​Christine Joseph

University of Illinois at Chicago
Bioengineering


WEEK 6B: The End

Radiation is a little horrifying. And a little amazing.

Conventional radiation machines concentrate and bend ions – not actually using any radiation.

OldRadiation

IMG_8619Isotopes

The actually radioactive materials are stored in the Isotope storage room, and are contained in tiny seeds inserted into the body’s orifices to irradiate the cancerous cells.

 We talked to the medical physicist, Brett, about automating processes. He uses Python to make his job easier.

He has the daily report automated and analyzed for his review at the end of the day. He runs a check to see where errors occur, and is working to isolate these variables further to solve these tiny, almost-imperceptible problems. He compares this verification and recording with the original device specifications.

New Interface

We learned that the diagnosis of cancers like prostate cancer have increased considerably in the past few years. Because everyone in the country must now have health insurance, more people are being screened for those cancers that almost inevitably develop with time. This reminded me of my father telling me that absolutely everyone in olden-day India died of a heart attack, simply because the final cause of death was always the heart stopping.

The engineer, Simeon, showed us what’s inside the machines. He brought out relevant textbooks to explain the theory. There is an incredible amount of engineering that goes into the process of maintaining these machines.

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Some problems with the machines are almost impossible to address, simply because they are so new, and even Simeon isn’t an expert. They have found creative solutions to problems, but everyone seems aware that these solutions are not permanent.

They purchase the machines by lowest cost, there is a higher governing body that determines how much they choose to spend.

The mask they use to immobilize the patients is rigid and can make the patients feel claustrophobic. The problem lies in the fact that the nose and chin must be held in order to ensure the most static fit.

We also sat in on chart rounds, attended by doctors virtual and corporeal. It was interesting to note the topography and intensity of each image, and their use in diagnostic and prescriptive measures.

An automated tool cannot yet adjust contrast. There are too many false positives. Auto fusion of images also does a poorer job than a human’s touch.

At present.

The big question is how to reduce radiation time, for both better clinical efficacy and safer common use.

Investigational PET scans are an example of this innovation, displaying different isodoses.

Imaging

Outside the brachytherapy room, there is a radiation field that bounces off of the lead inside the ceiling, creating hot areas outside of the door. There is talk of putting down an x-ray field to plot a gradients and analyze the dissipation of this radiation.

The three tenets of radiation are time, distance, and shielding – and these are all taken into consideration when formulating a treatment plan, especially when the isotopes are used.

Consistency in procedure is maintained by a tentative predictiveness in published scales.

These last few weeks in Oncology have really hit hard. But the last six weeks, altogether, have made a real impact, as well.

I have had an incredible time working with and growing closer to everyone in this program. It was an unbelievable experience that we were all thrown into understanding together. I have learned so much and grown in so many ways.

WEEK 6A: Lines and Rays

I’m sure you’ll remember the ceiling fish from my predecessors’ blog posts -today we heard a great story about how they were installed to the perspective specifications of someone facing in the exact opposite direction of a patient lying supine on the table. This gave the impression that the fish were dead and floating at the surface of the water. The tiles had to be rotated, and a valuable allegory about considering the patient was born.

 Fish

The machines here are just incredible.

 New InterfaceOld Interface

The physicians look through the diagnostic CT scans and make their recommendations for dosage and intensity. These recommendations head to the dosimetrists, who formulate a viable treatment plan, which is then sent to the physicists, who review the angles and targeting.

 Double Door

We came in early to watch the machines turn on. We walked through the Quality Assurance procedures, checking every component and every possible malfunction.

 Laser

Because red wavelengths are wider, green lasers make clearer and crisper lines.

 

The engineer on the staff told us a terrifying story of patients dying on the table during routine radiation therapy. In that particular machine, therapists were allowed to modify treatment during the procedure, changing the intensity of the concentrated beam. However, in a few cases, the machinery malfunctioned and the protective screens did not deploy. The patients were struck with a high-intensity ray, receiving lethal dosages of radiation in minutes.

The scariest part of it is that it wasn’t noticed at the onset. And that it happened more than once.

 In this increasingly technological world, it’s tempting to allow computers to do their work, unwatched and set to their own programming. The engineer on site was once called down to investigate a burning smell, thought to be coming from the vents, but it turned out to be a machine malfunction. That’s why today – when we heard a loud, pounding noise, disturbing the patients and the peace – we ventured into the tunnels and moldy stairwells hidden underneath the hospital, to find a jackhammer in action. A formal complaint was sent straight to the source, but there wasn’t much else we could do.

 

Another review of a stem cell infusion:

 We boarded an elevator at the third floor, heading up to the eighth, with a patient in a mobile bed set to be taken to the seventh floor. The wheels of his bed jammed themselves into the space between the elevator doors, and the patient winced and let out a cry of pain. Apologies were quickly uttered, the bed rammed through the obstruction, and the patient sent on his way.

 It’s either the unevenness of the elevator floors or the diameter of the wheels at fault here.

 

The insulated transportation container could definitely stand to be lighter and have a retractable handle to reach the arm level of the research technicians.

 Bath Outside

Even after the warm water bath, and the melting through of the cells, a small frozen piece remains in the nozzle. Youngmin prods at it until it melts. She explains that the color and saturation of the blood is variable; dependent on the unique RBC concentration in each patient’s sample. She twists the cap off of the sampling tubes before she begins to use the syringe.

 The DMSO used in the freeze mix begins to smell strongly of garlicy sickness as the infusion goes on.

 The IV bag is a little difficult to pierce through during each change.

 Suddenly the floor is in an uproar – the internet connection has failed and no one can log in to update vitals. They quickly switch over to a paper-based system as an interim measure.

WEEK 5B: Comfort

After our first encounter with them last week, Jagan and I decided to seek out the Palliative Care team.

We talked about the difference between living and putting off death.

There is an algorithm for measuring adequate care; a checklist that, when efficient, is less personal, less cerebral. What makes sense for health doesn’t make sense for policy; the goal is to promote health by preventing disease, which isn’t easy to quantify. Some doctors are too focused on numbers, on outcomes. It is easy to view a hospital as a business investment, especially from an administrative perspective. There are certain expectations for returns.

The Bone Marrow Biopsy was a real shock to the system. Make sure to take a look at Jagan’s post for his account of the procedure, as well as the vasovagal response, and research into the parasympathetic nervous system. For me, it was just a little horrifying how gruesome and visceral the procedure was.

This procedure is used to assess treatment options.

Dr. Zia, the fellow, performed the procedure, with some residents and students observing. A biopsy technician stood by the side, waiting to prepare slides and samples.

Tactile: the lower back was pressed to find the site, this site was marked with a pen.

Sterile: the tools are packaged together and triple wrapped.

Effective: the syringe is coated with heparin to prevent clotting, the needle attachments are color-coded and lidded.

Then comes the lidocaine, the tiny dagger, measurement with a needle, and the boring with the biopsy needle. A core sample is removed, and then aspirate fluid. The needles is twisted out and samples are taken in tubes, slides and a dish.

In the middle of the procedure, the phone started to ring, and ring, and ring. It stopped eventually, but seemed to go unheeded for too long.

Another problem we observed was that the biopsy needle didn’t fit into the sharps box. The doctor has to wrap it loosely in plastic, and carry it to another disposal bin.

We were also finally able to see a stem cell infusion. The cassettes are removed from the holding tank, and transported in a cooled cylindrical tank. They are thawed by the patient’s room, and infused into the venous system.

The diameter of the IV tube determines the rate of infusion. It is controlled based on the time and amount of liquid needed.

The viability of the cells decreases quickly with time. Time-saving ventures are definitely worth exploring – for instance, we watched Grace, one of the research technicians, struggle to unscrew a specimen tube with one hand, while having to hold on to the sampling syringe in another.

To test viability, cells are dyed and counter in quadrants – an improvement here could lie in the development of graphing notepads for consistent notation.We talked to a few more doctors that had worked in different departments, and different hospitals – they all spoke of Dr. Rondelli’s influence on them as a team as the driving force for the program here.

So I spoke to Dr Rondelli about his reasons for being here, his reasons for building the program just so. He is a pragmatic thinker, but never lets that stand in the way of his

Much like Mike and Misia’s testimonies, my conversation with Dr. Mahmud was humbling and inspiring and infuriating all at the same time. He gave me a quick tour of his research lab, where I was able to see the tools of the trade, and the innovative ways they’re hidden to deter theft. I met his research team, and we began to talk about the work they do there. There is a conventional understanding in the field of stem cell therapy that a differentiated cell can never become undifferentiated again – but this understanding has influenced the work of researchers hoping to propagate stem cells. Dr. Mahmud’s lab seeks to understand the homing aspects of stem cells, as well as work to perpetuate viable stem cells. He explained the limitations of the circulatory system, and we spoke about the inevitability of cancer with age.

We talked about finding a niche, about how intuitive it is for the cells to return to their geneses, and how hard it is for myself to do the same.

WEEK 5A: Understanding

We were able to see the process of collecting the stem cells we’ve already seen processed.

This machine separates the stem cells and the plasma from the blood, returning the blood into the body.

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We also watched the research technicians run stress tests on some old equipment. The experiment we watched involved testing the loss of liquid nitrogen in a transportation container with an imperfect seal.

Weight

Some of the different imaging modalities we’ve encountered are PET, CT, and gram staining. At the Tumor Board meeting, doctors and nurses take a look through each patient’s imaging and histories.

It’s here that they notice some patients who slipped through the cracks – where primary care doctors don’t know how to expedite the process through the UIC hospital system. It’s here that they talk about patients whose conditions aren’t accounted for in the literature, and it’s here that connections between these outliers are made.

There is often a difference in a person’s biological age and their actual age. The way our organs adapt to age is dependent on many physiological factors, and in determining the best course of treatment, the state of the body is often more important than the generalized considerations of age.

We got our first look of the specialized BMT wing in our rounds this week. The patients in this wing are all future transplant patients, and are kept sequestered by necessity as well as convenience.

Sometimes doctors and nurses orders are illegibly written.

The whole system of rounds in this teaching hospital is an interesting exercise in contribution and gaining experience. Each person on the team does a different thing, each brings their specialty to the talks in the hallway. I worried it would be a situation of too many cooks, but it turned out to be more of a balanced, helpful use of everyone’s talents.

The mobile computers in the hallways are not sterilized often.

During rounds, we heard the pharmacy students with us get admonished for not sanitizing their hands. We learned that a C. difficile outbreak had made its way around this unit. We caught an undercover agent scoping out the unit, checking that people took the appropriate disinfectant measures.

We waited outside the sequestered rooms to save costs on yellow gowns and decrease chances of infection.

We spoke with Mr. Manju, the director for Patient Care in the Oncology department. He talked about the difficulty of selecting between options when all the options are about equally good – just in different ways.

We talked to a groundskeeper, here, whose real calling in life is selling shoes. He told us how hard it is to move up in his line of work, maintaining the hospital grounds and building, but also about how those in the upper echelons of responsibility don’t even get to garden.

A small focus group of the bioengineers headed over to the Hospital Administration office at the tail end of our lunch break. We got the chance to talk to one of the secretaries, and ask any administration-related questions we had. The tiered system of accountability in this hospital sometimes allows for ideas and improvements to slip through the cracks, but altogether, the system seems to be as sound as it can be. There is an avenue for any of the hospital employees to submit grievances, and an administrative team always visits the unit in question before making a decision. The biggest problem we could see was a function of the incredible amount of emails that are sent to the administrative office – when all problems are thrown into the same bag, it’s difficult to distinguish the large from the small.

WEEK 4B: Risk/Reward

Inpatient rounds:

Some rooms have two doors to ensure safety and sterility for neutropenic patients.

Some smells and sights are particularly nauseating, but the doctors remain calm and comforting.

Some treatments are too expensive to be given in house. Some procedures rarely happen due to OR delays.

 Rounds1

Stem Cell Lab:

The freeze mix is meant to preserve the cells, which are later sent to be infused.These infusions can be autologous, meaning derived from the patient’s own body. Other options involve infusions from siblings and compatible donors.

Every piece of equipment is expensive and must be cared for precisely.

Sometime, the lab rents equipment, and though the overall costs might be greater,

The Foundation for the Accreditation of Cellular Therapy is the regulatory body that oversees this division.

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Research meeting:

On the impact of their research:

“what is the final goal? We have to make sure we know where we’re going”

“Where do you put the money? Realistic applications and a pragmatic approach”

Donors – regulatory openings, IRB consent

Data sharing from pharmaceutical companies

On presentation:

“they will try to make a story through the graphs, so we’ve got to be careful how we present them”

All of the imaging comes from Rad/Onc

 Research

Outpatient clinic:

We took a quick look around the infusion rooms. They’re set up to be comfortable to the patients. There are two rooms with beds, for patients who cannot sit up. There are eight other rooms with chairs, only two that are single rooms.

Chemo BedChemo Chairs

Jagan brought up the idea that communal infusions might be a comforting experience.

We sat in the most comfortable chairs that have ever existed.

Chair

In this department, patient comfort is of utmost importance.

There are politics in play at this state institution.

We watched a patient’s wife arguing loudly with a nurse, Dr. Quigley came out to reassure the woman that all that could be done was being done.

We met a patient with a tenuous social situation – a family disdainful of having to take care of her, and even willing to take advantage of her disability checks.

Dr. Bolshinsky talked to us about her experiences in Spain and Italy. The biggest difference she notices here is due to insurance. There, medical care is given freely. Here, patients must live with what they can afford.

Yasmin, a medical student from Brazil, talked to us about the system there. They enter medical school right out of high school. Medical care is funded by the government, but there is an overabundance of patients, as a result. She liked the chance to see medical care and teaching in a different light. In her experience, her teachers and mentors were never this welcoming and nurturing.

A patient’s son points out lies his father is telling.

Dr. Rondelli has so far revealed himself to be trilingual. He told us that he learned Spanish on the job, and it makes a huge difference in his ability to care for his patients.

On delivering a difficult diagnosis:

“It wouldn’t be honest for an oncologist to give a straight answer”

On helping a patient determine his course of treatment:

“this is something a doctor can’t decide”

The clinic is kept well-stocked, here’s the delivery cart:

Restock

Another mildly unrelated invention is the knee pads worn by the maintenance staff. They protect the shins, and were a real game-changer in the world of anyone who works on their knees.

Each patient has a special relationship with his/her oncology doctor – it’s about the human.

As cancer is not yet cured, a good number of treatments are experimental. Clinical trials are these experimental treatments.

The first iterations of chemotherapy heavily damaged the DNA.

Even nowadays, more is better, as dose limiting toxicity is linked to the number of treatments more than the intensity.

Dr. Patel explains that the current system of autologous transplant is a bit of a trick. The bone marrow is spared from the radiation, and taken for preservation in the stem cell lab.

Intensity modulated radiation therapy is now used to target the bone marrow alone.

Inter-departmental struggles are still abound. Sometimes doctors try to go over the authority of one another, sometimes their encounters aren’t adequately documented.

We met a patient whose vitiligo disappeared, as the donor cells changed the display of her skin cells.

We’ve noticed doctors attempting to change the angle of their computer screens, which isn’t a functionality currently in place.

Dr. Ghimire is a pretty new fellow, and it has been interesting following him around and taking notice of what he notices.

Young kidneys are only given to young donors, but things are changing quickly, as certain protocols are being developed to make older kidneys more viable.

Some doctors sit at eye level. Some tower over their patients.

Doctors must reassure patients that the medications didn’t cause the symptoms – because drug stewardship is very important in this department.

Some comfort can come from alleviating pressure.

Photophoresis is the process of exposing blood to UV light, and replaced into the system supplemented by immunosuppressants. The donor immune system reacts against the patient’s, at a positive outcome.

Hepatitis B resurgence comes from the effects of immunosuppressants.

Every determination of appropriate dosage, comfort, and intensity is based on physiological parameters. But it is also based on a great deal of weighing risk.

WEEK 4A: Blood and Guts

The first few days in the oncology rotation have been hard impact after hard impact. Here’s what we’ve seen so far, in a slight departure from my usual style of blog.

I spent much of the first day learning about the way the department works. I sat in on the scheduling meeting. Each patient was discussed, and their needs assessed for the next month. The entire team works together, bringing up their specific and specialized concerns. The doctors defer to the director, Dr. Rondelli, but the discussion is especially spirited as everyone participates.

I learned that there exists a discretionary fund to help patients with their expensive treatments.

We attended a research meeting, where each project was checked, reviewed, and finalized. Goals were set and challenges were given.

Research

We talked about the differences between the research done by the department, and the labwork that is done for treatment.

We visited the stem cell lab. We followed blood through the stages of collection, cryo-preservation, and will see the cells being infused in the coming days. The process is fairly methodical – but there is a lot of math involved, as the biological and hematological parameters differ from patient to patient.

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We talked about the staggering costs of healthcare, and how the quality of materials plays into this.

We also talked about the accreditation process, and the investigations and quality-checking that go along with it.

On our first set of rounds we learned that there must often be substitutions for clinical materials, as some are discontinued, and some are simply not available anymore. Some treatments are so expensive, they are not given “in house”. there is a lot of balancing and maneuvering between departments, as each set of doctors must argue for their course of treatment. Time is a serious factor, as each doctor has so much on their plate. Sometimes procedures must be done by residents, instead of the designated therapists, simply because they can’t afford to come back to see the patient after the external procedure. These checks and balances allow certain patients to be cleared for certain kinds of imaging, and serve to make the hospital work more efficiently.

 

We were the witnesses for a woman’s DNR order.

We watched her come to terms with her diagnosis.

We watched her husband reach out to hold her hand.

There are a lot of devices that make soft, tinny noises. When patients are being given serious news, the sound becomes infuriating.

There is also no clear way to mark that the attending team is in the room, talking to the patient. The closed door ended up being opened more than four times in a single session by well-meaning nurses, technicians, and other doctors.

In oncology, it is important to make sure the treatments do not become toxic. There are  drugs that increase the quality of life, but decrease survival. There are drugs that do the opposite.

It’s a heavy choice that oncology patients have to live with for the rest of their lives.

WEEK 3B: Medicine and Engineering

Early Wednesday morning, we attended a lecture given by Dr. Boulay about cholangitis, a biliary emergency. He spoke to the fellows about the past, present, and future of treatment options.

In essence, giving these doctors the equations they needed to be able to apply to different problems.

FELLOWS

An interesting procedure we saw concerned the deployment of an esophageal stent. From what we gathered, the patient’s esophagus was deteriorating, and the stent was needed to promote a healthy structure. The decision of which stent to use was a bit subjective on the doctor’s part – heavily dependent on the quantitative dimensions of the patient, but ultimately decided for by the physician. The stent began as a long and narrow tube, and when expanded, the qualities of the wire mesh made the end result shorter and wider. The rigid guidewire was inserted into the esophagus, and the scope was backed out of the system in a 1:1 ratio with the wire pushed forward. An external guidewire (in the form of a paperclip) was taped to the patient’s chest, and was able to be seen under fluoroscopy. An endoscopic view provides extra insurance. But sometime, the anatomy of a patient will not allow for further scoping.

The man had esophageal cancer, as well as an abnormal air picket. The stent was designed to dissipate the air and open up the esophagus. The stent was made of nitinol and coated with silicone – for biocompatibility. The gun was made considering the radiopacity of materials.

The procedure was a success, and the man was finally able to eat and swallow properly. This isn’t a permanent fix, but it’s where we are in Medicine today.

It’s been nice to search for answers to those simple questions no one thought to pursue. In our first week, Dr. Carroll asked us to explain how the pharmacy paper they use to print sensitive prescriptions on are unable to be copied – printing ‘VOID’ on the copy paper instead. We discovered it was due to miniature dots embedded in the paper’s design that became clear only when the bright light of a copier were exposed to the surface of the paper. Similarly, we were asked to explain why the lights at the end of the scopes flickered, and why the flickering was not seen on the video feed. We discovered the lights were LEDs, and that the shutter speed of the camera was coincident with the flickering of the lights.

Unattached

We went through the process of capsule endoscopy, first watching the nurse attach the sensors to the outside of the patient and outfit him with the monitor. We watched him swallow the pill, and saw him off. We ran into him a few more times doing rounds and he joked with us that we owed him money for all the shows he was giving us! We sat with Dr. Sleesman as he explained the results of the capsule. Over the course of the thousands of pictures it was determined that there was a significant amount of bleeding in the small bowel. We attended the next procedure, where they attempted to access the site of the bleeding with a forced scope. When that was determined to be impossible, they scheduled the patient for a double balloon endoscopy, which allows for the use of balloons to inch the probe into the small bowel. We attended that procedure, as well, and watched as the doctors found the source of the bleeding, and cauterized it.

The screens are hypnotic, the journey through the body so familiar and clear.

I’m not yet ready to say goodbye to GI.

WEEK 3A: Rounds and Ruminations

Inpatient rounds are at 7 AM – a team of an attending physician, a fellow, a few residents, and the occasional bioengineering undergraduates set off. The resident explains any new developments in the case, and a treatment plan is made together. These rounds include discussions of the different pathologies and etiologies that will be encountered, and some gentle quizzing of the residents. The whole gaggle of us walks into the room, where the attending or the fellow generally begins the conversation with the patient. The new information is compiled, and they discuss in the hallway, their theories and considerations. The hall is small and lit with blaring fluorescence. We noticed a screen that displays the heart charts of all of the patients in the wing – a clear and easy way to keep everyone in check. There are landline phones in easy reach that do not appear to be sterilized after each use. The residents print everything out to write on. Their pockets are big, and we’ve seen a folding clipboard comfortably nestled in there.

An unsung marvel of engineering is that loud medical devices have a mute button.

There are mobile computer stations scattered throughout that provide a useful resource when considering the patient’s past records in creating their future plan. These mobile computer stations are meant to be adjusted based on height, but remain static for lack of time. Some chairs have been brought into the hallway. Empty beds wait in the hall, as well.

MOBILE COMP

These hallways tend to get a bit congested, what with the different sets of rounds and consults, and miscellaneous chairs and hospital beds.

During rounds, they discuss the literature, and decide to consult with the oncology department before making a final decision.

They discuss which patients might be difficult to convince – especially when it’s simply the prep for procedure they find so repugnant. There are a few patients who cannot be trusted to follow through, there are a few patients who lie, and the doctors must account for that in their treatment plans.

Sometimes, less is more.

Many of the doctors at UIC also work at the Jesse Brown VA hospital. There is a completely different organizational system in place; from differences in the electronic medical records, patient population, and overall healthcare costs.

Many of the problems in the procedure room deal with the maneuverability of the tools. Another doctor suggested a combination snare and net. Dr. Watson, the senior resident, suggests a capsule endoscopy pill camera that can be controlled in the intestines a la Magic School Bus.

A neat thing done during procedures is layering gloves. This allows the doctors to remove a used glove, and not have to struggle with donning another. Generally, though, gloves are hard to work with; they are very necessary, but make the fingers a little less dexterous.

Sometimes keeping patients happy isn’t in their best interest. Here, the ideals of empathy and efficacy seem at odds. This is especially interesting in light of our Monday workshop about empathy in engineering.

We’ve seen patients, given a new lease on life through a transplant, taking poor care of their bodies. Some patients are dependent on narcotics, and some grow addicted to the protective cocoon of the hospital.

Consents for procedures are obtained and included in the patient binders, which are transported whole to the procedure room.

Some mornings, the list of patients is chock full of people who are indistinguishable on paper. The group must work to differentiate each patient, checking and double checking that their analysis is consistent with the records.

We heard a horror story about a patient accidentally being put on the wrong medication – medication that actually worsened his condition. The doctors work hard to ensure that this kind of thing never happens.

But there is only so much you can do when it comes to cross-departmental measures. Some GI patients are admitted in the ICU, some are still in the ER. Access to records and results is pretty immediate, especially in procedures don in this hospital, but some tests are not done in a timely manner. In one case we witnessed, in deciding the best imaging modality (here, between EUS, or MRI/MRCP), the onus lies on scheduling. The ICU doctors naturally, have their own priorities, and it is here that each doctor must be the advocate for themselves, and most importantly, for their patients. Resources – especially if something breaks – are spread disparately around the hospital. If a certain machine is not available in the GI department, they must get special permission from other departments with the machine to move a patient in, and use the equipment. Things, however, do get lost in the shuffle, and sometime the external department will deny access to machines, cancelling cases by their own metrics.

MAIL

Just as the body works as a whole, the system of specialists that treat each constituent ailment or part must communicate to ensure the best care for the patient. This means too that the gastroenterologists must focus on what is best for the GI tract, and the cardiologists on the heart. Each doctor considers every etiology, every indicator, and every part – and it is actually the best-rounded doctors that really know how to approach any compromise, that defer and accept when they are wrong.

I was really affected by a consult with a young girl afflicted with catatonia. She was trembling, couldn’t speak, and could just barely flicker her eyes.

In a smaller, but similarly impactful way, I was struck by a patient struggling to reach her bedside drawer handle.

Dr. Halline reassures a patient who is afraid of a budding cancer. Explaining the difference between a carcinoma and a carcinoid. Answering to “Doctor what could have caused this?” with a clear and gentle “the tumor is… and it means…”

There are people come to the hospital as a last resort, and it really hurts me to see them in such pain. There are patients who know they are on their deathbeds. There are patients who don’t.

There are patients who struggle forward increasing the quantity of their lives while destroying the quality. Most everyone wants to die quietly in their sleep. But when given the choice, no one is quite willing to let go. 

WEEK 2B: Closed Curtains

We’ve seen a lot of procedures in our time in the GI Lab! The obvious ones are the colonoscopies and endoscopies, both of which I’ve mentioned in the past entries. A new observation this week was a PEG – where a feeding tube is threaded through the stomach wall and out through the skin. This surgery is like watching a spider weaving silk, or watching an ethereal woman play a harp. Every movement is deliberate, and precise. If a mistake is made, no one panics, but works calmly and smoothly to address it. We observed the transillumination of the tip of the probe inside the woman’s stomach, and watched as the doctors carefully marked the location for piercing with the tip of the tube. The spell then breaks as we watch the doctor pull at the tether with all of his might, stretching the skin and using force to guide the tube to its emergence. A guide wire is used to position the tube, and after the surgery, the loosely sealed incision is left to heal.

When the doctors perform a dilation, the primary remedy  comes from a series of hard foam cones, slid down the throat in an ascending order. There is a push towards balloon dilations, where water will be used to stretch the walls of the balloon and the walls of the constriction.

Biopsies are painful to watch – the claw is magnified, and the site of extraction bleeds quite a bit. Dr. Sleesman reassures us that the nerves in the intestines don’t feel pain like we think they do.

We saw a few fluoroscopy procedures designed to remove blockages (usually from the bioengineered materials like stents moving awry within the body). These procedures are perhaps the most high-tech, with laproscopically scaled tools and constant imaging.

Because the University of Illinois Hospital is a teaching hospital, the organization of the overall system is a bit different than that of a traditional hospital or private practice. The fellows, residents, and medical students are funneled through the system, learning, teaching, and experiencing, all at the same time.

The Physician Quality Reporting System (PQRS) is a program designed to hold doctors accountable for the quality of their care. But even on a smaller scale, patients, themselves, have the capability to simply post on the internet their thoughts, feelings, concerns, and experiences.

It is important to maintain a level of regulation. But the balance is still a bit skewed.

There is so much information patients don’t know. And by the current system, there is no way they can take even the slightest peek behind the curtain.

These regulations simply compound with pressure from the FDA, campaigns run by lobbyists, and  specific hospital guidelines.

The quality of medical records is something else that is severely lacking. This, in turn affects the difficulty of patient care. The most clear-cut decisions on paper might emerge as the most complicated in practice. This is why the work of a doctor cannot be reduced to algorithms or coded  for clear outcomes.

And yet, as the costs of healthcare are ballooning, there is a saturation of lobbyists, and a decline in healthcare practitioners.

Some doctors feel trapped in this system.

Hoping to gain a brief respite from prison, a man swallowed some scrap pieces of metal. This was our first foreign body extraction. The doctors used an attachment threaded through the endoscope, with a claw end, to drag the metal out of the man.

Metal

I suppose his plan worked well enough, as he did end up in the hospital for a day and a half.

I cannot fathom the stifling feeling that might drive a man to such extremes.

The most salient thing we have learned from Dr. Sleesman is how to treat patients. Treat in the sense of prescribing cures for ailments, and treat in the sense of general human care. He does an excellent job balancing his responsibilities and proclivities as a physician, with his ability to make each case, each conversation important to those he teaches.

There will always and only be doctors who care.

 

WEEK 2A: The Tools of the Trade

The first machine we used was actually last week in the Outpatient Clinic. Here’s a picture of the ultrasound machine, used to identify fibrility, and other unusual internal organ characteristics. Dr. Carrol showed us how it could also illustrate the flow of blood in different directions through arteries and veins, and enabled the doppler functionality to allow us to correspond the sound to the patient’s pulse.

 Ultrasound

We’ve found that, especially in a university hospital, diagrams are the norm! Being able to draw and redraw ensures doctors have the familiarity with the anatomy – crucially important when that anatomy is unusual in any way.

 Diagram

Fluoroscopy is a process where a continuous series of X-rays are used to illuminate a contrast agent in the GI tract. We observed Dr. Shastri walk Dr. Soudagar through a procedure to remove a stent trapped in the bile duct, and talked with Dr. Boulay about another ERCP procedure he performed.

X RayMonitoring PillarMonitoring Pillar 2

Dr. Boulay showed us the stent he had placed to facilitate drainage, and explained how he had deliberately placed it incorrectly, so the device would fall out and be passed in a few days time.

Fluoro

It’s especially interesting when the most effective solution is an imperfect one.

Namrata and I were able to follow a specific scope, like we’ve followed specific patients through their routine. We watched the endoscopy, watched the preliminary disinfection, walked behind the bundled scope to the cleaning room, and talked to the lab technician about the process of testing the scopes for kinks, tears, and aberrations. An air pressure failsafe is used to test for holes, as submerging a broken scope in water will render it irreparable.

Leak Test

We were taken through the secondary cleaning process, using a thin brush to travel from port to port, cleaning the tubes within. Each scope is equipped with passages for air, water irrigation, thin wire tools (biopsy forceps, a net for retrial of stuck objects, clamps galore!).

Scope Cleaning

There is a specific attachment for each scope, dependent on function and french size. The process includes through another round of attachment and scanning to make sure the correct scope and cleaning port has been used. This is important to ensure that the system remains closed, and no damage will come to the scopes.

UnattachedCleaning AttachmentsAttachedDilators

The machine shuts tight and begins its washing cycle. The acid wash comes from the cabinet below the unit, and the device is cycled through different cleaning regimens.

WasherSudsCleaning Fluid

Once sterilized, they go into a closet to await their next use. The wire attachments that are sent through the tubing are also sterilized, and sent to be decontaminated and sealed for reuse in a room downstairs.

Scope ClosetSealed Attachments

The connectivity of the system as a whole is a bit lacking. The barcodes that must be scanned are stored in the individual CPUs of each washer, and some machines are not properly synced to the others.

These scopes come in different sizes, and the same basic design is used for the colonoscopes, the endoscopes, the pediatric scopes, and the nasal scopes. It seems self-evident, but the use of these scopes to peer into the body is a relatively recent development – without a useful optic method, only surgery could allow a look inside. Dr. Halline walked us through the timeline of scope development, explaining that the first scopes were rigid tubes with fiber optic cables running to the top, which were then viewed with a lens that could be modified to accommodate two viewers (halving the light input, but allowing for better instruction). The video advancements in even the past 20 years are wildly impressive.

Dr. Sleesman guided us through the process of labeling the checkpoints in the colonoscope’s journey. Pictures are taken at each “landmark”: the appendix, the small bowel, the ascending and descending colon, etc. This is a matter of patient edification, completeness in the procedure, as well as ensuring proper liability and protection. Dr. Halline spoke to us about transillumination – using the light from the end of a scope that glows through the skin and organs to identify the location of the scope. This process is difficult in heavier patients, and internal organs are not homogeneously close to the surface of the body. Here emerges a desire for a way to note the progress of the scope, that can be used in a heterogeneous population and still provide a map of the process in a physiologically relevant way.

Some other interesting devices and solutions:

Cords left in a pile/Cords tied up

 CordsZip tie

Organization in the sterile storage room

Sterile Storage 2

Sterile Storage

Pre-procedure organization

Operating TableLab Bed

Tape printed with the name of common sedatives, to label syringes in the procedure rooms

Label

My next post will be more about the patients, the doctors, the procedures, and the system, as a whole! It will likely include a no-holds-barred, brutally candid, tell-all from Dr. Sleesman!

 

 

Just kidding, you can breathe again, Dr. Sleesman.

We’ve really loved our time here, and so much of it is contingent on the people who guide us, teach us, and challenge us. My next post will be a testament to their support, honesty, and skill – seen through the lens of their procedures, their successes, their strides forward, and the vexing difficulties that emerge from the scope of their work.

 

 

 

WEEK 1B: Organizational Systems and Operating Machines

I noticed on the very first day that none of the doctors had the usual desk accoutrements – no pictures of family, no silly pens, no notes to self. We quickly understood that here is a severe lack of space in the work areas. This manifests itself, too, in the number of computers available to the doctors. No one has their own workspace, everything is communal, and first-come-first-serve. This is why some doctors insist on finishing their computer orders before they leave the examination room. There’s a bit of learned helplessness, here.

Doctors can check their list of scheduled patients at any time, but every morning, the Medical assistants put up a nearly finalized list on a bulletin board. They highlight the patients who have been called in, and have already been through a general examination. The priority goes to patients who arrive on time. Many are late, many are no-shows.

SCHEDULE

We had a patient in who had to wait, burdened with a painful gastric condition, for three months for an available appointment spot. Dr. Shastri talked to us about how quickly these spots get filled up, but given the high rate of patents not showing up, it’s unfortunate to think that those who play by the rules of the system get punished.

On Monday, we used an ultrasound machine to examine the man’s gallbladder. Dr. Carroll taught us how to decipher the images on the monitor, and showed us the different imaging modalities. I got the chance to freeze the frame and develop the image. We were even able to listen to the flow of blood through his descending aorta using the Doppler radar, which Namrata correlated with the man’s pulse.

Dr. Carroll also gave us the chance to work on creating a patient’s nutritional regimen. Namrata and I spent a morning working through formulas based on the patient’s health records and severity of illness. Dr. Carroll walked us through each variable, and explained why the numbers we had made sense. We talked about vitamin and mineral needs, and he gave us an article to read before our late clinic on Monday.

TPN

Even knowing to do so much, there is sometimes no conclusion to be drawn.

The most interesting procedure we learned about was a fecal transplant – using the unique properties of gut flora to address issues in the recipient system. There now exists an FDA-run repository for generic fecal samples. As the coming entries will show, regulation is a huge part of what doctors must deal with.

We learned about a swallowable pill that transmits a signal to a receptor worn around the waist.

We met Dr. Boulay on Thursday, and his style of working through problems aloud and using colloquial terms with the patients reminded me of Sherlock Holmes. He was another great teacher; respectful, understanding, and candid in his storytelling.

This is how all of the doctors we’ve seen sit:

Sitting

We met a patient from a mental institution. We met a patient suffering from depression. We met patients who could not speak English. We were also able to see the interpreters in action – through a tablet screen.

There are more variables to weigh when it comes to patients more variable.

Dr. Velpari thinks there is a trend towards telemedicine, which gives me a lot to think about. I don’t know if it would be easier to lie to a machine – maybe the incentive to lie would even go down. But the prevalence of algorithms, and the need for cheaper alternatives and efficient support is a bit damning. The online records are a bit tricky to learn to use, but invaluable from that point.

Perhaps the way to move forward is in making these algorithms accessible to laymen. As it stands now, doctors are needed to separate the signal from the noise.

 

 

WEEK 1A: The Virtue of Patients

It’s our first week in the Gastroenterology/Hepatology rotation, and we are spending our time in the Outpatient Clinic. We have met so many people, all extremely diverse and interesting. Everyone does things differently; each doctor, each patient. That’s why it is so hard to standardize this extremely subjective process.

I spent some time in the waiting room, feeling the palpable frustration. I talked to some patients who disliked other doctors for not listening, not explaining, not apologizing. On the first day of our rotation I got a piece of advice passed down from Nurse Nedra Chaney: “We’re here to alleviate the fear of the unknown – that’s in every patient – build trust, and then treat the patient.” That first step is incredibly important, it sets the foundation for good trust and good treatment. Patients, for the most part, want to understand. They want to take ownership of their own healthcare. If you’ll check Namrata’s blog, you’ll see a homemade chart one of our patients made for herself, detailing the dosage and time to take each of the medications. But this isn’t always the case.

What remains constant is that they want to be listened to, they want to have their questions answered, and they want to be treated with respect.

We observed Doctor Stewart who tailors her approach to each individual patient. Her fellows are the ones who type everything up during the consultation, while she stands, sits, and engages. I watched her nod for a good 30 seconds at a patient to impress upon him the importance of cutting out fatty root vegetables from his diet. I thought it was a bit overdone, but at the end of that half minute, the patient quietly asked “Really?”, to which the doctor responded, “Yes!” with another 30-second nod for good measure. She brings up patients’ holiday plans and families and hopes for the future when they are feeling burdened with their diagnoses. She knows what questions to ask. She is the perfect mix of severe and jocular all at the same time.

We did rounds with Doctor Shastri, who excels in explanations. This takes time, but serves as an excellent teaching experience for the fellows and bioengineering students walking with him.

Doctor Nannegari is fantastic at establishing a rapport with the patient, especially during her direct examinations. She is cheery and personable, greeting everyone in the clinic, uniformly. She is focused on getting a thorough and efficient examination, but is also focused on the screen, typing as the patient speaks. I notice the patient’s voice tapers away, until the doctor looks back to his face.

Dr. Nannegari’s caring and explanatory demeanor didn’t seem to fit with her propensity to turn away from the patients. It’s then that I noticed that a lot of it had to do with the layout changes between rooms. Two of the four of Dr. Nannegari’s assigned rooms were set up so the computer screen faced the patient. This means that if the doctor wants to document on the computer (as opposed to those doctors that want to write on paper, or delegate to their fellows), she has no choice but to turn away from the patient.

Doctor Carroll seems too clinical behind the walls of the conference room, but I know it is an important part of the job – balancing compassion with equanimity.

The doctor looks at a patient. The doctor touches the patient.

That makes a big difference.

Often, as bioengineers, we focus on the mechanics of an issue. We look at the machines, not the man. But in Medicine, it is crucial to consider the importance of touch, of comfort.

It is easy to think that the jobs of these doctors can be automated: A simple list of yes or no questions that branch towards the final diagnosis, the final prescription. Surely even the subtlest of symptoms can be coded for.

But people lie.

And people are somehow less willing to lie to a doctor.

People have motives. It’s important for each patient to be their own advocate, as doctors have motives, as well. But the vast majority of doctors are there to help, and need to know all of the information in order to make the right decision – especially when the difference between the right and the wrong choice is subtle and dangerous to confuse. In this regard, there is a certain respect patients give the attending physician, probably due to the deferment and respect we all automatically give the doctors. Even the fellows, extremely accomplished in their own right, defer to the attending physician.

We had a consult with a man diagnosed a few years ago with liver disease, but strangely unscarred by cirrhosis. He took up alcohol as a coping mechanism after his initial diagnosis, and we watched as Doctor Stewart skillfully noticed the holes in the man’s timeline of when he stopped drinking. The man also said he’d stopped using cocaine many years ago, but after the struggle in determining when he stopped drinking, I’m not sure the doctor felt compelled to follow through with ascertaining that. I noticed he had an exceptionally long pinky fingernail, which is tempting to speculate on.

But no matter his health choices, his liver was thriving.

I guess he was just lucky.

There was a woman who was so bluntly honest and self aware and, frankly, hilarious. She KNEW she would never be able to drink the gallon of briny fluid required for the colonoscopy cleanse. She claimed that ALL she ate were meat and fruits, and she ONLY drank a single glass of water a day. When told to drink only clear liquids in preparation for her colonoscopy, she asked in loud earnest “if a tiny, little, piece of chicken somehow made it’s way into my broth, would that be okay to eat?”, leaving Namrata and I doubled over in laughter, and Doctor Nannegari to respond with a resounding “NO!”

That patient was the one who suggested we work as bioengineers to eliminate invasive colonoscopies altogether. We noticed that even though the electrolyte liquid is needed to properly flush the system, overall liquid imbibed is further compounded by the enormous quantities of liquid laxative the patients need to take. Here emerges a need for a simple laxative pill that can properly dissolve and disseminate with less water – something currently available, but left uncovered by most insurance and at exorbitant cost.

I noticed something equally striking in the Hepatology examination rooms. The general format of the examination is a consult in the chairs, an examination on the table, and a return to the chairs to explain the situation and address the patient’s concerns. On the wall is a chart meant to explain the progression of Hepatitis and the resultant cirrhosis. But this chart is behind the chairs, meaning that whenever a physician is walking the patient through, the patient must crane their neck. It’s a little thing, but little things become big things when compounded time after time.

LIVERPOSTER

It was here that I encountered a sweet woman, brought to tears by her diagnosis. Though her disease was still in the early stages, the worry about her future was very affecting. The pharmacist walked the patient through her new drug regimen. She explained that no herbal pills could be taken at the same time as prescription pills, and that changes would need to be made in her culture and lifestyle to supplement the pharmacist’s prescription.

We saw patients that were stoic and patients that were emotional. We met people who had lived with viral infections for the vast majority of their lives – only finding out now.

We met a convict, and he was just the nicest man. They brought him in with rigid handcuffs that were chained around his waist. His feet were chained, as well. When gesturing toward the painful area in his midsection, he struggled to move his fingers enough to point. Doctor Shastri helped him out, and was not afraid. It was really jarring to learn he was incarcerated for carrying heroin while other patients were candidly admitting to us just how much of the same drug they had done in the past. Perhaps he was a dealer, perhaps his use was more severe, but perhaps he was the only one they caught.

Unlucky.

We met a patient who had been removed from the transplant list due to his noncompliance in taking his medications.

These kinds of tough choices might better be made by a machine.

But where would be the comfort? And could we be sure that patients believed what they heard?

I’ll go into detail about some of the technologies and processes we’ve observed in my next post about Week 1 of this program. There are a lot of organizational and systematic gripes that become clear after a few days working in this small outpatient clinic. But what really makes up the heart of this clinic is the people who come to it, so I figured that would be a good (long!) subject entry to start with.


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Gastroenterology/
Hepatology and
Hematology/Oncology & Radiation Oncology