Oh, What a Feeling!

This week offered new experiences. We were finally able to “coil” a patient that had previously been rescheduled due to complications. I am glad that it happened this soon as the patient had an aneurysm measuring 14 x 11 mm. Luckily, there was no hemorrhage or any other complications. The case went very well and the patient is expected to make a full recovery.

Cardiothoracic surgery is amazing. I was afforded the opportunity, along with my colleague, Jan Kostecki, to observe a CABG (coronary artery bypass graft). In this procedure, the patient’s vasculature around the heart was badly compromised. The plan was to endoscopically take veins from this patient’s legs to replace the vasculature of the heart. The process of removing the veins from the legs of the patient has come a long way. In the past, a surgeon excised the vein by scalpel, leaving horrible scars and a substantial would to heal from. This procedure was done with only to small incisions above and below the inside of both knees. It was very exciting to see how technology had changed.

While a doctor was getting the replacement vessels, another surgeon was working to prepare the thoracic cavity. For the procedure, the chest was opened via a scalpel and sternum saw. The appropriate vessels were cauterized to minimize bleeding and the patient was put on the heart and lung bypass machine. Cardiothoracic surgery is unlike neurosurgery where a screen shows you everything that the surgeon is doing. In cardio surgeries, one needs to be very close to see what is going on. Both Jan and I were constantly trying to walking around the room to get the best spot. At some point, one of the nurses told us that we could stand on a step stool behind the patient’s head so that we could have a better perspective. We were cautioned to only stay there momentarily as not to upset the attending surgeon, Dr. Krieger. By the time Dr. Krieger showed up, we were only on the outskirts, making sure not to be in anyone’s way. He saw us looking on and asked who we were. I explained that we were graduate students in BME from the main campus. At that point, he told us to reclaim our prior position near the patient’s head. He began explaining everything. The anesthesiologist had to ask us to move to check on the patient’s vitals. Those moments were very short as Dr. Krieger was intent to explain the finer points of this procedure and the procedure was progressing well. We were blown away by the procedure and his kindness. We learned so much and it was really exciting to see a person’s heart and lungs. Books can’t really capture what my eyes beheld. The heart’s beating was fascinating. Even when cooled with ice, this person heart was so strong that it continued to beat. After finishing the procedure, the person was immediately able to come off of the bypass machine and use his own heart to pump blood to his entire body. It was amazing to see and very fortunate for this patient. The procedure was a success and cardiothoracic surgery is a very cool place to be.

My experience really can’t be described in words. During these 6 weeks, I have tried to capture the highlights but my words pale in comparison to the actual experience. I hope that you all have enjoyed the depictions of my experiences. I hope that in the future I am afforded this opportunity again. Besides, the procedures, I was able to have meaningful dialogue with some physicians about potential collaborations and consulting opportunities after graduation. I am very excited and look forward to the future as I think that it will be a bright one. Also, I have a new appreciation for the hard work that so many put forth to take care of patients and give them the best opportunity for a successful recovery. I am glad to have been a participant in the 2006 Biomedical Engineering Summer Immersion at Weil Medical College of Cornell University.

5th Week Brings A Change to the Routine

So Monday and Tuesday were the normal routine where I got up early, went in for rounds with the residents on 4 North at 8am, and observed cases till about noon. After that was done, I headed down either to the MRI room or the SPECT room or the CT room and read images with the fellows and attending doctors that were in the room. It has become quite easy to diagnose the common diseases that the doctors see on a regular basis in the hospital and I have become proficient at using the software and manipulating the data/images to make a diagnosis or to show a person that is observing where the problem lies.

During these two days as well, I cleaned up my patient data set that I had already complied and excluded some patients that had complicating factors or that there was not enough data present to make sure that they fit our study. After going through this group and making sure that the patients that we had all fit our criteria, I took the list down to the MRI room to have the data retrieved and placed on the workstation so that I could begin the real data analysis. Suffice to say, retrieving the old records is always put on the back burner, and as I write this blog a week later, I am still waiting for the patient files.

In addition to the work that I had done, on Friday I met up with Dr. Matthew Janik and he showed me the correct way to trace images on the MRI software (the tracings use a complex algorithm that allows for the measurement of size, shape, and functionality of the heart). These tracings are the method in which I am going to obtain the data for our study, but one thing that is blatantly apparent is that the tracings are all subjective to the person that is doing the tracing. Since an MRI image takes a slice of the object, the image has items that are both in and out of the plane, and these items can be either traced or not traced. Therefore, the tracings of the images that we have will be evaluated by three experienced MRI imaging experts and then those opinions will be taken into account for the final values obtained.

Now the fun part of the week begins…well Wednesday and Thursday. So my clinician left for a conference and since I could not do anything related to my project I talked with Julius and asked if I could observe some of the medical procedures that had been going on in his area of expertise. On Wednesday I was able to see an aneurysm get clipped in a 30 year old woman. When we walked into the OR, the woman was already on the table and the fellow had already removed her scalp, pinned it in place, and was beginning to clean up the skull so that there could be access to the brain. At the same time, there was an incision made in the woman’s neck and a clamp was placed on her carotid artery to stop blood flow into the region where the aneurysm was. The first thing that struck me in comparison to the imaging that I had been doing these last few week was the smell of the OR. The smell of tissue being cauterized is something that many people don’t forget, and for those that wonder what its like, I think its like when you singe the hairs on your arms when reaching over a stove or a camp fire. The smell is really that pungent, but you begin to be desensitized to it quite quickly. After that I also realized the amount of instruments and technology that goes into a surgery and how everyone has a specific role to play. Once the skull was cleaned off the surgeon took a tool that looked like a Dremel and went to work cutting out a portion of the skull where the aneurysm was located. After removing the skull and dissecting the way down, the aneurysm was pinpointed on the microscope and tv monitors that were present in the room. The next step was to take small clips (yes, clips like those used to hold laundry on the line) and clip the blood flow to the aneurysm. To make sure that all the blood flow was stopped, both ultrasound was used to see if there was any flow through the area and a fluorescent dye was injected that could be seen under infra red monitors. The clip was in the correct place and then the surgeon popped the vessel and closed up the region. That was an amazing procedure and took about 5 hrs to complete.

The rest of Wednesday and Thursday were spent in the Interventional Radiology room on the 5^th floor where I was able to observe catheterization procedures that mapped the blood flow in the brain. These procedures were the same as those as I had seen in the cardiology catheterization room, but the focus was on mapping flow through the brain. One patient that we had seen had a tumor that was detected by CT, but upon looking at the blood flow via that catheterization the decision was not to perform surgery because there was no single vessel feeing the tumor and there was no risk to the patient. The rest of the cases were also uneventful but it was interesting to see how the same procedure could be used to diagnose other conditions in the body.

Are We There Yet?

Most of this week was spent trying to define the parameters of my project. I am very lucky to be shadowing Dr. Riina as he is a very busy surgeon. However, that also means that there is less time for defining project parameters and such. However, at this stage my project proposal looks as such.

Before any procedure or operation, most patients desire to know their chances of a successful outcome. In many situations, patients will not move forward with the proposed procedure if their chances are not favorable. Obviously, no doctor keeps track of every single case so it is very hard to calculate any success rate associated with any given procedure. Even more confounding are the different variables associated with each case. Ultimately, a physician’s attempt to give accurate prognostic information is a calculated guess. One can be certain that by no means does a physician intentionally mislead a patient as they are not computers and certainly not omnipotent. What if it was possible to devise a scale with predictive values based on a physician’s body of work? This prognostic indicator would be semi-quantitative and give a more accurate assessment of the patient’s chance of having a successful procedure. It is proposed that the scale would consider and account for the multiple variables effecting patient’s with an aneurysm such as location, size, age of patient. The value generated would then correlate to percentage ranges to be determined. For this type of study, a sample of historical data would be taken from multiple cases. After analysis, this information would be used to incorporate the multiple variables existing in aneurysm cases to be used as tool to give patients a truer assessment of their relative chances of a successful procedure.

This week was slow. Dr. Riina was in the hospital for two days so on the off days, I observed Dr. Pierre Gobin, a neurology interventional radiologist. He performs many of the same procedures as Dr. Riina. I saw an interesting case where this child had a retinoblastoma. To treat this, Dr. Gobin embolized the tumor by stopping its supply of blood with polyvinyl alcohol particles. At this stage, it is a possibility that the tumor will be carefully excised by surgeons at Memorial Sloan Kettering Cancer Center.

I also had a chance to get back to the OR. I saw another aneurysm clipping. This was much like others I have described but they never get old. A couple of the really cool things about this particular procedure were the location of the aneurysm and the clipping of the lower vessel that fed into the aneurysm. The aneurysm was located near the optic nerve. Because of the complexity of the area, a temporary clip was placed on the external carotid artery to stop blood flow to the aneurysm. At this point, Dr. Riina proceeded to clip the aneurysm. For this case, two clips measuring more than 10 mm each were used. One was initially in place but was not sufficient to stop blood flow to the aneurysm. This was because of the location and neck size of the aneurysm. After both clips were in place, Dr. Riina used infrared imaging and a Doppler instrument to check the blood flow integrity and assure that the abnormal vessel was properly repaired.

Well, the last week of this immersion is approaching quickly. I am looking forward to making more progress on my project. I will be collecting the much needed patient data to get the study underway. After receiving the patient data, the meat of the project will begin as I need to investigate if a correlation exists between a successful procedure and any variable or variables associated with each patient’s particular procedure. If all works well, a recipe may exist for each patient to have a successful procedure. Maybe as important, this study could offer semi-quantitative prognostic information for Dr. Riina’s patients in the future.