Nina Scalise

University of Illinois at Chicago
Bioengineering


Week 5 Part 1: Stem Cell Lab + Hem/Onc Rounding

We began our second week in oncology with a tour of the hemotherapy center and stem cell labs.  In the hemotherapy/hemaphoresis center, leukemia or multiple myeloma patients are given a drug to boost and mobilize their white blood cells, after which their blood is extracted, spun down in a centrifuge (see attached picture) and ultimately selected for CD34, which is a marker on hematopoietic stem cells (HSCs).  A similar process can also be done for red blood cell and plasma exchanges as well.  In the lab, the cells are frozen, initially at a controlled rate, and then stored in a freezer attached to a liquid nitrogen tank for 1-2 weeks, after which they are thawed and reinfused back into the patient.  In general, an HSC transplant can be used for blood diseases, severe immune deficiencies, and sickle cell disease; the stem cells can be derived from bone marrow (usually extracted from the hip bone), peripheral blood (using the machine pictured), or umbilical cord blood.  Transplants can also be autogenous (from one’s own cells) or allogenic (from a matched donor).

We were walked through all of the components and machinery involved in the stem cell processing and I was impressed at the extensive quality control measures built in to ensure consistency and viability of cells for the patient.  For each sample, the reagents and patient plasma are saved and sent for sterility testing in order to pinpoint the source of contamination in the event a sample doesn’t pass sterility testing.  The process itself from cell counting to freezing is highly protocol driven and has been optimized over the years; a few additional observations are as follows:

  • All of the freezers are equipped with alarms that are triggered when the temperature falls out of a specified range and these alarms are linked to a central computer in the lab that produces an alert sound and then automatically calls lab staff members if it is not disarmed in a certain amount of time.  Currently, the lab staff cannot disarm or control the system remotely and must physically come into lab to do so, although this does not happen often.
  • For some of the machines such as the CliniMACS CD4 cell selector, the cell solution must be placed in a plastic disposable tubing kit that then fits into the machine — this preserves sterility but produces considerable waste and adds to cost.  In addition, we were told the reagents for some of the cell processing machines can cost up to $4,000 and after so many years the company changes the reagents, forcing labs to upgrade the machinery.
  • In addition to an automatic cell counter, the lab has a microscope connected to a monitor for manual cell counting, since the differential count is done manually for each collection.  Manual cell counting is typically not a significant challenge for the techs, but with the current system they can only visualize a small range of cells – ideally, the range that is visible at one time would be larger to expedite the counting and reduce errors.

The following day, our team accompanied the hem/onc team as they rounded in the bone marrow transplant unit of UIH.

  • The group consisted of an attending, junior and senior residents, fellows, clinical pharmacist, pharmacy students, and our team 
  • One resident wheeled around a portable computer workstation to refer to patient charts and everyone else had paper copies of patient info that the residents would alternate presenting before we entered the rooms
  • Many patients on the floor were immunocompromised due to prior stem cell transplants and the list of relevant precautions (contact, gloves, etc) is visible on each patient’s door — some patients required that visitors wear disposable gowns, which are stacked in cabinets outside each room.
  • Sometimes the residents noted holdups in obtaining patient records from outside hospitals and miscommunications during patient handoffs between shifts.  On one occasion, a patient was given a dose of a very expensive drug by an overnight fellow because he was not aware of the plan made earlier by the team to administer a different (and much cheaper) drug.
  • Generally lots of moving parts in the care of inpatient cancer patients, often requiring consults from nutrition, pharmacy, social work, etc. and ultimate management by the medical oncology team

Week 4 Part 2: Tumor Boards and Brachytherapy

Our week in radiation oncology continued with multidisciplinary tumor board meetings, observing patient visits, and discussing treatment technologies with the residents and techs.  Tumor boards are meetings in which oncologists, surgeons, pathologists, radiologists and more review cases and discuss treatment options for patients.  Our first meeting was focussed on GU (genitourinary) cancers, with an emphasis on prostate cancer.  In this particular meeting, attendings and residents were seated around a table with microscopes at each seat so they could easily view the pathology slides from patient biopsies.  The radiologist would highlight key findings on CT or MRI and different surgical vs nonsurgical treatment plans were discussed among the various specialists; the images were also projected on a monitor so we could follow along.  Later in the week we also attended a CNS (central nervous system) tumor board.

We also discussed the use of brachytherapy for cervical cancer, in which radioactive seeds are inserted into the tissue itself and a high dose of radiation therapy is delivered to the tumor.  One of the residents demonstrated the use of a “tandem and ovoid fletcher suit set” (as pictured), where the central tandem component goes into the cervical os and measures the depth of the uterus, and the white ovoids are inserted into the vaginal fornices to further spread the radiation dose to the side of the cervix.  Our team discussed a few of the following features and shortcomings of the device:

  • There are two screwable “gear” pieces that hold the bars together in the preferred configuration and the bottom gear was consistently found to not tighten effectively
  • In a certain position when the gears are tightened, a metal piece sticks out from the bottom gear and can rub against the inner thigh and cause discomfort.  The current solution is to tape over the metal piece and bottom gear to provide stability and ensure greater comfort.  The patient is generally under anesthesia when this device is being used to deliver radiation
  • The rigid cylinder ovoid pieces come in different sizes and allow for precise positioning, durability, and easy sterilizability
  • The bottom ends of the device connect to a machine that dispenses the radiation dose — the 3 prongs of the device are matched to the machine according to the number of engraved rings around the post (1,2, or 3).  When they are not connected, there are light tan caps that cover the ends but are difficult to see and therefore easy to lose.

We also witnessed radiation treatments being delivered to patients.  In one instance, the patient’s head had to be secured in a frame for brain treatments and because this patient’s planning CT was taken slightly off center, the patient had to be manually adjusted for the subsequent treatment in order to match the position of the original CT.  X-rays are then taken directly by the machine and overlayed with the planning CT to confirm proper positioning.  I asked if there was a way to input the degrees of shift and the machine would automatically adjust the patient without the technician having to go back into the room.  This is actually possible with the current technology, but the technicians prefer to manually adjust the patient if necessary since if the machine auto-adjusts, there is a chance the table the patient is laying on will collide with the linear accelerator as it is rotating around to deliver the radiation.

We also witnessed a rare case of total body irradiation (TBI) for a patient with severe sickle cell anemia with recurrent vaso-occlusive pain crises.  The point of radiating the whole body is to deplete the immune system in preparation for a stem cell transplant, which will provide the cells that will ultimately differentiate into functional blood cells.  For the TBI the patient must spend half the time prone and half supine for an adequate distribution.  Rice packs are also packed around the patient to create the illusion of a “rectangle” shape that facilitates uniform radiation distribution and also to partially spare sensitive areas such as the head and genitals.

Week 4 Part 1: Intro to Radiation Oncology

I was definitely excited to move on to our next rotation of the program and experience a new clinical environment and unique patient population in the oncology departments.  I will miss the access to surgery that ophthalmology offered, since radiation + hematology/oncology are clinic based, but there is definitely not a shortage of activity high-tech care delivery.

Our first week is spent in radiation oncology — the rad onc program at UIC is a joint residency between UIH and University of Chicago, so the residents spend 2-3 months out of the year seeing patients at UIC.  I was immediately struck by the calm, quiet atmosphere of the rad onc clinic, especially when compared to the often hectic pace of the ophthalmology clinics.  The volume of patients at the UIC rad onc clinic is typically lower than the UChicago clinic, so the appointments are generally not rushed and wait times are not a significant patient complaint.  This also meant that I observed fewer patient encounters, but there was a certain gravity and sensitivity that surrounded the visits that was unlike what I had previously experienced.

We met the head of the radiation oncology department and the 3 residents, who were all extremely welcoming and eager to share the intricacies of their specialty with our team.  Each attending has one “academic day” per week to catch up on academic duties such as grant writing or paperwork, so their resident has a more flexible schedule that day; we benefited from this, since the residents were often able to spend significant time explaining concepts to us such as tumor staging or the physics principles that go into making a radiation plan.  Compared to other specialties I have experienced, the residents in rad onc are very academically oriented and well-versed in the literature of the field — we observed this during the weekly tumor board meetings in which oncology cases are discussed with a multidisciplinary team, and during “chart rounds” where the residents review their patients who are scheduled to start treatment that week and the indications for a particular plan.

When describing the aims of the clinical immersion program to the residents, they were generally interested in helping us recognize needs, but they also highlighted how radiation oncology has evolved even recently as a field to optimize care delivery.  This includes the advancement of image guided radiation therapy (IGRT) to ensure that the patient is in as close a position to their original planning CT as possible so that the radiation is precisely delivered to the same location each time.  Another example is the use of multi leaf columnator technology (MLC), in which metal “leaflets” interlock in a way that shapes the radiation beam as it exits the linear accelerator; this also allows targeted delivery of the radiation to a defined tumor area, and spares normal peripheral tissue.  In response to the prospect of optimizing current practices, one of the residents offered a unique perspective that “perfection is the opposite of good enough”.  He meant this in the sense that minor improvements often don’t amount to measurable outcome changes, so it is important to tackle a problem that has the potential to

A few additional notes/observations are as follows:

  • When planning the radiation treatment margin, an advanced software is used to contour the tumor, and then buffer layers are added that surround the initial contour to account for molecular spread of disease as well as for minor patient movement during treatment.
  • In order to ensure the patient remains in the same orientation for each treatment, they are placed in an immobilization “cast-like” structure that holds the head, limbs, etc in a certain fixed position that can be easily replicated.  The department has carbon fiber immobilizers for breast cancer patients (shown in image), and these are lightweight, sturdy, and radiolucent (although expensive). For other cases, a large plastic garbage bag is filled with a mixture of compounds that produce an effect similar to wall insulation and the patient lies on it in the desired position until it hardens and forms an imprint of the patient.  The immobilization molds are then labeled and stored on shelves for future use.
    • Although the initial immobilization process appeared streamlined, it still struck me as “crude” to use bags with an inflatable compound and store them for each patient for the duration of their treatment
  • Movement during radiation treatment (especially breathing for lung tumors) presents an issue for delivering consistent dosage.  Motion tracking and motion compensation technologies are key innovations that address this, including Vision RT that images the patient and reports parameters in real time to gate the radiation.
  • Pediatric patients can receive radiation as well, although it is generally not given under 3-4 years old.  However, they usually must be anesthetized for each treatment, since keeping a constant still position each time is often too difficult for children.  This surprised me, since although anesthesia has become safer it poses an additional risk as well as an additional cost associated with the treatment

Week 3 Part 2: Wrapping Up

Our last days in ophthalmology were spent presenting our observations to Dr. Sugar and having a final debriefing with him about our experience in the department.  We also spent a final day in the OR observing cornea and retina procedures.  In particular, we were able to talk with Dr. Rosenblatt, a cornea specialist and the head of the ophthalmology department, who also has an engineering and business background.  He shared with our team his views on the future of stem cells for corneal nerve regeneration, unifocal vs multifocal intraocular lenses (for cataract surgery), and the use of lasers in eye surgery for increased precision.  He also touched on the burdens of the current EHR situation at the hospital and the importance of efficient access of patient records.

I enjoyed the rotation as a whole and feel that I learned a considerable amount about a field that most medical students don’t explore on a deeper level.  I appreciated the exposure to the many subspecialties within ophthalmology, and gradually became more comfortable with my role as the weeks progressed.  However, it was sometimes challenging to reconcile my roles as a medical student and as an outsider identifying problems; having limited training in medicine and engineering made it difficult at times to recognize if my insights were actually significant or if change could feasibly be implemented.  Medicine and the technology behind it is constantly evolving, but adoption of change is a much more hesitant process, especially in the face of a limited budget and resources.

The process of observing in clinic was unique, since most of the providers I encountered were eager to explain any clinical findings and discuss where they see room for improvement in their practice or the field in general.  Sometimes it was more difficult to communicate with the providers especially when they also had a fellow, residents, and other senior medical students on their service (such as in pediatrics and neuro).  There were days when I played a mostly passive role so as not to interrupt the flow of clinic, but this was balanced by opportunities to observe procedures and ask questions between patients.  The senior medical students and residents were also great resources throughout the rotation who would explain basic concepts or walk us through a surgery.

Week 3 Part 1: General eye clinic + surgery simulation

7/19/16: General eye clinic + oculoplastics

For the first half of the day I followed our clinical supervisor Dr. Sugar between his regular cornea clinic and the General Eye Clinic (GEC).  The GEC is primarily run by the residents, but each patient must ultimately be examined and signed off by an attending.  

At some point during the day there was a communication breakdown and Dr. Sugar was not called/paged when he was needed in the GEC and as a result, a couple of patients left after waiting for an extended period of time.

In oculoplastics, we met a team of engineers/scientists who were working on honeycomb shaped molds in which to deposit patient lacrimal cells in order to grow a lacrimal gland (tear gland) that could ultimately be reimplanted into a patient experiencing issues due to chronic dry eye.

IMG_3486

7/20/16: Surgery simulation

Our team was able to practice surgical skills and techniques on the same equipment the residents use for training: the Eyesi surgical platform.  Manual dexterity and depth perception are the essential skills that are tested using this simulation and our team greatly enjoyed being able to demo the various surgical modules (see attached image).

In the afternoon, we also observed a demo by a new language translation service that offers 24/7 video support from interpreters in 16 languages, and audio support for many more.  The interface is a touch screen monitor on a rollable cart with an external speaker.  It was unclear how many of these systems would be provided to the Eye and Ear Infirmary, and if this was a UIH system-wide overhaul.  Our team has previously discussed and written about the inefficiency/lack of dependability of the current  translator system, and how office staff were often used as temporary translators.  This new system solves the issue of translator availability, since there are interpreters staffed in Chicago and Seattle.

Week 2 Part 2: Peds Clinic + surgery

7/13/16 + 7/14/16: Peds Ophtho Clinic + Surgery

Our day in the pediatric ophthalmology clinic revealed new methods of delivering care as well as new challenges.  Most of the younger children are too small to use the autorefractor that determines a patient’s refractive error for glasses/contacts, so a direct retinoscope must be used.  Children who are also too small to be examined using the standard slit lamps are examined with a portable one.  The limitation of a portable slit lamp is that you can’t do a fundus/posterior eye exam and it is sometimes necessary to stabilize the patient’s head with one hand if they are unable to sit still.  In addition, the majority of patient families we saw needed some degree of translation to fully understand the extent of their child’s condition; rather than calling dedicated translators, the surgery scheduler and techs were often called into the rooms to translate for families.

The attending we followed in peds was a strabismus specialist, who surgically and non-surgically manages the condition that prevents a patient from directing both eyes to fixate on the same point.  One eye can deviate outward (exotropia) or inward (esotropia) and this can contribute to double vision or a condition called amblyopia (lazy eye).  Babies born premature are especially at risk for high myopia and strabismus but usually progress to 20/20 vision by age 5.  The typical treatment for strabismus is wearing glasses with a corrective prism that straightens the gaze of the deviated eye, and also techniques to stimulate the visual cortex in the brain.  This usually involves patching the “good eye” for a few hours per day to force the patient to exercise the weaker eye.  There were cases we observed in which the child tolerated the patching well and others where parents reported that their child would try to rip the patch off.  The alternative in these cases is to use atropine drops in the good eye that will cause it to blur when focussing on a close object, forcing the patient to utilize the weaker eye.

If the strabismus is severe enough, surgery is used to relax or tighten the extraocular muscles (typically the lateral or medial rectus muscles).  It is preferable to do this type of surgery before the patient reaches visual maturity, typically around 7-9 yrs old.  Our team was able to observe part of a strabismus procedure in the OR, but the room was especially crowded with visiting physicians, residents and senior medical students.  The surgery is extremely intricate and the duration is dependent on how many muscles need to be re-positioned.  The measurements of how to adjust particular muscles are made one week prior to surgery, but we did not observe this being done that day.  It can also be necessary to make fine adjustments to the muscles immediately following surgery in the recovery room utilizing adjustable sutures in order to ensure the gaze remains straight.

In the first case we observed, the attending was finishing the first eye and noted that she heard some gurgling coming from the patient.  In a startling sequence of events, the patient’s pulse ox dropped and a code blue was called in the OR.  The anesthesia attending and numerous other doctors flooded the room and we were confined to a corner and eventually left the room until the situation was under control.  The patient was ultimately intubated and recovered from the incident which was thought to have been caused by secretions produced by the patient that temporarily blocked the airway.  I have observed a significant number of surgeries and never witnessed a code being called in the OR; I initially felt a wave of panic and helplessness but appreciated the swift action of the team to address the problem and stabilize the patient.

We later observed a vitrectomy procedure for a retinal detachment.  This involves removal of the vitreous humor (the fluid in the back of the eye) and replacement with either gas or silicone oil, followed by treatment of the retina with laser to flatten areas where it had become detached.  Although this was a procedure we had not yet observed, my mind was still on the blur of activity surrounding the previous case and the state of that patient, who was a young child.  Thankfully, we found out later the patient was able to finish the surgery after being intubated and monitored further.

Week 2 Part 1: Cornea Clinic and Glaucoma Clinic

7/11/16: Team Debrief + Cornea Clinic

We started the second week with a team debriefing session and talk from Dr. Neiderberger of urology on needs assessment and problem identification.  He discussed the importance of identifying a problem that is simple yet impacful, and also talked about a mental exercise called ‘subtraction’ where you remove the essential piece of a device or system and re-imagine how it can be done.  We also discussed the deliverables for the end of the rotation and how the presentation and report should revolve around one high level theme — for ophthalmology, I see ergonomics and comfortability during routine examinations as a primary theme that recurs in several of the subspecialties I have observed.

I spent the afternoon in the cornea clinic observing routine office visits with our clinical mentor.  As was mentioned in a previous post, it is especially difficult to examine patients with kyphoscoliosis using the slit lamp and I observed in clinic how it was difficult for such a patient to lift his head for the exam.  In addition to patient comfort issues, I noticed the majority of rolling chairs in the cornea exam rooms lack any back support, which could contribute to strain for the provider.  My attending dealt with a variety of cases including severe astigmatism, diplopia (double vision), and pemphagoid (an autoimmune condition affecting the extra cellular matrix of tissues such as the cornea). 

 

7/12/16: Glaucoma clinic

On the glaucoma service, the metric of highest importance is the intraocular pressure (IOP), measured in clinic by a technique called tonometry, where a tip with a mini pressure sensor is applied to the center of the cornea.  For patients with advanced glaucoma, the target pressure is < 18 mm Hg, while for mild-moderate glaucoma, the target pressure is in the mid teens.  The primary method of treatment that I observed was a regimen of different eye drops thats providers often referred to in terms of the color of the bottle cap: “purple top”, “orange top”, etc.  I would often hear that a patient was “maxed out” on drops, meaning they were on the maximum combination that could be safely prescribed.  My attending noted that patient compliance with the drop regimen can be low especially among elderly patients.  I did not see any new patients in clinic that day, but I wondered if there was any form of educational materials given to patients besides the instructions on the prescription bottle.  The dosage/frequency of the drops is often adjusted at office visits and confirmed with patients verbally; I imagined a possible solution to this where providers could give patients a pre-printed template sheets with colored circles and designate the frequency of each drop below the circle.  Additional observations from the glaucoma clinic:

  • I saw a couple cases of “narrow angle glaucoma”, the less common form of the disease in which the angle between the iris and cornea (iridocorneal angle) is smaller than normal (see attached photo).  This angle was assessed in clinic using a Zeiss indirect goniolens that employs 4 symmetrical prisms that visualize the angle in 4 quadrants of the eye.  The goniolens is slowly applied to the surface of the eye, forming suction, and is often used simultaneously with the slit lamp for visualization.
  • Narrow angle glaucoma is particularly dangerous because the drainage angle of the eye can be blocked resulting in an accumulation of fluid, spike in intraocular pressure, and damage to the optic nerve.  Pupil dilation presents an increased risk for such patients to have an acute angle attack, and it is therefore critical that pupil dilation in the clinic is either avoided or done with extreme care for these patients.
  • For patients with narrow angles, a procedure called laser peripheral iridotomy (LPI) is recommended, where a hole is “punched” in the iris to allow an alternate vent for fluid to drain from posterior to anterior in the eye.  It was stressed that this procedure would not completely eliminate the chance of an acute angle closure attack, but rather is a preventive measure.

 

Week 1 Part 2: Surgery + Contact clinic

7/7/16: Cornea Surgery

On Thursday, our team observed one of the cornea attendings in the OR at UIH.  The majority of his cases that day were cataract surgeries, and we also observed a partial cornea transplant.  The attending and assisting resident or fellow are seated at microscopes for the duration of the procedure, and the cataract procedures were especially streamlined, lasting 15 minutes or less.  During a cataract surgery that does not use laser, an ultrasound instrument is inserted into an incision in the limbus (the border of the cornea and sclera), and breaks up the center of the cloudy lens (which contributes to the vision impairment).  After the cloudy lens is suctioned out, the surgeon replaces it with a prosthetic intraocular lens (IOL) typically made of plastic or acrylic that becomes a permanent part of the eye.  From an outside perspective, the procedure itself seemed extremely efficient, especially when performed by an experienced surgeon.  A few additional observations:

  • The instrument that is inserted into the limbus at a slight angle to the horizontal has a straight tip, which doesn’t provide much mechanical advantage for suctioning, etc — our group speculated about the potential benefits of a curved tip instrument
  • One cataract case necessitated a 3 part IOL since the diameter of the patient’s eye exceeded what is considered “normal range” of up to 24 mm.
  • The tower that provides suction and ultrasound must be wheeled as close to the surgical field as possible, and the cords that extended back from the machine could have posed a hazard for the scrub nurse/tech to move back and forth if necessary
  • During cataract surgery, the patient is usually under “twilight” sedation and is able to respond to questions/commands — some patients respond well when told to keep their eye focussed directly on the light above and others have more difficulty and their gaze drifts off center, which can contribute to longer surgical times

The partial cornea transplant involved isolating the endothelial cell layer (single cell layer important in keeping the cornea clear) from a donor cornea and suturing it into place in the recipient’s eye.  This procedure required a separate small worktable adjacent to the surgical field where the surgeon prepared the donor graft.  It is essential to have this area close to the patient for efficient transport of the donor cornea.

 

7/8/16: Contact lens clinic

I was able to observe several patient office visits in the contact clinic; all of the patients I observed wore RGP (rigid gas permeable) contact lenses as opposed to the soft lenses I was familiar with.  I learned that the rigid lenses are beneficial especially for patients with corneal pathologies since they provide superior vision quality, O2 permeability, and less microbial keratinitis, with the major drawback being comfortability of the lenses.  One interesting case was a patient with scleral lenses, which cover the whites of the eyes and are used for patients with corneal issues such as keratoconus (a bulging out of the cornea).  The way to insert a scleral lens involves the patient bending forward with eyes looking down, filling the lens with sterile saline solution, and using a plunger to insert the contact (see attached).  This method is standard for this type of contact but seemed burdensome for the patient and physician. 

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In addition, for patients with corneal pathology, contact lens fitting is often a more challenging process and requires trial and error with lenses of varying size and curvature.  I was able to observe a patient whose contacts fit too tight around the edges, and this was evident from the more prominent, bulging vasculature around the edges of the lens.  I wondered whether preliminary topographic imaging for such patients would reduce the trial and error component to the contact fitting process, or if this was simply not feasible or cost effective.

 

Week 1 Part 1: Intro to Ophthalmology

“What you see is what you get.”

Our team’s introduction to Ophthalmology at the U of I Eye and Ear Infirmary on Tuesday 7/5 began with this quote from our physician supervisor.  Earlier in the day, we were introduced to our teammates and discussed our motivations for being in the clinical immersion program and goals moving into the first rotation.  I was excited about starting in ophthalmology because of the prevalence of advanced technology in imaging, biomaterials, and surgical techniques. 

Our supervising attending is a cornea specialist, and also has an active role in training residents – our first day in the rotation also corresponded to the first day for the new class of residents.  The attending educated our team on basic principles of optics including visual acuity, field, and stereopsis, as well as various examination + diagnostic instruments from the basic slit lamp to optical coherence tomography (OCT) and fluorescein angiography.  He also highlighted issues such as the continued dependence on paper charts due to limitations in ophtho EHR software, and the tradeoffs between resolution and intensity among the various imaging modalities.  “What you see is what you get” is particularly relevant in ophthalmology since the eye  is the only place in the body in which blood vessels can be directly viewed using non-invasive techniques such as via the slit lamp or OCT.

 

7/6/16: Slit Lamp Demo + Retina Clinic

Our team attended the morning slit lamp training for residents led by our supervising attending.  This device is the primary illumination device used in the standard eye exam (see attached photos).  During the training, the attending demonstrated some of the following shortcomings of the device to our team:

  • Providers often “overcrank” the light source knob when they first turn on the lamp, and this can contribute to a blown fuse — it is actually rarely necessary to move beyond the first brightness setting but many of the docs have become accustomed to this 
  • When the provider grabs the slit lamp table to slide it toward the patient to begin the exam, the plugs attached to the base of the table are often accidentally pulled out since they are in an inconvenient location
  • The lamp itself moves on a series of pins, and over time the track becomes stiff and difficult to maneuver smoothly with the joystick
  • Within the illumination tower, there is a small metal disc that is in contact with a light bulb — the gradual oxidation of the disc can contribute to the failure of the light source, which can be prevented by scraping the oxidation residue from the disc
  • Adjusting the height of the slit lamp is especially difficult for very short or wheelchair bound patients.  The current workaround is a portable slit lamp (see attached), which has existed for ~20 years, but doesn’t have a chin rest, so it is necessary to manually stabilize the head with one hand and control the device with the other handpsl_3205231

Our team then had a chance to adjust the slit lamp and “examine” each other to get a sense of the coordination required to control the various elements of the machine.  Some machines also have a side viewing scope for teaching purposes.  The attending also made a point of how prevalent cervical disc disease and neck/back pain are among ophthalmologists due to the postural strain associated with the exam, especially holding the condensing lenses up to the patient’s eye to visualize the retina.

In the retina department, I followed an attending through her extremely busy clinic day that included office visits, anti VEGF (vascular endothelial growth factor) injections, and laser treatments.  This clinic also utilized primarily paper charts.  A few interesting observations from retina clinic are as follows:

  • During the anti-VEGF eye injections, I was instructed not to breathe on or near the patient to maintain sterility.  The physician had a tech assistant who would prepare the injection materials and cover his/her mouth while giving the patient instructions.  The injection process only lasts a few minutes, but I wondered later if there was a reason masks were not used to maintain sterility
  • The retina attending reiterated what our clinical advisor expressed about neck+back strain from years of performing the exam.  The strain is even more severe for retina specialists who have to manually hold fundus lenses up to the patient’s eye while seated and looking though the slit lamp.
    • A few thoughts on improving this are possibly creating a stand or attachment for the fundus lenses that could be adjusted either on the slit lamp itself or on the headset that doctors use to examine the back of the eye.

About
I am a second year medical student from Chicago. I have an undergraduate degree in Biomedical Engineering from Northwestern University, where I participated in several team-based design projects that addressed physician and patient needs. Before starting medical school, I worked in clinical research for an orthopedic surgeon with a focus on the use of stem cells for cartilage repair and regeneration in the knee. I look forward to incorporating the practice of interdisciplinary problem solving and design into my medical school training through the IMED program.