Week 7 - "No more subway directions"

This week, I spent most of the days coding up for my project, and running that code analyzing different patients' MRI scans. We managed to obtain decent results in improving the imaging of myelin water content in T2-relaxometry data, though still a lot of work needs to be done.

I volunteered for another MRI scan this week. Though it takes a long time to complete ( around 2 hours this time), and my neck stays sour for another hour or so, but it's still feels really good to know there's nothing wrong with my brain as far as the MRI scans go.

Other than winding up the project and the MRI, there wasn't much else I did. Exploring NYC, farewell dinner and saying goodbyes. I'll miss having a McDonalds right next to me that operates 24 hours a day!

Overall it's been a great learning experience. Observing the patient treatments in the ORs exposed me to the practices and challenges of patient care ranging from anesthesia, to instrumentation, in both the usage and design. Following Dr. Gauthier in her clinical rounds gave me the opportunity to run through the psychological impacts of a disease, and that therapy is just part of the treatment.

Week 7 - Lindsey

With the hospital under inspection this week, my last week in nyc was the most uneventful. I was luckily able to see Dr. Girardi perform an open heart cardiac surgeries. The patient’s chest and sternum were cut through in order to access the heart and repair the patient’s failing mitral valve. The fellow’s induced cardiac arrest with paddles and the bypass technicians were all over their machines, perfusing the patient’s body with blood, while his heart was unable to do it for him. Since it was essentially a valve surgery not much was visible to the viewer during the operation but it was still a great experience. The anesthesiologist allowed us to stand on a stool and peer over the curtain above the patient’s head, down into her chest. Once a supportive device was placed in the patient, he was closed up and the patients vitals were carefully monitored as he was taken off bypass and his heart was started up again.

Other than this one surgery much time was spent in lab making sure my project wrapped up nicely.  I seeded one of my vessel networks in gel and found that water could in fact be injected at one end and come out the other, so the vessel network was a success. I injected Berlex Magnevist to help obtain images of the network itself.  We tried to get MRI images but these images were largely unclear and new prep methods were devised.

Overall, I really enjoyed my summer immersion experience and am looking forward to future collaborations with Weill Cornell.

Week 7 Goff

Sorry everyone. I know this is coming in a little late but I had really thought I posted week 7's over a month ago. It might just not have gone in.

This week was relatively uneventful due to the unexpected visit of the accreditation committee.

I finished my project and did a little imaging work with Taylor to see if metal paint could be seen in micro-ct images.

I'll keep it brief. It was a great summer hope everyone had as useful of a time as me.

Week 7... The end of a great summer

This week started off on a bad note for me, doctors in the ER had to remove my nail as my crush injury aggravated. This again gave me a new biology lesson on human body.
As far as research was concerned, luckily for me I had few successful experiments in the previous few weeks. It gave me enough data to analyze. My dependence on huge amounts of pain killers did inhibit me from doing experiments. But, I thought I could visit more surgeries and medical units this week. Which turned out to be impossible since The Joint Commission for Accreditation was visiting all campuses of NYP this week and we were specifically instructed by Dr. Laura Forese, Chief Medical Officer at Weill Cornell NYP to not participate in any clinical experiences for the rest of the week. Hence, majority of my time involved data analysis.

This summer experience gave an incredible insight into the medical world and its people. I think my trip back to Ithaca will be filled with the satisfaction of learning beyond my area, exploring a new life and enjoying myself at Weill Medicall College. Au revoir!

Week 6 – being patient....Poornima

My 2nd last week of Summer Immersion took on a pretty different note un-expectedly. The summer immersion ensures that we get an insight into almost every department but for one. And that is the patient side of the story - which turned into my story of the week. I crushed my finger in a door and spent most of my week immersed in ER visits and huge amount of pain killers. This interestingly gave me a new insight into the human body’s sensory process where finger tips and nails top the list. I came to know of the whole process on the ER side and found the nurses here to be really nice. Most of the patients during the day came with mostly minor ailments varying from fever, sprained ankles, fractures and viral fevers.

Later during the week I visited Dr. Schwartz for his clinic visits. This time I had the opportunity of seeing a lot more patients with a wide variety of tumor issues. One patient came in with a rare case of optic glioma. In the CT scans, the glioma appeared to be big round mass very close to the optic chiasm, and stressing on one of the optic nerves. This did cause loss of some sight in one of the eyes of the patient. The issue was that it could not be operated because of its proximity to the optical chiasm and possibility of harming both the eyes. The more focuses Stereotactic radiosurgery was chosen as the mode of treatment here. Another unique case was of a young patient suffering with Craniopharyngioma. It interestingly has calcium deposits found in teeth. Being near the pituitary gland and optic chiasm, it had significantly affected the patient’s eyesight.

I learnt about new diseases and medical terms in a manner that I believe I will never forget. This immersion term is certainly unforgettable. One more week to go!

Week 7 - Natalie

As promised, this week was packed full of clinical experiences at New York Presbyterian! I’ll give the day-by-day rundown:

Monday – I spent the afternoon in the emergency department and shadowed a resident. We saw approximately six patients, with varied complaints. Nothing was that earth-shattering: we saw a lot of fevers, abdominal pain, chest pain, one woman with continued pain after a C-section who wanted further pain medication, one woman who had fell down stairs and was cleared of any neck/back fractures. One patient that sounded very interesting but that I did not see personally was a Con Edison worker who was electrocuted. His co-workers performed CPR and defibrillated him in the field and that was the only reason he survived. I’ll come back to him when I visit the burn unit on Wednesday. Overall, my experience did not match the TV show “ER” – things were pretty laid back, and there wasn’t as much rushing around and saving lives as the show leads you to believe. That being said, I can see where it would be one of the more interesting places to work in the hospital, since you see such a variety of ailments.

Tuesday – I spent the day in the medical intensive care unit, starting with rounds in the morning with the medical team. I asked one of the residents what exactly the MICU specialized in, or which patients would come here specifically, and he explained that the main difference with the MICU was that the nursing staff to patient ratio was much higher, since these patients require such intensive care. The patients in general were not responsive, and were almost universally on assisted breathing devices. One patient became agitated during the day and began trying to get up and rip out his IVs and breathing device, and had to be restrained.

Wednesday – Burn unit. I was able to see several central lines be replaced, which is when there is a catheter placed into a large vein in the neck. These have to be replaced every 3 days to minimize infection at the site. The basic procedure involves advancing a wire down the existing catheter, removing the old one, sliding the new one over the wire, removing the wire, and suturing the new line into place. I also learned a bit more about the Con Edison worker, although I did not get a chance to see the extent of his burns in person. They were very concerned about his brain after the electrocution, so they chose to perform a cooling regimen, where his body temperature was reduced to 34C over 24 hours and then rewarmed to 37C over another 24 hours. They were just about to begin the rewarming process while I was on the unit, and he had handled the cooling process adequately. The extent of his burns had not really been assessed yet, due to this process. Unfortunately, there was another patient on the unit who was very sick, and the doctor met with the family to try and convince them to agree that the hospital would not take any extraordinary measures if the patient worsened. It was interesting that the family refused, saying that he was a fighter and that he would make it through and that they wanted everything possible to be done. The doctors had to accept this request, but were clearly frustrated by the family’s decision. This was an interesting aspect of medicine to see, as I can understand both sides of the argument. It must be incredibly difficult to basically “give up” on a family member, yet as a doctor who has seen this situation many times, it is probably frustrating to not be able to convince the family that there is very little chance the patient will recover.

Thursday – Neonatal intensive care unit. The highlight of this experience was assisting the fellow with a spinal tap on an infant. I was allowed to hold the baby in position, with the help of the nurse, and kept the infant preoccupied with its pacifier to try and distract it. I also saw a baby with a rare disease called “ichthyosis”, where the infant’s skin is scaly, like a fish (the ancient greek word “ichthys” means fish). The baby was doing much better, but apparently will eventually slough off the entire skin layer, almost like a snake. I was told the baby will always have strange skin, and some scarring, but should be otherwise healthy.

Friday – Labor and Delivery. I was able to see a natural birth, and I held the mother’s leg to assist her delivery. It was pretty powerful to see this very natural human experience in person, especially when I could be removed emotionally from it in a way, since it was neither my own labor nor anyone I know! At the same time I became part of the team as I encouraged the mother and put my own effort into the birth! The whole process was very rapid for this particular patient, she came in fully dilated and from start to end it was probably only 30-45 minutes. Although she requested an epidural, she was too far along for them to place it, so this was a truly natural birth. The result was a healthy baby boy who weighed 8lbs 3oz! After the birth, the fellow showed me the placenta, which was a lot larger than I realized. Seeing a baby born was quite the way to end a really incredible summer of clinical experiences!

Week 7-Brandon

The final week was semi-fun. I spent most of the time finishing measure the images that I had so I could report the information during lab meeting and during our conference call with Ithaca. The study seemed to fit well into the scope of what we are doing now and I received some feedback on what to expand on. Learning about teh cracking joints was no doubt one of the most memorable things I did this summer and I plan on continuing with the topic alongside my work on the intervertebral disc. I also started planning for the upcoming rat surgeries for my project. Overall I loved my time in NYC with the Hartl crew, however I doubt that it will be the last time I see them since we do collaborate on the IVD project and our in vivo work is done at the Medical college. I gained a great deal of knowledge that I will be bringing back and implementing in my research, especially when we begin to tackle the problem of scale up. I got to see numerous examples of what I am working on in Ithaca will be addressing in the clinic and got a sense for what I have to keep in mind when designing. I also learned a lot about the spine itself and how stuff goes on in the operating room. Everyone was great to work with and I look forward to coming down to the city again soon.

John - Week 7 - Cardiovascular Surgery

Due to the Joint Commission inspection of New York - Presbyterian this week, our involvement in clinical shadowing was limited. On Monday, I did have the opportunity to observe an aortic valve replacement.

This surgery was actually a little difficult to understand, because none of the surgeons, nurses, or technicians were willing to explain what was going on, despite there being an approximately 30 minute window during which everyone just stood around and waited. I tried asking the technician operating the bypass machine what they were waiting for, to which she replied, "Go ask somebody else. Can't you see I'm working? I'm busy here." Minutes later (and throughout the surgery, actually), I saw her chatting and joking with her colleague sitting beside her.

Thankfully, there was a medical student present who was also observing the surgery. She wasn't entirely sure of the procedure, but she explained to me what she knew, which helped me understand why everyone was just waiting. Because they were stopping the patient's heart, they wanted to cool the body so as to reduce metabolism, and thus minimize cell death. She wasn't sure why the surgeons decided to stop blood flow throughout the entire body except to the brain, as she told me that the bypass machine is usually used to pump blood continuously through the rest of the body during the surgery.

We asked the anesthesiologist if we could watch the procedure from her side, because we had already spent an hour just staring at backs of surgeons operating on the patient, but not the surgery itself. The anesthesiologist took pity on us, and allowed us to take turns watching the surgery up-close. Because of this, I finally got a glimpse of the patient's heart, which took me some time to identify because it just appeared to be a massive lump of fat. 

During the surgery, I saw the bag of cardioplegia solution that was used to induce cardiac arrest. I was unable to get someone to explain to me how that worked, so I did a little search online and found some information on http://www.drugs.com/pro/cardioplegic.html. 

Apparently, cardioplegia is induced by varying the ion concentrations in the heart muscles. The ion that precipitates cardiac arrest is potassium. The swiftness of the arrest induction preserves adenosine triphosphate (ATP) for myocardial contraction when the heart is made to function again. Magnesium ions are used to inhibit a myosin phosphorylase, further conserving ATP stores. A low calcium ion concentration is used to maintain cell membrane integrity. While sodium and chloride ions do not produce cardiac arrest, they maintain "ionic integrity of myocardial tissue", and electroneutrality of the cardiopledic solution, respectively. Finally, bicarbonate anions are used to counteract the metabolic acidosis resulting from ischemia. 

Week 6 - Brandon

Last week marked the first milestone of two of the three projects that I have been working on. First, I have been doing research into cracking joints; why they happen and any implications. Interest in this had come about during clinical interactions with patients. After searching the literature, I had come up with a few causes for the cracking and what science has been done to explore this phenomena thus far. Dr. Härtl requested that I present my findings in lab that week, which I did. It was a fairly long presentation in which I outlined the causes in general and then specifically into the "cavitation" experienced at the synovial joints. Physical experiments done around this cavitation in conjunction with joint cracking is very scarce, which is why there does not seem to be a concrete link between joint cracking and oestoarthritis. I am continuing the search for information regarding this topic and possibly looking into writing a type of review on the subject.

The second project, measuring intradiscal pressure in the caudal intervertebral discs of rats hit a major obstacle. We obtained a blood pressure monitor from the biomedical engineering dept at the hospital that we hoped to use in conjunction with a transducer and high gauge needle to measure the pressure in a few of our rat tail samples. Everything hooked up smoothly and we were able to obtain an initial reading of a pressure value (we think). However this value did not change, and slowly when it did, when we began to manipulate the tail. We thought that it was a problem with how responsive the transducer is, but the system is used to measure arterial pressure which is fairly dynamic. With this system now working we are looking at alternatives including collaboration with another lab that has the capability of measuring intradiscal pressures in human cadaveric models. The transducer in this case may be too large for our purposes. There is a smaller fiber optic sensor that would be useful, but it is quite expensive. Still it may be worth looking into negotiating a type of trial use period.

The third project, MRI vs XRAY in quantifying disc height changes, is moving along nicely. Measuring each image takes some time, but it is fairly easy and an interesting study. We are still missing a few of the most recent scans which would be extremely helpful in getting a time dependant look at how each imaging modality estimates the disc height changes; crucial information when it comes degeneration of discs and accurately studying this phenomenon. Conclusion of this study will also aid us in moving forward with our degeneration and replacement studies.

During the week I visited both the clinic and the OR. The cases were pretty familiar by now, mostly decompression diagnoses. I found it interesting that the same compression of the spinal cord could be brought on by so many different things ( i.e. thickening of the ligaments in the spinal canal, herniated discs, tumor, cysts). There is a very mechanical nature about pain associated with the spine, and it seems that one can only go so far with chemical treatments before mechanical intervention is needed. I also saw an open heart surgery in which two heart valves were replaced and another repaired. It was a bit weird not hearing the rhythmic beep of the monitor when I walked into the room. The surgery itself was quite interesting to watch, and a had a great view on a standing stool at the head of the table. Putting the valves in was fairly quick, most of the time was spent reviving and making sure everything was working properly again.

Week 7 Liz The Wrap Up

It's hard to believe seven weeks have passed already and that I am taking the C2C back to Ithaca's quiet campus.

On the left, I attached one of the pictures I took while at Weill Cornell Medical College. It shows the migration of bone marrow derived cells (BMDCs; green) into the tumor vasculature (red). It is two-photon image projection of volume of 600um x 600um x 300um into the brain tissue of an animal. I like this picture because you can see BMDCs hugging the vasculature and in some cases they appear to be inside the vessels themselves! It's pretty cool to be able to do this.

I also like this picture because I think it captures one of the benefits of summer immersion for me. In his clinical practice, Dr. Greenfield treats patients who have glioblastoma, an aggressive primary brain tumor with a two-year survival rate of a mere 25%. In his laboratory, Dr. Greenfield does genetic and molecular analysis of glioma mouse models as well as some analysis of patient samples. The aim is to determine the role of BMDCs in promoting new vessel growth, thereby promoting tumor growth. As an engineering student, I enhanced their animal model by adding in vivo imaging, like the picture shown above. We both had questions for each other: they were the experts on angiogeneis and vasculogenesis while I knew about live animal imaging and two-photon microscopy. When I left this summer, I had a better understanding of patients are treated and moreover, the multidiscplinary approach doctors use in making their treatment plans. In exchange, they now have an advanced imaging model and the means to carry out such research. I hope this collaboration will extend throughout my PhD education and beyond.

Being in a hospital setting has made me think about my career outlook differently. In particular, I'd like to work in a hospital setting. While there are more obstacles than working in an academic laboratory because of the need to protect patients and their privacy etc., I believe a more direct interaction between clinicians and engineers would speed up the process of discovery and creative thinking.

I had a great, beneficial summer experience. I like to believe that most of my peers did the same as I looked forward to hearing about their daily adventures through the operating room and clinics.

And of course, living in NYC for seven weeks was an amazing experience within itself. I am grateful to HHMI for funding, Dr. Frayer and Prof Wang for their guidance during the program, and to the Cornell BME Department for believing this is a valuable enough experience to allow us seven-weeks of time to find out how our research and skills can benefit the world.

Waiting for the 4th of July fireworks on the Hudson River. (left to right: Liz Wayne, Young-hye Song, Stephanie Lindsey, Sara Che, Ryan Nolan, and Jose Rios)