University of Illinois at Chicago
In our last few days in gastroenterology, we observed a few colonoscopies and EGDs, and tried to really hone in on the clinical needs in our department.
Something interesting I noticed during a colonoscopy is that there were three different settings that the doctor could switch between to visualize the colon better. The Pentax endoscopy system has three iScan image enhancement settings to visualize different types of lesions. iScan1 is involved in surface enhancement, and enhances structures by edge recognition. iScan2 (which we saw used most frequently aside from the normal setting) is done to enhance contrast, and the doctors used it in patients suspected to have dysphagia. iScan3 is a tone enhancement, and modifies the “combination of RGB components for each pixel” to enhance individual organs.
Gastroenterology differs from other specialties in that the doctors don’t know what they will be treating until they get inside of the patient. For example, during routine colonoscopy screenings (which are recommended for all patients above age 50) doctors recognize and treat any polyps that they see. In most other fields, the doctors know what they will be doing and what tools they need to use. In GI, all tools need to be kept on hand and all nurses and doctors need to be prepared for any eventuality.
An emerging field of research in gastroenterology is the capsule endoscopy (see below), which I mentioned in an earlier blog. We decided to look into capsule cameras for the colon, which have only recently been made. An issue with these capsules is that they only identify 60-70% of true polyps and falsely identify 10-20% of polyps that don’t exist. The likely problem here is that in the colon has pouches called haustra. These pouches are difficult to visualize with only a front facing camera. We considered series of 2-4 cameras that could be placed along the length of the pill that would allow for visualization of all angles of the colon. Another possibility is to develop image analysis software that would ensure the doctors don’t miss any abnormalities in the gut.
Image source: http://mayoclinichealthsystem.org/locations/eau-claire/medical-services/gastroenterology-and-hepatology/capsule-endoscopy
Another problem with capsule endoscopies is that in patients with slow stomachs, the battery may die and not record crucial area of the digestive tract. To remedy this, we considered a wireless/inductive charger that would be attached to the electrodes that stem from the receiver (see image below). There would be tiny coils of wire in this charger that would generate flux and charge the pill. The electrodes themselves could also be charged wirelessly, or could be powered with a more powerful battery.
Image source: http://www.sgihealth.com/capsule-endoscopy/
After analyzing all of our data, we presented to Dr. Patel on Thursday. She suggested that the electromagnetic field created by the recharging feature could interfere with pacemakers and defibrillators, which many of these older patients have. The solution to this, then, could be to only use it for patients without pacemakers or to develop a short range magnetic field that would not radiate more than 1-2 inches from the electrode.
On Friday, we met as a class and presented and discussed our rotations and what we gained through this experience. Overall, I found this rotation to be amazing, from both a technical and a personal standpoint. I am glad I chose GI, and was happy with how much I learned from both patients and physicians!
In the beginning of our last week, Mark and I decided to divide our time between following around Dr. KumKum Patel and just jumping into any interesting procedures going on. We followed Dr. Patel up to the 7th floor of the main hospital to listen in on some inpatient rounds discussions. Here we listened to five doctors talk about the status of 5 patients in the GI inpatient wing. Much like in Hematology/Oncology, the doctors discussed the protein and electrolyte level of each patient as well as any side effects from medications. The main difference between rounds here and in oncology was that almost every patient was to have a colonoscopy or endoscopy at some time in the future.
The two most interesting and unique procedures we observed were endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). Most of these procedures are done in procedure room 5, which has arrangements for general anesthesia and x-ray imaging. Double balloon enteroscopies (DBE, to examine the small bowel) are also done here, although we did not see one.
The first procedure with ERCP was done to place stents to transport bile. Two stents were placed into the common bile duct and pancreatic duct through the hepatopancreatic ampulla in the duodenum. The ERCP scope has the camera on the side rather than in the front, so it is tricky to maneuver the scope down the GI tract. However, once it hits the duodenum, the side facing camera makes it easy to visualize anatomical features on the wall, such as the ampulla. One monitor displayed the camera on the scope, and two monitors displayed an x ray image that was being taken of the patient’s abdomen. After injecting contrast into the bile ducts, the doctors could see where they were aiming for and they could make sure they were placing the stents in the right spot. These plastic stents need to be replaced every 3 or so months, so this is a relatively common procedure for the doctors.
During each ERCP, everyone in the room had to wear a lead apron to protect their bodies from any stray radiation beams, including Mark and myself. The most interesting aspect of this first ERCP was that I saw the stents both outside of the body on the tray and inside of the body on the scope camera and on the X-ray. Comparing the old, brown stent to the new, blue stent was also very interesting. The stents turn brown because of how much bile they come into contact with.
Another interesting case was a patient that received an EGD, EUS, and ERCP one right after the other! The whole operation took 4-5 hours. The EGD was very quick and was just done diagnostically to see if there were any ulcers that might be missed with the more specialized scopes. Next, the EUS was done with a different scope. This scope had a camera but also had an ultrasound probe at the end. A balloon was filled with water and placed on the end of the scope to minimize interference from interaction with a different medium (air). The scope also had an attachment that was inserted into the portable ultrasound machine (pictured below). As the doctors used this probe, they looked at the ultrasound machine the entire time, and could see different organs such as the pancreas, liver, and gallbladder. In this case they were looking for a possible tumor mass that could explain the patient’s weight loss and painless jaundice.
The ultrasound was inconclusive save for some irregularity with the ampulla, so they decided to do an ERCP to see the ampulla more closely and take a few biopsies. The ampulla was extremely large and the bile ducts were blocked, so they used a needle knife tool to cut it open and release the bile. The needle knife was essentially a hot needle that was pressed against tissue and broke it apart. As it cut through the ampulla, I saw smoke on the screen, which was very odd to see inside the human body. They actually had to bring in a separate machine to use the needle knife. Attached to this machine were blue and yellow pedals that the doctor could press depending on which setting he desired. The settings were either cut, which resulted in more bleeding but a faster cut, or cauterize, which had less bleeding but a less precise incision. For this case, the doctor just cut right through the ampulla. I really enjoyed observing this procedure, and felt especially honored to see it since one of the fellows said he had never seen it before!
After this experience, I finally understood what my classmates felt when they complained about foot pain during long procedures.
After a few days of seeing the scopes in action, Mark and I decided to check out the endoscope cleaning room. A technician, Shay, explained the process of cleaning the scopes as well as how the machines worked. The process actually begins in the procedure room, where the inside and outside of the scope are flushed with an enzyme cleaning solution. The scope and associated components are then sealed up in a drawstring bag and transported to the cleaning room.
Here, the technician will first remove all buttons, check that the motor is sealed in its air-tight container, and brush clean every button and opening two times. Every opening is then flushed with the enzyme detergent. The sink is then drained and fresh water is poured in and used to clean the detergent out of the scope. At this point, the scope is moved to the washing machine, which looks and sounds like a unique dishwasher. The scope is sprayed with alcohol, and the various IDs are scanned, namely the patient ID, scope ID, cleaner cassette ID, and the technician’s own ID.
When this is done, the scope is taken out, dried, capped with a green foam cylinder, and placed in a closet to hang. There are closets specific to the scope type. Everything must be handled with gloves to maintain sterility.
It was very interesting to observe the scope while it was in the washing machine. Each machine can handle two scopes at a time, and it uses a potent solution to clean everything properly. There is a metal bar that rotates and ejects water onto the scope at different intervals.
On Wednesday, Mark and I observed a bronchoscopy with Namrata. There were two fellows, an attending physician, a nurse, and two nursing students in the room with us. All bronchoscopies are done in a room that is next to but separate from the GI procedures. Bronchoscopies, like endoscopies and colonoscopies, begin with patient anesthesia. A vaporizer is first used by the patient to numb her airway. She then snorts a lidocaine gel (2%) to numb the area where the scope will enter (the nasal cavity). As the scope progresses down the airway, lidocaine is injected via syringe into the scope before hitting any new branch (primary bronchus, secondary bronchus, etc). In this procedure, we saw a few bumps on the bronchus which later turned out to be cancerous.
This particular bronchoscopy made me extremely uncomfortable and stressed. It was the fellow’s first time, and the attending was screaming at him whenever he did something incorrectly. This led to the fellow becoming more stressed, which led to more mistakes, which led to more pain and coughing for the patient, which caused the endoscope to hit the tracheal and bronchial wall, which resulted in a blood-filled airway that was impossible to navigate! The 15 minute procedure turned into 2 hours of pain for everyone in the room.
Before there was blood everywhere, I could see the scope travel down the trachea and into the left lobe. It was here that I was particularly thankful for my year in anatomy class as I knew exactly what I was seeing. Even though I knew what I was looking at, I still found it incredible to see the lungs from this perspective. The most interesting part was looking at the trachea when the patient coughed. The back of the trachea contracted in a unique way that I now think of every time I cough myself.
Today we finally saw an upper endoscopy (EGD) and colonoscopy, and on the same patient! The procedure surpassed all expectations. I had never seen any type of surgery in Oncology, so this was a particularly fascinating experience.
Before a colonoscopy, patients have to drink 4 liters of a solution called “Go Lightly” which will clear out their intestines. Before endoscopies, they have to refrain from eating for several hours before the procedure. When the patient first enters the room, he/she is anesthetized using two drugs that are injected intravenously. The patient then enters a “twilight” stage, which is halfway between no anesthesia and complete anesthesia. The tolerance for these drugs widely varies from patient to patient, and different people can remember different aspects of the procedure. In some cases the patient is actually able to hold a full conversation with the doctor while he is performing the colonoscopy!
The sheer number of devices in the room was a bit overwhelming at first. Next to the patient’s bed is a large monitor that the doctor looks at while scoping. Near where the doctor stands is the processor for the scope as well as the cauterizing machine. Next to the processor is a cart which holds the water reservoir and specimen jars. The scopes for EGDs and colonoscopies are very similar, save for their diameters. At the end that goes into the patient, there is an LED light and a digital camera. Most of these scopes have three channels in addition to the fiber optic cable that transmits the video to the screen. These channels are for air, water, and tools, such as biopsy forceps or snares. In the middle of the scope is the control center, where doctors can direct where the scope will turn and how much water and air to use. The scope then plugs into a console, with separate plugs for the image processor and the light source. Different scope diameters are reserved for different procedures and patient sizes.
In colonoscopies, polyps are removed using snares. These tools come in many different shapes and sizes depending on the orientation and size of the polyp. The three we saw were the standard circular, lariat, and duck-billed. The removal of one of the polyps took three attempts with two different types of snares to get everything. The cauterizing machine has two settings: cut and coagulate. These two are used in varying amounts to remove the polyp. After the polyp was cut off of the GI wall, the doctor turned on the suction feature and just removed the endoscope with the suction on the whole time, which pulled the polyp out. Another option would be to insert the net tool, which can grab the polyp, allowing the nurse to remove it through the channel.
During endoscopies, an interesting green plastic device is used to restrict the patient’s tongue and allow the scope to enter the mouth easily. Also, before the scope is inserted, it is lubricated using a packet of sterile jelly that is poured onto a square of gauze and then rubbed onto the scope. The same is done during colonoscopies. To me, this seemed like a waste of the packaging since one full package was used per patient, and only one half got onto the scope. Perhaps it could be dispensed in a different way.
It was remarkable to see the insides of a patient lying right in front of me. In the first colonoscopy we saw, the intestines were lined with a yellow liquid that looked like bile (which was actually stool). In almost every procedure the doctor would take several tissue biopsies from different parts of the GI tract. These biopsies, or “bites,” were taken with a biopsy forceps that looks like a tiny clamp with a needle in the middle to hold onto the tissues. The biopsies are taken out through the channel and dumped into a very large jar filled with water.
image source: http://g.vatgia.vn/gallery_img/14/dbm1397362828.jpg
There was quite a bit of blood that seeped out of every “bite,” but Dr. Cemal said that it would not typically cause infection unless the bite went too deep.
During the procedure, a nurse monitored the patient’s heart rate, end tidal carbon dioxide level, respiration, and blood pressure. One of the most interesting things I noticed during the procedure was the interaction between the doctor and the nurse when using the forceps or snare. The doctor controls where the scope/tool is oriented, but the nurse controls the opening and closing of the tool. For example, while injecting methylene blue, a chemical that helps distinguish polyp tissue from regular mucosa, the doctor put the needle next to the tissue and said “Inject.” The nurse would inject and say “injecting…injecting…injecting” until the doctor told her to stop. There were 4-5 people in the room and they all watched the screen and discussed what they saw.
On Thursday, Mark and I got the chance to really connect with a liver transplant patient—we spent about 1 hour just talking to him in his room. We came in with the nurse practitioner, and stayed in his room as the pharmacist, fellow, and doctor came in and out. He confirmed what we learned from the medical assistant about the flow of the clinic. First, the patients check in at the front desk. They wait in the waiting room until their names are called. Then, the medical assistant will show them to their room, taking their vital signs and conducting a physical assessment. The patient then waits in the room until the pharmacist, nurse, or fellow come in. There is no real order here; it just depends on how many patients there are and who is free first. The pharmacist asks about the medications they are taking and if they are experiencing any side effects. The nurse will also ask about side effects and general symptoms. If it is a new consult, the fellow will ask enough questions to establish a medical history, but if not he will conduct a physical examination and again listen to any symptoms the patient is having. The fellow then goes to the doctor’s office and tells the attending everything he/she learned and suggests a possible treatment. The attending will then comment and the two will come up with an appropriate plan of attack. The attending and fellow then come in at the end and give the patient his final recommendation and examination.
I asked the patient if he thought the procedure was too repetitive, and he stated that it was a little bit, but he didn’t really mind since everyone had to write a different report. He seemed glad that everyone was concerned about him and wanted to help him.
The patient also told us about the transplant process, including the waiting list, the operation itself, and the liver disease present in his family. After patients have their transplant, they must take a very high dose of prograph, an immunosuppression drug. After some time, the dose is lowered until an optimal dose is reached—the patient will then take that dose for the rest of their lives. In some cases, the body will reject the new liver. Typically, the only solution to this is to give the patient a higher dose of immunosuppressant drugs and wait for another liver transplant donor. I was very surprised by this. It’s hard to imagine that the rejection of a large organ like the liver wouldn’t have an incredible toxic effect on a patient.
Most patients in the liver clinic have actually had liver transplants or are planning to get one soon. Otherwise, they have hepatitis C or some type of liver cancer. We actually sat in on several consultations where the patient had sunglasses on. Dr. Boulay, the attending on Friday, said that this is very common—hepatitis C tends to make the white of the eyes yellow because of the high levels of bilirubin.
Hepatitis C medication have come a long way in recent years. In the past, a very painful shot was injected into the abdomen, and this drug actually did not cure the disease. Now, a simple pill is given to the patient for 12 months and he/she is cured. There were a few patients who were living with hepatitis C and did not want treatment for fear of the older medication. The nurse and attending physician tried to explain to one patient that the new medicine was about 97% effective and had close to no side effects, but he stated that “if it ain’t broke, don’t fix it” since he did not have very strong symptoms from it.
Mark and I later met a patient who had a transplant two weeks earlier, and still had staples in his stomach where it was opened for the operation. He also had a JP drain in place, which looked like a urine bag to me. A JP drain (Jackson-Pratt Drain) is a suction device that is used post-operatively to collect excess fluids from surgical sites (which in this case was right underneath the liver). The yellow fluids were collected in a clear container that the patient had strapped to his pants. About 6 inches of the drain was actually inside of the patient’s abdomen, since the drain exited the body near his pelvis. This was done so the surgical site would not be exposed to potential infection. The doctor took this out, along with his staples. He used what looked like a staple remover at the end of a small pair of metal scissors. This was really interesting to watch, and the patient looked like he didn’t feel it at all. The doctor then put sterile tape on the incision to make sure it wouldn’t open up.
After seeing a few more patients, I noticed that each of them was taking 5-15 pills each day. I asked the pharmacists if patients ever mix up their drugs, and she said that it actually happens all the time. I thought of an idea for a pill dispenser to be used by patients in their homes. The patient could input what they were supposed to be taking and how they should take it, and the machine would take the pills out of their bottles and distribute them each day, displaying instructions if prompted. Or, another option is for the doctor to control the dispensing of the drugs, even communicating with the patient through the device. For example, if a patient’s blood work comes back with a very high level of creatine, the doctor could tell the device to give the patient a lower dose of prograph instead of having to call the patient and tell him/her to take a lower dose.
On another note, I really enjoyed shadowing Dr. Boulay. He uses candid language when talking to the patient, which makes him seem more trustworthy. He also does not use the computer at all when in the examination room. He prints out the patient’s records and writes notes on them, which he then transfers to a computer that evening at home. He also showed us some youtube videos and interesting information.
We also talked about how one of the main medications for certain GI problems is to take an antidepressant. However, if a patient is already taking antidepressants, adding any more drugs of that class can lead to serotonin syndrome, which can be potentially deadly. I always knew the brain and gut were closely related, but I had no idea that antidepressants could make both your mind and stomach happier.
Finally, the last patient we were with on Friday was asking about allopathic medicines to cure ulcerative colitis, such as ginger root and herbal tea. The attending physician said that she doesn’t want to discredit them, but just doesn’t know enough about them to say whether or not they will help his condition. I was really surprised by this, since nutrition and diet seems like it should be key in the field of gastroenterology. Not a lot of actual diet advice was given to any of the patients I observed.
Below are a few more images of the doctor’s office and the clinic entrance.
This week marked the beginning of my next rotation – gastroenterology and hepatology! For this week, we are in the outpatient clinic on Taylor Street. The clinic is divided up into half days, with either GI or hepatology dominating the clinic at any given time. Mark and I spent time shadowing attending physicians, fellows, residents, a nurse practitioner, a pharmacist, a transplant nurse, a medical assistant, and patients. Much about this clinic was comparable to the hematology/oncology clinic: the awkward organization of the doctor’s office, the communal computers, discussions of patients between fellow and attending physician, and writing notes.
Medical staff in the GI/Hep clinic use Cerner, as well as a system called Provation that allows for easy analysis of endoscopic and colonoscopic images.
Something unique about the GI clinic is that each patient is visited by 3-4 people: the pharmacist, nurse, fellow, and attending physician. Each person is there for a different reason, but the patient still has to repeat their symptoms and concerns for each. I enjoyed observing differences and similarities in technique. As they are asking questions, everyone except for the attending physician sits at the computer the entire time and only looks up from their notes every once in a while. This is also different from the oncology clinic—there, the fellows wrote down the information by hand and transferred it to online notes after the appointment. It seems like typing the notes is actually very distracting and makes the patient feel awkward and ignored, even though the notes are all about them.
In one particular case, a patient could only speak Spanish, so they brought in Ivan, the infamous tablet translator to help. As the interpreter was speaking in Spanish to the patient, the fellow was typing very loudly on the computer so I could barely hear what was being said. There were actually many issues with setting up Ivan—in one case it took the nurse about 30 minutes to set up the Cantonese translator, resulting in a 3 hour appointment for the patient.
Imaging the upper digestive system is typically done with an endoscopy, where a tube with a camera and light at one end are inserted into a patient’s mouth and moved down the esophagus, through the stomach, and into the duodenum. The lower digestive system is imaged in a colonoscopy, where a tube is inserted into the anus to image the rectum and colon. We talked with one attending physician extensively about camera capsules that a patient swallows to image the small intestine. The capsule is not retrieved after it travels through the digestive system; rather, the images are transmitted to a device clipped onto the patient’s belt. Because of the small focal length of the camera, it is really only good for imaging the small intestine—it bounces around too much in the stomach and is too small to visualize the colon properly. These imaging techniques can find ulcers (stomach), polyps (colon), cancer, inflammation, and other diagnostic features that will steer the doctor towards a certain treatment regimen.
I also saw an ultrasound! A patient complained of some RUQ (right upper quadrant) abdominal pain, and a fellow (Rupa) did a quick ultrasound of that area just to rule out any gallbladder problems. She first had the patient lay back on the bed and rubbed some blue gel onto her stomach. Then, Rupa grabbed a probe from the portable ultrasound machine and rubbed it back and forth in the area until she located the liver. She then moved down a bit and found the gallbladder. The image below was found online, but it’s comparable to what I saw. The gallbladder looks black underneath the liver, and any white marks inside of it might indicate gallstones. I had never seen an ultrasound before and was surprised by how truly real-time it is. During the procedure, the patient actually felt uncomfortable with so many people watching her, so Mark and Dr. Carroll left the room. Both the patient and I were surprised with how quick the ultrasound lasted, as it was only about 1-2 minutes, since Rupa was only looking for one thing.
Below I am including some images of the physician’s office. The first image shows the station where doctors can look more closely at endoscopic/colonoscopic images with a larger monitor. The middle image shows the printer and table where doctors put food they bring to share. Everyone was incredibly friendly, and offered Mark and I grapes, turkish candy, and peaches. The last image shows one of the computer stations. On the wall are several papers that pertain to both GI and liver disease.
source for ultrasound image: BCF technology (http://www.uk-ireland.bcftechnology.com)
We spent most of the end of the week talking to Drs. Bhave and Kauffman in the physician’s office, and a bit of time observing the CT simulator in action. On Thursday morning, we sat in on table rounds, where each new patient plan was discussed in turn, including a presentation of their scans and symptoms. I learned that anaplastic thyroid cancer is the worst cancer one could possibly have. It is incredibly fast growing and kills by constricting the trachea to the point where the patient can no longer breathe. The images of this patient were truly striking–the tumor looked to be almost twice the size of his neck.
A topic discussed at length with every case is whether the radiation will be palliative or curative. In metastatic cancers, most therapies are strictly palliative, to minimize symptoms and provide a better quality of life for the time the patient has left. Doctors also often refer to the National Cancer Center Network (NCCN), which provides documentation on staging cancers as well as treatment options to choose from. Everyone at the meeting was very welcoming and explained complicated cases to us.
We then watched the CT Sim technician arrange a patient on the bed and develop the molds, which took about 30 minutes to dry and harden. This was a patient with a tumor just under his skull, so he also had a face mask made for him. The technician first covered his face and head with saran wrap, and then made the mask out of strips of cloth-like covering dipped in a white paste. Another option was to make a more modern fiber “hockey mask” for him, but the technician said that in reality the two are almost identically effective. One difference is that in the hockey mask, the mouthpiece is built in, but for the paste/cloth a separate mouthpiece must be made. This mouthpiece is important in radiation because it keeps the teeth the same distance apart every time. As it turns out, nothing can be used to cover the patient’s healthy tissue, as I had thought. Placing lead over some part of the patient’s body only directs the photons to the surface of the body, leading to more skin burning, peeling, and complications. The patient also received contrast delivered by a robotic arm.
Later, Dr. Kauffman told us about a plaque brachytherapy he observed, where a patient had an operation to insert a gold/steel plaque behind his eye to treat his eye cancer. The plaque had radioactive seeds in it that would work over time to treat the tumor. The patient actually needs to keep a lead eye patch over their eye so they do not radiate other people they encounter. This seemed like something out of a superhero movie.
The doctors seemed to spend a good amount of time in their office. I noticed a large portion of the patients did not show up to their appointments, and after asking Dr. Kauffman about it he said that around 50% were no-shows. The department might consider a rescheduling fee or missed appointment fee to avoid this type of thing from happening—otherwise the doctors could have focused more closely on drawing the tumor volumes or discussing other patients.
On Friday we discussed emotions and comforting patients. The doctors explained that although their work can be depressing at times, radiation oncology is one of the most rewarding fields of medicine because without radiation treatment, some of these patients would pass away within the next few weeks. The patients are incredibly delicate, both mentally and physically, and sometimes can only find solace in the doctor who understands what exactly is happening in their body. Dr. Bhave mentioned that one physician in the radiation clinic actually cries with his patients, and that this helps them both to cope. Half of the time, palliative treatment is the only option, and the doctors just have to try and give the patient as pain-free a life as possible. As Hippocrates once said, doctors must “cure sometimes, treat often, comfort always.” This really holds true in the field of oncology.
In our last moments in oncology, we attended a breast tumor board meeting. The most surprising thing here was that the solution to everything seemed to be a mastectomy, regardless of the severity of the cancer. The reasoning behind this was that when a tumor is resected, the most likely place for cancer to come back is in the empty space left over. Perhaps the doctors might consider placing something in the empty space or applying necrotizing chemicals that will prevent the resurgence of cancer.
Overall, I really enjoyed my time in hemeonc/radonc. I have worked on cancer research for the last year now, but this experience allowed me to see the disease from both the patient’s and physician’s perspective.
Although it does not have to do with bioengineering or biomedical device design, the most surprising aspect of this rotation was the relatively positive attitudes of the patients. With how lighthearted some of the patients were, it was easy to forget that they are suffering through one of the worst diseases mankind can contract. After hearing that we were bioengineers, some patients even offered suggestions for procedures that could be improved.
Even so, when going on inpatient rounds, in some rooms I almost cried after seeing the patients in their weakened state. Although they try to remain humorous and positive, an inner sadness is unmistakable.
At noon, I attended the general tumor board meeting. I was surprised to see that in some cases, in addition to analyzing the pathology and PETCT or MRI images of cancers, the doctors also looked at a macroscopic view of the removed tumor (which in one striking case had taken over an entire testicle).
And so begins radiation oncology! After we descended into the basement of the oncology clinic, we were introduced to Dr. Bhave, who explained the flow of radiation treatment. First, patients are referred to the department. Typically, once they are referred they have already gone through one or more other departments in the hospital, and have received PET/CT, MRI, or other images that help the physicians see exactly where the tumor is and what volume to radiate. Nonetheless, the patient is placed into the CT Simulator, also known as the “CT Sim,” where he is immobilized using custom-made devices that encase his legs and arms, as well as the part of the body he will be receiving radiation. A CT scan is taken, and the scan and immobilization devices will be used for every subsequent treatment to make sure radiation is delivered to the same spot.
Dr. Bhave also explained that there are two main types of radiation therapy done in the hospital. The first is fractionated treatment, which is where the patient comes in for 25-30 sessions of radiation, every day for 5-6 weeks. Another option is radiosurgery (1-3 sessions), which is typically done for lung cancer, or for patients with poor lungs. Often times, chemotherapy and/or steroids (to reduce inflammation) will be administered to the patient in tandem with either of these two procedures. I was surprised to learn that radiation can be given for a wide variety of other conditions, namely keloids, heterotopic ossification, gynecomastia, and excessive salivation, among others.
We were introduced to the radiation technicians who operate the linear accelerator (LINAC) that actually delivers the radiation. The machine delivers IMRT (intensity modulated radiation therapy), where there are several beams passing through dynamically opening and closing MLCs (multileaf collimators) that shape the beam to the target area. The beams rotate all the way around the patient, and can even deliver radiation through the bed.
When a patient comes to the clinic to receive radiation, a technician first brings the patient into the room and uses their immobilization devices and aligning lasers to align him/her onto the bed. The other technician then does a preliminary x-ray of the patient, and uses the computer to move the bed, aligning him/her with the initial CT scan done in the CT simulator. He then pushes a button and the radiation begins.
Interestingly, a pelvis cancer patient’s elbow was near the edge of the bed, and as the linear accelerator was rotating around her pelvis, the machine displayed an error and stopped treatment although it was nowhere near it. The technician had to press an override button while the rest of the radiation was conducted. It was strange to see that such a sophisticated machine could not match its motion sensor to the area of treatment.
We started the next day with 7 AM gynecological oncology and genitourinary oncology tumor board meetings in the pathology department. Afterwards, we were able to observe a brachytherapy procedure, which is actually another type of radiation therapy, done over 3-5 sessions. Here, a device (whose shape varies depending on the cancer) is inserted into the patient and a targeted dose of radiation is given, typically in the form of a radioactive iridium “seed”. We observed cervical cancer brachytherapy, and thus the device was a long cylinder inserted into the vagina.
We then spent more time with the radiation technicians, and discussed another type of alignment. In lung and torso cancers, a common issue is delivering radiation to the tumor while the patient is breathing, since the tumor is displaced with each breath. At the UIC hospital, the physician will just circle a larger radiation area that will cover the tumor at all stages of breathing. In other machines in different hospitals, the radiation will only turn on for a certain stage of the breathing cycle, resulting in a more targeted radiation effect and less damaged healthy tissue.
After some discussion, I asked the technicians if they had ever treated a pregnant patient. In fact, a past patient with pelvic cancer had been pregnant, and she had to decide between saving her life and the life of her unborn child, since there was no chance for the child to survive the high energy beams. In the end, she decided to save her own life, taking her four other children into consideration. This ethical dilemma opened my eyes to how truly devastating cancer can be, to not only a person, but to his/her entire family.
The two main tasks for radiation oncologists seem to be looking at MRI/PET/CT scans and drawing out tumor volumes, as well as seeing patients. I sat in on a few of these consults. Radiation oncology differs from other hospital departments in that none of the physicians use pagers (or cell phones, for that matter). For one, all the doctors are from the University of Chicago, and have not been issued UIC pagers. Also, since they are in the basement, the reception is terrible. Therefore, all communications are sent to the nurses’ station landline, and are then broadcasted via intercom. I thought this would result in some confusion, but everyone actually seems to prefer it.
On a related note, Drs. Kauffman and Bhave mentioned that one of the only problems they came across in the clinic was that it is difficult to communicate with other departments (medical oncology in particular). This can actually lead to ineffective radiation treatment if not correctly matched with a chemotherapy regimen.
On Thursday we finally saw a stem cell infusion. We also were given lab coats to wear, because we would be entering the patients’ rooms. The order of events in a stem cell infusion is as follows. First, the appropriate cassettes (filled with donor stem cells) are removed from the storage liquid nitrogen tank and moved to the small, portable liquid nitrogen tank that will be transported to the patient room. A water bath was also moved to outside of the patient’s room a half hour before the procedure, so it would have time to heat up and be ready to thaw the frozen blood. Once ready, the blood is removed from the cassette and thawed by moving it back and forth in the water bath. Next, two samples of the blood are extracted into vials, one to check the viability (usually 75-80%, if less than 50% the infusion cannot proceed), and one to be sent to the microbiology lab to check for infection. If an infection is found in the blood, the patient receives antibiotics or antifungal medication to counteract this.
While the sample tests are being done outside, the patient is receiving a saline solution intravenously. As seen in the picture, once the stem cells are ready, they are connected to the line with the saline and then filtered, to minimize injection of debris or unnecessary red blood cells. After filtration, the cells travel down the IV tube into the patient’s arm. When looking at the IV tubing, I saw clumps of white traveling through and into the patient, which are actually the clumped stem cells.
Before the procedure, the patient will receive Benadryl to calm him/her down or hopefully fall asleep. If the patient was nervous or anxious during the procedure, this could cause a hypersensitivity reaction, leading to a rejection of the stem cell transplant. It surprised me how big of a factor mental stressors were to the procedure. To ensure there are no adverse effects and that the body is accepting the transplant, a nurse will monitor the patient’s vital signs every five minutes. A doctor is not present, but is told to remain in the wing in case of complications.
When one bag looks like it is reaching its end, the technician heads back outside into the hallway to thaw the next bag of blood. It is important not to thaw all the bags at one time because this will severely decrease cell viability, as cells start dying as soon as they are thawed. Thursday’s infusion involved only 4 bags (50 mL x 4 = 200 mL), but infusions can use up to 8 bags of 50 mL. After the infusion, we went to the clinical stem cell laboratory and saw the viability tests, done with Trypan blue on a hemocytometer. We also learned how to use the heat-powered IV tube sealer and cutter, which can actually combine two tubes into one continuous one. I was surprised by the strength and integrity of the IV tubing after sealing two distinct parts together.
After lab, we headed to the clinic and went on rounds with Dr. Khan. I noticed that all of the beds/examining chairs in the clinic had outlets on them, although I have never seen them used.
One patient in clinic had had a liver transplant some years before, and as Dr. Khan examined her abdomen I saw an interesting scar on her stomach. Dr. Khan explained that a common surgical technique for liver transplants is to cut a “Mercedes sign,” and it really did look that way, with little dots lining the incisions where the sutures had been.
The rest of the patients in the clinic only spoke Spanish, and Dr. Khan used the Interpretalk service both on a portable tablet and on a fellow’s iPhone. It seemed to work better on the tablet, since the interpreter from the iPhone really had trouble understanding anything, not to mention that there was a 5 second lag, which really added up when asking many questions.
After we saw a patient on a clinical trial medication, Dr. Khan explained to me that clinical trial patients need to be assessed on a standard scale in order to have the data accepted by the NIH. There are certain grades of disease; for example a grade 1 allergic reaction involves some redness and hives. The patients are assessed in this way in an effort to make the data more quantitative, as it is difficult to know what symptoms one doctor perceives as severe rather than moderate. Also, each patient on clinical trial medicine undergoes detailed testing after three months.
The last patient in clinic that day was an older gentleman with mylofibrosis who was there with his daughter. Dr. Khan told him and his daughter that he had leukemia, and they both took it surprisingly well. He was hard of hearing, so it is possible that he did not exactly hear the diagnosis, but his daughter was calm and collected, as if she had expected it. Dr. Khan discussed their options with them, which were either to have supportive care (antibiotics, transfusions, etc.) or to take a drug meant to cure the leukemia (which could extend his life by 8-12 months).
The next morning was spent on a patient discussion around a table, with the intent for actual rounds to begin at 2 PM. I did not realize that attending physicians could decide when to do rounds or how to do them, since there is a schedule to medication and food and blood draws.
After our class meeting from 1 – 3 PM, we met with Dr. Mahmud, the director of the stem cell laboratory. Our discussion was something I never would have expected. We talked about our future career goals, and about thinking about problems as a child would, without any limiting mental schemas or ideas. Dr. Mahmud also discussed the science and history of stem cell research and bone marrow transplant, as well as his own career history and how he came to UIC. As a group we even discussed some lines from a book of philosophy of the Indian poet Gitanjali, which were about a man who was building up a plaster wall to perfection, not realizing that he was standing in its shadow. Something else interesting he shared with us was that we have enough bone marrow to sustain us for 4 lifespans.
The beginning of this week was spent doing much of what we did last week. Monday afternoon was one of the more depressing days of the rotation so far. We were able to observe a chemotherapy infusion, which is done by a nurse. The patient was a multiple myeloma survivor in remission. Before injecting the actual drug (which in this case was a bone strengthener), he received an injection of saline because he was dehydrated and his blood volume was low. The saline flowed into his veins while the nurse checked on his insurance. There seemed to be no exact science to the length of time to use for the saline, it was just pumped through his veins until the nurse was done. I noticed that only about 10% of the saline in the bag was used before he was switched to the bone strengthener. The rest of the saline was then thrown away, which seemed like an incredible waste. Perhaps if smaller bags were used, much of that waste could be avoided.
We talked with him and his wife for close to an hour, and they explained exactly what he went through, starting with his diagnosis last year. His wife mentioned that they had also lost their daughter to myeloma a few years ago, and began crying as she was explaining it. This was the first time I had seen someone cry in the clinic, and because I didn’t want to cross any boundaries, I was not sure how to console her or continue the conversation. Something interesting they mentioned was that when he was staying in the hospital for about 3 weeks after his bone marrow transplant, he had to take 15 pills, three times a day, which was exhausting. This surprised me because I had assumed that hospital patients receive most of their medications intravenously rather than in pill form. He also showed us some purple discs that appeared on his skin, and said that he was waiting on a pulse skin biopsy that would indicate what those lesions were.
Hearing about how long everything took, the patient’s feelings, and aspects of his care he wished were different led me to think differently while observing all other physician-patient interactions.
As we left to go to the hematology/oncology board meeting, Dr. Patel came in the room to talk to the patients. He later told us that he had to break the news that the patient’s myeloma was back and he stood little chance of living much longer. It was incredibly sad to hear this after spending so much time getting to know the patient and seeing how much hardship he and his family had already been through.
Later that afternoon, we had a chance to speak to a fellow, who explained that attending doctors have to write notes after every time they go on rounds, which actually takes up a good part of their day. Often times the fellows will write this to save time for the attending physicians.
On Tuesday, we attended a 7 AM gynecological tumor meeting in the pathology department. It was much different than both the leukemia meeting and the lung tumor meeting because it took place around a 16-person microscope. The image was reflected around the room by a series of mirrors. One doctor led the meeting and went through each patient individually, showing the accompanying slides (differentially stained tissue slices) and describing the cells and what they mean for the prognosis of the patient. This meeting was much more understandable than the other meetings because of its slower pace. Something I found interesting here was that the doctors are able to determine the size of the tumor by looking at these stained slides, and estimating the length in relation to the diameter of the field of view. For example, for a 4x magnification, the circular field of view represents a diameter of 5mm, while the 20x magnification boasted a diameter of 1 mm. If using the 4x objective and the tumor took up half the screen, one could say it was about 2.5 mm. I also learned about different types of tumors (cul-de-sac, serous, mesothelial) as well as different types of diagnostic tools. Something else mentioned was that, if mesothelioma is suspected and traditional microscopy proves inconclusive, electron microscopy can sometimes be used to examine the fresh tissue. I had previously though that electron microscopy was reserved for research labs, so this was a pleasant surprise.
One hour later in the same room, we attended a genitourinary tumor meeting. The doctors sat around the same microscope, but strangely did not use it. Instead, we looked at PETCT scans on a small monitor in the corner of the room. Before I attended these board meetings, I had thought that one doctor would present the patient to the group, and then each physician would in turn say what they thought would be the best next course of action. Conversely, for almost all of these tumor board meetings, it seemed like it was only a conversation between the presenter and 1-3 top physicians in the group, with 10 residents, students, and even senior physicians just listening in.
After the meetings, we went up to the 8th floor of the hospital to see if we could catch the tail end of rounds, but were surprised to find the attending physician, Dr. Khan, and the 5-6 fellows/residents talking about the patients around a table instead of at the portable computer in front of each respective door. I later learned that this was because it was Dr. Khan’s last day as attending physician in the clinic, and on Wednesday she was replaced by Dr. Quigley. Attending physicians rotate every 2 weeks, which I think has both positive and negative aspects. On one hand, patients who are used to one doctor are confused by the new doctor and feel uncomfortable with them. However, on the positive side, two doctors can have completely different diagnostic styles, which can lead to an overall better treatment. Another benefit is that if a patient and doctor did not get along well or understand one another, the patient might feel more comfortable with another physician.
As they discussed each patient and his/her medical history, medications, and complications, I couldn’t help but notice the wide variety of ailments that befell these patients. One patient had end stage renal disease, while another had a catheter, and yet another had temporal wasting and dysphasia. I suspect that surgeons or other specialty physicians only need a deep understanding of the part of the body they work most intimately with. Because chemotherapy can affect almost every organ or part of the body, these hematology/oncology physicians must truly have a sophisticated understanding of every organ and disease.
That afternoon, we shadowed Dr. Oh in clinic, and were able to see two patients, both of which spoke Spanish with Dr. Oh. Nearly half of all of the patients I have seen in clinic have Spanish as their primary language. Luckily, Dr. Oh spoke Spanish and we did not need to use the tablet translator, which takes a long time to set up and can make for an uncomfortable situation, not to mention that these sessions take twice as long. I think that public hospitals such as UIC might consider providing a Spanish training program for their physicians, so they at least know the most important phrases and questions to ask their patients. I also speak Spanish, and more than once I heard a discrepancy between what the patient said and what the translator conveyed to the doctor. It did not affect the diagnosis, but in some cases it might.
Dr. Oh also took some time to discuss new immunotherapic cancer treatments with us and had us research three similar drugs, Rituximab, Ofatumumab, and Obinutuzumab, and then present to her what we found. What is interesting about these drugs is that they are all for CD20 positive CLL, chronic lymphoidal leukemia, (leukemia where B-cells contain the CD20 receptor on their cell surfaces), but induce cell death in different ways. They are all monoclonal antibody drugs, but Rituximab dimishes the NF-kappa-B pathway, leading to cellular toxicity. Obinutuzumab involves caspase-independent apoptosis (not including NF-kappa-B), while Ofatumumab involves complement dependent cell lysis. Dr. Oh also told us about two other emerging chemotherapy strategies that are not yet available at this hospital, Car T Cells, and biTE treatment. Both of these treatments take advantage of the body’s own immune system, using it to target and kill only cancer cells.
The next day we attended rounds with Dr. Quigley, which started once again sitting down around a table. The residents presented each patient to Dr. Quigley, and had to adhere to a strict format while presenting, which led to a much different atmosphere than with Dr. Khan. After a several-hour discussion, we went to each patient’s room, once again debriefing Dr. Quigley before each room. It seemed quite repetitive and perhaps it would have been better if the discussion happened just in the hallway, with the patient visit immediately after his presentation. I know that if I were the attending physician, I would have preferred it that way. Something I noticed on rounds is that on each IV stand are little strips of green caps. A resident explained that those were alcohol-filled caps that helped to minimize the spread of disease when transporting and administering the IV bags.
After rounds, we visited the lab of Dr. Oh, Dr. Patel, and Dr. Mahmud in COMRB. Not many experiments were going on, but it looked to be a similar set up to that which I have in my own lab in MBRB, including culture hoods, liquid nitrogen tanks, an incubator, a cold room, and lab desks and benches. A researcher in the lab showed us a flow cytometry machine, which I had never seen before. Cells in suspension are sucked into a thin metal tube, and are sorted by a variety of factors, such as fluorescent label, FSC (granule level), and SSC (cell size). Four distinct graphs were produced per sample. Water needed to be fed into the metal tube between samples, to avoid contamination and incorrect readings from residual cells and media. The two main receptors tested when looking for stem cells are CD33 and CD45. The computer was very old and worked very slowly, but I assume the flow cytometer software was only compatible to the old operating system, which is why they did not replace the computer.
The next day was spent almost entirely in the clinic. In the morning, Dr. Patel had five or six patients. For one of these patient discussions, a polish translator was necessary. The translator’s first language was not polish, and she had a difficult time explaining some of the more technical medical procedures to the patient and her spouse. It was uncomfortable for everyone, since the patient was frustrated that she could not understand, on top of receiving the news that a bone marrow transplant would be the best route of action. A handheld translator may have been more useful here.
We were then able to observe a bone marrow biopsy, where a nurse placed the patient to lay on his stomach, and essentially drove a large needle into his hip bone in order to extract some bone and the liquid marrow inside. I was surprised with the ease with which she could dig into the bone. The patient was not in too much pain, as the nurse injected a local anesthetic into the skin, and into the periosteum, which covers the bone. I did hear him groan a few times, which was a little unsettling.
Later that afternoon, I was then able to look at the marrow sample under a 6-person microscope in the pathology department. When looking through the eyepiece, I saw a cursor in the middle of the field of view. As the pathologist analyzed the sample, he would point to different cells using this cursor and tell us what the cell indicated about the success of the patient’s bone marrow transplant. We did not see many blast cells, meaning that the cancerous nature of the leukemia was essentially eliminated. We looked at the peripheral blood sample and at the bone marrow sample. In the bone marrow sample, I saw fat, connective tissue, and a variety of blood cell types in varying stages of development.
The next day, we did rounds in the morning with Dr. Khan and then went to the clinic with Dr. Patel. We only saw one patient, who had a tumor in his spinal cord. The PET sagittal slice of his cervical spine is below.
I began my week in a meeting with Dr. Kotche and Dr. Stirling, who explained to us what to look for as we observe medical procedures in our respective rotations. Later that afternoon, I went down to the oncology clinic and met with Dr. Pritesh Patel, who is our mentor. We sat in the nurse’s station in the bustling clinic until he came by. As he took us around the clinic, I noticed that there were three hallways, containing both infusion rooms (where patients would receive chemotherapy) and examination rooms (where patients would meet with physicians and discuss the medication they were to receive or the status of their cancer treatment). Dr. Patel also explained that bone marrow transplants are often used to treat aggressive lymphomas and myelomas, and are generally very effective for certain types of cancers.
We also spoke with a perfusion nurse, Lupe, who explained how the clinic operates. When receiving chemotherapy, patients first come in for their appointment and have their blood drawn. They then wait anywhere from 30 minutes to 2 hours for their blood results and vitals to be analyzed, which is something that particularly surprised me. This information is used to calculate the optimal chemotherapy rate of injection and quantity of injection for the patient. Lupe also mentioned that a very important part of chemotherapy is ensuring that patients have a nutritious diet complementary to their treatment. She suggested that they might be better off with a nutritionist on staff. As we walked around the clinic, I also noticed that there was a pharmacy and lab where patients could easily access their drugs.
We then attended a board meeting with all of the hematology /oncology staff, including physicians, pharmacists, nurses, and social workers. The patients were discussed one by one, and all the physicians and nurses were invited to contribute any information about the patient or any suggestions for a change in treatment. Each person was given a spreadsheet with the patients and their status. It was difficult to follow the discussion because of the jargon and acronyms the physicians used.
The next day we went on rounds on the eighth floor of the hospital, in the stem cell transplant wing. We followed Dr. Khan as she and a team of 3 or 4 fellows discussed each patient on a portable desktop computer stand, and then went into the room to ask the patient how he/she was feeling, check his/her heart and lung function using a stethoscope, and ask if he/she had any questions or problems with the treatment. I was surprised by the amount of waste used in this process. The patients’ rooms were labeled with the level of protection necessary to enter the room. For our first patient we had to wear yellow gowns and face masks, and the physicians who touched the patients had to wear gloves. It took a long time to put on the gowns, and when one was pulled out of the container attached to the door, all of the gowns also fell out. Perhaps a dispenser system could be implemented which only gave one of each item. Almost all of the patients were neutropenic, which means that they had a low blood count. This meant that they were very susceptible to infection, and the main reason for our protective equipment was to protect the patient from our germs. Something I noticed about the portable computer the doctors used to review the medical history and test results from the patients was that there was a stack of pill cups that were taped to the top of it, since nurses also use the same stand to administer medications. Perhaps a cylindrical indent could be implemented into the stand for the pill cups, and it could even be operated on a spring.
Later that day, we observed a lumbar puncture, which lasted for one hour and was very painful for the patient.
We were also able to observe the stem cell collection storage. When stem cells are harvested from a donor, the donor must sit for 4-8 hours with two IVs, which are connected to a machine. Blood is taken out of the patient’s vein, centrifuged and filtered so only the white blood cells are collected, and the red blood cells and plasma go back into the donor. The blood is then brought to the lab, where it is processed to filter out only the white blood cells, then to filter out only the stem cells, and finally to store them in a liquid nitrogen tank for later infusion into the appropriate patient. Something Youngmin (the main lab technician) mentioned was the the monitors on the Liquid Nitrogen tanks tend to malfunction, since they are so absurdly cold (-150 to -190 degrees).
The next day, we attended a lung tumor board meeting, where each patient was again discussed in turn. This time, however, we were able to see a PETCT or CT scan of the patient’s lungs and any tumors or lesions that might be observed therein. It was fascinating. Next, we sat in on a meeting where the main doctors discussed some financially beneficial strategies for the hospital. This surprised me because I thought that hospital administrators mainly discussed such things, rather than doctors. We went on rounds again and then went to the radiology department to look at the machines they used to make the scans analyzed in the meetings. Some machines we were able to observed were the PET scan machine, CT scanner, Xray, Fluorimetric X ray, and Ultrasound. We then met with Dr. Patel and discussed some of the things we learned.