University of Illinois at Chicago
A procedure I failed to mention last entry is the capsule endoscopy. It’s more at test than a procedure actually and is used when physicians need to assess portions of the small bowel between those reachable by either EGD or colonoscopy. It involves the patient swallowing a larger-than-average (30 mm length) pill that contains a battery, camera, and four LEDs. Each manufacturer varies so all pill designs are not created equal. The capsule used at UIC boasts a 2 Hz image capture rate as well as 12 hours of battery life. To clear the digestive tract patients typically drink 2 liters (half what is required for a colonoscopy) of special concoction the night before. If a patient has diverticulitis, complications can arise. Sometimes the pill will remain stuck inside a coil of the small intestine where it stays. If left alone for a long period of time (weeks, months, years) the body will form a protective coating around the pill which fuses it to the intestine wall. Many times, however, pills that do not exit the patient’s system after a few days must be manually retrieved. This requires even more work that carries much higher risks. An attending physician told us that for every 10 colonoscopies/EGDs performed there is one capsule endoscopy. Common reasons for doing Capsule Endoscopy include unexplained bleeding, unexplained iron deficiency, unexplained abdominal pain, search for polyps, ulcers and tumors of small intestine and inflammatory bowel disease such as Crohn’s disease [wiki]. One major downside of this test is that pills are not reusable. Perhaps if the battery could be recharged wirelessly the exterior of the pill could be sterilized and the pill itself could be used more than once.. All images are transmitted to a receiver the patient wears around their waist. This also produces a map of the small intestine from the time the capsule is activated and enters the mouth to the time the battery dies. Very neat stuff.
We were also given the opportunity to witness a liver transplant meeting. This was exciting and we are grateful for being there. It involved about 12 people including four attending physicians, 3-4 residents, and a few administrative people. One-by-one the patients were talked about. The meeting discussed the patient’s current condition, how many “points” they had, and their viability as a potential transplant candidate. The points system, which I believe was talked about in a earlier blog, is extensive and only the most qualified are chosen. Patients with any current substance abuse issues not 100% controlled are dismissed immediately. It’s not worth the hard work necessary by the medical team to deal with noncompliant patients. Sometimes physicians have differing view on the same patient which leads to debate. It was really interesting to see the room dynamic learn about the process. We were lucky to be there.
The day before a colonoscopy patients are supposed to drink 4 liters of a not-so-delicious drink. For EGD patients drink only 2 liters. The purpose of the drink is to clear the GI tract until stool is clear and almost all water. Clearing the system not only make the cleaning job easier for physicians but vastly improves the overall exam accuracy. A colon spotted feces with makes it super difficult to identify potentially suspicious polyps. Overall if patients follow directions they can be certain of the thoroughness of their exam. The scopes are cleaned after each use. The process is extensive. We had the opportunity to watch step-by-step exactly how it’s done. 1. Remove all buttons. It’s important to scrub every single crevice to rid all bacteria. 2. Test for leaks. This is done by placing curling at the bottom of a sink and submerging it in water. Leaks are found when air bubbles rise to the surface. 3. Leaks are examined further by the bubble test. This entails pushing air into the tube and visually inspecting if any bubbles rise. 4. Let the air pumped into the tube disperse. 5. Next, a chemical agent is distributed to the sink at 4-5 ounces per gallon of water. The scope is then scrubbed to give it an initial cleaning. 6. The areas where the buttons were removed need to be brushed thoroughly. It is here that bacteria tends to build up. 7. Then a brush is fed all the way through the biopsy channel until zero debris is seen exiting. 8. The channel is suctioned with water/cleaning agent solution. 9. Now the tube is ready to be prepped for the cleaning machine. All holes in the machine are attached to a suction valve. It is now that the scope goes through a 40 minute deep clean cycle. 10. Before the cycle begins the biopsy channel is flushed one last time. 11. Then flush the scope with clean water (tap water). 12. The scope is encircled at the bottom of the washing machine and wrapped so it is as loose as possible. The chemical agent is Rapicide. Our friend told us it is extremely strong. She has to be careful when replacing the bottles as to not breath/sniff any. 13. All parts of the tube have a bar code which are scanned before the wash begins. This is part of the record keeping process. The employee also scans in when the chemicals are changed or when they begin/end a wash cycle. After the was the end of the scopes are fitted with a green protection sponge and hung in a closet to dry.
So, Misia and I are currently in the second week of GI/Liver rotation. Last week was entirely patient consults. Pretty much it entailed watching people have their doctor’s appointments. Not to downplay the importance of consults, but this week is more exciting and interesting for us. There are five procedures routinely done throughout GI lab. Being given the opportunity to watch and be exposed to these procedures is just incredible. The five are as follows: EGD which stands for esophagogastroduodenoscopy and visualizes the upper GI tract, colonoscopy which visualizes the lower GI tract, ERCP or endoscopic retrograde cholangiopancreatogram which checks the tubes that drain the liver, gallbladder, and pancreas, EUS or endoscopic ultrasound which aids in visualizing points of interest within the pancreas, gallbladder, liver, and lower lungs through the first section of the small bowel in order to take biopsies and examine potentially suspicious tissue, and double balloon enteroscopy which looks extensively at the small bowel. Capsule endoscopy is not really a procedure but I’ll expand on that later. There has been so much learning and great information accumulated since the beginning of this week that I want to include in this blog but find it difficult because there is just SO MUCH. Ok, well I guess we can start with….Ugh I’m having trouble making this decision. Let’s begin with a typical upper GI scope.
Typically if a patient is experiencing high volume diarrhea the likely source is within the upper GI tract (stomach, small intestine). However, if the diarrhea at patient experiences is low volume the likely culprit resides somewhere in the lower bowels. This helps physicians determine which tests to consider. Sometimes both an EGD and colonoscopy are performed in series. Because patients are injected with benzodiazepine and narcotic medications throughout their stay they are not allowed to drive home. One huge advantage of these procedures that I noticed in urology also is their noninvasive nature. Most patients go directly home later that day and experience little soreness/inflammation if any over the next few days. The two drugs used to sedate the patient and transform them into a “Happy Land” are fentanyl and versed. Both are administered throughout the procedure the make the patient more comfortable. When a procedure ends and the physician goes through assigning the captured pictures to their respective anatomical locations and finishing the procedure note, they always ask nurse “How much did we give?”. This refers to these two aforementioned drugs. Fentanyl is very potent and given in micrograms with versed given in milligrams. Typical number I’ve witness hover around 75 and 4, respectively. Some people require more, some less. After the patient is sedated the physician enters either their lower/upper GI opening. A lot can be determine by simple visual inspection throughout these procedures. Biopsies are taken when suspicious tissue is visualized or as part of routine maintenance for long-term diseased patients. This is done through a “bite”. I’m very surprised not one group reenacted the bite process three Mondays ago when we divided into groups and thought up a skit. The bite reminds me a little PacMan. Except it has teeth, and literally rips tissue from the point of interest. I also related it to the cookie cutter shark: https://www.google.com/search?q=cookie+cutter+fish&oq=cookie+cutter+fish&aqs=chrome..69i57.2831j0j7&sourceid=chrome&es_sm=93&ie=UTF-8. Taking a biopsy through a bite is a two person process. The nurse feeds a wire through an inlet in the tubed scope. The wire has the “jaw” at one end and the lock/unlock mechanism at the other. I think the mechanism is spring loaded. When a nurse squeezes the apparatus with two fingers the jaws open and are ready for impact. Then a physician rams the jaw toward the tissue of interest and finely maneuvers it to grip and recover the best sample possible. Then the doctor says “close” and the nurse releases. “Open” and “close” can be said many times before adequate samples are taken. The wire is then pulled from the tube and the jaw opened in a sample jar. Pretty neat. Bites are very small, usually half the size of a sharpened pencil tip. If a patient reacts negatively to the two sedative drugs or if their blood pressure/pulse lowers unreasonably, a pure antagonist GABA blocker called narcan can be administered to reverse the effects. The same drug is used to treat overdosed heroin users. Usually patients do not lie on their back during procedures due to the underlying asphyxiation risk.
The cost of a Pentax GI scope is around $35k and the EUS scope around $85k. The cleaning process is extensive and we were lucky enough to be shown step-by-step how it is done. I’ll include this and other stories in the next post. Stay tuned!
Second Half Week Four (GI/Liver)
Hello again. The last half of the week was mostly GI and Misia and I had the chance to meet even more friendly/enthusiastic physicians. The empathy aspect really hit home over the last few days. There was one patient who had an average of ten and sometimes forty bowel movements per day. He was rightfully very frustrated. His brother had a history of IBS. I had a feeling of willingness to help this man because his situation was so miserable. I sincerely hope his situation improves. He stopped taking all medications in 2011 after he was laid off from work. The fellow and attending devised a great plan to help push his life in a more bearable direction. During the 9-12am time period Misia and I have noticed an average of 2 patients. Sometimes the business flow is closer to 1 patient/hour. The majority of the time spent on a patient is writing their note. I’d estimate around ¾ of the time. This is a huge inconvenience. It converts the profession of doctor into more of a clerical position. Even time spent in the room with patients is time spent typing and looking at a computer and not patients. There is one physician who never uses the computer in the room and chooses to write all his notes while at home. He cites “it’s embarrassing to have to look into a note if you don’t know some of the patient’s history. I never want to be stumped by the patient.” A much valid point. Even a speech recognition software such as dragon would save tremendous amounts of time. I know exactly how doctor’s notes work because I wrote them for six months in an ER setting. It’s surprising that scribing has not been more widely accepted in clinical settings. Although, if it was, these physicians would not have much to do in terms of note writing. They could instead spend more time caring for and seeing additional patients. I know the scribing movement has caught on in clinical settings such as general family medicine. More about the company I’m familiar with can be seen here: https://www.scribeamerica.com/
GI Week One
Misia and I are super excited after hearing so much about the wonders of GI rotation. On the first day we were greeted by one attending, one fellow, and one hepatologist. We were quickly thrown into the mix and began seeing patients. I remember being super happy at this time after not being charged for a double chocolate cookie at Subway. The order was also inputted wrongly in that the sandwich listed on the receipt was a turkey when in fact I had chicken teriyaki. Muahaha, anyways, back to GI. The first patient we saw was an older woman in her late 70s who was falling apart. It was pretty sad. She had lung, heart, liver, bone, diabetes, and heartburn issues. She was also too frail to undergo an upper GI scope. This type of procedure is essential to determine esophageal, stomach, and beginnings of the small intestinal tract health. The doctor present was very thorough and nice. He slowly indicated what he was doing each and every step with comments like “Going to open a note here. . . “. The next patient we saw was a 44 yr old with acid reflux. Nothing too remarkable happened there. We next saw a patient with fatty liver. The doctor was slightly concerned about H Pylori infection. For this patient a translator service called “Ivan” was used. It worked nicely, although Namrata is right in saying a smartphone is just as capable. The language translator service must cost a pretty penny. For this patient the doctor recommended pancreatic enzyme and amylase tests. One physician was nice enough to explain the difference between sensitivity and specificity to us. So far Misia and I have absorbed information just like little sponges.
One realization even more pronounced this rotation is the omnipresent patient fatness. It’s pretty disgusting. I’m not sure why but not one physician/nurse/PA has remotely suggested to a patient that he/she change their dietary habits. This really bothers me. Many diseases of the gut are caused by inflammation. The main driver of inflammation is the immune system’s overresponse to a perceived threat. Feeding your body food with little nutrition, little fiber, and lots of sugar is a recipe for disaster. Instead we as an advanced society choose to load people up with countless medications. It would be neat to see doctors prescribe patients vegetables. Wow, that sounded so earth-loving. Anyways, the next patient had multiple complaints including HA and neck pain. It was interesting to learn that narcotics and marijuana slow gut motility.
The second day of GI/Liver rotation was all about livers. Many people we had the privilege of meeting were transplant patients who had just recently undergone surgery and were in the recovery stage. I learned that for the rest of their lives these people must take immunosuppressant drugs. The days, weeks, and months following a transplant surgery are forth telling to the patient’s future prognosis. We spoke to one good spirited man who had surgery the 6th of July, so around three weeks ago. We were in the room for one and half hours with him while various professionals entered/exited the room (pharmacist, attending, nurse…). He was so friendly and told us he was walking the second day after surgery. His older brother passed away three years ago after he refused to have a liver transplant. His family has a genetic propensity for liver disease. But this man explained to us the points system for liver donation/reception. It’s based on your severity level. You can receive points for good behavior and lose points for violating rules. He was very thorough and mentioned that above all his family was right by his side through the entire process supporting him. He said if you don’t have that and you’re all by yourself, he could not have made it this far. This man was awesome. He told us stories about him being a picky eater beginning in childhood and how he wouldn’t eat the chorizo his mother would cook when him and siblings were little tots. Some people like this man were so very thankful for the treatment he was able to receive. He was a true pleasure to be around. He also commented about how he had changed his entire diet to not include salts or other unhealthy food. Others, however, seem to just not “get it”. They don’t follow the rules or listen to what they are told. They expect to get better and live a normal life by continuing to not take care of themselves. The liver transplant is truly a marvel of medicine. Wow, I can’t wait to learn more.
Today (7/23/15) is the second to last day of our Urology rotation. We decided to visit the University Center for Urology located at 60 East Delaware. This facility caters to patients with private insurance. Overall, the facility is very similar to the clinic located in the medical campus. Actually the medicaid facility had newer equipment, larger rooms, and more working space. Maybe because the volume of patients is that much greater. It would be interesting to see some numbers. Pretty much Jagan and I saw a prostate 12 core ultrasound guided prostate biopsy. It was fun to watch. Before this the physician looked through and eyepiece attached to a flexible cystoscope to examine the inside of the patient’s bladder wall. it was interesting because Jagan and I have seen this procedure done tens of times before in the OR while the patient was under general anesthesia. In the OR, sometimes patients would be awake and numbed if the cystoscopy was simply a visual examination. If the urethra had to be resected the patient would not be awake. Urology has been an incredible experience and I am going to miss it. The people we’ve had the opportunity to interact with have been amazing.
The last day of Urology rotation also allowed us the privilege of witnessing a semi-catastrophic event. During a routine nephrectomy a resident physician accidentally trimmed too much supporting tissue near the renal vein. This caused the blood vessel to tear and blood to openly flow through an unknown location. The attending physician quickly realized the gravity of the situation and told the resident to scrub in. They two men switched places and the physician began work locating and fixing the tear. Tributary vessels had to be clamped shut and cut. All in all, I think around 15 clamps were used. Some of the vessels were so large in diameter that the clamp barely fit. Even though the scale of Davinci camera is small, there was significant blood loss. I remember thinking to myself while watching the entire situation in 3D through the second console that this patient was going to die. The entire room remained calm throughout. Incidents like this must be commonplace. Attending surgeons with 20+ year experience have seen mostly every situation imaginable, and then some. It was fascinating to watch and I feel extremely privileged.
Jagan and I were lucky enough to witness the removal of an old and implantation of a new device previously unseen by us. The procedure was called artificial urinary sphincter placement. And the device is as the name suggests. We had some down time between procedures which provided ample time to learn about the device. We came across one thorough source with background and functional workings. It was actually pretty awesome because we both became immersed in the history, development of, and future implications of the device. The device is actually remarkable simple. Though the components may be difficult to see on the picture (actually, I’ll upload it as the main picture J), there are only three of them: occlusive cuff, pressure regulating balloon, control pump. This quote was found on a website but I found it very interesting, here you go: ”An artificial urinary sphincter is reserved for treatment of complex or severe stress urinary incontinence. Type III stress urinary incontinence, or intrinsic sphincteric dysfunction, is the inability of the urethra to maintain effective resting urethral closure pressure sufficient to keep the patient clinically dry at rest and during periods of reasonable physical activity.” Pretty much it’s not a common procedure and reserved only for individuals with severe incontinence but who also have the mental sufficiency and motivation to operate such a device. No Dementia permitted.
The balloon part is available in five differing pressures which are chosen based on the minimal pressure required to close the urethra entirely. The cuff also comes in varying sizes and wraps around the urethra near the bladder exit. The control pump is pretty amazing as it is placed inside the scrotum or labia and is multifunctional. It obviously deflates the cuff letting urine flow from the bladder through the urethra. But it can also be locked in the deflate position. This would be a useful feature during catheter placement. There is also a delay fill mechanism meaning after the cuff has been deflated and no additional urine remains in the bladder, the cuff re-inflates within 3-5 minutes. The fluid traveling between the balloon and cuff passes through the cuff and is unidirectional at any given time. When the patient wishes to urinate, the pump is squeeze which sends fluid from the cuff to the balloon reservoir. I would love to find the criteria for cuff size selection. And how the designers came up with proper tubing lengths between balloon and control and control and cuff. The device is so simple yet improves a select few people’s lives tremendously. When urinary incontinence becomes this severe, the patient must either choose between having permanent catheter inside their urethra at all times with accompanying urine drainage bag or undergoing the artificial sphincter placement procedure.
This is related to the last device and procedure. Many of the devices used throughout urologic surgeries seem entirely mechanical and dated in a way. I don’t mean this in a bad way. But I do see a huge opportunity to improve many of them. Many of the devices and machines (minus robot) were designed in decades past and remain little unchanged. There is this massive window of opportunity to improve basically every part of a surgery. The new DaVinci system proves this. One of the doctors recently explained to us how the new model (released this year) automatically “finds” the insertion holes in the patient and connects to them automatically. This makes moving the sometimes cumbersome machine across the room and lining up each and every hole obsolete. Step by step these little changes will continue taking place. The next decades are going to be exciting.
Hello again! This week was not as eventful or jaw-dropping as the last, but Jagan and I were given the opportunity to have some quality one-on-one time with a few of the senior-level residents. The urology specialty requires a six year residency and UIC department of urology has at the moment one sixth year and one fifth year resident. There is also a first or second year resident on the team. Most of the routine procedures are performed mostly by the residents however some rarer ones are almost entirely done by the attending physician. Jagan and I were able to witness a new procedure. It was called greenlight laser therapy to treat benign prostatic hyperplasia. BPH is also know as enlargement of the prostate. Symptoms include difficulty starting flow, frequent urination, and feeling like you just didn’t get it all out. So the laser is inserted into the urethra and literally vaporizes enlarged prostate tissue near the bladder. It was pretty neat to watch and reminded me of being in a haunted house with flashing green strobe lights. The company also spared no opportunity to add as many LEDs to the device as possible. The cord was green, there were green buttons decorating the housing unit which was about the size of 1 foot x 2 feet x 4 feet cuboid. Pretty neat device. Also, there were two techs from the company present during the entire operation. They oversaw the procedure and adjusted the instruments as needed and provided advice at times. The procedure was damn bloody. There was a steady flow exiting the catheter after the resident removed the laser apparatus. At one time I wasn’t sure the flow would stop. It eventually subsided. . . I felt bad for this guy. He will undoubtedly have a rough recovery. Jagan and I then excited the room and switched rooms in hope there would be another procedure either started or even better just starting. There was a circumcision but the resident prepping the patient told us to go and read about a device that would be used in an upcoming procedure. So we did. More to come in next blog! Stay tuned!
Wednesday July 15, 2015
It is now the third day of week two and Jagan and I are in full swing urology immersion. The week began in the OR where we witnessed a few interesting and notable procedures. One was a circumcision performed on a ~25 year old male. The procedure was more complex than one might think. This man had a sort of congenital permanently encapsulating foreskin that the physicians had to forcefully excise using a few snips of the scissors. They then had to peel back the excess skin and cauterize the trickling blood vessels. It was a little disturbing. But the procedure will change this man’s life forever. Which is amazing. All instruments used throughout this procedure were pretty basic. Somehow I became amazed by all the little kits used by physicians and nurse’s alike. There is a disposable kit for everything. Cleaning the area of interest with iodine, grab a kit. Need to insert a catheter? Grab a kit. Manufacturers must make a fortune. Everything is throw away. Nothing is reused except the mainstay machines such as those used for imaging, lighting, power, Davinci, etc. Anyway, on to some clinical experiences.
Tuesday we had the opportunity to witness some interesting/sad cases. One man complained of urine with a pink tinge and extreme pain along his left flank. In the ER in Indiana, he underwent an abdomen CT w/wo contrast. The result was not pretty. The young man, age 42 and a former smoker, had kidney cancer with potential seeding in the bladder. It was just awful, but entirely routine for the urology staff who see on average one patient every 15 minutes on clinical days. Jagan mentioned a complete disconnect between physician and patient on an emotional basis. I agree but cite desensitization as the main culprit, not a lack of empathy. The doctored carefully explained to the sobbing patient and his mother that seeding is actually better than spreading. Because for cancer to spread, it must travel through the blood. Seeding, however, contained the cancer within the same organ system. This makes is much easier to treat and provides a higher probability of treatment success. It was interesting because the same patient just mentioned underwent a ureter/bladder biopsy to determine if the cancer had spread around 2 pm this afternoon. The attending doctor was busy performing a partial nephrectomy on a different patient using Davinci when a resident entered the room and explained to the attending physician the positive results of the biopsy. The physician gave an “Oh that’s great news!” upon hearing.
The beginning of this week has allowed Jagan and I to meet two additional attending urologists. One has over 40 years of experience. The other is a bit younger but still very experienced and an expert with the Davinci system. We’ve spent more time with the younger of the two new doctor’s the past few days and have learned a great deal. /He’s very willing to explain techniques and machines to us. He likes answering why a procedure is necessary or what treatment options were available in the past. As described before, the Davinci surgical system has three elements. A console, power supply/software and the four arms. The model used in UIC ORs is around three years old, he told us. The new machine (we looked on the website) is sleeker and has an auto attach feature that quickly finds the joining parts from arm to patient’s body. Just incredible. There is still so much improvement potential for these machines. Jagan has mentioned a few times a resistance gauge of sorts. It would act as a tissue biopsy, testing only a few parameters, but producing an accurate model of what tissues lie where. Many times during these surgeries physicians have difficulty identifying between veins, arteries, lymph tissue, connective tissue/fascia, and others. The result is most of surgery time is spend differentiating between tissues and finding/reaching the point of interests instead of on the points of interest themselves. Below are some pictures of the sterile table with instruments used during a Davinci partial nephrectomy. As shown there are multiple replacement attachments for each instrument. The other picture is the software/power component of the Davinci. Jagan and I will spend an hour after work tomorrow to brainstorm and decide on a doable/worthwhile problem statement. More to come on that in next entry. Bye for now!
Saturday July 11, 2015
Since last entry was a little engineering-light, I’ll try to focus more on the devices this time around. Jagan and I have been exposed to a whole slew of new machines and procedures over the past few days. Urologic procedures in the OR take place on Mondays, Thursdays, and Fridays. Tuesdays and Wednesdays are spent in the clinic. Although procedures do take place in the clinic environment, they are much less invasive. There is a small “procedure room” among the less well-equipped rooms in the clinic where we observed an ultrasound guided prostate biopsy. All procedures performed in the clinic are done with the patient awake. Sometimes lidocaine is used to numb entry points and make the experience more bearable and comfortable for the patient. Some of the equipment we encountered in clinic are pictured below. One piece I found interesting was a translating machine. Turns out the hospital contracts this function to a separate company who provides either video or audio real-time calling. It seemed pretty simple to use and had eight languages listed with more available to search. These included Spanish, Chinese, Korean, polish, french, … you name it. Language barriers are sometimes very difficult to overcome so I was happy to see this machine in place to help people who may not be super familiar with the English language. :o)
Thursday and Friday were by far my favorite days of the internship thus far. Thursday Jagan and I witness an extremely rate 8 hour ureter resection. The patient had her right kidney removed previously (nephrectomy) with the left ureter exiting the left kidney in a zig-zag shape and connecting to the right ureter entry point into the bladder. I’ll never forget the rest of my life when the surgeon literally cut the patient’s small intestine in two because the procedure had to be modified which meant they had to feed urine from her kidney into the small intestine using a piece of the small intestine as tubing. It was a complete mess and I felt so sorry for her. She probably won’t live much longer. It was however a fantastic learning experience as Jagan and I and the medical students witness real-time peristalsis of her intestines. So incredible. The kidneys are located along the back wall abdominal cavity and the surgeons entered her body through the front. So they were forced to shove aside all sorts of organs just to reach the left kidney. Very cool to see. They used a gauze-like pad at one point called “Surgiskin” to absorb blood quickly. The pad is convenient in that it can be left inside the patient. One more interesting point. Just “opening up” the patient took 2 hours. This involves making the correct cuts and familiarizing yourself with the patient’s insides.
Friday included just two procedures, both involving the DaVinci robotic machine. The first was a partial kidney nephrectomy to remove a cyst attached to the right kidney and also to remove the right adrenal gland. I never realized how compartmentalized the body is. Each organ is anchored to structures which are encapsulated with various tissues that are then protected with even more attachments. The design also provides a nice cushion. The woman undergoing this procedure weighed around ~400 lbs so just finding the kidney and rummaging through the caverns of excess fat was a challenge. The doctors had to be extremely careful as the vena cava and ovarian vein were in super close proximity to the points of interest. I swear it was just like a scavenger hunt or video game. Except if you opened the wrong door (cut in the wrong area) someone would die. The doctors are equipped with an expert level of anatomical knowledge but still encounter challenges when determining what is what and where certain organs are and also the next steps to take. There were a few times when a staple or needed or some other instrument would be dropped inside the body. Recovering such small leftover pieces of equipment must be daunting and super stressful. What if you can’t find it? Gosh I don’t even want to imagine.
The second procedure Friday was a prostatectomy. Midway through one of the sixth year residents left the room to assist another doctor in a separate OR. This freed up one of the two control consoles of the DaVinci robot (other console was being controlled by Dr. Abern). I was privileged to watch the 3D action from the unoccupied console. It was amazing to witness. Watching the masterful technique of a skilled surgeon operate this machine is just beautiful. All the movements flow smoothly. So to prep the robot 4 entry points are made in the beginning of the surgery. Once inside the body, the operator is equipped with a few tools. One is called the bipolar dissecting forceps and is used to electrically cut, cauterize, and coagulate blood. It can also act as a non-electrical cutting tool. The second tool used was a forceps. I’ve been reading about all the attachments through the website, but basically it’s a gripping tool. It never slipped during the procedure and is so amazing to watch in action. It looks like two paper clips lines with serrated teeth that clamp together. One observation made was that all machines in the OR are situated on top of wheels. This is convenient but also sometimes cumbersome as the wires attaching each machine to an outlet can become tangled. I really love this internship so far.
One aspect of our medical system that I noticed and thought about excluding from this entry because it may not be deemed relevant or appropriate is the fact that a significant percentage of people undergoing these surgeries are grossly obese. Sure there are genetic causes but overwhelmingly a person’s (excess) weight is their decision. There have been such incredible advances in medicine in recent times that it just seems so wasteful for patients to undergo extraordinarily complex procedures when the most effective treatment could be the simple choice to eat more carrots, and less cake. As bioengineers I think we all have a deep-rooted desire to help people. But it’s difficult to have sympathy (at least for me) for people who have eaten their way into oblivion and don’t want to help themselves. People in less rich countries don’t even have access to simple antibiotics, yet alone a $2 million dollar DaVinci surgical robot machine. Sorry if the above sounded cruel, it’s just how I see it.
I also apologize for the one day late and less descriptive entry – somehow my notebook with tons of good information was misplaced on Friday after leaving the internship. I’ve been searching extra hard and trying to retrace my steps but so far no luck. It will show up eventually. I hope the descriptions in this entry were adequate – they were produced all from memory. I really want to share more because there are so many extraordinary things we are seeing and learning!!! That statement is genuine. Can’t wait for Monday.
Today was a very eventful first day of the clinical immersion experience. We began with a brief orientation at the innovation center (which I had never been to) which included bagels and some meet and greet. Dr. Kotche and Susan shared some great information and past stories with us. They also provided us a solid framework of the weeks to come including deadlines and a great deal of worthwhile advice. Overall a very productive morning. For the first three-week rotation I am paired with Jagan. We discussed some hopes and fears we have toward the next six weeks during the morning session and decided to walk to west campus just after being dismissed from the innovation center. It was a good walk. We caught up with Misia, Julie, and Tiana about half way to 1700 West Taylor and all five of us walked together for a bit before parting ways. Jagan and I went to SCW to sit and relax a little before our 1:00 pm start time.
We arrived at the hospital around 12:50 pm and proceeded to find the elevators. We had no problem gaining access because the security man saw our handy dandy badges. The next fifteen minutes were a bit hectic. We had to check out a scrubs-vending-machine-card which is just as it sounds. Jagan and I eventually found it after asking some nice people for directions, checked out scrubs from the machine, and proceeded to ask more nice people to direct us toward the changing room.
After changing we were told that Urology surgeries were taking place in rooms 4 and 17 today. So we decided to visit room 17 first. After we approached the room and peeked through the door it was obvious the room was very crowded. Room 17 was one of the smaller ORs on the floor. We didn’t feel comfortable entering a room full of people with masks who looked quite serious so we decided not to enter. Not sure where to go next, we walked to room 4. This room was being sterilized as a surgery had just ended. We met a very nice nurse and anesthesiologist nurse (not the proper title) who explained much of the room’s equipment to us. These included a ventilator, power supplies, and the cauterization tool. The room is pictured below (). Because the patient had eaten food earlier in the day, the next surgery had been postponed to 3:30 pm. The nurse said that usually patients must abstain from eating for at least 6 hours before surgery, 8 hours in some cases. So Jagan and I migrated back to the smaller operating room 17 to see what was happening there.
I guess when we peeked through the window before everyone was just setting up. When we arrived back there were medical students in the hallway picking out lead vests with supplemental lead neck coverings. The procedure was being done on a morbidly obese patient who had recently underwent gastric bypass surgery and was currently suffering from a subsequent kidney stone. The vests were needed because x-ray images were being taken throughout the procedure. I made the mistake of choosing a vest that covered my entire torso but fell just short of protecting my male parts from radiation. The nice nurse noticed this and told me halfway through and advised me to stand behind Jagan (who picked a vest of adequate length). I decided to just leave the room and find a longer vest to be better protected. Hopefully the short exposure did not cause any significant damage (fingers crossed). The situation caused me to remember my parents telling me that when they were kids they used to play with liquid mercury balls when a thermometer broke and see a live x-ray of their feet while at the shoe store. Back on topic. After this procedure Jagan and I talked with the medical students, residents, and the attending physician briefly. We told them a little about ourselves, the internship we were a part of, and what we hope to learn in the coming six weeks.
Jagan and I then walked back to the larger OR (room 4) as did most of the people from the procedure that just occurred in room 17. People are required to wear masks in the OR and someone needs to be in the room at all times to supervise and make sure none of the equipment and sterilized tools are tampered with. The man was eventually brought in for surgery. He complained of difficulty urinating. This surgery was absolutely fascinating to witness. The surgeons went right in through his urethra and eventually found a narrowing section just before the bladder. Many methods were used to penetrate a tough section of built-up scar tissue from a previous surgery. The tool the surgeons used has two functions: to cut tissue and to cauterize tissue if blood vessels are punctured. The whole process is monitored in real time from the monitor. The clump of tissue was stubborn and the surgeons were making little progress with the electric cutting tool, so they switched gears to what looked like an x-acto knife. After a few swipes and jabs, they broke into the bladder. There was a mild cheer from the audience and a subtle fist clench from the physician. Next the electric cutting tool was reinserted and the abnormal growth began to be trimmed. It was so neat to watch this on the monitor. We even had access to the two ureters (which connect both kidneys to the bladder). As the trimming continued we came across a few staples that must have been leftovers from a previous surgery. As the obstruction between bladder and urethra was slowly sheared away, a large amount of urine began flowing. The whole procedure was just incredible to observe. I guess I had this preconception that surgeries dealing with male/female reproductive organs would be more finessed and gentle. It was anything but. At times violent and thrusting to acquire the best angle. A giant rod needs to be inserted into the urethra. It is here that cuts are made and cauterized when made too deep and capillaries burst. The reproductive organs are dense with nerves so it’s a good thing patients are sedated during these procedures.
I assume the patient will be quite sore over the next few days.