Raahil Kajani

University of Illinois at Chicago
Bioengineering


Uro in Review

In my final blog post for the clinical immersion program, I’d like to discuss the key takeaways during my time in the Urology rotation. First and foremost, it was an awesome experience. I definitely learned a lot about medical devices and gained a better appreciation for the coordination it takes at the institutional level to schedule and perform surgeries on a daily basis. There are so many people who work hard to deliver care to patients and I definitely think that, even with all the inefficiencies we observed throughout this program, it is something to be appreciated.

With that said, here are some of the experiences/observations that stuck with me:

  • The ergonomics of the DaVinci Robot console is something that can be applied to the medical equipment used in Ophthalmology. Although we spent most of our time trying to assess areas that need improvement, I thought it would be a good idea to see what is done well in particular devices. The console of the DaVinci robot is set up in a way that is very comfortable for the user. To quote one of the surgeons who frequently uses the DaVinci Robot, the console is so comfortable that he “could fall asleep using it”. Especially since ophthalmology is a specialty that is known to have physicians with neck and back problems, applying some of the ergonomics to equipment like the slit lamp could be beneficial.
  • Transferring the patient from the bed to the operating table is a process that can definitely be improved. I imagine that if patients had the opportunity to watch a video of how they currently move patients, they would be surprised. From the few weeks we spent watching surgeries in the operating room, we saw that the best current technique is to have a group of people physically lift the patient and move them to the operating table. Most of the time, the patient is under anesthesia and is hooked up to various types of equipment, including devices that are used to maintain the patients airway. Additionally, the people who are moving the patient are generally the same people who will be playing a role in the procedure that is about to be performed. This can include someone as vital as an Anesthesiology attending. It’s been mentioned before, but the students who were on the Anesthesiology rotation saw an attending physician get injured moving the patient to the operating table. This is definitely a process people are already looking into, so it would be a valuable exercise to see the approaches people are taking to solving this issue.
  • On top of transferring the patient to the operating table, securing the patient in the proper position for the surgery can also be a time consuming process. From what I observed, the current method of securing a patient is to basically grab whatever you can to support the patient in the position you want. Generally, foam pads, pillows, blankets, and other types of support equipment (like a large gel type pillow) are stuffed under and around the patient. The only thing holding all of these things together is multiple pieces of tape. Essentially, there is no method; the physicians and staff basically figure it out as they go. Again, there has to be a better way.
  • Finally, the flow of equipment from the operating room to the sterilization department and back is a process that needs evaluation. Missing equipment is by far one of the most common causes for delays in the operating room. In fact, most surgical teams expect that some sort of equipment will be missing before they start the procedure and do their best to prepare for that. Although our team spent time asking staff in the OR and SPD about their work and how they hope to fix the issue of missing equipment, this is a process that requires more observation. In order to really get to the key issues in this process, we’d need to create surveys and collect data that can be analyzed and looked at.

These are the main experiences that stuck out to me. As always, thank you for reading!

Some Assembly Required

In this post, I’d like to discuss our team’s second visit to the Sterile Processing Department (SPD). After our first visit, we still had many questions and thought it would be best to take a closer look at some of the processes SPD is responsible for, mainly surgery cart assembly and surgical instrument tray assembly.

As soon as we walked back into SPD this morning, we saw a whole fleet of surgical carts either completely or near completely ready to send up to the operating room. On top of each cart was a thick packet containing a checklist of the cart’s contents. These were the same checklists that the surgical teams send out to SPD the day before the surgeries are scheduled. Upon closer inspection, it was clear that someone had thoroughly gone through the checklist, making a mark to indicate whether or not a particular item was included in the cart. It was encouraging to see this especially after hearing the operating room staff talk about their frustrations regarding missing equipment/equipment availability. 

However, one thing that was not so encouraging was the presence of another piece of paper on top of each cart: a missing instruments list. Almost every single cart that was either prepared or almost prepared for surgical cases scheduled to take place in a couple hours had a missing instruments list attached to it. When I asked if this was normal, the staff member told us this was a daily occurrence. I’m not sure exactly how much time the surgical team gets to try and find these missing instruments before a procedure is set to take place, but the fact that this is something operating room physicians and staff must prepare for before almost every surgery is a huge issue.

After learning about the various instrument lists for each cart, we learned a little bit more about how carts are prepared. One thing we found out was that the SPD staff are indeed trained to prepare carts for particular surgeries, at least to a certain extent. From what I understood, the carts are prepared for one particular surgical case rather than making a “one size fits all” style cart. However, the types of carts that can be prepared are the same for a particular department. For example, there is a cart for plastics surgeries, a cart for orthopedic surgeries, a cart for ENT surgeries, etc. While it is great that the surgical carts can be tailored for particular types of procedures, the hospital generally schedules similar types of procedures on a particular day. For example, today was a Tuesday, and the OR usually has many orthopedic cases scheduled on Tuesdays. This can pose a problem, especially since there are many surgeries that require the same equipment. This means that all available instruments for these surgeries are in circulation and will need to be cleaned and sterilized on the same day which can be difficult for SPD. Even though they do their best to prioritize those types of carts, turnover of sterilizing equipment is a long process. Surgical teams tend to request the soiled equipment to be ready in an hour. When I asked how long is usually takes for soiled equipment to be ready, the staff members replied that it generally takes three hours. As you can see, this is not ideal.

After learning about how carts are assembled, we then spent time learning how the trays in the carts are assembled. The best way to view how equipment is organized for surgeries is as follows:

  • there are three levels to look at (from macro to micro): carts, trays, instruments
  • individual instruments are organized into trays. These trays are organized to hold instruments for particular surgeries organized again by department. There is also a general instruments tray.
  • When carts are being assembled for a particular procedure, a group of about 5 trays gets loaded onto the cart. Additional items are loaded onto the carts along with the trays.

Watching the tray assembly process was interesting. This step of the process occurs after soiled equipment has been sent and cleaned of any tissue or debris left from the last surgery. Ideally, instruments are sent back in the same tray they were taken from. This way, after initial cleaning occurs, the tray is scanned by the assembler (to document that it as been decontaminated and is now being assembled) and assembly can begin. The assembler then empties out the tray and can go through the checklist to ensure that all the items are included. However, it isn’t always the case that equipment is put back in the proper trays after surgery is complete. The SPD staff must communicate often to let other assemblers know what they are missing and what they may have extra. If OR staff were more thorough in putting away the equipment in the correct trays, time can be saved for the SPD staff to assemble trays. 

While constant communication about the many instruments involved in tray assembly is difficult and can’t always be maintained, there is a system in place to try and organize this process. Currently, if there is extra equipment that does not belong in the tray, the tray assembler puts the extra equipment into an “extras” bin. Periodically, the extras bin gets sorted and the extra instruments are organized into bins with similar type of instruments (but not the exact same instrument; for example, microscissors of every length and size would be together in the same bin). On the other hand, if equipment that is supposed to be in the tray is not present, then the assembler must input in the system that the instrument is missing. Unless the assembler can locate it by communicating with other staff members, the tray is assembled without the instrument and sent to sterilization.

This is just a quick overview of some of today’s experiences. Thanks for reading!

Left to their own devices

In this post, I’d like to discuss some of the surgical devices our team has learned about after two weeks of our rotation in Urology. While all of these devices may not be as complex and sophisticated as the DaVinci Robot, they are important for the specific procedures that they are used for.

First, I’d like to discuss a tool that is used in minimally invasive prostate resections. A prostate resection is a procedure that is performed on men who have an enlarged prostate. In the procedure, a small scope with a cutting tool attached to it is inserted through the urethra to the prostate. Once the prostate is located, the surgeon looks at a screen which shows a live feed from the scope as a guide to remove part of the prostate. With the help of electricity, the surgeon will heat the cutting tool (positioned immediately in view of the scope) until it becomes red hot and then will start shaving off pieces of the prostate. As the surgeon continually removes small bits of tissue, the small blood vessels in the prostate begin to bleed. In order to control the bleeding, the surgeon electrically heats the tool to another temperature and touches it to the bleeding vessels, cauterizing the wounds. The surgeon is able to control whether he wants to cut or cauterize by using two foot pedals. With his eyes on the screen, his hands on the scope/cutting tool, and feet on the pedals, the physician carefully removes parts of the prostate. Once enough tissue is removed and all the bleeding is controlled, the surgeon removes the resected tissue from the patient and the procedure is complete. 

The next medical device we learned about was the inflatable penile pump, which we were able to see implanted in one patient. The inflatable penile pump is an entirely internal implant that can be operated by the patient using a mechanical pump located in the patient’s scrotum. Attached to the pump is a reservoir that holds saline fluid that is used to fill the tubes that are placed in the penis’ corporal bodies. When the patient desires an erect penis, he simply squeezes the pump about 10 times to fill the tubes in the corporal bodies. When the patient wants his penis to return to a flaccid state, the patient simply pushes the release valve until almost all of the fluid in the tubes return to the reservoir.  To successfully implant the device, the tissue in the penis’ corporal bodies must be destroyed to make room for the inflatable tubes of the implant. The main concerns for the physician and patient is to prevent infection during and after the procedure is complete. To account for this, the implant is generally coated in antibiotics before it is placed inside the patient’s body.

With regards to the device, the company representative was kind enough to speak about some of the common issues with the penis pump. First, the penis pump generally only lasts about 10 years before another one must be placed. One of the most common reasons for a pump to fail is that the material of the pump ruptures, causing the saline fluid to be released into the body. While the release of the fluid in the body does not put the patient at risk, the pump is no longer functional and must be replaced. Usually since most of the patients who want a penis pump are older, generally they will need only one implant. However, for those patients who have greater longevity, multiple implants may be required.

Another area where the manufacture wants to improve the device is in the design of the fluid reservoir. Currently, the fluid reservoir is placed between layers of connective tissue in an empty space within the pelvis. To properly place this device in this specific location, the reservoir must be looped into the inguinal ring, a site where hernias commonly occur. Placing the reservoir can be problematic if the patient has had a hernia in the past, which can be common for the elderly patients that elect for the penis pump implant surgery. The manufacture representative told us that the reservoir is currently being redesigned to be placed in another area of the body. As of now, the reservoir is shaped like a sphere and is relatively large. One of the approaches being taken to redesign the reservoir is that they are making it flatter and pancake shaped. The ultimate end goal is to create a reservoir that can be easily implanted and will not physically show up on the exterior of the patient.

The last surgical device I’d like to discuss are the lasers that are used to destroy kidney stones. For most kidney stone procedures, a scope equipped with a laser must pass from the urethra through the bladder and up the ureter towards the kidney. Once the stone is visualized by the scope, the laser is aimed at the stone through the use of a green light. The surgeon then adjusts the wavelength, frequency, and energy settings for the laser to ensure a safe removal of the stone. The laser company representative told us how higher wavelengths/low energy settings are starting to be used more frequently now to make ensure that fragments of the stone are not pushed back into the kidney as the laser destroys the stone.

These are some of the devices we got to learn about. Thanks for reading!

Urodynamics

In today’s post, I’d like to discuss a piece of equipment that is used to assess bladder functions in patients: the Urodynamic System. The Urodynamics System is the best device when it comes to finding out what is happening with the bladder and the factors that influence bladder related diseases. 

First, I’d like to briefly go over what the machine does and how data is gathered using this machine. The type of patient who would require a Urodynamics test would be an individual who is experiencing problems related to urination, whether it be increased frequency or issues with voiding completely. The Urodynamics test takes objective data about a patient’s bladder and couples it with subjective information coming from the patient. Before the Urodynamics test can be done, the patient is instructed to come to the clinic with a full bladder to take a preliminary test, the Uroflow test. The patient is instructed to pee in an electronic toilet, where data is collected about the urine’s flow (volume, rate, etc.). After this test is completed, the Urodynamics test can begin.

In a nutshell, the Urodynamics test assesses a patient’s desire to use the bathroom as water fills the patient’s bladder. This data, along with other data collected in the test (including the pressure generated by muscles in the pelvis and the bladder wall) can tell the physician whether the patient has an overactive bladder or a different condition related to the bladder. To get all of this data, several catheters are used. One catheter is responsible for filling up the bladder with water via the urethra. A second urethral catheter is also inserted to measure the pressure generated by the muscles that make up the wall of the bladder. Finally, a third catheter is inserted in the patient’s rectum. This catheter measures the pressure generated by pelvic muscles that are involved in the voiding process. The difference between the pressures in the urinary catheter and rectal catheter is used to assess the pressure generated on the urine as it leaves the body.

As water is pumped into the bladder, the patient states how great their desire is to void (on a scale of 1-4, with 1 meaning “I feel a small desire to urinate” and 4 meaning “I need to go right now”). As the patient reports these sensations, the nurse marks this information, correlating the desire to void with the volume of water in the bladder. Once the patient can no longer hold in the water, the patient voids into the electronic toilet again, where the data from the urine flow test is gathered again. Based on the data collected, the physician can have an accurate and precise picture of how this patient’s bladder is functioning and can then make a diagnosis based on these results.

Although there is no better way to assess bladder functions, the Urodynamic test does have its limitations and can be difficult to use. The following are some of the aspects of the test that can be improved:

  • The test, on average, takes 2 hours to complete. Part of the reason why this process takes so long is because patient’s generally require the procedure to be explained before the test can be conducted. This generally takes about 20-30 minutes, especially since patients can be frightened by the amount of equipment that will be place inside of their body. 
  • Calibrating the pressure-reading catheters is a difficult process. Before the test can start, the pressure readings on the two catheters must be equal. To do this, the placement of the catheters must be adjusted by either feeding the catheter deeper into the body or pulling the catheter out by a small distance. In order to take a preliminary reading of the pressure sensors, the patient is instructed to cough. Once the patient coughs and the catheters are secured at their specific lengths, the test can begin.
  • Adjusting the length of the catheters is a challenge, especially because the anatomy of each person is different. To account for these differences, the nurse has estimates about how far the catheter must be inserted based on how tall the patient is and whether the patient is male or female.
  • An additional obstacle for the nurse is securing the catheters at the proper length for calibration. Once the catheters are calibrated, the nurse secures the catheters by thoroughly taping them up. Once the taping is completed, the patient must walk about 3 feet from the examination table to the electronic toilet. In this process, the position of the catheters can change and the catheters must be recalibrated. This can be a frustrating and time consuming process for everyone involved. After discussing this with the nurse, she expressed the desire for something that can secure the catheters in a position by locking but also has the ability to unlock so small adjustments can be made.
  • If the patient talks or moves during the urodynamics testing, it will be registered by the pressure sensors in the catheters. 

These were some of the limitations of the Urodynamics machine in assessing bladder function. While it is an amazing diagnostic test, conducting the test can be a hassle. Thanks for reading!

Equipped for Success

Hello again! In today’s post, I want to discuss a part of the hospital that most medical students and health care professionals do not usually get the opportunity to learn about: surgical equipment sterilization and processing. Although cleaning and organizing equipment is not the most glamorous or interesting aspect of hospitals, they are vital processes that are essential to patient safety and an efficient operating room workflow.

From a macro view, equipment use and processing at University of Illinois Hospital by UIC involves three major departments: the operating room, the sterile processing department (SPD), and the transport department. Over the past week, our team got to spend time in the operating room and the SPD, learning how equipment is organized in each department and where potential delays in equipment availability arise.

First, let’s start in the OR. Obviously, the OR is where all the equipment is used. This involves anything that comes in direct contact with the patient during surgery that is reusable including clamps, irrigation/aspiration devices, IV pumps, and many other devices. Over here, the nursing staff is usually in charge or locating the correct equipment and making sure that all the tools necessary for a certain procedure is available. This is not always as smooth of a process as it should be and can lead to many delays in the operating room. Some potential delays at this stage include:

  • if sterility is compromised, new equipment is needed
  • if crash carts are not assembled correctly, staff needs to locate and deliver sterile equipment
  • if changes to surgery schedule are made, SPD and transport are not always aware of these changes

Ensuring that the physicians have all the equipment that they need is not an easy process and is something could be made more efficient. At this point in time, there is no sort of system that keeps track of where any piece of equipment is located at any given time. Additionally, if a tool is needed, it’s not always known whether there is one available. The only system in place is a loose inventory and scheduling system that is coordinated between SPD and an OR staff liaison. 

This brings us to the next step of equipment processing: sterilization at SPD. Once equipment is used, SPD organizes and cleans the parts. After SPD receives used equipment, each item is scanned, marking it as a decontaminated item. Next, these scanned items are then sent to the proper location for sterilization. After the equipment is cleaned, they are scanned again. This second scan essentially makes a note that this piece of equipment is clean. Once sterile, the carts are assembled and equipment is handed off to the transport department, which takes the equipment back to the OR.

While there is some organized process here, there are still many delays and inefficiencies in SPD. One source or delay for SPD is maintenance of equipment that is necessary for SPD to do their work. For example, the equipment elevators that carry used equipment from the OR directly into SPD sometimes don’t work. When this happens, someone needs to physically transfer all the carts of soiled equipment from the OR through an alternate path to SPD, which ends up taking much longer than if the elevators were working. Another piece of equipment that also needs servicing are the computers that are used to scan equipment. When these computers break down, there are long lines to scan equipment for decontamination and sterilization and employees not always scan equipment. As a result, pieces of equipment can get lost while they are being cleaned and processed.

While some of these inefficiencies are a result of issues within each individual department, delays can be avoided by better communication between these departments. All of the surgeries in the OR rely on transport and SPD to make sure that the equipment they need is available when they need it. Usually, around 1 PM on any given day, the OR sends SPD a schedule with all the surgeries planned for the next day. Based on this schedule, SPD does it’s best to make sure there are enough crash carts available. However, SPD staff is not trained to tailor the carts to the procedures that they are being used for. For example, it’s clear that different procedures will require different pieces of equipment. However, SPD staff does not know how to assemble the carts for one type of procedure versus another. Instead, they are trained to just assemble a standardized cart that has the exact same equipment.  When these carts are taken to the operating room, the surgeons and staff do not always have the specific equipment they need. Additionally, a lot of the equipment in the carts are sometimes not used and can get in the way.

Learning about equipment processing in the hospital was definitely an eye opening experience. Our team hopes to learn more about the transport department’s role in equipment processing in the future. Thanks for reading!

Bodies in Motion

What’s up everyone! Today was the first day of my rotation in Urology as part of the clinical immersion program. Now that I have one whole rotation under my belt, I felt much more comfortable to dive into my assessment of needs in the clinic and operating room. Here are just a few of my thoughts and experiences from my first day of this rotation.

Since Urology is a specialty that includes a substantial surgical component, our team really wanted to evaluate some of the processes and work flow particularly in the operating room. Almost immediately after we started talking to some of the physicians and staff, some of the same needs that were identified during my rotation in ophthalmology started popping up again. In particular, communication between physicians and staff was a common complaint when I would ask people what they wish they could improve. In a clinical setting, communication regarding patient information (like medical records, prescriptions, etc.) tended to be the main issue. However, here in the OR, communication regarding equipment use and location was the core issue. I heard groans and sighs all day as various nurses and physicians recounted their stories of surgeries being delayed because some piece of equipment was not available. Often times people must hope that the equipment they need is available when they want to use it. If they can not find it, they must go on a search to find where it is, how long it is being used, and when it will be ready for them to use afterwards. This can be a time consuming process, especially when we consider that after use, the equipment must be cleaned and prepared for the next use. This is something our team definitely wants to evaluate as we continue our rotation.

The next experience that stood out to me was how one patient was being prepped for a procedure that involved the use of the DaVinci Robot. What made this experience so vivid in my mind was how inefficient and makeshift the whole process of positioning the patient was. First, the patient was wheeled into the room on her hospital bed. Next, a team of three people were required to lift the patient off of the bed and transfer her to the operating table. It did not seem as though there was a method to this maneuver as they pretty much just lifted her from the bed straight onto the table. Once the patient was on the operating table, various equipment was hooked up to the patient, including the heart rate monitor, IV fluids, and devices used to maintain the patients airway during the procedure. Once the patient was sedated and put to sleep, the team in the operating room then faced the task of getting the patient in the proper position for the DaVinci robot.

Since this particular procedure required the surgeons to work on the kidney, the patient needed to be positioned and secured on her side; this was a process that ended up requiring more improvisation than I expected. With the patient asleep and connected to various equipment, a group of 4 men needed to lift this patient up and onto her side. Especially since this patient was overweight, this was very difficult for all of the people involved. The physicians and nurses had to make sure they had a secure hold on the patient before making any movements. They needed to count down and make sure that they moved the patient at the same time. From my perspective, it looked like they were just trying to get the best grip they could before they moved the patient from place to place on the operating table. Once the patient was in an acceptable position, the next task was to secure the patient in this position. To do this, the doctors would grab whatever they could to make sure the patient would stay still. This included blankets, pillows, pieces of cut foam, and a big jelly looking roll type thing (I’ll try to grab a picture next time) that was placed behind the patient to prevent her from rolling onto her back. After all these pieces of support were added, the physicians then took multiple long strips of tape and used it to attach the patient to the operating table. Once that was complete, a drape was attached over the patient and was secured to two IV bag poles using what I could best describe as the clips I use to keep my cereal bags closed. It was definitely a process where the physicians and staff figured it out as they went along.

Needless to say, I was shocked at how much improvisation was required to get the patient in the proper position. Overall, the whole process took about 25 to 30 minutes. Especially when I juxtaposed this process next to the robotic surgery that immediately followed (a procedure that is all about using precision), it was eye opening. There has to be a better way to do this. I would imagine that the patient would not be happy to see how she was being moved around on the operating table. Additionally, the way everything was done, there seemed to be a high risk that one of the physicians could have hurt himself moving the patient around (in fact, I remember one of the other students talking about how Dr. Edelman hurt himself moving a patient a couple of weeks ago). This could be problematic, especially when the physician who hurts himself ends up being the person who must perform the procedure.

Other things that stood out to me today:

  • Before the robotic surgery started, there was some trouble getting the robot into the correct positioning for the surgery. In particular, the arms of the equipment hanging from the ceiling (mostly lights and monitors) were getting in the way and had to be moved multiple times before the surgery could begin.
  • Once the surgery did begin, the team standing around the patient would often bang their heads against the monitors that were closely behind/around them. This happened at least 3 times to different people within the first 20 minutes.
  • The surgeon who was using the DaVinci Robot talked about how comfortable it was to use the machine. In fact, he stated that he could fall asleep because he would be so comfortable. This was a stark contrast to the Ophthalmologists who would complain of back and neck pain after performing various procedures.

Thanks for reading!

Room for Improvement

As the first rotation of the clinical rotation program comes to an end, I’d like to share some thoughts regarding my time in the Ophthalmology department.

Ergonomics is (surprisingly) a big issue in Ophthalmology, whether or not people will say it is. Just based on conversations that I had with practicing physicians during the rotation, at least half of the doctors were experiencing some sort of back pain or neck pain. Some people would even have regularly scheduled appointments with chiropractors and acupuncturists just to treat the pain. When I asked those with pain how it started, I was given a variety of answers, but most of them had to do with posture/positioning during surgeries and procedures. Just something as simple as having your chair too high or leaning over to have a resident look over your shoulder during surgery is enough to create constant discomfort for the physician. There has to be a better way, especially since this problem is so widespread within the specialty.

Patient flow is another area that has a great amount of room for improvement. By far, the most common patient complaint I heard about was regarding wait times. During my time in the department, it was clear that there were many inefficiencies that ends up wasting the time of both the physician and patient. Especially since many of the patients that come to the Illinois Ear and Eye Infirmary are referred by another physician, medical records for patients aren’t always readily available. Many times, patients will not remember exactly what the last physician they saw told them, and that requires the physician to perform the same examination to get information that was already obtained. So much time would be saved for physicians if they knew exactly what the referring physician’s concerns and treatment plan is for the patient. However, this information is usually not available (especially if the records are from another institution or medical system) and the onus is on the patient to make sure he or she has all the information they need to give to the physician.

While the need for better ergonomics and patient flow were clear, there were other areas that had room for improvement:

  • The type of health records used in the ophthalmology department definitely needs revamping. The current system in place requires physicians to take their notes on paper. These records are then scanned and added to the patient’s digital folder. Even though this does technically qualify as an electronic system, the patient information cannot be searched electronically and information is only available once it’s scanned (which can take a couple days).
  • Patients often had their time wasted because referring physicians would not know where to send their patient to get the treatment they needed. This was especially true with patients who needed to see a neuro-ophthalmologist. Generally, when a physician does not know where to send their patient, the default answer is to send that patient to the emergency department. The burden is then placed on the ED physician to assess the patient and find the correct specialist to treat the patient. This process can sometimes take days, with the patient wasting countless hours just finding the right physician that they need.
  • Patients often need multiple visits to get the proper contact lenses that they need. Many patients require contacts to be customized by a third party company that fabricates the lenses. Doctors are limited in their ability to find an optimal fit for patients as they usually have to rely on trial lenses to estimate a fit for the patient. Essentially, a trial and error process is used to find the right fit for patients, a process which often requires a minimum of 3 visits.

Overall, I really enjoyed my time in the ophthalmology department. Especially as a specialty that uses a variety of medical devices, I was fascinated every step of the way. Thanks again for reading. Up next are my adventures in the Urology department!

The Beauty in the Eye of the Beholder

In today’s blog post, I’d like to share my experience in the oculoplastics division of Ophthalmology. Here are a couple of the thoughts and experiences that stuck with me.

As a specialty that is highly concerned with design and aesthetics, many patients who seen in this department have concerns with outwards appearances. For example, one of the patients that came into the clinic had previously had an eye entirely removed and was looking to get a prosthetic eye fitted. In a nutshell, the process of getting a prosthetic eye first requires a ball to be placed into the orbit and attached to the extraocular muscles. Once the proper size ball is placed and attached, the patient must wait for tissue to grow around and integrate this part of the prosthetic. Once this tissue has grown, a shell that is created to look like the patient’s natural eye is then placed onto the ball, completing the process.

While this method does allow the patient to have the appearance of a realistic eye, it’s not perfect. One capability this prosthetic lacks is the ability to have realistic eye movements. Since the shell is essentially sitting on the ball that is attached to the eye muscles, it does not always completely follow the movements of the ball underneath. One solution that the physician had discussed was to physically attach the shell to the underlying ball. This would require the physician to drill a hole into the ball and have the shell attach to it using a peg. While this solution creates realistic eye movements for the prosthetic eye, the hole that is drilled in the ball can serve as a conduit for infections. Another solution the physician posed was to add a magnet in the ball and the shell. That way, once the shell is placed onto the ball, the movements of both parts will be synchronized, creating realistic eye movements. From his knowledge, there is no prosthetic eye that currently uses this type of mechanism.

Another experience that resonated with me was when we observed a patient who had been experiencing eyelid spasms for several years. Essentially, the patient was blinking uncontrollably and needed routine botox injections to control the spasms. During the visit, the physician had to carefully inject botox into the eyelid and orbicularis muscle, making a total of 6 to 7 injections for each eye. After watching this minor procedure, I was shocked to hear that this patient needed to have this done about 4 times a year and had been receiving this treatment for the last 7 years. It’s very unfortunate that in order to maintain control of her eyelids, the patient needed to receive approximately 56 uncomfortable injections in her eye every year. Additionally, the fact that the physician must be careful to avoid nerves and administer the correct dose for each injection means there is potential for error especially given the high volume of injections. When I asked the physician what he wishes he could do to improve this treatment, he mentioned that it would be convenient for both the patient and the physician if there was a botox that could last longer. This way, the patient would need less visits for the treatment and therefore less injections.

Thanks again for reading!

Operation!

Hello again! I’d like to spend today’s blog post discussing an aspect of ophthalmology that I have not really touched on so far: surgery. For most of the clinical immersion program, I’ve followed physicians as they work in the clinic. However, for the last two Thursdays, I’ve had the wonderful opportunity to observe several different surgeries including cataract procedures and a corneal transplant.

The first type of procedure I’d like to discuss is the cataract surgery. In a nutshell, cataracts occur when the lens of the eye becomes cloudy, impairing vision. To correct this, the ophthalmologist must remove the patient’s cloudy lens and replace it with a plastic lens. Like all eye procedures, cataract surgeries require precision and so the use of medical devices are very important in aiding the physician to perform the procedure in the most efficient way possible. First, a small incision is made in the eye. Next, ultrasound waves are used to emulsify the lens, making it easy for the physician to remove the lens via a suction device. Finally, a plastic lens that has been selected for the particular patient is then inserted and the surgery is complete. Incredibly enough, this procedure only takes about 15 to 20 minutes to perform and has very, very few complications. 

In the span of an hour, I was able to witness 3 cataract surgeries, including all the pre-op and post-op procedures for each patient. The attending physician was an absolute expert; he would explain each step of the procedure as he did it, looking through the scope the whole time while we admired his work on a monitor above. Every movement he made was deliberate and had purpose. There were only a few tools that the physician used, but they were all available to him on a table by his side. The assisting resident was seated on his other side, making sure that the patient’s eye did not dry out during the procedure. An anesthesiologist was also present in the room, but it almost seemed like a formality as she spent most of the procedure checking her email, looking for apartments, and reading Buzzfeed articles. If there was one word I could use to describe what I saw, it would be “routine”. Everybody performed their role comfortably and without worry. And with a surgery time that is only 15 minutes long and has a minimal recovery time with a patient, it almost seems that this is the best it can get. However, things can always be improved, no matter how efficient the current process is.

One thing that stood out to me about the cataract procedure (besides how easy the physicians made it look) was that the physician’s performed the entire surgery without wearing shoes. When I asked one of the residents about it, they explained that the chair used by the surgeon is controlled using different foot pedals. According to the resident, using the foot pedals is much easier without shoes because you can feel where everything is. Especially since the physician cannot see the foot pedals and must keep their hands sterile during the procedure, feeling the pedals through socks and not shoes is helpful. Now, whether or not the absence of shoes poses a potential hazard for the physician is something that can be evaluated. Off the top of my head, most of the equipment in the operating room is on wheels, so that may be a hazard. Also, especially since sterility of the physician and protection from hazardous body fluids are a concern, just wearing socks doesn’t seem to be the best option for the physicians.

While most ophthalmology procedures are considered to have low risk of complications, I did witness one procedure where there was a medical emergency. The procedure was to correct strabismus, a condition where the eyes do not look at the same direction at the same time (lazy eye), in a 20-month-old patient. Unlike the cataract surgery, this procedure is extraoccular, meaning it did not involve anything within the eye. Rather, the muscles external to the eye (these control the direction we look) are detached and then reattached to the eye so that the eyes line up like normal. 

For the first hour of the procedure, everything was going as smooth as possible. Like my experience observing the cataract surgeries, everything seemed routine for everyone involved. The attending physician was teaching the residents and medical students about what she was doing as she did it. Calm music was playing in the background while the physician hummed along. The nurses were figuring out what they were going to eat for dinner after all the procedures were done for the day. Everything appeared to be going well. 

However, just as the physician was suturing up the conjunctiva of the first eye (this is the last step of the strabismus procedure, but for this patient, both eyes were being operated on), she heard some gurgling noises coming from the patient. The gurgling sound was very soft and was something I could not hear from where I was standing, roughly 3 feet away from the patient. However, this is never a good sign since it indicates that the patient’s airway is obstructed. Immediately, the anesthesiologist goes to assess the patient and quickly finds out that something is not right. Almost 5 seconds later, we hear the heart rate monitor ping slow down as the patient’s heart starts beating slower. The anesthesiologist then sees that the patient’s pulse oximeter is at 60%, dangerously low (for reference, a healthy individual generally has a pulse oximeter reading of 99%).

The anesthesiologist then quickly says he needs to call his attending and immediately starts trying to resuscitate the patient. At this point, the eye surgery is no longer a concern and getting the patient to breath is the primary mission. The ophthalmologists step away and let those who can save the patient work. Almost 10 seconds later, we can hear the code being announced over the PA system. Seconds after that, almost 10 different people rush into the room and begin to assist the anesthesiologist. Fortunately, the emergency team was able to intubate the patient and establish a clear airway. The patient becomes stable almost 20 minutes after the gurgling sound was heard. Amazingly enough, the ophthalmologists completed the procedure after the emergency.

Reflecting on this experience, there were some things that stood out. First, the speed at which the emergency situation was addressed was blazing. It took maybe one minute after the attending heard the gurgling for the emergency team to be in the room helping the patient. Next, I commend the physicians who in the room for recognizing the warning signs as they happened. In a situation like this where every second matters, it’s so important that the physician heard the soft gurgling sounds and immediately let the anesthesiologist know. Had the ophthalmologist not said anything, the physicians would have only known that something was wrong when the heart rate monitor started slowing down. This happened only seconds later, but every second counts. These doctors were on top of their game, and as a result, helped the patient survive this scare.

However, there was something that concerned me. In order for the patient’s heart rate and pulse ox readings to drop as far as they did, the patient must have breathing struggles for at least a minute. This means that even before the physician heard the gurgling, the patient was struggling to breath.

Is there a way that this struggle could be identified before the patient’s heart rate and pulse oximeter reading drop? I don’t know the answer, but I have some thoughts. During the surgery, the entire patient’s body is covered; the only body part exposed is the eye that is being operated on. Therefore, it’s basically impossible to visually see the patient struggle since the patient is covered entirely. I don’t know whether or not this breathing struggle could be noticed if a transparent cover were used instead, but it is something that could be evaluated. The way the patient’s breathing struggle was identified in this case was the soft gurgling sound. I don’t know if this sound was present during the entirety of the patient’s breathing struggle, but if there was a way to alert the physician whenever a breathing obstruction is first present, it could be very helpful. 

Overall, my experiences in the operating room so far have been impactful. I was able to appreciate the skill and efficiency of the cataract surgery while also seeing how emergencies are handled, even when they are not expected. Thankfully, all went well. Thanks again for reading! I apologize that I didn’t have any photos to share this time.

Lasers (and other awesome experiences) in the retina department!

In today’s post, I’d like to discuss one of my most memorable days so far into the clinical immersion program. Yesterday, I spent the day in retina, a division of ophthalmology that utilizes many fascinating medical devices (yes, including lasers). Thanks to the great doctors I got to shadow, I was fortunate enough to observe a couple of procedures that used technology that I didn’t even know existed. I definitely gained a greater appreciation for the kind of skill and dexterity required by ophthalmologists to perform certain procedures.

 

Before I discuss my experiences, I wanted to talk about the retina a little bit. The retina is a small area of tissue located inside of the the eyeball and is responsible for transmitting light information into a signal that can be interpreted by the brain via the optic nerve. Because of the it’s size and location, treatment of the retina requires an incredible amount of precision by the care provider. Fortunately, there are many tools an ophthalmologist can use to visualize and even operate on the retina using minimally invasive techniques. 

 

One of the first procedures I learned about in the retina department is the delivery of medication to the interior of the eye by an intravitreal injection. This particular patient was sent to the retina specialist because he was worried about his lymphoma potentially spreading to his eyes. The physician explained that in the case that they found the lymphoma spreading into his eyes, it would be be necessary to supplement his systemic medication (which he receives during chemotherapy) with an intravitreal injection. This procedure requires a needle to travel through the anterior and posterior chambers of the eye into the vitreous chamber where medication can be delivered directly to the retina.

 

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It’s clear that this is a relatively invasive procedure that requires the physician to deliver an injection to a part of the body that cannot be visualized without the use of at least an ophthalmoscope and a lens. Based on current medical technology, this is the best way for drugs to reach the retina especially since systemic medications do not always reach the eye in an efficient and effective manner. Some of the benefits of this procedure is that it can be done in a clinic, does not require any recovery time, and is effective at delivering medication. Unfortunately for the patient, this procedure can be painful. However, the physicians noted that there is research being done to develop a drug delivery method that is even less invasive. I wasn’t able to learn too much about it, but it basically would be a gel or eye drop that would use some sort of receptor or ligand based mechanism that allows the medication to reach the retina without affecting other tissue in the eye. It was definitely very interesting to learn that alternative methods of drug delivery are being developed.

 

The next procedure I observed was the repair of a small retinal tear using an argon laser. This was by far the coolest thing I have ever witnessed during my time as a medical student. Using a lens and what basically is a slit lamp equipped with a laser, the physician was able to stop the flow of vitreous fluid through the tear by coagulating the retinal tissue surrounding the tear. This is important because the flow of vitreous fluid through a retinal tear can cause the retina to detach. Amazingly, this is a procedure that does not require the physician to physically enter the eye and can be done in the clinic. The patient does experience some discomfort, but this is the only downside of the procedure. As I watched the procedure from an additional scope, I could not believe what I was seeing. It was definitely a sight to see.

 

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What may be even more impressive than the technology itself is the amount of dexterity the physician must have when conducting this procedure. Before the treatment can begin, the tear must first be located. This is done by using the optics of the laser (which operates like a slit lamp) and a handheld lens. Next, the laser must be positioned correctly around the tear and set to the correct energy level. Once the physician is ready, he uses his foot to fire the laser while simultaneously moving it around the tear. To do this, almost all of the physician’s limbs are being engaged: the physician’s eyes are fixed to the scope with one hand holding a lens to the patient’s eye, the other hand controlling the movement of the laser, and one foot pushing a pedal to fire the laser. Needless to say, this requires an incredible amount of precision and proprioception by the physician.

 

 

 

As amazing as this procedure is, I definitely think there can be improvements made to how it is performed. First, the handheld lens being used inverts and rotates the image that the physician can see. I can only imagine how difficult it could be to hold that lens up the entire time, especially when you have to consciously think about which direction to move your hand when trying to appreciate all parts of the retina. A lens that is more intuitive to use for the physician could potentially help. Next, there has to be some way to make this procedure more comfortable for the physician. Perhaps if instead having to hold up the lenses needed to see the retina, the lenses could instead be incorporated into the laser apparatus itself. Additionally, it could be helpful if instead of having to look into a scope, the images being picked up by the apparatus could be shown on a screen. On top of all of this, it would also be helpful if a larger portion of the retina could be visualized during the procedure. From what I observed, only a small strip down the middle of the handheld lens would actually show the retina. These are just a few quickly thought out ideas and are by no means a comprehensive solution to this ergonomic issue. However, I do believe it’s important to examine how to improve the physician’s experience when performing this procedure.

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These are just some of the thoughts that struck me during my time in the retina department. I definitely enjoyed my day there and hope I can spend more time observing more procedures. I’d also like to make a quick shoutout to the retina fellow Dr. Dunn for answering all of my questions and showing me some cool procedures. Thanks for reading!

 

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The Waiting Game

As the first week of my ophthalmology rotation in the clinical immersion program comes to an end, I find myself enjoying the time I have spent in clinic as well as reflecting on my observations. All the doctors and hospital staff that I have worked with have been awesome. They’ve really taken the time to explain diseases and answer any questions I had. It’s amazing to see not only how hard everyone works, but also how much they care about their patients. Physicians and staff in the ophthalmology department understand that many of their patients travel long distances for their appointment and do everything they can to decrease the amount of trips they make to the clinic. 

However, for some patients, in order to get the treatment they need multiple visits are required. During my time in the contact lens division, I noticed many of the patients fell into this catergory. For example, patients with keratoconus need multiple visits in order to get the correct lenses that fit their eyes. Keratoconus is a condition where the corneal surface is not smooth but instead is irregular. In order to get the proper lenses that will provide the patient with comfort and restore vision, the patient must first have the topography of their cornea mapped using one a device. Once the cornea is mapped, doctors figure out which of the trial lenses they have available in the department best fit the patients eyes. Each time the patient tries on a different lens, a special dye called fluorescein is used to assess the fit of the lens. Based on this assessment as well as the patient’s preferences, a custom lens is made. Once the lens is ready, the patient must come back and this process is repeated.

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Generally, these patients need at least 3 visits and can sometimes require up to 12 visits to get the lenses that they need. From the patient’s perspective, that’s a lot of times that will have to be spent traveling to and from the doctor’s office. This can be extremely frustrating for patients, especially considering that most visits will end without the patient having the contacts that would be best. If there were some way to create the lenses in the clinic, perhaps using some type of 3D printing technology, it would save many patients and their care providers a great amount of time. There are already devices that can map the topography of the cornea. If that date could be used as in input for a 3D printer that had the proper materials needed to create the contact, the lens could be customized entirely to the patients liking.

Building on this idea of a printer being used to customize contacts, it could also be useful for patients who have aniridia (people who do not have one or both of their irises). From a medical standpoint, patients with aniridia need special contact lenses that can limit the amount of sunlight that enters the eye. Additionally, these contacts are made to look aesthetically like the patients functional eye. The current process for making these lenses starts with the care provider taking high quality photographs of the functional eye. These are then sent to a company like TechColors, where an artist uses the images to hand paint the iris onto the lens (http://techcolors.com/ProductsandServices/HandpaintedIrisLenses). Next, the lens is sent to the clinic, where the patient tries on the contacts and compares it to the functional eye. If the patient is not satisfied with how it looks, they have 90 days to send it back as many times to make the changes. Below is an example of the hand painted lenses.

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Once again, a printer that could create a design (like an iris) onto a contact lens using a information from a photograph would save everyone involved time. In fact, it could also save the patient money since the labor of hand painting the lens would be taken out. Whether or not a 3D printer which could create a contact lens and then print an iris on it is economically viable is a whole other topic in itself. There would be many factors to consider, mainly if there is a large enough market for either device.

The main take away is that there clearly is a need to help save people time. When I asked the front desk in the cornea department what the most common complaint they get from patients, they answered without hesitation: wait times. Fortunately, the physicians and staff in the ophthalmology department do make a conscious effort of reducing the wait times for patients. In fact, when I asked the residents where they felt time could be saved in the patient visit, one resident brought up the topic of translator services.

Currently, when patients who needs a translator comes to the clinic, a cart with an iPad that connects to translator services is wheeled into the room. The translator is then requested through the service, and within a couple minutes the translator is available and the patient visit can start. As of now, translators are requested on demand with the hope that a translator who speaks the language needed is available. Additionally, there is only one cart available in the cornea department, so if two patients who need it come to the office at the same time, there will definitely be delays. One solution posed by a resident stated that an appointment for the translator service should be made in conjunction with the appointment for the clinic. That way, when the patient comes into the clinic, arrangements have been made not only for the cart and the correct translator to be available at that specific time. Again, whether or not this specific solution is viable is an entire other topic. 

Ultimately, I found that there are plenty of ways that patient care can be made more efficient. Whether it’s because a the patient’s full medical records are not available from the referring physician or because the translator isn’t available, these little delays can add up quickly. Addressing all of these delays will take a long time, but recognizing where they originate is a good first step.

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Before I go, I’d like to make a quick shout out to Dr. Scanzera and Dr. Shorter in the contact lens department for spending time to answer every single one of my questions patiently! Thanks again for reading!

What you see is what you get!

Welcome to my blog! This is the first post in a series of many that will chronicle my thoughts, experiences, and ideas during my participation in the Clinical Immersion Program. I’m really excited for this opportunity and thank you for taking the time to read my posts.

 

Before I dive into my experiences so far, I want to explain the perspective through which I’ll be sharing my thoughts. As this is part of the Innovation in Medicine program, I wanted to make sure that I viewed this shadowing opportunity differently from all the times I’ve shadowed physicians in the past. Rather than just observing patient  encounters, my goal was to integrate the perspectives of the patient, doctor, and others involved in the care process to assess potential needs in medicine and the process of providing care.

 

With that being said, I’d like to provide a sort of introduction to my rotation in the Ophthalmology Department. As Dr. Sugar provided a brief orientation, showing us the various divisions in the department, he mentioned one thing that stood out to me: the major aspect about ophthalmology that differentiates it from other medical specialties is that “what you see is what you get”. 

 

But what did he mean by that? After elaborating, I gained a greater appreciation for the anatomy of the eye. Although the eye can be categorized as an external structure, it is still an extension of the central nervous system. As a result, an examination of the eye can reveal information about the internal aspects of the body. Additionally, the structure of the eye is built in such a way that the interior parts of the eye, including blood vessels and nerves, can be appreciated using light and different lenses (which means the use of radiation is not needed).

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In light of this, one could imagine that the use of visualization and imaging tools would be very important to an ophthalmologist. One instrument that I found to be commonly used is the slit lamp. The slit lamp, to my understanding, is the main diagnostic tool used by ophthalmologists to get a general idea of what is going on in the various parts of the eye. In the few days that I have spent inside the clinic so far (one day in the cornea division, one day in contact lenses), the slit lamp was used for almost every single patient.

 

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Because the slit lamp is such an important device that care providers in Ophthalmology use, I was surprised to learn that this is technology invented in 1911 (source: http://eyehistory.azurewebsites.net/the-history-of-the-slit-lamp/). In fact, the most recent update to the slit lamp came in 1996 with the development of new slit lamp optics (source:  “Eye Examination with the Slit Lamp”, Carl Zeiss Meditec, AG, p. 39, accessed: February 6, 2011). That means the most recent update was made 20 years ago!

 

Certainly, there had to be some way that something used so frequently could be improved or updated. The only way to know how was to use the slit lamp myself, both as an examiner and as a patient. Thankfully, the physicians and staff in the cornea department graciously let the students in the clinical immersion program spend time using the slit lamp. They even spent time teaching us how to properly operate and adjust various parts of the device, as well as the proper protocols used when seeing patients and device maintenance.IMG_2141

 

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I had a great time learning all about the slit lamp. It was incredible to see the versatility and capabilities of the one single machine, especially since it was invented over 100 years ago. However, the one thing that immediately struck me after my time using the slit lamp was that it was very uncomfortable to use. Whether I was the patient or the examiner, it felt awkward to properly position myself when using the machine. Both users of the machine must lean forward in their chairs and position their heads in a way that is “comfortable” for everyone (which can be difficult with varying heights).

 

Although the various adjustments to the slit lamps and the chairs being used can be made, I still found it to be uncomfortable. The patient must push their face against the strap while their chin sits in a holder, waiting for a bright (but necessary) light to shine across their eyes. The examiner, on the other hand, must fix their heads to the eye holes of the slit lamp and move along with any movements the machine makes during the exam. The fact that ophthalmologists and their patients sometimes have to sit at the slit lamp for long periods of time (sometimes as long as an 1-2 hours if a procedure is being done) makes me think that there must be some effect this discomfort has on the people using them.

 

Therefore, I wasn’t surprised to hear a physician tell me that ophthalmologists have a high incidence of cervical disc disease compared to physicians in other specialties. After using the slit lamp, it was easy to understand why. I even noticed one of the doctors in the contact lens department was complaining about neck pain, only to proceed to use the slit lamp on every single patient she saw on that very busy day. As I did a little more research on the topic, I found that there are many ophthalmologists who complain about neck and back pain. (Source: http://www.reviewofophthalmology.com/article/will-ophthalmology-cripple-you). It almost seems that by trying to provide care to the patient, the long term health of the care provider has been compromised and/or neglected.

 

There must be an alternative, right? After all, it has been over 100 years, and I could not be the first person to ever think that using a slit lamp is uncomfortable. That is when I found out that there is an alternative type of slit lamp that is portable and can be used in situations where a patient can’t come to the clinic or sit in the large patient chair connected to the slit lamp (like when the patient is in a hospital bed).

 

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While the portable slit lamp does provide diagnostic capabilities without all the arms, lenses, and moving parts of a traditional slit lamp, it can be difficult to use since both the patient and examiner must be still and stable. Additionally, because of this lack of stability, procedures which require both the patient and physician to use the slit lamp for long periods of time cannot be done.

 

These were some of the experiences I had during my first week. I had an amazing time so far and cannot wait to continue to share my experiences over here. Thanks for reading!


About
Second year medical student at UI COM interested in helping improve the care physicians provide to their patients. Born and raised in Los Angeles, CA. Basketball enthusiast and Lakers fan.