Monday, August 28, 2006

Last Post - EP

In my last blog, and probably the last blog for all immersion participants, I want to thank first my clnical mentor, Dr. Kenneth Stein for his assistance and mentorship throughout the term. My immersion did not have a definite stop date like the rest of the students because of the proximity between my lab and the EP lab here at Weill. In fact, I am still currently waiting to here back from the Israeli company so that they can gain us access to the patient data that I need for a large scale study. I was obtaining data up until the week before last in an effort to make any sort of conclusions regarding my project, but I am afraid I still need a lot more data. But nonetheless, the experience was well worth it and I learned a great deal. I also want to thank the other EP attendings: Dr. Sei Iwai, Dr. Steven Markowitz, Dr. Suneet Mittal, Dr. Bindi Shah and the head of EP and Cardiology at Weill, Dr. Bruce Lerman. They all took time out of their busy schedules to explain some of the basics of their work. I also want to thank the senior fellows, Dr. Dmitry nemirovsky and Dr. David Dobesh for making time in their day to help me out. The junior fellows and residents alike also provided me with helpful words of knowledge along the way. The nurses and technicians in the EP lab were incredibly nice and helpful as well.

I learned a great deal, but the one thing that sticks out the most is my new outlook on the engineering-clinical relationship. Almost all of the medical devices, operating instruments, data acquisition units and other types of technology that a doctor or nurse uses was made with the help of engineers. The only way to improve the existing technology is to make the avenue of communication even bigger. There were plenty of simple things that I notices in the operating room which would make the lives of the doctors, and ultimately patients, better. But I believe that we, and more specifically Cornell, are on the right track.

Again thanks for the time, I had a blast.

With that, I bid you all adieu...

Monday, August 21, 2006

Ben Hawkins: Week #6 (Thank You!)

My final week was a very different experience from the first. In part, because I changed locations, from the NICU to MICU (Medical Intensive Care Unit) where the patients were no longer children, but adults. The treatment of adult patients, at least in these cases, was much more complex, with a number of conditions overlapping. In one particular case, a woman had diabetes and kidney failure and other overlaying conditions that significantly complicated treatment. On the one hand, treatment for her kidney failure causes her insulin levels to fluctuate wildly, while keeping the insulin levels appropriate for her diabetes complicated her kidney failure. There were many more situations like this, where treatment decisions are not so easy as they were in the NICU or PICU. There the name of the game is simpler: keep the patient alive and breathing until they get better. But in many of these cases, with older patients the decision is not so clear cut.

In addition, I found the MICU to be a more stressful environment. Where a child might live or not (and all of them did, I'm happy to say), patients here are faced with the realization that they are going to die soon, and that there is nothing to be done. Another female patient was terminally ill with metastitized breast cancer, and treatment decisions were secondary to comfort. It was no longer a question of whether they could beat the condition or not, but what could be done to make her final days better. This was a sobering experience.

Outside of the MICU, I managed to spend some time in the laboratory. The hospital maintains its own set of labs for almost every imaginable test, and I spent the day with lab technicians, watching as they carried out urine protein alalysis or any number of other tests. The equipment they used was very sophisticated, and made light work of much of their procedures.

Beyond those experiences, much of my work was spent on the project. My project began with the previous student, who outlined the work to be done by future BME Immersion students. The project was to develop a lung model that could eventually be used in a predictive or diagnostic manner to analyze patient conditions who are on, or require mechanical ventilation. The development of the model follows and expands upon research already conducted and published in the field, but with an aim of making a more usable tool for doctors and clinicians in a bedside setting. By inputing some basic patient parameters; data gathered from examination, X-ray, and other imaging techniques, a model for the patient lung is constructed, based on an fine-grained lumped electrical parameter model. With this model in place, ventilator settings are input to the system and the model should predict the airway pressure and flow throughout the lung airway network. This information can be vital to doctors prescribing treatment to patients with distal airway damage, pneumothorax (collapsed lung), atelectasis, and any number of conditions requiring mechanical ventilation. For my part, I wrote the lung model itself in MATLAB. The patient parameter model and its interaction with the lung parameter model, as well as the ventilator model, will be left to future work. A basic set of parameters govern the operation of the model to this point.

To describe the model, we begin by condsidering the lumped parameter model of the lung. In this way the function of the airway is decomposed into three lumped electrical parameters: resistance (how much the airway resists the flow of air; largely a function of the cross-sectional area), compliance(how resistant the airway walls are to expansion and contraction), and inertance (the time required to start and stop the movement of air). The original lumped parameter model uses these values to model the whole lung. We expand this, and begin thinking about these three parameters as describing and descrete section of the airway (between bifurcations). The values for resistance, compliance, and inertance vary distally from the trachea, and can vary significantly in local sections due to various disease states. It is therefore important that the model be able to incorporate this sort of functionality. By allowing the parameter values to vary spatially over the lung, we accomplish this. By using an electric circuit model, we can solve for the potential and current (pressure and flow) using frequency domain analysis. This allows for a simplified solution, and by Fourier transform we can accomodate any periodic input waveform specified by the mechanical ventilator. The additional advantage to the modular design of the model allows independent development of each section, meaning the project can be undertaken by multiple people, in different locations, simultaneously.

To all those involved:
While participating in the program, I was attempting to absorb as much information as possible, but I wasn't being very effective at it. Most of what went on went right over my head, or in one ear and out the other. So many acronyms and so much jargon; it was overwhelming. But looking back now, even at what I wrote, I can observe my learning more easily retrospectively. Dr. Frayer told me at one point, that I wouldn't really understand how useful this experience was until much later, when my circumstances had changed. I now understand a little of that; I feel like I know a good deal more now than when I started, and about thing, and in ways, that I would never have access to otherwise. I would like to thank Dr. Steven Pon, in the PICU, for his patience and willingness to share his knowledge; to Dr. Joseph Schulman, for everything, but specifically answering all my questions and always willing to discuss conditions and treatment decisions. Also to Dr. Richard Lent, for allowing me to explore the laboratory spaces and spend time watching their operation; to Dr. Priscilla Winchester and Dr. David Trost, for allowing me to spend time in interventional radiology. To all these people, their collegues and assistants: Thank you so much for being an integral part of a truly unique program.

Thank you Rachel for organizing events and keeping everyone sane. Thank you Dr. Wang for having the vision to set this program in motion.

Most of all, I would like to thank Dr. William Frayer for his advice on everything from talking to doctors, recommending experiences, facilitating my experiencel; for helping me figure out where I needed to be, and where I wanted to go; for conversations and discussions; for help with my project; and most of all for his role as my mentor over the six week period.

Kindest regards,

Ben Hawkins

Thursday, August 17, 2006

Sharing some pictures

One night that we were playing cards and watching TV downstairs in Olin Hall (dorms), Jan took my camera and took pictures of the moment.

Here are the pictures, sorry for those that didn't want that everybody look at their picture. But remember that I didn't take it!

This is my favorite one, Julius and Christine seem so worried about their game! it is just dominos!


Thank You

The time pass very quick and my immerse term at the hospital in NYC is over. Following very close the physician and observing how things work in the clinic was a unique experience. Finally, I want to give thanks to all the people that make me feel part of the hospital team. I have to say that all the people that I found was very friendly and helpful.

From the neuropathy center, special thanks to Dr. Howard Sander, my assigned physician for accept me in the clinic, share his time and knowledge. To the other doctors on the clinic Brannagan III, Thomas H. Chin, Russell L., who were always glad to answer all my questions. Malena, the EMG-technician, for make me easier my stay in the clinic, and orienting me about things that I need specially for my project.

From the HSS thank to the doctors that allow us to attend the operations in the HSS, and their efforts explaining us even though they were in the middle of the surgery. Thank to the nurses that try to explain us what is happening on the operation room, also thank to the nurses that were nice and offered us a coffee or a cookie while we were waiting on the lounge.. Special thanks to Suzanne Maher, who was the one that schedule all the surgeries and orient us in anything that we needed. Dr. Wright who coordinated the implant project. Dr. Alejandro de la Valle, that was very kind to share his time to explain me about hip implants.

Thanks to Rachel, who coordinates the social activities. To Belinda that even though she was far she was very efficient and helped me. And Dr. Yi Wang for organizing the program, his efforts to making it a nice experience, and taking care of us. And, of course the BME department who plan this program.

Finally, my classmates with who I passed great times.

Thank You!

Tuesday, August 15, 2006

Final Week

What a six weeks it was. The final week was filled with giving a presentation to Dr. Wright's lab group on my case study that I described in the fifth week blog. In addition, I spent time with Dr. Potter obtaining an MRI of the lumbar spine from which I can segment the Intervertebral Disc. The picture above is a sample of the segmented IVD obtained from the MRI images. It became quit apparent during the obtaining of the MRI images that obtaining segmenation data was not a simple process when dealing with the lumbar spine. Many issue were incurred due to poor SNR and much of the resolution was lost when the voxel size was increased to obtain better SNR for segmenting purposes. However, the image of the disc is encouraging for these techniques to be possible.

As my final bussiness on this blog I would like to thank all the physicians who gave there time to help me through these six weeks with a listing of all those involved. Thanks to everyone listed below for an unforgetable learning experience!

Hollis Potter, MD
Mathias Bostrom, MD
Robert Marx, MD
James Farmer, MD
Russell Warren, MD
Timothy Wright, PhD
Suzanne Maher, PhD

Sunday, August 13, 2006

My last week

From the respect of my project the biggest discovery was that there were already several similar patents on pretty much exactly the heater than I wanted to make. The three examples I found were:
As it seemed the main reason Dr. Tewari wanted to build the heater was for patenting the idea I am unsure if I will be going ahead with putting together one, although it should be more clear within the next few days.

Also I attended a robotic prostatectomy symposium put on at the medical school by Dr. Tewari, along with several other people in urology. The talks varied greatly in how good they were, but the bad ones were made worth it to watch a room full of doctors either laugh, or squirm in response to the MIT robotics professor claiming that within 50 years surgeons will be obsolete because robots will be capable of independently doing everything they currently do. That lead to me having a rather odd conversation with a doctor claiming that it was better to think of a person as "an energy field" rather than these modern scientific methods. While I mostly smiled and nodded, this really shocked me. I would have only expected such a reaction from a alternative health person, not a doctor.

I should finish by thanking Dr. Ash Tewari and, his residents, in particular Kevin and Dan, for letting me follow them around and observe a wide range of surgeries. This is one of the best places for an engineering student to be for the simple reason that here is the products of the best engineering, being used by some of the best medical professionals in the world. Seeing this really gives you a better insight into why we go through so much pain to learn about such abstract concepts. These concepts really do lead to improved technology that betters the lives of people.
At the same time this is a very new, hastily put together world. If things as simple as a heater to clean there lens are not in common use, then it is particularly clear that there is huge room for improvements to this technology.

Wednesday, August 09, 2006

I left early to present my work at a conference, so I haven't described my last week at the hospital nor properly acknowledged the help of the clinicians I worked with. I worked on two research projects and observed surgery for a total hip revision.
The first project I presented a case study on a failed shoulder implant to the biomechanics research group. I looked at the records and radiographs and the removed implant to see what happened. The glenoid socket replacement had worn out, causing the person pain so that she had to get it replaced last year. Shoulder replacements do not last as long as hip or knee replacements and they are much less common. When joint replacements wear, the particles cause an osteolytic response in the immune system that tries to digest the metal or plastic particles, and the surrounding bone. This makes a revision difficult to put in, especially in the shoulder where so little bone exists.
During the hip revision surgery, the attending surgeon showed us the damaged bone affected by osteolysis. It had the consistency of gritty toothpaste. In the surgery the cavity was repacked with synthetic bone replacement.
The other project I worked on was for an in-vivo study of wrist motion to establish a better plane of motion for functional evaluation than the current flexion-extension and radial-ulnar. I worked with a physical therapist to craft a model with thermoplastic used in standard wrist splints but with make-shift hinges to allow the wrist to be positioned in a variety of angles. Then I created a CAD drawing of the same so they can get a machinist to make a working model for their experiments.
A huge thank you goes to Dr Sherry Backus of the Motion Analysis lab for facilitating my stay at Hospital for Special Surgery and helping with the implant project. To Dr Wolfe, hand surgeon, who let me observe a surgery of his and included me in the other research project. Aviva Wolfe and others in Hand Therapy who let me watch their work that also has a lot to do with engineering proper bracing and loadings. Others at the Motion Analysis, Brian, Dr Hillstrom, Corinne... Thanks to Biomechanical engineering, especially Dr Maher who arranged so many visits to the OR and Dr Wright who handled the implant study. Thanks also to BME and Dr Wang for hosting such a great program.

Tuesday, August 08, 2006

More EP

It hasn't been even 24 hours and here I am posting again on the week after the BME immersion term technically ended. Somebody stop me! No, but seriously, since I started later than everyone else I owe it to the program and everyone involved to continue this week in the same way as I have been the previous 5 weeks. While everyone is posting their final post wrapping up the immersion, I'm here to make it last that-much-longer. This time I want to share a few thoughts that I have after being in an several operating rooms.

I hadn't been inside on operating ever before this immersion program. But there were a few things that I noticed almost immediately about how one is run most effectively. The first thing that was readily apparent was the chain of command in the operating room. Well, maybe not so much chain of command as knowledge of ones position and duty. That is to say that everyone in the operating room not only knew exactly what he/she was expected to do, but that he/she also knew what everyone else in the room was expected to do. The top man (or woman) is obviously the attending clinician. This is the person with all the years of school, all the years of training, and all the years of practical experience. From what I saw, whatever this person says is final. That is not to say that they may not ask others in the room for an opinion or suggestion. It is true that most times the attending will ask questions as a way to quiz the other fellows or residents in the room. But there were sometimes that I witnessed when a fellow's or resident's thoughts were actually acknowledged and considered in a operating room scenario. But for all intents and purposes, the attending was always right, and everyone there acted as his/her assistance. Which brings me to the fellow/resident. I've heard the both terminologies for what I consider as the same position, so let me elaborate. This is the person who is only a few years away from being an attending themselves. To make life easier I will call this the 3rd or 4th year fellow. Their main goal is to learn as much as possible by both closely observing all and actually performing some the procedures. Comparing the 3rd and 4th year fellow, you have another interesting dynamic. Because the 4th year fellow has had one more year of experience, they are often required to act as teacher to the 3rd year fellow while at the same time being student to the attending. This is important to the 4th year because it further solidifies his/her knowledge of the subject matter and it is important to the 3rd year because every chance to learn is beneficial. The nurses in the room play an invaluable role in making sure everything runs smoothly in perfect harmony. Previous records, patient comfort, operating room sterility and medical tool retrieval are just a few of their many tasks. The attending and/or fellow constantly rely on these people to keep the operation moving forward. The technician is responsible for all the computers/software/hardware in the room. As technology becomes more and more advanced, more sensors and digital recorders and high powered imaging devices are finding their way into the operating room. A malfunction of any could create major problems and its their job to make sure all of the technology cooperates. The anesthesiologist is in every operating room as well and their job is extremely important to everyone as well because no one wants a patent waking up in the middle of open heart surgery! All in all a smooth operating room is quite a marvel to witness as each piece of the puzzle fits in perfectly to create a masterpiece. (that is the cheeziest line in the whole blog I promise) Another thing to highlight specifically is everyones ability to mutli-task. Just because the jobs are relatively well defined in an OR room, that doesn't mean that everyone has one or two things they are expected to do.

On another note, I want to express my desire to see operating rooms go completely digital. Maybe its because I'm an engineer, but I really think that in an operating room there not need be one piece of paper. What I mean by this is that everything should be digitized and on some sort of computer. This would make the creating, retrieval, and transfer of data along with all other forms of documentations much more easy to manage. This would save time and everyone knows that time is money. I'm sure it would take boat-loads of money to revamp all operating rooms in the U.S., but I fee like the 6th best hospital in the nation should be a little more 'wired' than it is now.

Vishal's Sixth Week: Acknowledgements and Thanks

I spent my final week at Weill helping Dr. Min finalize and revise our study on plaque type (as measured by MDCT) as a predictor of ischemia (as measured by MPS a.k.a nuclear stress testing). Several physicians have been tremendously generous with their time and were incredibly helpful in different ways. I would like to acknowledge their help here.

Cardiac Catheterization Labs
Dr. Shing-Chiu Wong: Dr. Wong was my 'official' mentor. He allowed me to observe several diagnostic angiography and stent insertion operations, and taught me a lot about cardiac anatomy and function.

Dr. Morin: Dr. Morin is a fellow who works with Dr. Wong. He was an excellent teacher, and also helped me learn a lot about cardiac anatomy

Dr. Robert Minutello: I also observed some surgeries performed by Dr. Minutello, and at one point considered working on a project with him exploring the correlation between stent size and stent fracture.

Interventional Radiology - Cardiovascular
Dr. Priscilla Winchester: Dr. Winchester invited me to observe procedures in interventional radiology, and was instrumental in helping me find a project to work on. She was extremely helpful, and introduced me to several other doctors in an attempt to find work for me.

Dr. David Trost: I also considered working on a project with Dr. Trost, involving a correlation between stent size and patient return visits.

Tim Levi: Tim is a senior medical student spending time in interventional radiology. He was very helpful in explaining some of the procedures.

Division of Cardiology
Dr. Jonathan Weinsaft: Dr. Winchester arranged a meeting for me with Dr. Weinsaft, who happens to be Jan's mentor. He spent some time looking for a project for me, and ultimately helped me find Dr. Min. He also demonstrated the reading of CT images, and explained some of the advantages and disadvantages of CT vs. MR.

Dr. James K. Min: Dr. Min was effectively my mentor for the last 3 weeks. We worked effectively together, and accomplished a lot in those 3 weeks (see other blog entries for details). Working on this project has been a pleasure, and I am grateful for the opportunity.

Dr. Fay Lin: Dr. Lin is a fellow working with Dr. Min. Without her, we wouldn't have had the data necessary to complete our study.

Dr. Todd Pullowitz: Dr. Pullowitz was visiting for a short time to learn how to read CT scans. He was always in the reading room, and always ready to explain the scans.

Dr. Matthew Cham: Dr. Cham is responsible for the evaluation of the lungs in the CT scans. He was also very friendly and helpful.

Finally, I would like to thank the BME department for giving us this opportunity, Rachel Bowles for her help in organizing activities, and Dr. Yi Wang for coordinating the program.

My Farewell

Well, now its time to say, “Farewell.” Overall, I have had an awesome, unforgettable experience. I would like to thank God for giving me everything that He has to sustain me thus far. This is only possible because of you. I would like to thank Dr. Howard Riina in Neurological Surgery. Dr. Riina, you made this an enjoyable experience. You taught and showed me a great deal in these 6 weeks. Because of it, I have a new appreciation for medicine, especially neurosurgery. Next in line is Dr. Kyle Chapple, a Neurological Surgery fellow. I would like to thank you for my interaction with you and your honesty. You also taught me volumes of information and gave me valuable perspective from that of a resident and fellow. Beyond that, you made the experience fun and enjoyable. To the staff in the Neurological Surgery office and in Interventional Neuroradiology, my hat is off to you all. I felt very comfortable with you all and thank you for your time and insight given to me during the procedures. I would like to also thank the Biomedical Engineering Department of Cornell University and all pertinent faculty and staff that made the 2006 Summer Immersion possible. Lastly but not least, I would like to thank my beautiful wife, Dr. LaShanda T. J. Korley, and my unborn child due August 31. You could have objected but you supported me throughout. I can’t wait to see you. To Baby Clara, I am glad that you waited on your dear old dad. We talked several times about you waiting to arrive after the program in NYC was finished. You are listening well at any early age and I truly appreciate it.