University of Illinois at Chicago
My rotation in Orthopaedics came to a close along with the Clinical Immersion Program. I am extremely pleased with the vast amount of knowledge I have acquired in just six weeks!
On Thursday, our last day in orthopaedics, we were scheduled to watch a few surgeries, with a majority of them being hand procedures. The last case we observed in the orthopaedics OR consisted of a patient dealing with an infection in the hip. Dr. Gonzalez and the residents had to remove the original implant and insert an antibiotic spacer that releases a high dose of antibiotics into the joint and the surrounding tissue. A new prosthesis can be placed into the patient once the infection has cleared up. This individual may be more prone to a reoccurrence of an infection.
During the Orthopaedics rotation, we had a great deal of exposure to patient physician interaction. It was interesting to see how people had different pain tolerances. The doctor always wanted to start with therapy, followed by cortical steroid, and surgery if needed. Shadowing the doctor at the clinic was both interesting and enlightening. Each day he tended to about 20-80 patients, all with a wide range of symptoms and conditions. The other aspect of this rotation was in the OR and dealt with mostly invasive procedures. Here we observed all the different tools used, implants, and a wide range of procedures on various parts of the body. Orthopaedics was a great opportunity to get exposure to both clinic and OR aspects.
My time in Interventional Radiology was spent almost entirely in the OR. The ORs of the my rotations were very different. The orthopaedic OR consisted of highly invasive procedures while interventional radiology made procedures less invasive by using imaging modalities. Both departments have their pros and cons while their appeal depends on what an individual prefers to observe. Both rotations gave me invaluable knowledge in the clinical setting. There are many problems in the medical world and this program helps identify which problems need to be addressed and the severity of the need to find the solutions to those problems. Being in the OR gives more opportunities for engineers to observe the equipment, tools, and devices used. This kind of exposure and thought process allows to help further identify complications and possible solutions.
Thank you to Dr. Kotche and everyone involved for providing us with this amazing opportunity and unforgettable experience.
The patient in this case came in today for a follow up. Her surgery was last week. She is due to get her stitches removed about 2 weeks after the surgery. She is scheduled to keep a cast on for 6-8 weeks. The doctor instructed her not to lift weights because she will not have a good grip and may fall.
After shadowing physicians in this department, it is clear that they act conservatively. When a patient comes in regarding pain in their joints, the doctor tells them to attend therapy for 6-8 weeks. If they come back with pain, a steroid injection is administered. However, this only relieves pain temporarily. Injecting a steroid also has bad side effects such as wearing of the cartilage. Surgery is the final option physicians take when evidence and complaints indicate the patient is still in pain.
By the end of this week, we observed three knee replacements and one hip replacement. The procedure for all of the knee replacements were done very routinely. First, an incision about 5 inches long is made and the patella is placed along the lateral side percutaneously. After aligning the tibia with a device called Knee Align, they screwed and pinned a slotted cutting guide. This guide contains a small slit where the saw is placed to create smooth, leveled surfaces. Once the tibia and femur were properly trimmed, trial components of various sizes were inserted to determine the correct size for the patient at hand. Dr. Gonzalez has experienced complications with the patellar component of the prosthesis, therefore he keeps the real human patella in the patient. Cement is used to adhere the prosthesis onto the bone, and the wound is then cleaned up and either stapled or stitched.
I was excited to watch the total hip arthroplasty since we haven’t watched it yet. Initially, an incision was made, about 4 to 5 inches long, and the femoral head was removed. Similarly to the knee replacement, trial components, from Depuy (a Johnson & Johnson company), were inserted to determine the correct size prosthesis. A plastic liner is used to separate the acetabular component from the femoral head in order to avoid contact between the two metals. Afterwards, the cut is sanitized and sealed.
The one day we had in the OR this week consisted of repetitive procedures. I wish we had at least two days observing surgery rather than one to allow for more exposure to the vast amount of cases and equipment this department has to offer. Although the clinic allows for much observation on physician patient interaction, the OR holds more of the knowledge bioengineers need to identify possible improvements.
During week five, a patient came in complaining about knee pain and how it got worse as the day went on. The doctor wanted to do a knee replacement but had concerns about her being overweight. Dr. Gonzalez then informed the patient of her BMI and the correlated data that has been accumulated, illustrating complications. These occur during total knee arthroplasty when the BMI is over 40. Blood clotting and infection are a couple of those complications. Since her BMI was right below 40, the surgery was scheduled to be in the first week of September.
I noticed quite a few patients coming in regarding carpal tunnel syndrome. One, in particular, had a carpal tunnel reoccurrance due to the scar tissue that formed after the first surgery. This patient’s immune system produced more scar tissue than usual, thus resulting in the compression of the median nerve.
This syndrome occurs when the transverse carpal ligament presses down on the median nerve. The transverse carpal ligament holds the tendons and nerves in the hand together. However, after the surgery, the scar tissue replaces that function. A resident explained to us how Dr. Gonzalez performs surgery in order to relieve symptoms of carpal tunnel syndrome. First, an incision is made and using endoscopic guidance, the transverse carpal ligament is cut with a small knife that is attached to the endoscope.
I’ve become really comfortable in the clinic atmosphere and having a great time learning something new every day.
By the end of this week, we have seen a few surgeries in orthopaedics. The first procedure we observed was a total knee arthroplasty which consists of installing an artificial knee replacement. Many of the tools used, along with the knee replacement, were from Smith & Nephew.
The knee alignment device was positioned onto the lower leg to assure correct alignment before the cutting took place. A saw was used to shave off part of the proximal end of the tibia along with the distal end of the femur. A temporary knee replacement was used to help further assist the doctor with guidance for cutting, pinning, and drilling. Once the bones were carved to the correct shape for the knee replacement, cement manufactured by Stryker was applied. This acts as a glue between the bone and the knee replacement. Finally, the knee replacement was carefully inserted into the path created. Saline and Betadine were poured into the exposed knee and the opening was then sewed shut.
Rheumatoid arthritis is a chronic inflammatory disorder that causes pain and problems in the joints of the hand, sometimes requiring reconstructive hand surgery. Another case we saw dealt with a metacarpal phalangeal (MCP) joint prosthesis. The physician informed us on a scholarly resource that we can use to further explain details about this procedure and the equipment it requires. During this procedure, the physician removed the damaged joint and implanted an artificial joint made of silicone rubber. The implants have a stem that gets inserted into the bone on each end and a spacer in between the two components.
An incision was made on the proximal side of the knuckles. Then, part of the metacarpal and phalangeal bones were cut down using a saw. Afterwards, the joint was aligned and prepared for the installation of the implant. Trial implants were tested for size. Once the correct size was established, the stems on each part of the implants were inserted into the specified bones. The wound was treated with saline and antiseptic solutions and then sewn up. This procedure helps many rheumatoid arthritis patients who have deformities to their conditions.
People weren’t joking when they described orthopaedics as human carpentry. I noticed bone particles flying in the air when the saw was being utilized. I had a great first week in orthopaedics and can’t wait to see what else is in store for the final two weeks!
My next clinical rotation is in orthopaedics which has been very interesting thus far. I originally thought the department would be bombarded with surgeries, but Tiana and I haven’t seen any surgeries so far. Instead we shadowed Dr. Gonzalez, Dr. Shmell, and a couple residents in the clinic.
I definitely had more exposure to physician and patient interaction in these past two days than I did throughout my entire rotation in interventional radiology. It is a pleasure to see how Dr. Gonzalez diagnoses the patient and develops different treatment plans according to the patient’s lifestyle. I noticed him asking patients personal questions like where they work, if they lift heavy objects, etc.
In between appointments, Dr. Gonzalez showed us an x-ray of a patient with a knee replacement. It consisted of two metal pieces, one attached to the femur and one to the tibia, and a wedge to diminish issues in between the two. He informed us on the issues with the wedge wearing away due to the excessive shear stress between wedge and the knee replacement. I noticed that the wedge is a darker shade of grey compared to the rest of the knee replacement obviously telling us that the material of the wedge is less dense than the counterparts.
One interesting case was a patient who came in regarding pain in his hand. The doctor said his hand looked like he had broken it a while ago because the bones in his hand were deformed. The patient then remembered that he may have originally broken it 10 years ago. The doctor informed the patient of the details about the procedure necessary to gain back the flexibility in his hand. It consisted of making an incision, breaking the deformed bones, taking some bone from the ilium, and screwing it all together. The doctor also said the hip may hurt more than the hand right after surgery. Another possible treatment is to take out the bad bone and bring the rest of the bones together. The fallback with this route is that it will take away 50% of the wrist’s mobility. The doctor said he has already lost about 50% for waiting a decade and causing a deformity.
On Tuesdays, we are to report to the 14th floor of the Crain Communications building, which is a skyscraper with a beautiful view of Millennium Park and the lake. On the first day, we met with Dr. Gonzalez and he took us out for lunch at The Gage. That was really nice of him, plus they had delicious food! Afterwards, we continued the day by going back to the clinic to attend to the rest of the patients. I am really enjoying orthopaedics so far and excited to observe surgery later this week.
This week, we observed a chest port removal, a procedure which calls for anesthesia. This device is installed in the upper chest underneath the skin. A catheter is used to connect the device to a vein in order to administer medication. The modern ports, pictured below, are easier to remove and have two septems so they can be used twice as long. One of the physicians informed us that each septum can take about 2000 injections. Under the guidance of fluoroscopy, the interventional radiologist makes a small incision and removes the device. These ports are used for chemotherapy and hemodialysis as well as a variety of other uses.
We also witnessed a transjugular liver biopsy. The physician uses ultrasound as guidance and makes a small incision in order to insert a catheter into the jugular vein and into the liver. A biopsy needle is inserted in order to retrieve a tissue sample.
Interventional Radiology has been enlightening as to how important technology and imaging can be in the medical world. Thank you to Dr. Bui and the entire IR department for teaching us so much and making us feel welcomed! This experience is unforgettable and invaluable as it has opened my eyes to much of what is done in hospitals and things that could use some improvement.
In the third week, Wali and I witnessed a physician perform a percutaneous nephrostomy (PCN). This procedure consists of gaining access to the kidney by placing a tube through the skin of the patient for drainage purposes. The doctor informed us that this procedure is often used to relieve the kidney of urine overload. In this procedure, access to the kidney for a catheter is granted percutaneously by using fluoroscopic guidance. After reviewing the patient’s medical condition, antibiotics were administered prior to the start of the procedure. The patient was sedated during the placement of the catheter.
To begin the process, Lidocaine was injected in the patient’s back near the kidney using an ultrasound as visual guidance. This needle is used as a guide for the placement of a nephrostomy tube, a specific catheter that travels from the incision to the kidney. After insertion, the stylet was removed, allowing for free flow of the renal tract. A drainage bag attached to the catheter was utilized to collect the urine.
Another interesting case that we witnessed was a ureteral stent placement. This was performed on the first pediatric patient we have seen thus far. Due to a blockage in the ureter, there was an accumulation of urine in the kidney. A ureteral stent is a thin tube that allows urine to flow from the kidney and into the bladder. This stent is placed temporarily to prevent damage from occurring to the kidney. After the procedure was complete, we sat down with Dr. Ray and discussed the complications with this case. He explained how the ureteral stent was difficult to see under fluoroscopic guidance. For that reason, excess radiation was emitted to the patient in order for the physician to determine the location of the stent. We then discussed how coating methods may improve the visualization of the stent when using a fluoroscope.
An interesting procedure we observed this week dealt with portal hypertension. Blood flows from the esophagus, stomach, and intestines through the liver. Damaged livers disrupt this flow and cause portal hypertension, which is the elevated pressure of the portal vein. Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure that is used to create a connection between two blood vessels in your liver. The connection of these blood vessels, the hepatic vein and the portal vein, allow for relief of portal hypertension.
The physician conducts this procedure by observing the patient’s fluoroscopy. The patient was on his back and hooked up to heart and blood pressure monitors. This non-surgical procedure consisted of a catheter being inserted into the jugular vein in the neck. Using fluoroscopic visualization, this tube was guided into the portal vein. Once in proper position, the balloon was inflated to a specific pressure in order to dilate the path between the hepatic and portal veins. The physician then connected the portal vein to one of the hepatic veins. This connection relieves the portal hypertension. The pressure of the portal vein is observed using a pressure wedge in order to confirm the declination of pressure in the portal vein, thus declaring the procedure a success. The new pathway allows for blood flow to be regulated while easing the pressure on the organs involved.
This week has been a blast and I am looking forward to my final week in IR!
Week two is off to a great start. Observing the daily routines of these physicians is enlightening. One procedure my partner and I observed was a biopsy of the sacrum. The physician began by inserting a needle used for guidance into the back near the iliac crest. He then observed the patient’s CT scan in the axial view in order to assure it had been properly inserted into the sacrum. A drill, pictured below, was then utilized to cut through the tissue and into the bone in order to retrieve a sample. Observations made suggest an improvement in the way data is viewed, as a biopsy may be easier if the CT scan was observed in the sagittal and the axial view simultaneously.
Also observed was a patient with cancer in the kidney. The treatment for this patient consisted of microspheres being injected into the renal artery. This is a minimally invasive procedure in which microspheres block the flow of blood to the kidney. Once the microspheres are injected, they travel with the blood to the network of vessels that lead to the kidney. These microspheres block the blood flow leading to the tumor. This procedure is done in order to prevent growth and encourage shrinking of the tumor. Embospheres are microspheres that are heavily used in interventional radiology.
Embospheres are seen again in uterine fibroid-embolization (UFE). This process, pictured below, takes place when there is a benign tumor in the uterus. In this process, the catheter and stylet are placed into the uterus. Once in the desired location, a contrast, usually organically-bound iodine, is injected to assure the correct placement of the catheter. The embospheres are then injected and used to block the uterine artery in order to stop blood flow to the tumor. Uterine fibroid-embolization is the most common procedure that makes use of these embospheres.
The first week, my partner and I observed Dr. Bui performing a radiofrequency ablation procedure. This medical procedure ablates the tumor or other abnormal tissue using heat produced from high frequency alternating current. Dr. Bui used a Starburst Talon Device in order to destroy the tumor located in the patient. An ultrasound was utilized to locate the tumor in the liver. The Talon device was driven into the liver and the distal end of the device was placed directly in the middle of the tumor. After that, the four talons sprung out and each of them were heated to a temperature of 105° C. The device was held in place for nine minutes in order to destroy the tumor cells along with the surrounding tissue. The device shown below displays the temperature readings situated in a circle that represents each prong on the Talon.
My partner and I noticed that the Talon device did not look secure when the physician took his hands off of it. We thought that an improvement to this device would be to further secure it when it is heating and destroying the tumor. However, when addressing this to the doctor, we were told that the four prongs secure the device completely. The pictures below demonstrate the Talon device in both positions, prongs closed and prongs opened.
Another case that my partner and I observed was a patient with pancreatic cancer. Dr. Bui went over this patient’s CT scan while telling us about the biopsy procedure. He explained how he had to have the perfect placement of the needle in order to get a sample and study its’ pathology. The CT scan is performed first to find the correct needle placement. Then, this needle is used as guidance in order to obtain a biopsy sample. This case brought to light the importance of precision and how some cases come down to a matter of millimeters.
An interesting case we saw was a patient that was suffering from deep vein thrombosis. This is a condition in which blood clots reside in the deep veins of the leg or pelvis. Earlier in the day, Dr. Ray, another physician, had briefly spoken to us about filters that they place in a patient’s abdomen to assist with this condition. Filters are placed in the inferior vena cava (IVC) in order to break down blood clots that travel up from the veins of the leg or pelvis. These filters are vital in preventing blood clots from traveling to the lung or heart as this could result in pulmonary embolisms or even death. An example of this filter is pictured below. These cases brought to light the extreme amount of precision that is required in the clinical setting.
Monday, July 6, was the first day of our participation in the Clinical Immersion Program. My partner Wali and I were given the opportunity to observe the Interventional Radiology (IR) department of the University of Illinois Hospital. The first few days of the program definitely lived up to my expectations. Dr. Bui and the rest of the radiology staff were all nice and extremely welcoming. The staff members introduced themselves and explained things to us in between surgical procedures. The doctor himself was very calm when conducting his daily rounds. He also communicated and explained the procedures while he was performing them.
On the first day of the program, my partner and I were able to observe Dr. Bui performing a biopsy on a patient. An ultrasound was utilized to locate the tumor using sound pressure waves to create an image. Dr. Bui used a biopsy gun to extract a tissue sample from the given location. This biopsy gun is shown below followed by the extraction process.
The gun is inserted into the determined location. Once it is placed into the tissue, the trigger is pulled and the tip is released, the space between is sliced, clutching onto the desired sample.
Following the biopsy, we went to observe another case. Here, we were instructed to stand outside the room due to the fact that we were not wearing lead around our chest and waist while the x-ray machine was in use. Dr. Gaba, another physician that works in IR, revealed to us how chemotherapy is performed. He had two syringes containing two different substances. A syringe containing a concentrated chemotherapy medication is mixed with the contents of another syringe that contains a lipid-based solution using a simple connector (shown below).
After the two solutions were properly mixed to create an emulsifier, the doctor injected the mixed solution into the hepatic artery of the patient by way of a catheter. The patient showed signs of some pain and discomfort after the time of injection.
I made quite a number of observations while shadowing in the OR. We went into the OR where a number of physicians and nurses were stationed. The machinery is covered in disposable plastic sheets so that it does not get contaminated. I noticed there was a table that was prepped and sanitized. On it, we could see surgical tools, petri dishes, and a number of syringes. In the OR, the doctor observes a monitor that displays the most ideal version of the designated area in order for comparison. The doctor seems to have multiple monitors at his disposal. These monitors often times display the x-ray images of the area being treated. The nurses are ready to assist the doctor instantly and a few medical students are also watching the procedure. I noticed the tangled mess of electrical cords on the OR floor as this could be very hazardous.
My initial experience in the Clinical Immersion Program proved to be highly enlightening. Not only do these doctors handle the most delicate of procedures with complete ease, but they are eager to teach us bioengineers everything we need to know about the technology and equipment used along with the procedures being conducted. After day one, I’ve become very comfortable with Dr. Bui and asking questions at the appropriate times. I am extremely excited to learn more and looking forward to all the different experiences this program will bring.