot about the changes in prosthetics that have occurred over the years. Everyone we spoke to made a point of telling us how amazing David Rotter, the prosthetist, was. He has designed many different customized prosthetics for many people.
Overall, this experience has been an incredibly positive one. I have had the opportunity to see things that I may never again have the opportunity to see and learned so much about problem identification.
This week we had a chance to spend some time learning about the rehab side of neurology. It has been interesting to get to see a completely different side of the department. Thus far, this side of neurology has been a bit more uplifting because there is more that can be done that allows us to see direct improvement to the patients quality of life. The occupational therapist who showed us around was incredible and very innovative. She helps patients regain their ability to go about their daily activities in several ways, including by providing them with various tools and devices. She told us that many patients don’t realize all of the types of equipment that is available to assist them with activities, so they don’t even mention struggling with certain activities. That being said, when the tools are available for people, they don’t always meet the needs of patients because each person’s needs are so different. For this reason she designs tools for her patients on the fly and creates many of them by using thermal plastic or sewing. She also mentioned that she sometimes modifies the existing equipment to better meet each patients need. She noted that sometimes the people coming up with the original design don’t know how the patient will actually be using the device in their homes. Because of her direct interaction with the patients and her experience in home health care, she has a more clear idea of how patients will use the equipment and how it can be modified to meet their needs.
The therapist said the biggest problem she faces is funding. She said as culture is changing the facility hasn’t been able to keep up with the patient’s needs. For instance, many people will be using their laptop or tablet at home but the OT department doesn’t have either at their facility to work with patients on. She also said that funding can be such a problem that she sometimes will use her own money to purchase items she finds to be necessities. I was so impressed by her, her innovative mindset, and the work she does to help her patients get back to their daily lives.
The first week of the rotation we noticed that the video EEG is frequently used in the hospital and clinic for diagnostics. Last week we had a chance to read EEGs and this week we were able to shadow a technician while she set up the EEG exams in the clinic. She told us that the best readings happen when the patient is able to achieve light sleep. During this time your brain is the most likely to emit epeleptiform waves. Sleep can be very difficult to achieve in a doctor’s office or hospital in a 30-45 minute window of time, which makes me think this exam would be more effective if done in the patients home. The technician also noted that her biggest frustration with the testing is the noise interference. She said it is particularly difficult to eliminate interference in the hospital when so much other equipment is being used and so many people are coming in and out of the room. The field is disrupted when a nurse, physician, or anyone else comes to close to the machine or wires and noise is created. Braiding the wires together can help cut back on artifacts in the recording, but is not done because it makes it more difficult to place the electrodes correctly. Further, the EEG is completely unreadable if the patient moves. Therefore, if the patient has a seizure and is jerking around, the EEG shows nothing and information about the seizure must be taken from the moments just before the clinical seizure (movement) begins. I assume this could present a problem if the patient happens to be moving for an unrelated reason right before the seizure begins.
This week we had a chance to learn more about MRI testing. First, we learned how to tell different types of MRI scans apart and got some practice in identifying abnormalities. Of course it would take much, much longer than we have to learn how to identify all of the abnormalities one might see. Nevertheless, it was interesting to learn about the variation in human anatomy as well as about the many different types of scans can be done with MRI. After learning some basics about the images produced by MRI we had a chance to go to the MRI center and sit in with a couple of technicians to learn how the scans are done. One of the techs explained some of the physics on how the machine works and how the different types of images are produced. I’m unsure how it is humanly possible that someone figured out how to get such amazing images in such an abstract manner. He also talked to us about how the room is designed which was nearly as mind blowing. There is a copper mesh lining the insides of all of the walls so that radio frequencies from outside do not effect the machine’s readings. The technician also explained to us that the MRI room is the only place in the hospital where you can die just from walking through the door. The magnetic field is so strong that if someone walks into the room with metal, it will be drawn toward the magnet at such a high velocity anyone in its path could be injured or killed. He shared plenty of stories with us where breaches in safety protocol ended in death (not specifically at UIC). After scaring us to death, he brought us into the room and showed us how strong the field was by having us hold up a very small metal key and try to manipulate it. When we asked the technician what, in his opinion, is the biggest problem for him he told us it was lack of safety education for hospital staff. He said that although staff may be told the dangers of going near the machines without a technician’s clearance, is not enough. He thinks all staff should be brought to the MRI center for an orientation where the strength of the magnetic field is demonstrated in a similar way to how it was demonstrated to us.
Thus far, one of the biggest problems I have noticed lies in the exams. To asses patients in neurology there is a standard series of exams that are done to check muscle tone, reflexes, and vision. To check muscle tone the patient is asked to push back or pull on the doctors hand with various parts of their extremities. As previously noted this can be very difficult when dealing with non-compliant patients. Furthermore, the persons tone is scored out of 5 based on how much effort is given and how much resistance there is. The scoring system is subjective and there is no way to quantify the results. The system does seem to be rather standardized, but sometimes a resident will present a patient with one score and the attending’s evaluation will result in another. This makes it difficult to track a patient’s progress accurately.
I also had a chance to observe a memory evaluation this week. When patients come to the office and are concerned about changes in their memory function, there is a short, 15-25 minute, test that can be given. Depending on the results the patient can be sent to get a more extensive evaluation. The in-office evaluation has sections to test the patients verbal memory, computational memory, etc. Part of the assessment requires the patient to identify animals. It is intended to be a bit difficult so the animals are a bit rare, and the patient’s ability to answer can be influenced by their educational background. The physician mentioned that it can be difficult to score the results when you are unsure if the patient has answered some of the question incorrectly because their memory has changed or because they didn’t know the information to begin with.
The first week in Neurology rotation has been going quite well. It is a very different experience than my time with the Urology department. One reason for this difference is that in Neurology the patient’s history is one of the most important parts of their diagnosis. According to our mentor, Dr. Shapiro, 80% of the diagnosis is based on history. For this reason, the doctors spend a very long time in the room with patients as compared to what I am used to. Of course, during some routine follow-up appointments this is not the case. During general inpatient rotations, when the attending arrives to the hospital in the morning, it takes between 25-25 minutes for the residents to present each new patient.
Because so much of diagnosis is based on patient history and how the patient is presenting, there seems to be very little equipment used in clinic and hospital settings. The most frequently used technology that I have seen so far is the video EEG. Today we had the chance to go to the EEG lab and learn a bit about reading them. We noted that the readings are done manually and the doctor must sometimes scroll through hours worth of output looking for epileptiform discharges. Muscle movement also causes constant noise in the signal, which must be filtered out. However, this filtering causes the EEG reading to be less accurate.
So far its has been difficult to asses clinical problems, although there have been a few I have noted. As I’ve mention, patient history is very important, however, because of the nature of Neurology, many of the patients have altered mental states. It can be difficult to obtain medical history for this reason.
It seems that many of the problems we will be identifying will come from the lack of technology available in neurology!
In the final week of the rotation, we presented our findings to several members of the department. Our presentation focused on four general areas that commonly give rise to frustrations for staff and/or patients: (1) communication among staff and institutions; (2) patient involvement; (3) non-comprehensive diagnostics; and (4) steep learning curves for procedures and equipment. Of these four areas, I am particularly interested in the steep learning curves for procedures because of what I observed in the OR. I also think that this area has some exciting potential solutions.
The first time I went into the OR I noticed that medical students and residents alike had trouble identifying structures in the body. Due to the nature of how anatomy is taught it is very difficult for students to re-learn to identify organs as they appear in vivo. It seems there could be a better way to teach incoming medical staff about anatomy so they have more time practicing procedures under an attending as opposed to spending much of their time re-learning the anatomy.
Of course, we are not supposed to be thinking of solutions, but I did want to mention one idea my teammate and I discussed. I had noted that it would be ideal if the robot could tell the user what structures they were viewing. Generally, the surgeries performed using the robot are recorded. Joel suggested that having medical students review the footage, identify structures, and upload the annotated footage to the robot would help the students learn and also help the robot learn to identify structures. The trouble, of course, is that there is so much variation in anatomy from human to human.
The first rotation was very exciting and I had a great team with whom I was able to identify several clinical needs. I am so thankful to the Urology Department for being so welcoming and helpful to us. I am very excited to start my next rotation!
The final week with the Urology department was again split between the OR and the clinic. This week I had the chance to observe some procedures for a second or third time. As I mentioned previously, it is nice to see procedures more than once because you may pick up something you had previously overlooked. It is particularly beneficial to see the same procedure performed by a different doctor because there are so many ways to perform the same procedure. One of the things that stood out most to me during this last week is how differently things are done by staff within the same department. From patient interaction to procedures, there are many differences between the staff.
While observing different doctors in the clinic, I noticed that each has a different style. Some doctors list all of the treatment options available to the patient, make recommendations, and then ask the patient to choose. Others tend to tell the patient only about the procedure/s they feel would be the best, most beneficial option/s. I think both of these approaches are great, but it is interesting to note the variation.
Doctors also have great variation in their approaches to surgery. When talking to one of the doctors about the prostatectomy he explained some of the different approaches surgeons take to get access to the prostate. He said there are hundreds of ways to perform a prostatectomy. I imagine this makes learning more difficult for the residents because they must keep track of manners in which each doctor performs each procedure.
The second part of week two was spent back in the OR. It was nice to switch it up for the latter half of the week. I had the opportunity to witness the da Vinci robot in action once again, only this time it was the Si model. One notable difference between the two models lies in the camera. The Xi camera automatically focuses, while the Si camera has to be focused manually. The operating room that the surgery took place in had two consoles connected to the Si robot. Only one of the consoles was in use, so we were able to take turns watching the surgery through the lens, which shows the footage in 3D. The 3D image made an incredible difference. Sitting at the console also gave us a chance to get a closer look at the controls used by the surgeon, which are an incredible work of art.
This week our team was able to watch a prostatectomy performed by a different doctor than we had previously observed. I noticed some differences, especially in the amount of blood present in the abdomen. I believe this was in part due to personal preference and technique, but also could have been related to the different patient. It was good to have a second opportunity to watch the procedure since the first time through the amazement at what you’re watching can be a bit distracting.
This week we had a chance to finalize our thoughts on some of the themes that came out of our collective observations. It proved difficult to narrow things down and most of the themes seem to be so connected that their almost inseparable. I look forward to presenting out findings to the Urology department next week!
Monday and Tuesday of week two were spent at the Mile Square Health Center. Because the rooms at this location are on the small side, the four students had to alternate going in to see patients. One of the patients, who had a history of kidney stones, had a stone visible on a CT scan. It was suspected the stones could be uric acid stones and not the typical calcium stone. To check which type of stone was present the density was checked on the CT scan image and compared to that of bone (a calcium stone would be comparable to bone). The x-ray was also checked because a uric acid stone would not be visible, but a calcium stone would. It was convenient that this information could be found on the computers in the office, instead of having to be sent back to radiology. The rest of the patients I had the opportunity to see were consultations or follow ups. These appointments help me get an idea of how the procedure/treatment went, or is going, for the patient.
In the evening we went with the doctors to make rounds at the hospital, which was another good opportunity to gain insight to the patient’s perspective. During week one Cody and Savan were present for a nephrectomy and during these rounds we had a chance to check in with the patient. It was nice to come full circle and get a patient’s perspective on the tolerability of the procedure.
The rest of week one went as wonderfully as the beginning. Day three was spent in the clinic shadowing Dr. Garvey, who sees about twenty patients a day. He mentioned to us that his biggest frustration is electronic medical records. Although he stops seeing patients at 4pm, he stays in the office until midnight typing up his notes. Prior to electronic record keeping he would dictate notes into a tape recorder and hand them off to someone else to type. He said it is still possible to hire a scribe to enter dictated notes into the system, but the service isn’t used at this location. Several patients were scheduled on Thursday to have a uroflow exam. For this exam the patient urinates into a special toilet which records the flow rate and output volume. If this test yields abnormal results, a bladder scan must be done to see if the patient is retaining urine in their bladder. The bladder scanner happened to be broken this day, so any patient who had abnormal uroflow results had to be rescheduled to repeat the Uroflow test and to have a bladder scan. It appeared to me that the Uroflow machine could be improved so that it did not require the use of another device in order to provide useful results. It was suggested by one doctor that having a bladder scanner built into a smartphone would eliminate the issue of having to wait several days for a repair.
Day one of clinical rotation in urology started off in the Mile Square Health Center where we shadowed several doctors. Once we arrived we began right away by seeing a prostate biopsy. I noted how uncomfortable the patient appeared to be before and during the procedure. He was very nervous that he would be in pain and even asked the doctor if it would be possible to do the procedure under general anesthesia. The patient appeared to be made more nervous by the sight of the equipment, especially the long needles. The needle used to extract tissue for biopsy made a very loud clicking noise when it was prepped, when it extracted tissue, and when it released the sample into the specimen cup. The noise made me feel uneasy, so I imagine it did not help the patient’s nerves during the procedure. It appeared to me that the tools used, although functioning effectively, could be improved for the patient’s comfort.