University of Illinois at Chicago
The second half of the week my partner and I were able to see a few more interesting things, while being in a hustle to put together the final report and presentation. The rounding experience in the department was quite different from all of them I have seen so far. The physicians, physicist, nurse, and dosimetrist all meet in the conference room and go through the case of each patient. Given that most of their patients comes in and leave after each of their session, this is the most reasonable way in which they may do patient rounds. I was really impressed with the computers and the additional tech they have down in their department. Obviously, this is expected since the nature of the department requires extensive use of imaging results that need computers with fast processors and quality display.
Moreover, we were able to seek out and learn more about what the dosimetrist and the medical physicist does as part of the team. We were able to see the medical physicist carry out the process of ordering the necessary radioactive components for someone with a tumor around or near the eye. The order is sent via email to the medical physicist who does some numerical calculation by hand to determine how many radioactive components are needed to administer the prescribed dosage. Once he determines that amount and creates a report of it, he then has to place the order by phone. Interestingly enough, he also said that it is him who make the customized eye patch for the patient using lead material so that they may wear it when going out, etc. as to keep those around them safe. Another cool thing was that the way they position the radioactive components in the plaque of the appropriate size is standardized based on research findings; the best part is that there is a program available that models how the radiation is distributed and its intensity from the sources for various position combinations.
Moreover, my partner and I were able to see a stem cell infusion. Interestingly enough the infusion was that of the same patient who we saw they collection of earlier. As the frozen cells are transported in the portable cooler a few inconveniences were noticed. For example, it would be a lot more helpful if the portable cooler had an accurate built in temperature read, and also a handle that can either be folded out to or is at the level of the technician so that the cooler may be pushed around more easily. The thawing procedure was simple enough such that the frozen sample was placed in a larger bag which acts as a buffer to the treatment of sudden heat and it is placed in to a hot water bay at 37 degree Celsius.
While thawing the frozen sample, the technician informed us about how at some infusion centers they take additional steps in order to remove the DMSO that was added to the sample as part of the freezing mix. This step is helpful since it reduces or eliminates the possibility of the patient experiencing some side effects to it. Upon infusion anyone in the room can smell the DMSO since it has a garlic-like smell to it. Moreover, the nurse practitioner present there did inform us about how it would be much convenient if there was an easier way to attach the infusion line to the sample.
Once we were done seeing the infusion we heard the nurses talking about the network being down. The then had to record their measurements and other values on paper and later transfer it when the network was active again. In the ten additional minutes that we were there the problem wasn’t fixed and didn’t see any software tech working nearby.
Another interesting, yet a very rigorous treatment that we were able to witness was brachytherapy. The medical physicist informed us that the this treatment is usually used as either the last resort in the fight with cancer, or as the way to ensure cancer has been entirely wiped out from the region of interest. The patient we say receiving the treatment was unfortunately using it as a last resort to treat her aggressive cervical cancer. The treatment requires high team work and great precision from the medical physicist and the physician since the tissue is being directly placed in contact with heavy radiation. The treatment was also a bit scary for the patient since while being exposed to radiation, everyone else vacates the room. Nevertheless, the three most important factors of radiation to consider at all times when formulating a treatment plan are distance, time, and shielding.
Lastly, the wonderful engineer in the department was so kind enough to show my partner and I the interior of the machine radiation machines. He took apart the external covering of the older machine for us alone and went out of his way to explain the theory and concepts behind it. Although I wasn’t able to understand or absorb some of the information he shared his brief tour gave us a general idea of how the machine works. Moreover, it was interesting to see that many of the flaws he mentioned with the older machine was either solved or improved in the newer machine. As an engineer he shared that a lot of the things that he does requires learning on the spot. Over the years he has become accustomed to the workings of the older machine and is able to fix the problems that arise with it. However, he himself is still only learning the newer and more sophisticated machine piece by piece. If the newer machine shows any problem, it is usually reported to manufacturer who then sends their own specialized tech/engineer to solve the issue. The department is looking forward to getting a newer machine in early 2016. The process of replacing the old machine takes about 9 months since the entire room needs to be re-built to fit the new machine and its specifications.
With such wonderful experience the internship finally came to an end.
I must say this internship is by far one of the most enriching experience I had as a bioengineer and a prospective medical student. The wide variety of people I met over the past six weeks were simply amazing and impressed me with their contributions to helping people and advancing medicine. The up-close view I got of the hospital motivated me to be a physician and an engineer simultaneously, because there are simply too many medical problems to be resolved, questions to be answered, and lives to be saved.
P.s. The picture indicates a favorite phrase of an inspiring individual I met during the latter half of the internship. Although the quote maybe simple, the message is definitely something that is overlooked often and needs to be valued more.
This was unfortunately the last week of the internship. I was actually looking forward to meeting with the members of the radiation oncology department. Upon entering the department we were able to meet with few of the residents and the attending, and then we got to meet with the medical physicists. We were able to talk with a few of the medical physicists there. I was absolutely intrigued by getting to know that particular profession, as I have never heard of them before (as I write this blog, I am about 55% sure I want to be a medical physicist, and about 45% sure about going into medical school). Talking to the medical physicist I learned about what they do and the potential for the profession.
Talking to the radiation physicist he told us about future of imaging and radiation. Ideally in the future, imaging should be able provide the same information as a biopsy. The physicist and researchers work on developing new techniques for administering radiation while minimizing unnecessary exposure. Efforts are also being made to make the most imaging techniques and analysis computerized. Overall, the medical physicists and other workers there do a lot of different tasks some more clinical, whereas some do more theoretical work.
One of the days we were able to come in early to see the radiation machines being turned on. One of the medical physicist was responsible for starting things up and running the quality assessment. The medical physicist was an intelligent fellow who was able to successfully automate many of the machine check tests that they do. Interestingly enough, the fellow said often the machines are turned on by the therapists rather than the physicist however when there are monthly assessments that need to be done the physicists has to do it.
Moreover, the patients usually come in during their assigned time for the therapy session. One thing I noticed was that they have a tight schedule for the radiation therapy especially with many of the patients are scheduled for therapy every day for a couple of weeks. Nevertheless, ideally they shouldn’t be starting any procedure prior to the arrival of at least one attending. However, one of the days the attending that was supposed to come in early slept in and they had to wait till they start the first therapy session.
Moreover, we were able to talk with the engineer in the department about his role and how he fits into the environment. He told us how he is mainly called upon if any problems rises and that most of his work is afterhours. He runs some diagnostic testing at the end of the day. He said he isn’t experienced with the newer machine, however a relatively good expert on the older machine’s functioning. I found his job to be quite interesting as it required a lot of on-the-job learning. Furthermore, he shared with us the story of how a problem with the machine where the radiation beam wasn’t being positioned correctly killed a few patients. It was a bit scary to hear that more than one patient died on the table because the flaw of the machine went unnoticed. Nevertheless, this is why it is even more important for someone like him to check the machine and run some diagnostic testing every day the machine is used. Also, he shared that a common problem with working with the machines is that, since the machine is so big often it is quite difficult to identify the actual problem is because they have to check the machine all around to identify the problem.
The second half of the second week of the rotation is probably going to be one of those moments I will best remember whenever I recall this internship. Nevertheless, prior to spilling the interesting story here is a brief overview of the other events that my partner and I participated in.
One of the mornings we attended the Lung Tumor board meeting. The meeting had medical students, nurses, physician assistants, and attending and residents from the oncology, and the pulmonary and cardiology departments present there. The meeting took place in a well spacious room. As with the bone marrow meeting, the list of patients dealing with lung tumors that are being treated was by those doctors were discussed and reviewed. Interestingly enough, some of the patients were from the VA. Thus, they had to remotely access the VA server to pull up the images of the patient. The computer was quite slow at the accessing the VA server remotely. The discussion about the patients may have gone by quicker if the computer worked faster.
Moreover, during the meeting something that caught my attention was the concerns and problems one of the physician assistants brought up. She was talking about one of the patient’s primary physician noted a serious tumor however did not directly send the patient to Oncology by getting the patient an appointment that week, but instead the patient only got an appointment a month later. Which brought up the topic of leaving time slots in the physician’s schedule for immediate and emergency cases that need an appointment. They physicians nonetheless become overbooked and are often not able to fit in the new patient into their schedule. Which then raises the question about if they were to prioritize seeing a patient over another one, what standards would be used to determine which patients’ case is more pressing than the other.
Following that, we got the chance to spend some time with the palliative care residents, and got to know about what Palliative care is. They told us how it is a new field and that it wasn’t till recently that UIC got a palliative care department. Nevertheless, the residents shared their reasons to want to go into Palliative care and informed us that because the field itself is only about a decade or so old there aren’t that many programs that offer it and that it is quite a non-competitive field.
Then later on, we were able to go watch an HPC-A collection. HPC-A collection means hematopoietic progenitor cells apheresis collection. The collection was done by Septia Optia Apheresis system, which was linked directly to the central line. The machine system is able to separate the HPC cells along with some other components of blood from the plasma. The plasma is returned into the patient whereas the remaining is collected.
Now comes the eventful part of the week. My partner and I were lucky enough to be allowed to observe a bone marrow biopsy. The procedure is very medieval, yet straightforward. The physician sterilized the area being injected and numbed it. The biopsy needle is then inserted into the bone, and the center of the needle is removed through which then the hollow needle is inserted to get the biopsy sample. Something interesting the physician did was that she coated the inside tubing of the syringes with heparin so that when collecting blood it wouldn’t clog in the syringe. Lastly, once the necessary samples were obtained the biopsy needle was removed. And that’s when things started going downhill for me. Prior to the procedure the attending did warn my partner and I to sit down while watching the procedure, especially since it was our first time. Initially we were seated, however since our view of the procedure was obstructed we stood up to get a better view; and we had thought the physician suggested us to sit because we may be squeamish about blood and needles, which neither of us are we didn’t see the problem with standing up.
Anyways, once the biopsy needle was removed my I started to sweat rapidly, I felt like a heat wave was passing over me, especially back and forth on my scalp. My field of vision began narrowing. I could still hear what other people were saying but I started to lose comprehension of what I hear. Then I felt like I was unstable and had immediately sat down. For a few seconds I couldn’t process anything going around, I recall hearing my partner asking if I was okay however I was unable to respond. One of the brilliant residents realized what was going on from afar and kindly offered me a fruit punch, lemonade, and orange juice. After which the medical student insisted I sit down for a while, just to ensure that I won’t faint again. Meanwhile, she described the episode as a vasovagal syncope. I later on looked in to the condition, and found that it is a “malfunction” of the nervous system upon exposure to a trigger. Interestingly enough, it does happened during or post biopsy procedures. Even though, I felt like my body system failed me because I was totally comfortable seeing the biopsy procedure, given that I have seen even more gruesome stuff in urology, this incident reminded me about how there is so much more to the human body that I don’t know and has yet to be discovered.
The second week of rotation in the department was quite exciting, if not more exciting than the first week. This week we got to spend more time in the Hematology unit of the department. Just like last week one of the main thing we were able to do was go on rounds with Dr. Sharaf. This rounding experience was far different from the rounding experience we had in terms of the number of people going on rounds. Aside from us, there were the physician, fellows, residents, medical students, pharmacist, pharmacy resident, pharmacy students, and the dietician. Overall, there was about thirteen people in the group as we went on rounds. One thing I noticed was that the use of hand sanitizer was more prominent in this department than it is in the other ones. Upon further inquiry, the dietician was able to inform us that this is the case because recently they had an incident where the patient in that one entire wing of the hospital all acquired a specific disease – even the patient who weren’t prone to the disease. Thus, in that case the only explanation was that it was a problem on behalf of the staff. The thought that the medical staff giving the patients disease is quite frightening especially in this department. The patients who are in the department already has a severely weak immune system and thus even slightest exposure to something foreign could make them sick. Obviously, such instances of infection spreading isn’t necessarily because people deliberately do not follow direction, but instead its due to instances where someone sticking their head into the patient room to ask a quick question etc. These tiny instance may not seem to be doing much harm, but evidently enough the consequences of these small slipups can be devastating. This made me wonder why they didn’t have a communication system (like a direct intercom to the patient room form the outside) that nurses or doctors could use to communicate with the patient briefly without having to go inside. The dietician also informed us that to ensure infection control protocols were being followed there would often be people (often designated students, or staff) that would lurk around checking if hand hygiene and other procedures were being followed.
While doing rounds I came to appreciate the dietician’s actions about patient privacy. She was generous enough to not go into some rooms collectively with the group. She wanted to give the patient more privacy, thus visited the patient privately after the group left. Also, she was more economically conservative about not going into rooms where the visitors are required to wear a yellow gown. She didn’t want to waste a gown and go in because prior to rounding she had visited them. My partner and I also decided best not to go into room that required yellow gowns in order to minimize the usage of the gowns. Nevertheless, she informed us that the main reason why everyone goes into the room together is because it is inevitably a learning experience. By having everyone be present in the room, problems won’t be overlooked, and problems may be solved on the spot rather than requiring additional consulting.
The usage of the gowns while visiting a lot of the patients was required because many of them were bone marrow transplant candidate and were on immunosuppressant. Given that they are on immunosuppressant, it is important to not expose them to many foreign substances. Thus, it would be a lot better if the ones who were wearing the gown did put it on properly rather than be lazy about it. Also, an interesting thing I noticed was that there was a stethoscope designated to most patients, so that it stays in the room and only comes into contact with the patient. Lastly, one of the things I noticed while on rounds was that often the care given is hindered or delayed by insurance since the doctors are limited to offering the patients care that they are able to afford – having to make such decisions in such a field is quite saddening because I don’t think anyone should have to think twice about saving someone’s life and saving it using the most efficient method available.
Moreover, we were also able to talk with the director of patient care services. Talking to him was quite interesting. He shared his past work experiences with us and told us about how he got to doing what he does today and such. In terms of his role in the department there wasn’t a well-defined/restricted set of activities or responsibilities that he carry out because he is involved in so many things such as addressing patient concerns directly and indirectly and working with the administration about management issues and such.
We were then also able to get another glimpse into the bone marrow transplant meeting. During the meeting the team involved in the unit comes together and discusses each patient they have seen and talks about their status and asks for suggestions about future decisions if needed. We unfortunately had to leave the meeting early to see the processing of an HPC-A collection. This time around I noticed how the collection had to be transferred into a narrower bag from the bag in which it was originally collected because that bag isn’t ideal for centrifuging. In order to avoid wasting time transferring the collection, it would be highly beneficial if the bag in which the collection was collected was the narrow bag. Since the collection bag is part of a kit the manufacturer would have to produce bags in such shape.
Nevertheless, since it was a larger sample a bigger centrifuge system had to be used, and even that system required placement of a bag of equal weight to that of the collected sample for it to centrifuge properly.
A picture of the centrifuge system is shown here.
The remainder of the first week with the Hematology/Oncology department was even more exciting than the first half. During the second half of the week we primarily went on rounds with the attending and residents, as well shadowed/observed a few physicians at the clinic.
My partner and I were able to do inpatient rounds with Dr. Venepalli in the Oncology section of the department. It honestly was one of the coolest experiences ever. At a fixed time the attending and the residents meet to do rounds; however, prior to meeting up, the residents and the attending seem to have read up quite a bit on the patient status and history, the former seems to have done a more extensive review of the patients. Each resident seemed to be only responsible for a portion of all the patients on the list. Whether the residents split up the patients among themselves or whether they are assigned to them, I do not know. Nevertheless, upon meeting up, the attending, the residents, and us (interns) collectively walked towards the room of the first patient on the list to see. They stop at the entrance of each of the room and the resident who is responsible for the patient begins to debrief. The review the patient demographics, the diagnosis, complications, current state of being, the state of being for the past few days, any new symptoms, their vitals, and even their alertness. Without flaw, they review every health aspect of the patient. Obviously, to memorize such large amount of information can be tricky thus they all seemed to have small pieces of paper, each being dedicated to jotting down notes on one patient so that recalling information while reporting is easier. The attending also takes notes as the residents are reporting patient info, and she often asks the resident what they think about the patients’ current status, what a diagnosis might be for a set of symptoms, etc. Such practice of requiring the patients to do some critical thinking definitely helps them learn more and makes them more competent doctors.
One of the interesting things I noticed was how calm and caring the attending was when interacting with the residents and patients. I suppose this is why medical school look for candidates that are socially well-rounded and able to keep cool.
During the second half of the week we were also able to spend some time in the clinic with Dr. Rondelli and Dr. Patel. We followed Dr. Rondelli almost through every one of his patient. I was shocked by how different the physician-patient interaction was in the department when compared with Urology. The physicians and patients here seemed to know each other well enough given that they have been working together for a long period of time. The interesting part was that as we walk into the room it is evident to tell how the patients are. The ones who are improving their conditions seems are excited and thrilled, whereas the ones who are not feeling as great or is undergoing the chemotherapy seem to be quite saddened and in pain. Nevertheless, the diverse amount of emotions the patients’ exhibit does require the physician to be quite emotionally competent. While in the clinic two specific cases caught my attention. One was that of a young woman undergoing chemotherapy. Dr. Rondelli informed us of the therapy is difficult on her not only physically, but also emotionally as she is not getting the sufficient social and emotional care she needs outside the hospital. Her situation was quite sad such that her siblings aren’t on good terms with her thus the motive for the siblings to even pay any attention to her are monetary reasons. Such a relation was evident in the clinic, as the sister wasn’t actively engaged in talking about the patient’s care and such.
The second case that caught my attention was that of an elderly man who is terminal, however currently feeling quite healthy. The doctor suggested that he can enjoy the good quality of life that he is experiencing currently or that he may enroll in drug trials that may or may not work and that could have side effects. When compared to the other patients he was actively involved in his care such that he didn’t leave the doctor to making all the decisions. Thus, elderly man was excited enough to enroll in the trial with the reasoning that it may do well to more people. I was quite touched by his decision because he was willing to sacrifice the good quality of life so that medicine research and technology may be advanced.
Furthermore, while spending time in the clinic with Dr. Patel one of the biggest thing that caught my attention was the use of the translation device with a patient. I had previously seen the device however never seen it in use. It is almost like a telephone in that the translator who is virtually connected from a different location listens to the physician and translates to the patient. The major downfall of the system is that since the translator is not physically present in the room they aren’t seeing the physician speak and the non-verbal communication taking place. Lacking such physical cues could lead to not translating the physician’s words with the current tone and pitch. Furthermore, another major drawback was that the translator often couldn’t tell the difference when the physician was talking to the patient versus the resident in the room. Thus, in such cases the translator often interrupts by translating the physician-resident conversation. Overall, one can’t say the system is useless, however it definitely is a slow system that could be improved. The system is placed on a wheeling stand and works through an iPad, however given the actual use of the system one may conclude that having such extensive support system is unnecessary. Further inquire revealed the system is set up in such fancy manner because it was originally meant to be used as a video call system.
As we start the fourth week of this wonderful internship, everyone is starting their second rotation in a new department. I had to wrap up my stay at the Urology department and start exploring the Hematology/Oncology department with a new partner. Unfortunately enough, I was unable to come in on Monday and therefore didn’t get to meet the handful of members at the new department along with my partner. Nevertheless over the next two days I was able to meet most of the staff there and attend a few events such as the research lab meeting, see the stem cell lab, and even do inpatient rounds with an attending and the residents.
I found the research lab meeting to be interesting, however it wasn’t anything out of the ordinary. The meeting had only eight individuals involved (excluding us two interns). The lab meeting reminded me very much that I am used to having with the members of UIC LPPD. Dr. Rondelli talked to each one of them about their research or about the tasks they ought to complete. He spent the most time discussing with Dr. Patel about edits to the figures for a paper they are writing. I found it interesting that even doctors with years of experience as researchers still have to spend a great deal of time making figures for researchers papers a great deal appealing. Moreover, another major portion of the meeting was a discussion with another member there (whose name I did not catch nor could find on the department’s website). Interestingly enough, the discussion between the researcher and Dr. Rondelli was about which of the research, carried out by the former, to prioritize and pursue. Inevitably, despite how cool a topic maybe what would be appealing the most to the investors and the people who fund the research was heavily considered when determining when deciding which area to further purse.
An interesting characteristic I observed about Dr. Rondelli was that from the way he communicates to his peers he seems to be able to get them to do what he sees fit without having to order or demand them to do so. I suppose it is because he possesses such profound leadership skills, along with other skills, that he was able to reach the position of the department director. Asides from that, nothing out of the ordinary took place during that hour. The meeting took place in an extremely small conference room equipped with a large TV with smartboard tools equipped to it.
After that, my partner and I were able to visit the Stem Cell Lab. The manager of the Lab gave us a brief overview of the various tasks they carried out in the lab. While doing so, she also mentioned that the lab is a clinical lab and not a research lab – meaning that they don’t store or in general deal with stem cells of anything aside from humans. Overall, the lab employs three very friendly technicians. While giving us a tour of the lab, we were also able to get a glimpse at the costly aspect of healthcare. She said the usage of various machines in the lab, and even some of the lab equipment are simply too expensive to be affordable by the patients who the UI health system serves.
Nevertheless, during our visit we were able to observe the cryopreservation process of a patients stem cells. The sample blood collected was centrifuged altogether in a huge centrifuge machine. In order to prevent the bag with the blood from being thrown out of the machine another bag of equal weight with water needed to be placed opposite to the machine. Once the centrifuge process is complete the bag with the blood is taken out, which at this point has various levels of blood content separated. Based on the total amount of sample collected the lab tech has a way of calculating how much of the platelet should be taken out and how much freezing mixture should be added to the sample. Meanwhile, another lab technician also took a sample of the blood and viewed it under the microscope with a blue dye applied on it in order to calculate what percent of the cells are viable. If the cell is dead its membrane becomes weak and allows the dye to perfuse into it, which then shows up as a blue circle under the microscope. The live cells then would appear as non-blue circles under the microscope. Nevertheless, the technician carries out a counting procedure and determines the viability of the sample. The sample is not stored if the viability is not above the standard set in place. Note that at this point some of the steps are time restricted and are carried out by the lab technician very efficiently. Nevertheless, the sample from which the plateles have been removed and freezing mixture added is then place in a container that lowers its temperature to -90oC in a series of steps. This process alone takes about an hour. Then the sample is placed in a large storage “tank” that is kept cool using liquid nitrogen. Note that the boiling temperature of nitrogen in -196 oC, thus one can imagine how cold those storage units must be.
I think the lab can greatly benefit from a large timer to monitor their time restricted procedures and a software that could determine the amounts of freezing mixture components for a specific sample could make their technicians work easier and more efficient.
A picture of lab technicians checking for cell viability and adding freezing mixture to the sample is being shown here.
During the second half of the week my rotation partner (Mark) and I were able to visit the University Center for Urology and get a glance at the OR one last time. The University Center for Urology is on the fourteenth floor of the building located at 60 E Delaware Avenue. The clinic is still part of the UI Health system, however it is dedicated exclusively to seeing/serving private patients. From what we saw when we were there, there were only three nurses present at the clinic, and we were told that the clinic only has one attending at a time. While we were there, the attending present was Dr. Ross. As how it was at the other clinic, we were able to observe the two common clinical procedures of performed by urologist: a cystoscopy, and a transrectal prostate biopsy.
The clinic being dedicated to private patients, I had expected the instruments and such of the clinic to be up-to-date with what’s available in the market. However, I couldn’t be any more wrong about making such an assumption. The clinic in fact had instruments that were older and outdated than the ones the outpatient clinic open to the public at the main hospital had. Dr. Ross explained that the clinic doesn’t need the costly newer equipment because the clinic isn’t big enough nor have lot of patients requiring newer equipment. Whereas, the outpatient clinic at the main hospital need newer equipment since more patient is being seen there and the newer models makes procedures a bit easier and faster.
Note that here when I refer to old and new equipment, I am primarily referring to the cystoscope and the prostate biopsy needle gun. The cystoscope at the University Center for Urology is a flexible one however it isn’t high-tech enough to allow to be connected to a monitor and such to display the visual. The user has to look in through the eye-piece at the external end of the cystoscope. Whereas, at the outpatient clinic at the new hospital has cystoscopes by which the user may see the visual enlarged on a monitor. Similarly, the prostate needle biopsy gun used at the former location is a reusable one whereas at the other clinic it is disposable one.
Overall, the environment at the University Center for Urology was quite calming and organized. The patients barely had any waiting time as there weren’t many of them and was never overbooked. Moreover, I think it would do injustice to accounting for our experience at the University Center if I didn’t mention a few words about Dr. Ross. Given the vast experience he has had in the field, he is able to explain thoroughly even the most complicated concepts humbly in simple terms to the patients and students. He is greatly passionate about education and patient care, so that while ensuring the patient’s comfort he also acts as a great teacher by narrating every procedure and encouraging active participation.
Following the clinic we were able to be visit the OR one last time as part of our Urology rotation. During our rotation we say a robot assisted laparoscopic prostatectomy. At this point my partner and I have seen more than five prostatectomies by different surgeons over the past three weeks, and it is safe to say that we know the procedure well enough to provide a general narration. Nevertheless, each time we see the surgery there are different specifics we notice and identify. For example this time around we were noticed that for laparoscopic procedure having suction that is flexible at the tip so that it may be angled to reach certain corners. Whether such suction tool exists for as a Da Vinci robot addition is unknown, however such a tool doesn’t exist for manual laparoscopic uses and could be highly useful.
The past three weeks have shown me how wonderful the realms of medicine and engineering are when they coincide. The rotation has provided me with an in-depth exposure to the hospital areas and settings that I wouldn’t have been able to see, otherwise. I have come to realize the importance of innovative and efficient engineering as the needs for the new instruments and concepts are far great in the general discipline of surgery. Hopefully, one day advanced robots or medicine or an even other convenient forms of treatment may be engineered that’s highly effective, yet minimally invasive to improve health of the people. Nonetheless, it is extremely important to acknowledge the great effort put in by the medical students in the rotation, residents, and the attending surgeons who helped us explore the department and shared their thoughts to make the experience a memorable one. Two individuals I would like to thank specifically would be Dr. Tony Nimeh, M.D and Dr Niedenberger. The former for put up with us and making sure that we are getting a wide variety of exposure and helping us out whenever we were lost, and the latter mentioned for taking the initiative to have urology department in the Clinical Immersion program. Thank you Urology for the wonderful three weeks.
Next up, it’s time to explore Hematology/Oncology and Radiation Oncology. I am excited and looking forward to that rotation.
*Note: To the handful of individuals who take the time out of their day to look over at my blog, I am thankful for your time and attention, and am genuinely sorry for not updating some of these posts sooner.
**I have included here a picture of the cart containing the cystoscope that is pushed around from room to room as needed at the University Center for Urology as needed.
During the first half of the week we were fortunate enough to see a few interesting procedures. The procedures we saw were the vaporization of a prostate tumor, artificial urinary sphincter placement, and a full radical nephrectomy. The vaporization of the prostate tumor was a surprisingly simple procedure. A scope with a laser attached was simply inserted through the urethra and the laser therapy provided by the AMS green light XPS system was focused on the tumorous area. I may include the picture of the procedure if it isn’t too big for the blog to upload (If I can’t upload I will upload an image from online of the laser being used)
After that we were fortunate enough to see a major portion of the artificial urinary sphincter placement procedure. The urinary sphincter placement was for a patient whom we saw in the clinic last week. It was interesting to understand how simple the functioning of the artificial sphincter was. The artificial sphincter has three components to it: a balloon with a fluid, a pump, and a cleft (see image). The balloon is the pressure regulator and a fluid reservoir. The pump acts to move the liquid back from the cleft to the balloon; and the cleft is what encases the urethra near by the bladder neck. The balloon is placed in the lower abdominal region. The balloon will be adjusted so that the regular pressure abdomen (with an empty bladder) will be sufficient enough to cause the balloon to push the fluid it holds into the cleft. As the fluid moves into the cleft, the cleft inflates and pinches on the urethra thus preventing incontinence. In order to void when the bladder is full, one needs to squeeze the pump repeatedly so that the fluid that inflated the cleft may be pushed back to the balloon, which then loosens the urethra and allows for voiding. Due to a delayed resistor system placed in the pump, the cleft is then automatically re-inflated as the fluid moves from the balloon to the cleft. The procedure is a bit complicated due to the importance of the placement of the components of the artificial sphincter. One of the major downside of the sphincter is the liquid that inflates the cuff or the one that is moved between the balloon and the cleft disappears over time. Which means that they diffuse out of the tube, leading the sphincter to artificial sphincter to fail.
Another procedure that we able to observe was a robot assisted radical nephrectomy. The procedure was different from the other nephrectomies that we previously saw because this was the first full nephrectomy we saw. Once again the patient was one who we saw last week in the clinic. Overall, the set up and such is not any different from the other nephrectomies. Once the patient is brought into the OR they are put under anesthesia, then under the guidance of the attending surgeon the patient is positioned to allow for optimal use of the Da Vince robot. First an incision in the region of operation is made and using a scope the internal position of the organs and such are examined and the surgeon makes the decision as to where to make the additional incisions for the robotic arms. There are certain rules about how far the incisions for the robotic arms should be made for the robotic arm to be able to move around once inside. Once the robotic arms were in place the surgery was started out by the resident surgeon by cauterizing and cutting one tissue at a time. The complicated portion of the surgery was having to clip the major vessels such as the renal artery and the renal veins. During the procedure a thick branch of the renal vein began bleeding, and the surgeon had to quickly cut off the blood supply and clip the ends. However, the surgeon couldn’t do this fast enough because the clip applier could only hold one clip at a time and had to be detached from the arm for the nurse to reload it. Nonetheless, after clipping all the major vessels carrying the various fluids in and out of the left kidney were clipped and cut off, and after all the fascia (connective tissue) around the kidney was detached the kidney was bagged. I personally found the surgeons’ attempt at removing the bagged kidney from abdominal cavity through one of the incision to be quite weird. They literally tried to pull out entire bag through a small incision while stretching out the skin. However, after being unsuccessful they had no other choice but to make the incision larger to get the kidney out. To my surprise the kidney they pulled out was quite large. It was about 7 inches in length and its central portion was as big, if not bigger than, my fist. Also, during the procedure one thing I noticed was that the distance between the console and the patient is far enough that sometimes the surgeon at the console cannot communicate properly to the resident by the patient.
So that pretty much sums up the most exciting things we saw during the first half of the week. Look for the next blog to know more about our visit to urology department’s clinic for private patients, and about my overall thoughts on the first rotation.
The second half of the week is always more exciting than the first half because we get to spend more time observing surgeries. One of the interesting procedures we observed was varicochelectomy. The procedure is about simply the removal of the varicose veins around the testes. Given that it was a microsurgery, only two surgeons (residents) were operating on the patient at a time by using a microscope. The attending present at the surgery was generous enough to narrate the whole procedure. Once an incision of necessary size was made the tissue of interest was brought forward for better visual under the microscope. Under the microscope the operating surgeons examined the tissue to determine which of it were the arteries, veins, lymphatic vessels, and just fascia. This task seemed to be a bit difficult since they often look very much alike. Interestingly, enough they also used a Doppler ultrasound to distinguish between the artery and the other vessels. However, there seemed to be considerable ambient noises that results in the ultrasound being active. Upon further inquiry with medical students, they informed us that the microsurgeries cannot typically be done by robot assisted. Another interesting observation I made during the surgery was that when the sealer/divider ran out of staples, rather than reloading with the staple the entire tool was disposed and a new one was used. I found such discarding to be quite unnecessary and inefficient.
On the same day we were able to observe two more robotic surgeries. The procedures were robotic assisted laparoscopic prostatectomy, and a partial nephrectomy. The unfortunate truth is that having seen these same procedures more than one does start to make the observation less exciting. At this point having already mentioned what the procedures through the earlier blogs I am not going to define the procedures here. However, a few observations I made was that the camera used for internal view often gets smudge on them from the cauterizing, blood, etc. In such cases the camera has to be taken out and removed from the robotic arm and replaced with a different one. In such cases I think it would significantly more important if the camera was self-cleaning or could be cleaned and used again. I have attached here a picture of the resident in action during the robotic laparoscopic prostatectomy, along with the wide array of tools used.
The following day we got to see three more surgeries. The first of which was a cyst urethra extraction – an extraction of a cyst in the urethra. It may be because the patient was a female that the surgeon didn’t have to do the procedure laparoscopically, since anatomically the female urethra is much shorter than that of the male and may be operated on easily. The second one was a transurethral removal of bladder tumor. The procedure was laparoscopic and the tumor was simply removed using a resectoscope. I noted that it would be a bit better if they could adjust the pressure of the irrigation on the scope. Also the bag into which the water that was flowing out of the urethra was collected could have been bigger since there were many instances during which the residual fluid spilled on the floor.
Following that we were able to observer a vesicovaginal fistula repair. The procedure is simply in that the surgeon simply closes the fistula that formed between the bladder and the vaginal tract. It was a bit odd that the surgery had to be delayed by a few hours so that one of the staff could go obtain a special kind of retractor known as the lone star retractor. I have attached a picture of the retractor below. The retractors use is simple such that the tissue may be hooked to a string or cord and latched on the retractor to hold back the tissue.
Week two of the clinical immersion in the urology department started out with even more surgeries for us to watch. I was able to observe placement of a suprapubic catheter, two lithotripsy procedures, and a circumcision. The suprapubic catheter was placed because the elderly patient was unable to have a catheter placed in her urethra. An odd act I noticed was that the attending physician was checking the placement of the catheter manually and ensuring it was in place without having a sterile gown or gloves on. This may be due to the fact that the procedure overall is a simply one, where the catheter is directly inserted into the bladder through an incision in the abdomen. The main downfall of having the procedure done is that the catheter is required to be replaced once every month and the abdominal incision remains open so long as the suprapubic catheter is in place.
The lithotripsy is a procedure by which kidney stones are broken into smaller pieces using sound waves and then removed from the urinary system. In either case of lithotripsy it is standard to use a holmium laser – a laser that emits sound waves at a specific wavelength. One of the procedure had to use laser in order to crush the stones, however the other one didn’t require the use of the laser. The second lithotripsy didn’t require the use of the laser because the kidney stone descended down the ureter quite easily since the patient had a stent placement. The medical student informed us that usually in cases where the patient already have a stent placed in the ureter it is most likely that the stone will descend and not require the laser. Which made me wonder whether if such an occurrence is quite common then isn’t it a lot more efficient to hold back from opening the sterile container containing components of the laser once it use has been ensured. Additionally, the attending mentioned that with the various scopes that they use, whether it be cystoscope or a ureteroscope, the ones that have good flexibility are the thin ones however the weaker the irrigation capabilities and vice versa for the thicker probes. Nevertheless, the adult circumcision procedure that followed was quite straight forward. The procedure is primarily done using the traditional tools with the exception of using a cauterizing tool to remove the foreskin and stop the bleeding.
Then during our time at the clinic, which unfortunately isn’t as exciting as the OR, we were able to observe some patient-physician interaction. However note that the new location of the clinic, which was supposed to be fully equipped and functional by the first of this month, still lack the equipment to do the procedures. Nevertheless, the prior to the physician seeing the patient the medical students and/or the residents goes in and collect information from the patient and reports it back to the attending. Patients who have been with the UIH system has all their information available readily and structured in the Cernet system. However, patients with documents, scan results, etc. from clinical environments outside the UIH system has to bring it in with them and isn’t automatically transferred. For example one of the case we observed was that of an individual in their mid-forty. They had to carry around their CT scans throughout on a CD. I didn’t understand why the resident who collected the patient information didn’t simply upload the CT scan images under their name. Moreover, an interesting thing I noticed is that it took a while for the computers to load the CT scan results because there were hundreds of pictures. Had the clinic had computers with the latest high-speed processors I am sure the time to load imaging results (which are usually large files) can be decreased a lot. Lastly, one thing I noticed is that the doctors doesn’t seem to be the best at providing emotional care for the patients. It may be because that the doctors I observe are surgeons specialized in urology and they usually simply deal with surgery. But there does seem to be a lack of empathic connection between them.
Tune in for my experience with seeing two robotic surgery back to back and more in the next blog post. I have attached below a figure of the rigid cystoscope and ureteroscope so that you may see how the potential capabilities of either tool differs based on its physical structure – the thinner one is the ureteroscope.
The remainder of the week held even more exciting events than the first day. So far the schedule for the urology department is such that on Mondays, Thursdays, and Fridays are OR days when surgeries are performed. Tuesdays and Thursdays are clinic days during which the surgeons, residents, and medical students are all in the clinic and see patients while doing some minor procedures. The weekends are off days for the surgeon, and only emergency cases are attended to. Currently, the urology department is experiencing some technical difficulty seeing patient properly at the moment since they are relocating their clinic to a bigger building. Since the examination tools and other procedural tools haven’t been transferred to the new location the physicians simply sees patients on Tuesdays at the new location, and meet patients scheduled for simple procedure at the old location, where the tools are at. So Wednesday was more engaging and eventful that Tuesday. The old location that currently houses much of the department’s equipment is adjacent to the hematology/oncology clinic. An observer can easily see that because the two departments shares the clinic, the waiting area and the surroundings of the clinic are quite crowded.
While at the clinic we primarily just observed two procedures: cystoscopy, and transurethral biopsy. However, before I share an account of witnessing those procedures, I would like to share the insight we gained from the nurse working there. One of the male nurses at the clinic was generous enough to give us brief overview of the working of the clinic. He said that typically once a patient comes in they have to wait quite a while in the waiting area before bringing them in so that the nurse may prepare the procedure room. Note that these patients are the ones that are at the old locations where the department’s procedure tools still are at; therefore, the patients who came there already had an appointment. Once the nurse bring the patient to the procedure room, usually they give a brief overview of the procedure that is about to be done and addresses any concerns of the patient. Soon enough the patient is left to change in to a patient gown that’s more appropriate for the procedure. Then typically the patient waits there for anywhere from 30 minutes to an hour and sometimes more because they may be only one attending at the clinic. Since all patient seeing must be overseen by an attending, the resident cannot see the patient alone. Thus, during the long wait time the patient is usually left alone in the room, while the nurse checks in on them.
Another interesting observation that we made while we were there was that given the diversity of the area in which the hospital is located at, often the patients who comes in are not fluent in or doesn’t entirely speak English. In such cases, an interpreter is requested for the appropriate language. Having an interpreter present is an excellent choice since the patient wouldn’t feel so isolated and alone in the room among stranger; however, the drawback of it is that it can be time consuming because the interpreter needs to translate the doctor’s words and those of the patient. Nevertheless, the communication between the physician and the patient without the interpreter would be even more time consuming.
As mentioned above, the main procedures we observed were cystoscopy and transurethral biopsy. The resident (Dr. Tony) who carried out some of the procedures was helpful in explaining the procedure and the tools being used. Cystoscopy is simply an examination of the bladder. The procedure is done using a cystoscope. The biopsy was performed to obtain samples of the prostate to check whether the enlargement of the prostate was cancerous or not. In order to do so, an ultrasound probe was inserted into the anus of the patient to locate the spot. The ultrasound probe had an accessory that allowed the biopsy needle to be inserted and the ultrasound image shows where the needle is in relation to the prostate and from what angles to get the samples. An unfortunate need the nurse expressed is that the ultrasound probes are only available in the clinic in one size. Thus, for some patient the size of the probe can be a bit uncomfortable and painful.
Then during the last two surgical observation days we were able to observe some mind-blowing surgeries. One of the surgery was an explorative laparotomy. The patient was an elderly woman. The patient renal condition was critical because the right kidney was non-functional, and the left ureter being obstructed. Therefore, the previous surgery had connected the right ureter to the left kidney. However, due to the distance between the two parts the right ureter had two sharp turn to make before passing the urine into the bladder. Thus, the surgeons decided it is best to remove a portion of the bowel and create a ureter using that portion, and so they did. While doing so a tool that they used frequently is a sealer/divider. Basically a scissors that staples the edges of the two sides it cuts through to prevent bleeding. Nevertheless, the surgery took up almost the whole day because the surgeons took about 2 hours to simply cut into the peritoneal region due to many adhesions formed from previous surgery. Then it took them about an hour to properly reach the left kidney and locate it – the difficulty was primarily due to lack of visual. Once having done so they proceeded with the plane mentioned above. The surgeons were on their feet for about 7 hours until the urology surgeons could transfer the patient over to the general surgeons who dealt with the patient’s abdominal hernia.
The following day we were able to see an adrenalectomy and partial nephrectomy carried out on a patient, and a prostatectomy on a second patient. What made these two cases quite exciting was the fact that they were both carried out by robotic laparoscopy. The Da Vinci robot is truly a magnificent device. In either case the surgeon made incisions on the patients and simply inserted the robotic arm with the tools that he would need while conducting the surgery. Often a resident would also be holding a tool laparoscopically so that they may practice the procedure while the robot (controlled by the attending) do the main portion of the surgery. The two main issues I have encountered are that because the attending sits at the control console of the robot that’s in the corner of the OR, while the resident with the manual probe/tool stays by the patient it is often a bit difficult to communicate between them due to the noise in the environment. Another flaw is that the da Vinci robot while being cutting edge technology fails to provide haptic feedback to the user. Inclusion of haptic feedback could in essence replicate the sense of touch the surgeon would have during open surgery.
With that, I’m going to stop the blog because to provide the fullest detail of the surgeries and the clinical procedures we observed would be a much longer post.
Note* the picture attached to this post is that of the Da Vinci robot. The picture I took which I wanted to upload seems to be too large such that I am unable to upload it.
Picture source: http://middlesexhospital.org/images/dmImage/StandardImage/450-da-vinci-system.jpg
Upon going up to the third floor of the main hospital building, we were asked to change into scrubs and to put on a head and shoe cap just like everyone else there. After having done as we were told, with a pen, a clinical immersion notebook, and our cell phones we stepped out in to the hallway. Stepping out of the locker room immediately left us in the middle of the intersection of two main hallways where the OR information desk was located. The young lady at the desk, with the deep and serious expression, seemed tired and stressed. It wouldn’t be a surprise for anyone sitting in her position to be tired and stressed because she had two large monitors on her crowded desk, and numerous people approaching her for information. One of the screens was evidently reporting the status of all the operating rooms. The information about the department occupying the OR, the attending in there, and the procedure, among other color-coded information seemed to be displayed on it. On that single floor based on the screen alone, there seemed to be about 19 operating rooms. The second screen in front of the lady seemed to be where she is making appointments and such.
Nonetheless, upon asking in which ORs where the urology department operating, she quickly gave us two OR room numbers and resumed her work while answering about at least 2 people at the same time. Through the relatively crowded hallway we stumbled upon the first OR. An extremely small packed room. We knew it was the right place because peeking through the rectangular glass window of the door we could see a room half filled with machines and the other half filled up with people. The doctor seemed to be working on a female patient while various curious faces of medical students hoovered around observing the procedure. Since there were practically no room in there, we decided to check out the second OR the lady at the information desk told us. While finding the second OR, I couldn’t help but notice the amount of people passing through the hallways, some rushing through, some pushing huge medical devices I have never seen before, some with large carts full of OR instruments, and some just hanging on the sides for a small chit chat.
When we reached the second OR, there were no patient or doctor to be found in there, but instead only a few surgical nurses and a nurse anesthetist were present there. Upon chatting with them a bit we learned that a surgery had just finished and that they were prepping for the next patient that would be brought in within an hour or so. The patient would have been in the OR sooner, however they seem to have ingested some food thus had to wait for complete digestion of the food. Nevertheless, one of the nurses was kind enough to show us various machines in the room and their uses, she was willing to do so because the sterilized tools for the next surgery had been put out already thus by standard protocol a nurse has to be in the room to ensure that the sterilized wouldn’t be contaminated. An interesting term I heard from her as she was pointing out the various equipment was “energy devices”, which turned out to be surgical tools and machines that make use of some degree of current. A picture of the OR in which the nurse introduced my partner and I to the various equipment is shown here.
After our conversation with the surgical nurse, we returned to the OR we visited first. Thankfully, enough the surgeons and the medical student were standing outside because the x-ray technician had just brought in the x-ray machine and was setting it up. Meanwhile, we seized the opportunity to introduce ourselves to the medical students, residents, and the attending physician. The resident conducting the operation told us to come in to the OR, which would be about half of the size of the OR pictured above yet with almost all of the same equipment. However, in order to enter we were required to wear a leaded vest in order to protect ourselves from the radiation. Since the procedure being carried out at that point was a stent placement in the ureter to remove a kidney stone, which is a common procedure, some of the medical students didn’t bother to re-enter the OR, thus leaving my partner and I sufficient room in the OR to observe the procedure. The operating resident was using a resectoscope for the procedure, therefore the entire process was completed by looking at the visual provided by the camera on the resectoscope.
Following the procedure, most people in the OR moved to the larger OR that we had explored. This time an elderly gentlemen was brought in for a procedure known as Transurethral resection of the prostate (TURP). Given that it was a larger OR, it allowed a better view of the procedure and space for general observation. The case being operated was simply that there was a significant amount of scar tissue formation of the prostate gland around by the portion of the urethra that is close to the bladder. The scar tissue lead to obstruction of urine flow, which results in the buildup of the urine in the bladder; the buildup of urine could lead to further sever complications if not dealt with soon. The operating resident used a resectoscope to find the point of obstruction by inserting the resectoscope through the urinary meatus and sliding it through the urethra. The resident used the resectoscope to cauterize and remove the excess tissue gently and cleared the urethral pathway. The scarring was said to be due to the previous urological surgical procedure that the patient underwent. Nevertheless, while clearing the obstruction a few staples were found to be loosely hanging on the urethral wall – I found this to be interesting yet strange as I didn’t understand why they were placed in that part of the body in the first place. With that the, the resident finished up the work and was able to schedule the patient to leave home in the evening.
With the TURP procedure our first day in the OR came to an end. I was shocked to find that the surgical atmosphere was quite crowded in terms of the tools being used and the number of people involved in the procedure or simply observing. Nevertheless, it was an eye-opening experience to not only know the kind of task surgeons do on a daily basis but to also learn about the vast amount of surgical tools that have been engineered to make the surgical procedures minimally invasive and the safest.
I will be sharing with you more experiences from the OR and the urology clinic in my next post that will be posted within a day or two.