University of Illinois at Chicago
In order to further my expertise in the pediatrics/adult strabismus department, I decided to devote an entire day to shadowing an orthoptist. An orthoptist can be thought of as a “technician” of sorts: he or she sees the patients before the attending physician. In my case, the orthoptist tested patients for double vision, amblyopia (when the brain ignores the signal one particular eye receives), color blindness, and general vision. She also applied dilating drops, or in one unfortunate case, the dilation spray. On one hand, the dilation spray (which is an all-in-one for the various drops needed for pediatric patients) is efficient. You don’t have to constantly switch back and forth between three bottles. On the other hand, a brave high school boy looked very very affected by the sheer blasting power that little spray bottle held. An alternative to the inevitable resistance posed by children having liquid dropped into their eye is the papoose. For the past week and a half, I’d heard “I’m gonna papoose ya!” and I didn’t know it was a serious offer. Turns out wrapping children like burritos is pretty effective at immobilizing them from the neck down, leaving just a pair of resistant eyelids to overcome. Plus, just look how relaxed and comfortable this little boy looks.
In all seriousness, I didn’t have to see the papoose employed, but I was able to take the same vision-related tests as the patients. There is a book with 3D glasses included. The back cover has a giant fly on it whose wings jump out of the page in people with binocular vision. Inside, there are diamonds where one of four circles is supposed to become 3D. These increase in difficulty and I’m not ashamed to admit I failed 2 of 9. Another technique for measuring communication between the eyes is the Worth 4-dot test.
I put on the John Lennon glasses and was able to see the two green dots with a red dot on top and on the bottom. I didn’t realize until this moment that I’ve had controlled strabismus since middle school. My eyes naturally separate when I’m not focusing them, so I took this opportunity to see if I could manipulate my results. I didn’t see the diplopic results, but more of a vertical summation of the red lights and the green lights.
In retina clinic, I followed Dr. Ulamski who was very efficient at seeing patients. We saw a woman who was seeing clouds. After inspecting her cornea, Dr. Ulamski realized she had some scratches on the surface of her eye. He needed to test her vision, but there wasn’t enough distance between the chair and the wall for the patient to read letters from the wall. To solve this, Dr. Ulamski ran across to another building to get the PAM visual acuity tester. It is added on to the slit lamp and the patient reads through the lines as they normally would with letters on the wall. I felt like it was a pretty dated piece of technology and the fact that he had to leave the building to get it was something that stood out to me.
The second week of our rotation in ophthalmology resumed in much the same way the first week ended. Due to space restrictions, and the fact that we’d seen different departments individually, this was the time to “fill in the blanks” in our exposure, so to say. Julie needed to see what plastics was all about, and I had still barely scratched the surface in the retina building. However, I was offered several choices, one of which was to observe retina surgery! A pleasant chill went down my spine and I trotted off to the secret corridor that connects the eye and ear infirmary to the hospital.
I had a much easier experience with changing into scrubs and applying the mask and booties. As I entered OR room 18, the team was in the middle of a cataract/vitrectomy surgery. I should first begin by explaining why a vitrectomy is needed and why it is accompanied with cataract surgery. Firstly, the vitreous (humor) is a clear gel that fills the space in the eye between the lens and retina, giving the eye its spherical shape. A very high majority (98-99%) of this vitreous is water, and it can become detached from the optic nerve disc. In cases like this, the patient will see constant floaters which represent the vitreous shifting within the eye during movement. Surgery on this part of the eye cannot be done under the surface of the cornea, as there is no access. Therefore, the surgeon must establish access to the inner part of the eye, both physically and visually. The least invasive way to see inside the eye is to look through the cornea and the lens toward the back of the eye. Because of this, it becomes apparent why cataracts must be removed prior to the vitrectomy (otherwise there would be a cloudy wall for the surgeon to look through). I will be describing a more strenuous case of vitrectomy, PVR, which follows mostly the same methodology. PVR stands for Proliferative Vitrioretinopathy, where a previously reattached retina becomes re-detached and folded due to contraction of the vitreous shown below.
In order for the surgeon to access the back of the eye, three trocars are plunged through the sclera. One trocar is for irrigation, to maintain desired pressure in the eye, while the other two are for tools: a light, a snare, a blade, or forceps. These tools are usually less than a millimeter in diameter and can fit easily through the trocars. For much of the procedure, the surgeon will chip away vitreous, which is quite difficult due to the poor illumination within the eye. Dr. Lim suggested forceps with a light attached to better allow the surgeon to see exactly what he or she is gripping. We saw that the blade had a light on it, but obviously the forceps did not. Comparing the PVR vitrectomy to its more “standard” counterpart, I noticed a much longer operational period. The combination of cataract and vitrectomy for non PVR lasted 30-40 minutes, maximum. However, the painstaking chipping away of the vitreous lasted close to 3.5 hours. Bear in mind the patient is awake and expected to look up at a light during this entire process. Eventually, to re-affix the retina to the back of the eye, the surgeon fills the eye with air and lasers the retina to reattach it. After this, a long-lasting gas (C3F8) is recruited to replace the air. The C3F8 will last a few weeks and its purpose is to keep the retina pressed up against the back of the eye long enough for it to heal. The patient will experience blurred vision during this recovery time, but once the gas dissipates things should improve.
After the surgery, we asked one of the fellows if we could take pictures of the tools and he told us we could keep them! Sanitizing was imperative first because of the dangers of Hepatitis C, but after that was handled, we were free to take our trophies for future research and bragging.
Julie and I have not quite had the chance to be partners so far in this rotation. In lieu of Dr. Sugar’s orders, we split our day Thursday between contacts and pediatrics. We would split up and switch departments after lunch. My vicious paternal instinct lunged me down to the second floor for pediatrics, where I met Dr. Abbasian. She is so incredibly personable and knowledgeable! I felt completely comfortable asking her questions I had (which were numerous). For starters, I couldn’t understand why pediatric ophthalmology used the same chairs as all the adult departments. Many of the younger patients I saw had to sit on their knees to match their faces up with the slit scope. Additionally, children are very squirmy! Adults are usually more resilient when having lights shined in their eyes, but some of the kids I ran into were not having it. In some situations, Dr. Abbasian had to call in help to hold the children still. Things have to get done; it’s not like the patients can be sedated for vision exams either. It was tough to be around, but the talent in pediatrics is inspiring; and I had a blast seeing the different children’s movies in the rooms. I don’t think I was in the department for more than 5 minutes before I heard Frozen playing in the background.
Due to the previously discussed squirminess, it can be difficult to obtain eye pressure measurements too. To solve this, I saw a newer tool used, called the iCare tonometer.
Supposedly, this device is able to measure intraocular pressure without the patient feeling anything. This is a great concept for sensitive patients such as children, but if IOP is above normal (~20), it gives very unrealistic readings so the doctor has to measure manually anyway.
My time in contacts was somewhat reminiscent of oncology. Dr. Joslin was personable with patients and myself. She was always able to recall facts about patients’ lives, which I think is important especially in gaining patients’ trust. She explained to me that many of the patients she sees need hard contacts due to eye surface irregularities. Hard contacts create an artificial, uniform surface on the eye. If the eye has ridges on its surface, light can split off of them causing impaired vision; soft lenses would simply fall into the grooves and just create a raised, still irregular surface. I’ve yet to investigate deep into big technologies that the contacts specialization uses, however I’ve identified plungers that are used for inserting and removing tough-to-manage lenses. In some cases, patients need scleral lenses which cover much of the front of your eye. These lenses are usually filled with a solution prior to being placed in the eye, so the patient will have to face straight down and put the lens in vertically. I can see how it’d be uncomfortable and difficult, so the plunger below is designed to help with that.
Has it really been three weeks already? I feel like a parent whose children are growing up a bit too fast. Either way, ophthalmology is already a night and day transition from oncology! My new partner, Julie (Dr. Wagner), and I arrived at the eye and ear infirmary Monday afternoon quite unsure of what to expect. Nothing could have prepared us for the man we would soon face: Dr. Sugar. He has an interesting way of teaching in that he will give us mini-quizzes to make sure we’re paying attention and learning. I’m quite sad to say I don’t think my quiz average is very high. One thing that can be observed about the technology used in ophthalmology involves the most common tool for observing the cornea, the slit scope.
You can see the patient rests their chin on part of the device, with their forehead pressed flush against a bar. A lot of times, the patient’s head does not stay completely flush with the bar and Dr. Sugar had to readjust them before continuing the examination. A head-strap sounds like an easy fix, but I don’t think the solution can be that simple. We sat in on a few outpatient visits in the cornea department before Dr. Sugar toured us around the ophthalmology department. There are 9 divisions in the ophthalmology department. I’m only going to list the divisions I’ve seen so far this week.
1. Cornea – involves the surface of the eye as well as cataracts and all things cornea.
2. Glaucoma – involves high eye pressure (note: marijuana is a very poor method of treating glaucoma. It only lowers intraocular pressure for 3-4 hours. This means patients would have to be under the influence pretty much all day every day).
3. Plastics – involves the eyelids, eye socket, and bones around the area.
4. Retina – involves, you guessed it, the retina.
I haven’t had much exposure to the retina department, so I’m not exactly well versed on what they cover. The technology seems fairly consistent throughout: the aforementioned slit scope, an indirect scope for viewing a bigger portion of the retina using lenses, and fluorescein dye, which is used to stain the surface of the eye. The staining of the eye allows physicians to asses any surface abnormalities that could indicate dryness or damage to the cornea.
Wednesday is a very important day because Julie and I were able to go to the OR! “Finally,” I thought, walking through the doors with Julie to get the scrub card “I get to see some action!” I didn’t know how to get scrubs, I didn’t know how to get changed, and I definitely didn’t know where to find the booties for my shoes. But it was incredible. With the help of Sam, Wali, Julie and Dr. Sugar, I was able to figure things out and get suited up for some carnage. We primarily hung around with Dr. Sugar; he doesn’t do surgeries anymore, but he oversees them closely. In the case of the cataract surgeries we watched, Dr. Sugar sat right next to the operating doctor and irrigated the eye. Dr. Sugar reassured the patient while also calling us in during important moments. The surgery uses two incisions on the surface of the eye to access the cataract inside. The physicians uses several intermediate methods before employing an ultrasonic hose device to break up and extract the cataract. After it is removed, an artificial lens is loaded into a syringe which is placed in the incisions and deployed into the eye. The lens unfolds and after a little positioning, the surgery is pretty much complete. It’s miraculous how quickly these procedures were: 17-30 minutes only. We became somewhat versed in the overhead microscope used during the procedure. By this I mean Julie was able to focus on her watch and I was incredibly clumsy while trying to find my arm in the microscope.
We heard of another surgery happening nearby: an enucleation. This patient had trauma to his eye which caused pain and blindness in the eye. The solution? Cut it out. This procedure is much longer than cataract surgery, so Julie and I bounced back and forth between the two rooms. In order to extract the eye, the doctors had to sever the four muscles that move the eye. These must be preserved to give a natural appearance to a prosthetic eye later.
There are many tools used throughout the procedure, I can detail the specific function of only a few of them. There are scissors for cutting sutures and different scissors for cutting flesh. They use packing with epinephrine to absorb blood and hinder bleeding. The most interesting devices to me are the ball-on-the-rod devices in the previous pictures.
While I do not know the exact name of these devices, I know they are used to measure the size of the orbit in the skull. After enucleation, the patient will have a gaping chasm that needs to be filled for several reasons. The physicians measures the orbit with these devices and chooses the appropriate size when he or she can observe only a small amount of space with the device in. A corresponding orbital implant is chosen and placed in the orbit. After the implant is in, the doctors begin sewing the muscles together to seal with cavity. A patient’s options after this surgery usually include eye prosthesis which can sometimes be fixed to the muscles to simulate natural movement.
The final two days in Oncology! This week ended in a bittersweet way. With one final 8:00 am board meeting, the early mornings were behind me. In said meeting, the radiation team reviewed patient cases. Dr. Howard from UofC was unavailable to be on-site, so he was added to the conference via Skype. I didn’t think this would be as fruitful as it was; he could speak freely without the rest of us drowning him out. Misia and I saw volume maps for radiation treatment of these patients. After the meeting, we were able to walk around the floor more. Misia and I discovered the CT simulator, where patients are fitted for their immobilization devices and CT scanned for future treatment plans. We watched as Bill used fiberglass casting material (think broken arm) to mold the patients face. Using the mold, Bill was able to create a mask that would prevent the patient from moving his head during radiation treatment.
I was able to catch a glimpse (and a picture) of an MRI scan involving a bullet in a patient’s lung. Please keep in mind this bullet has been in the lung for several months. Also please keep in mind the bullet has nothing to do with cancer. It is the sparkly object on the left side of the scan; the cancer is on the right side, just as bright but less sparkly.
The last memory I will have of this rotation lies in the hands of Dr. Mahmud. We saw him on the previous Friday; our conversation was so meaningful to all of us that it seemed only natural to revisit him. He educated Misia and I on the concept of stem cells–what is stem-ness, and how does a bone marrow transplant intend to fight cancer? Overall I am very thankful for the time I was able to spend in hematology/oncology and radiation oncology. So much thinking goes in to the treatment of cancer and it really is a team-oriented science. It has been a truly unique experience that I would love to revisit, given the chance.
This is the week we transitioned into radiation oncology! Upon descending to the concourse of the oncology clinic, we were immediately met by friendly receptionists at the front desk. They directed Misia and me to Dr. Kauffman, who we bumped into in the hallway. Dr. Kauffman is a radation oncology resident from University of Chicago. In fact, most of the doctors in radiation oncology are on rotation from UofC; because of this, they don’t have pagers but rather a floor-wide intercom system. I think the pager system works well for this area. It’s a relatively small floor with fewer physicians, and I’ll admit I enjoyed trying to identify the voices of the people behind the intercom.
There weren’t many patient consultations, so we were able to shadow the radiation therapists, mainly the man pictured above: Joe Miller. Joe did an awesome job of giving us a step-by-step explanation of how the Linear Accelerator works to administer radiation treatment to patients. He showed us the interface on the computer as well as the monitors that show different angles of the treatment room.
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There were fish on the ceiling and Pandora radio playing softly in the treatment room.
We saw the linear accelerator up close! All it took was a journey down a hallway consisting of six-inch thick walls and doors, with two turns and a very foreboding warning sign.
Eventually we saw patients with Dr. Kauffman; these were very similar to the patient consults in HemOnc, just with different details. I couldn’t get a picture, but one of the examination rooms had a curtain that would catch in the door every time I tried to shut it. Not only did that make me feel like I looked super new, but I feel like it impeded the door’s closing ability. After a few more bright-and-early board meetings, it was more of the same in the RadOnc clinic: patient consults, radiation therapy, discussions with Dr. Kauffman and Dr. Bhave. One of the most unfortunate patterns I noticed throughout the week was that most patients were coming in for palliative treatment, with no cure in sight. There was a case of someone who had anaplastic thyroid cancer, which progresses very quickly. With treatment, these patients are expected to live half a year; without treatment–maybe a week. Eventually though, the tumor will grow to be so large that it constricts the airway completely, making breathing impossible. I’m beginning to wonder if all this exposure is numbing me emotionally..
Thursday morning, we were scheduled to return to the stem cell lab prior to a transfusion. We met with Youngmin and waited in the office while students from Dr. Mahmud’s lab were shown around the facility. We had the pleasure of trying out the back-support attachment on Najma’s chair in the meantime. Eventually the tour came to a close and the transplant was ready to begin. Maintaining a temperature of -150 C is important until the samples are ready to be thawed. The lab uses a cryoshipper to keep the cassettes of blood frozen during transport to the eighth floor.
Once the team arrived outside the patient’s room, we could begin thawing the stem cells in preparation for the transplant. In our case, the patient received eight bags of 50ml each of stem cells. After thawing each bag, a sample must be analyzed for viability or contamination. If a bag has bacteria or some other contamination, the team will usually treat the patient rather than the sample being transplanted. The transfusion is done intravenously with the patient somewhat sedated. The sedation is to prevent an anxiety response; being pumped with someone else’s blood can be kind of weird.
Most of Friday was spent wrapping up the rotation and preparing to transition to Radiation Oncology. We sat in with Dr. Quigley for a decent portion of the morning. After that, we got to revisit the man we spoke to in the oncology clinic; this time he was staying in the inpatient unit and had to have a bone marrow biopsy. His great personality still shone through even though he was kind of being a baby about the whole process. It’s understandable if the patient groans or winces when being stuck with a needle, but he was yelling “OW!” when the doctor was locating his bone with her fingers. He turned to Misia when she walked in the room and said “Look away, Marianne. You’re too young to see this!” Turns out I was too young to see it because I started feeling faint again and had to leave the room.
After a presentation by Dr. Gonzalez, we were scheduled to meet Dr. Mahmud in his office at COMRB. The insight we received from him kind of shattered my world for the rest of that day. We were supposed to discuss the department and field of bone marrow transplants, but we ended up having a much more philosophical discussion than I expected. He kept stressing the importance of working for a goal and loving what you do. I told him I was planning to enter industry with a focus on medical device design, which he challenged. He asked me why I wanted to do device design and I didn’t have a very strong reason. I like the field and I don’t think I would mind developing devices. However, he made me remember why I switched to Bioengineering: my grandmother needed a lung transplant which caused me to look into synthesizing organs. Dr. Mahmud concluded that I had a reason to work in regenerative medicine thanks to my grandmother.
The beginning of the second week of the internship saw an abrupt shift from learning to collaborating. In the innovation center, Misia and I were able to compare our observations from the previous week and assemble them spatially on a board. We grouped our observations in terms of where we noticed them: Clinic, Rounds, Lab, or Meetings. In retrospect, these groups can and will be changed to better suit our problem statements. Upon the class adjourning, we zipped back to the hospital to try to make the general tumor board meeting (scheduled for noon).
We ended up not knowing where the board meeting was held (and we arrived considerably later than noon), so we agreed to head to the clinic to further process the layout and also interact with patients. Thankfully, Monday was swamped in the clinic. I think having two interns following you around is fine on relaxed days, but Dr. Patel was happy to allow us to interact with a chemotherapy infusion patient for a while. Due to the very busy nature of the clinic on Monday, there were multiple patients put into each room. Bear in mind, these people are expecting to have their own rooms, but when life hands you too many patients… you assign roommates! So we conversed with a man for close to an hour about the trials and tribulations he went through from the beginning of his transplant to the present, where his cancer is in remission. He told us in the hospital he had to take fifteen pills, three times a day. In addition to this, he said he barely got much sleep. Nurses come in every five hours or so to draw blood and change the bedding in the room. He was pleased to say he was never bored because of this, but sleep is definitely something recovering transplant patients need. I really enjoyed interacting with him and hearing his story. I also remembered to get a picture of the odd bathroom setup I detailed in my previous blog post.
As you can see, this door to a bathroom is connected to the clinic room. This is super convenient for patients who use this room, but as I said there is hallway access. You can hear random people come into the bathroom from the hallway, do their business, and then wash their hands. Also, it doesn’t seem like it’s really intended to be used by the patient (note the large scale seeming to block the door).
The next day is very cloudy to me. As someone who has been conditioned to wake up at 11:00AM all summer, getting to work at 9AM is a struggle, let alone 7AM for board meetings! Disclaimer: if anyone from another rotation (anesthesiology) is reading this, please forgive me. I know you have to be at the hospital earlier, but I am weak, and I must complain about this. So the first board meeting was at 7AM for gynecological oncology. There was a 12 person microscope that everyone was sitting around, and the presenter would put a slide under his lens, allowing everyone to observe. I thought this was a very novel way to review patient cases and discuss the courses of action. What I felt was not novel was that in one location of the microscope, two of the viewing stations were uncomfortably close together. If two people were to sit next to each other and use those stations, the proximity would lead to cheek touching (which is more than I could handle, especially at 7AM). This meeting was followed shortly after by a urologolical oncology board meeting. The microscopes were not used, but rather a computer display showed scans of the patients. Nothing too remarkable was gathered from this meeting. The rest of our day was spent with Dr. Oh in the clinic. Dr. Oh gave us a more engineering-centric (as engineering-centric as you can get with blood cancer) view on oncology. We talked about how certain cancer cells have markers to distinguish them from other cells. Using antigens, these markers can be honed in on to deliver targetted drug therapy to eliminate the cancer.
Wednesday was the day I learned that attending physicians rotate on rounds every two weeks. Gone were the days of Dr. Khan; this was the beginning of the Quigley Era. Immediately we could see a difference in the personality of the doctors and the way they preferred to conduct rounds. This difference seemed to throw some of the team off, especially when he insisted the patient information be described just-so. Each category had to be presented in a specific order; he would stop the resident if this rule was not followed. One more thing of note on this rounding day was that I officially located the gauze patch-up on one of the doors. I’m not sure what purpose it served, but I know gauze is definitely not designed for that.
The rest of our week in heme/onc kicked off with Dr. Patel’s morning clinic. Misia and I met with him in the oncology department and we followed him into the office where the physician and resident computers are. In this area, doctors are able to view and update patient information, compile notes from the appointments, and discuss cases together. There were a few problems with the entire space. For one, it is a very compact area for the amount of people that we have seen in there. Especially when several people are gathered around one station to review patient information, it can be difficult to navigate the area. When nurses or other physicians are looking for someone, the first place to look is in the office area. Usually we have to shuffle behind people throughout the whole area to find the person we’re looking for and it’s disheartening when the person isn’t there. Misia can be seen in the featured photo expressing her delight to be in such a well-engineered area.
Following Dr. Patel to each patient’s room, we were able to experience the difficult task he faces most days: telling someone they have cancer. To be quite honest though, he was very matter-of-fact in telling them their situation. He said what the condition was, what the patient could expect, and possible side-effects from the treatment. The first room we went in was a Polish woman and her husband who didn’t really speak english. Suffice to say I was lost for much of this interaction but hey, there were no tears! Following the first room, I was able to observe a bone marrow biopsy. I would have assumed general anesthetic would be necessary for something as painful as penetrating bone, but a nice slathering of lidocaine on the periosteum seemed to do the trick. I’m willing to admit the biopsy was not for me and I started to feel a bit squeamish when the sample was sucked out of the patient.
The final bit of information I can recall from Thursday is that, in the event of a patient not having a family member able to donate stem cells, there are over 40 million donors worldwide. Unfortunately, due to paperwork and testing, arranging to have these donor samples brought to the hospital can take 6-8 weeks. If I was a patient awaiting transplant those would be a very nervous uncertain 6-8 weeks.
Nothing terribly exciting happened Friday. We had rounds in the morning with Dr. Khan. I believe there was a new patient or two. We’d only seen transplant patients who had been there for multiple days or weeks, so we had no idea the amount of time that was needed to really catch everyone up on the condition of the patient. During this time, we actually found out that the packs of gowns outside each patient’s room are charged to the patient in the sum of $5 per pack. I feel like there can’t be more than six in a pack and Misia and I must have used three or four apiece now. With our new-found “financial burden” mindset, we headed down to the clinic to get more exposure to the outpatient procedures. We met a man whose legs and arms were greatly weakened due to a tumor that was compressing his spine for a very long time. In his room I noticed there was an additional door to a bathroom. This bathroom was also open to the hallway so we could hear it being used while speaking to the patient. Weird. Toward the end of the day Dr. Patel was trying to order a prescription for a patient, but there were complications and ultimately the system had to be restarted. Turns out the computers are somewhat dated and freezing problems are not uncommon.
I feel the need to start by saying, wow. What an eye-opening three days it’s been! While the experience is still only beginning, I feel like I’ve learned so much in these three days.
My partner, Misia, and I met up at the Clinical Sciences Building where we were met by Cindy Bernabe. Cindy took us to the Bone Marrow Transplant unit of the Oncology clinic off of Taylor Street. Since our mentor was still finishing up some patient appointments, we were allowed to sit behind the front desk. It’s kind of sad to admit, but this was my first taste of celebrity status in the oncology department. Soon enough, Dr. Patel was ready to show us around the BMT unit. We saw patients sitting in rooms, having chemotherapy inductions done. These patients come routinely for chemotherapy through IV, and don’t need to be admitted for treatment. Most of the induction rooms consist of chairs and TVs, but there are two beds for patients who are unable to sit up comfortably.
We were scheduled to attend a transplant meeting later in the day, and resolved to meet with Dr. Patel closer to the meeting time. With this downtime, we took it upon ourselves to speak to Lupe, one of the induction nurses. Lupe explained some of the standard procedures, what the clinic does well, and what the clinic could improve on. Nutrition is very important for cancer patients, and the clinic is lacking a nutritionist. Lupe told us other hospitals have nutritionists to speak with patients and advise them on how to eat healthy to aid in their treatment. We were well educated on patient reactions to the chemotherapy, and the precautions in place to care for them in the case of such reactions. There are crash carts, oxygen tanks, a pharmacy on-site, and 911 is also an option for severe cases.
We met back up with Dr. Patel and attended the transplant meeting. During this time, physicians and other oncology staff discussed patient conditions, as well as what point in their treatment the patients were in. There is a lot of abbreviation in the department, which was kind of hard to follow, but I feel as if I’m becoming more accustomed to hearing things like “ALL” and “CML” which are types of leukemia. Also, the meeting gave some background information on the patients who I would be visiting the following day. We ended our first day by following Dr. Patel up to 8 West, where the admitted transplant patients are. Dr. Patel advised us to follow Dr. Khan on rounds the following morning, and we departed.
The next morning, Misia and I returned to 8 West and met with Dr. Khan at 9am. Dr. Khan was accompanied by hospital Fellows and Residents; altogether I think there were 6 of us. The patients in this area of the hospital have either completed stem cell/bone marrow transplant, or are awaiting transplant. In either case, their immune systems are compromised, so precaution must always be taken to eliminate contamination risk. The first patient we visited required us to don gowns, gloves and masks. It was pretty emotional for me to see her; she reminded me of a co-worker I lost due to breast cancer. Despite her condition she was seemed to have a lot of energy, and she was very personable toward the doctors, Misia and me. Other patients after her were not in such serious conditions, so masks were usually not necessary. Some required gowns, some simply required hand sanitizer upon entering and leaving the room. One thing I noticed was that the stethoscopes were never in the same place in every room, and sometimes were not in the room at all. It’s my understanding that these particular stethoscopes have to be disposable, so that could explain some of the non-uniformity.
Everything seemed to be going fine until one of the last patients. We walked into the room of a patient much younger than any of the previous ones we visited. Hearing how real her situation was and how matter-of-fact she spoke about her treatment really affected me. Imagining how the cancer is robbing her of her youth, as well as seeing her mom… it was at that moment I realized cancer really sucks. I never took the time to understand how much time is actually required to even treat these diseases. The treatments these patients undergo weaken their immune systems over the course of 10 days, and they don’t recover for another week after that. Everything must be very precise in terms of measuring white blood cells, hemoglobin, and platelet counts. After finishing rounds, we took some time to see the cafeteria and eat lunch.
After lunch, we returned to 8 West and were informed that the girl from earlier was undergoing a lumbar puncture procedure. Thankfully we were allowed to observe. I was surprised to see the numbing agent, Lidocaine was in a glass bottle that had to be broken to access. Sterility reasons seem to be a valid explanation, but perhaps there is another way of guaranteeing a sterile dose. I was able to get a picture of the lumbar puncture kit, which shows the Lidocaine bottles and needles, thermometers and sample containers.
The entire procedure took an hour, which is not that common. There is a very small area in the spine that the needle must find in order to collect CSF, and it is made even more difficult by basically being a “blind” procedure. There are options to use imagining to easily guide the needle in between the vertebrae, but that is expensive and difficult to schedule. After an hour, enough CSF was collected from the patient, and she was given an equal amount of chemo medication. This is important to alleviate headaches due to CSF removal. I feel like I still cannot express my gratitude to the patient for bearing through the procedure and allowing me to be there for all of it.
We were due to meet Youngmin in the stem cell lab on the third floor later in that day, so we took an early trip down to what we expected would be the lab–we were wrong. Youngmin instructed us to go to a particular room number on the third floor, but we didn’t know that there were two completely different rooms with the same number. Misia and I ended up in the OR and were stopped in our tracks when we were the only people not wearing scrubs or hair nets. With a little guidance, we found our way to the stem cell lab. Youngmin explained the processes involved with obtaining stem cells from blood, centrifuging the sample to separate the plasma, white blood cells, and red blood cells. After separating these phases, the goal is to keep the plasma in a separate bag, namely “waste”.
Above is the apparatus used to separate the plasma and the other contents of the bag. The 60ml syringe is used to extract plasma from one bag, and also inject it into the waste bag. The device is quite interesting, but it seems really inefficient. When going from bag to bag, the valve in the middle must be turned to block flow to the bag not receiving or giving fluid. in addition to valve management, there are individual stops on the tubing coming from the bags. Thus, every time someone switches from extracting plasma to adding plasma, they have to undo the stopper on the tubing, turn the valve to block one bag, then operate the syringe. Going back and forth doing this is quite time consuming, and one of the bags’ tubing stopped up completely and inexplicably.
This morning began with a lung tumor board meeting at 7:30 am. Not the ideal start to a day in my opinion, but it was very informative. We were able to observe PET scans of patients, and got a little insight into the cost/benefit balance of patient care. I’m not sure how much I can say, but it’s frustrating that funding can rule out certain services to patients. Prior to the meeting we met Dr. Menchaca, who was interested in having us shadow her in radiology. We took down her information and decided we’d meet up with her later if there wasn’t anything else to do in oncology. As soon as the meeting was over, we shot back up to 8 West for more rounds.
Today was certainly more relaxed for me. We had already seen most of these patients the previous day, and we were more familiar with the protocol in preventing infection. I realized today moreso than yesterday that we have something in common with House, M.D. Doctors in that show gather in a glass room and discuss patient conditions, but during rounds the patients are discussed with mobile computer stations outside of their rooms. I also got to see the hospital’s iPad translator in action toward the end of rounds. It’s very cool to see how far technology has come; you can just Skype someone to translate conversation between doctor and patient. I made more observations about the layout of patient rooms and hallways, and how certain equipment might be cumbersome or annoying to patients and physicians. The medicine pumps beep occasionally (I’m not sure why), but it seemed like it was a nurse’s responsibility to tend to the machines. Because of this, if a pump begins beeping, it will do so until the end of a physician’s evaluation. Rounds finished around noon again, and it was lunch time.
After lunch, we met up with Dr. Menchaca in ultrasound and she showed us some of the imagining machines they use. I’ll try to make another blog post for these pictures; I think this post may be too long to include them. For writing lengthy reports, we saw Dr. Menchaca use a program that converted her spoken words to text on a screen. She spoke very fast, but it was still able to pick everything up accurately. Radiology was very interested and I saw a few scans that would do quite nicely as a computer background. We ended the day meeting with Dr. Patel in his office, eager to hear about our plans for the next day and clear up questions we developed during rounds. All in all, it has been a very tiresome few days for my feet and back, but also very fulfilling in so many ways.