Jan Kostecki – Immersion Student but Test Subject Too

So this week started off a little differently than the others have; instead of going to 4 North for 8am rounds, I began the day by going to the 2^nd floor GCRC to get a full blood work up. You may be wondering why I needed to get a workup, but this was for Dr. Kizer and his THrombophilia In Cryptogenic stroke (THICK) study. I was recruited by Lily, who is a echocardiology nurse on the 4^th floor. The study started off with filling out the standard medical history questionnaire, followed by a round of questions about my background, and a bunch of other paper work that needed to get done. After that I was lead into a room where a nurse was going to take the blood, at first I thought this was going to be like any other blood draw, but it turns out that they needed 15 vials of blood, each vial was only a tablespoon in size, but still 15! I’m normally ok with having my blood drawn, but I’ve never had the need for an IV needle, so when the nurse put the IV in and even before she began to take the blood, I had begun to see stars and soon I couldn’t see at all. This followed by a cold sweat, becoming completely pale, and on the verge of passing out. This whole time I was talking to the nurses and had this big grin across my face, and they thought I was just messing around with them. As soon as they saw me turn white and break out in a sweat they new I was not kidding. I stayed conscious through the whole draw, and regained my vision to see the last five vials get filled up. At this time, the whole room was filled with nurses just talking about what had gone one, suffice to say, I had put on quite a spectacle for the floor. After getting some juice and taking a few minutes to regain my composure, I went up to the fourth floor and by this time news had already spread to Lily who had a good chuckle. I then went in to get my echocardiogram and Lily took her time to show and describe the different parts of my heart, what she was looking at, along with the anatomy of the heart and blood flow. After the basic imaging of my heart was done, Dr. Kizer came in and took saline that had been oxygenated and injected it into the IV that was in my right arm. Upon injection of the saline, the echocardiograms revealed the oxygenated bubbles in the saline as they traveled to my lungs and were then expelled (no need to worry about a bubble of air heading to my brain). The study was to see if there was a hole between the two atria of my heart, and subsequently revealed that I was a normal control patient. The group is still looking for another 300 control subjects, and if you are interested please let me know and I will get you the contact information. A plus side is that the blood work and the echocardiogram are all free, so you’re looking at around $4000 for a whole cardiac work up for free!

After having that fun of a morning, I read MRI images with my clinician (mainly normal hearts so that I could see what a normal heart looks in comparison to a diseased one), and then was lead into the EP lab where I observed the mapping of a patients heart. The patient had passed out a few times and the doctors wanted to know if it was due to a electrical conduction problem (either the heart was beating too slow or too fast). The room looked like a standard catheterization lab where I had observed angiograms, with a slight modification. There was a big black box in the control room and two computer monitors that had about 30 different electrical signals being displayed. Here I was able to observe how the doctors were able to map the electrical signals across the heart and diagnose where the problems were occurring. It turned out that the patients electrical system was function correctly and did not have any abnormalities.

Tuesday through Friday were back to the standard routine of getting up for 8am rounds on 4 North, followed by meeting up with Dr. Weinsaft and reading images of MRI, CT, and nuclear exams. I also attended a seminar for fellows at the hospital on how to read nuclear exams (specifically related to SPECT images). From what I had already learned first hand with Dr. Weinsaft, this was basically a review course for me and I could already pick out the problems in the heart before the presenter got to them.

In addition to reading images through the week, I continued to work on my project. Since I had the list of patients that we would be using for the study, I now had to compile a demographics sheet that had the patients age, previous medical history, family history, and list of medications that they were on before getting their MRI and echocardiograms done. Many of the patient’s records were easy to access and the database entry was straightforward. There was however a handful of patients that did not have their records on file, so I learned how to use the hospitals other database to locate the patients records. In these records, I had to go through them page by page to see what the physicians had listed. This was more time consuming because I had to decipher hand writing of physicians, and what they do say about a doctors hand writing is true: its completely illegible most of the time, but then there are those exception to the rule which makes it so much easier to find the information that you need.

Overall it was quite a eventful and fun week, and I learned many more new things, not only about the medical field, but also about my own physiology.

Listed below are a few pictures of my mentor, Dr. Jonathan Weinsaft and I reading CT images. Basically my days are spent in small room looking at computer monitors.

The God Complex: Truth or Myth

This past week has been very enlightening. From my perspective before this experience, it seemed that surgeons were mavericks blazing a trail into a new horizon. TV made surgeons out to be egotistical maniacs that had the “God Complex.” As my time has progressed here, I have slowly learned of the teamwork needed between all of the people in healthcare to effectively treat a patient. Many patients have multiples issues and it is only with good teamwork by way of great communication that these patients have their best chance of successful treatment. In my experience here at Weill, I have not found a surgeon that could be accused of having a “God Complex.” It is easy to understand why they need so much confidence. As a resident and or fellow, they are constantly torn down by the attending physicians. Yes, it is deliberate but the intentions are not malicious in nature. One of the goals is to create people of strong character who will stand up for what they feel is the best treatment for a patient. Surgery has proven to be a field where aspirants should have a “thick” skin. The surgeons that I have met have been very confident. I am sure that I only want surgeons operating on me that have confidence. I think that there is a fine line between overconfidence and confidence; the surgeons here tread carefully.

Last week proved to be very challenging. There was more of the same but some cases draw a person in more than others. I asked a Neurological Surgery fellow,”How do you not get emotionally attached?” He began telling me a story about his third year in medical school. As he entered an examination room to see a patient, the patient took a deep breath and died before his very eyes. He explained that becoming emotionally vested in the patients that he cared for would be too taxing. Before coming for this Summer Immersion program, I probably would have thought that to be harsh and the easy way out. Now I understand how true his statements are. Each week there has been at least one case in which I felt some attachment. Sometimes your heart can not help caring for patients with compelling circumstances. In my position, shadowing a clinician, I began feeling the weight of this burden. It seems an almost impossible task to carry all of that baggage around. I began thinking about the patients too often. I was vested in their successful recovery. Being vested in their recovery alone would probably be ok, but that’s not life. Recovery is not always the path chosen. Death occurs often and sometimes without warning. I can’t begin to imagine the bag of bricks that I would have to drag around if I became attached the patients that we have seen thus far. Well, enough of that, we are moving on to the fun stuff!

A 36 year old woman was brought to the ER after suffering from numbness on her left side. We were told by her husband that her chief complaint before loosing consciousness was severe headache and splitting pains. For whatever reasons, she thought this would pass but it obviously ended up being more than she bargained for. While in the ER, she had a seizure involving her torso and left leg. This seizing began spontaneously. A CT scan showed an area of hypodensity measuring 3.3 cm with associated hemorrhage. At this stage, it was thought that the patient could be suffering from an AVM. On day 2, a second seizure was observed and treated. The patient’s movement was severely retarded. The patient was transferred to the NYH NSICU. After angiography, it was determined that this patient was suffering from sinus thrombosis. In this condition, a clot, thrombosis, has migrated the vasculature of the head and become trapped in one of the sinuses, venous system for the head. In short, blood was collecting in the patient’s head causing damage to surrounding tissues which resulted in paralysis on the left side.

After review angiography footage, a team of physicians were called in to consult on this case. It was determined that the best course of action would be to wait on TPA (tissue-plasminogen activator) treatment as the patient’s movement on her right side had become better. TPA involved certain risks and it seemed that the IV medications were helping. One of the risks was bleeding around the clot that had formed in the sinus. If this bleeding was unable to be controlled, a vegetative state could be the result. On the other hand, TPA could dissolve some or the entire clot and restore drainage. After no improvement over 12 hours, a couple of rounds of TPA were administered in the NSICU. The patient has improved at his point but is still undergoing treatment. She is a soldier with much to fight for as she is a wife and the mother of 4.

More on TPA http://www.americanheart.org/presenter.jhtml?identifier=4751