James Week 7

This is the last week that I will be here in New York City. This week I cannot do anything inside the hospital because the Joint Commission Survey is around. I have two projects that I am currently working on. The first is the database, which has now received PI input, so I have been correcting issues and reformatting. I surprisingly spent a very long time this week on the database, but it ended up to my mentor’s liking. The second project was for Dr. Frayer and it entailed a 3D reconstruction of an infant’s airway, trying to reconstruct out 5 generations. I worked in the radiology department with software for 3D rendering and was able to reconstruct the trachea and the first three generations of bronchial. Any further rendering only gave lung tissue; this is due to the CT resolution. I took many videos of how I went about doing the 3D reconstruction.

This has been an interesting neurological experience. I have seen just about everything on the neurology clinical side and have learned how the hospital system works. As for incorporating my thesis from Ithaca, I believe that this really helped focus my project on different aspects than I normally would have. For instance, I did not realize that stroke could actually be detected to the micro level and that the time is not as critical an issue as I had first thought it to be. Also, there are many stroke experts around the hospital that can diagnose without the use of any technology; I found that to be very interesting. I was able to enter into collaborations on my project and have thus far gotten useful input.

I believe the program needs to be more organized in the future with a rotation like feel. Basically, we should go through what med students go through and rotate weekly so that we can get a holistic experience. I also believe that the projects should be optional or tightly controlled, I did not get a good experience with the project and even if I was able to do what was asked, I do not believe it would have added to further my research experience.

Week 7 - Young Hye

This week went by slowly. I had planned to shadow ER, NICU, and labor, but because of the Joint Committee for Accreditation visit, all of us immersion students were not allowed to be in hospital at all. I spent time trying to finish my project as well as the PS-OC experiment. I met with Dr Vahdat on Friday, which helped me greatly in terms of how to put together a poster as I was unsure how and what I would present.

Overall, it was a great experience as I got to see different surgeries, struggles that patients go through (it felt real for the first time), know for sure that doctors do care about patient health care and it's not just mechanical get an idea of what doctors expect from engineers such as ourselves, and how research groups take advantage of ample resources available in hospitals for their work. I'm a little disappointed that I didnt get to spend time in hospital this week as I had planned, but overall I'm glad I was able to be a part of the summer immersion term. I'd like to thank Drs Wang and Frayer and Mitch for all the help and organizing this program.

Week 7 - Stevenson T

This is the last week of our seven week long summer immersions term at Weill Cornell Medical college. I’m going to spend a little time discussing my overall experience before getting to specifically what I accomplished this week. After seven weeks of “city living” in Manhattan, my wallet, waistline, and personal space are going to be very happy heading back to Ithaca. Though, I consider Cornell’s main campus to be a more comfortable location, I will miss working at the hospital. Though we didn’t actually get to “help” patients directly, being in the hospital made me feel much closer to the ultimate goal of biomedical engineering which is improving patient diagnosis, treatment, and quality of life. In Ithaca, we are much further removed from the actually application of our research that I sometimes lose sight of this “ultimate goal”.Interacting with the patients and their physicians left a lasting impression on me.

On a more research oriented side of things, following Dr. Osborne through several of his clinical rounds and studies, I was able to get a basic understanding of a variety of nuclear medicine techniques that may one day prove valuable to my thesis work. I use words like “may” and “one day” to emphasize the point I made in my previous paragraph. The work we are doing at the Ithaca main campus is sooooo far away from practical application that the techniques and imaging methods I learned would only possibly be useful after 3-4 of research. That may be because I’m a molecular engineer, but I feel that a lot of ground work in design, and in vitrotesting must be performed before a biomedical researcher can even go as far as animal testing.Overall, I’d give the experience a B+. The program did accomplish the goal of “teaching me how clinicians think”, but the overall contribution to my thesis will be minimal. My only advice for future years is to pair up students/clinicians much earlier so that they (+/- the student’s PI at Ithaca) can set up a schedule that will not only familiarize the student with clinical practices, but get them involved in a project that may contribute the student’s PhD thesis.

Orienting a model of an ex vivo prostate specimen (aka arts and crafts): As I have mentioned in my previous blog entries, the research project I’m involved in is trying to use¹¹¹indium labeled antibodies for imaging of prostate cancer. Specifically, we’re trying to determine if we can localize the disease within the prostate. Patients are injected with indium labeled antibody 2 days prior to prostatectomy, and then imaged using SPECT. An “extra step” in this study which usually isn’t performed in similar studies, is imaging of the prostate after it’s been removed. We (that is the nuclear medicine dept) get the prostate and put it on the same SPECT scanner on which the patients were previously imaged. One problem that radiologists ran into is that they weren’t able to orient the 3D activity map to an subsection of the prostate. On a clinical scanner with limited resolution, the ex vivo prostate looks like a spherical blob. This is usually ok when the prostate is being imaged inside of a patient, when the radiologist reading the image has physiological “landmarks” (bladder, rectum, etc.) to orient his view of the prostate. In an ex vivo specimen, these landmarks do not exist. So in an attempt to have the image 3D activity image of the prostate oriented, I tested several metallic paints as possible contrast agents that could easily mark the prostate, providing a coordinate system to describe observed regions of activity as well as allowing the radiologist to say the activity is posterior, anterior, cephalic, etc. The image I have in included shows several types of fruits that I painted with candidate contrast agents including aluminum, brass, and stainless steel. Unfortunately, none of the paints were dense enough to show up on a X-ray CT scan. It was then that Dr. Osborne got the idea to use barium paste, an X-ray contrast agent present in the hospital. Marking the fruit, specifically the tomato, with even the smallest drops of the paste provided sufficient contrast to see on the CT scan, allowing for proper orientation, and the development of a coordinate system.

Plastics Week 6 – Lindsey

This week I branched out from my mentor and visited a lot of the other departments. I went on NICU rounds, PICU rounds, Pediatric Cardiology rounds, spent a day in labor and delivery, as well as an afternoon in endoscopy. Labor and Delivery was a very rewarding experience. I was surprised how much I enjoyed it, and how quickly all my hesitations went away. Matt and I went together and were able to see a vaginal delivery as well as a C-section. We started with the C-section, and it was amazing how quick the surgery was. Before I knew it the baby was out and crying. He was beautifully pink and perfectly shaped, as it didn’t have to make his way through the birth canal. The vaginal delivery was a different story. The mom was a nurse in the psychology department and was what the obstetrician called the ideal patient. “This is the perfect birth for these students to see,” she said “no complications and they get to see what happens when you really push.” The mom had no drugs, and worked hard through her contractions. Only the very end was extremely difficult for her and even then it was better than any televised birth where the mom is in so much agony and screaming for her life. I held one of her legs and gave her the appropriate pressure throughout her contractions. When the baby came out, they plopped her on top of her mom’s belly and prepared for the placenta.

It was a spontaneous delivery of the placenta and the doctor pimped Matt and I a little as she was delivering the placenta and closing up. “how long can you wait for the delivery of the placenta? What are some of the complications of manual delivery? What do you have to watch out for?  How do you know the placenta is about to separate? ”   I thought back to my Antropology of birth class and realized I actually knew the answers to all of these questions. It was a good week. We also saw a 3-D ultrasound. I found myself wanting a baby, as they were so cute.

 On the Pediatric Cardiology rounds one of the Fellows was pimped by an attending as to the formation of interrupted aorta and its pathology. He said there are two models for disease formation, which is generally true for all congenital heart defects, a hemodynamic model and a genetic model. When asked what genes were linked he said NOS-2 and you could tell he was really nervous and unsure as to the correct response. He was right in some ways, NOS-3 is a shear stress related gene, whose expression changes have been correlated to changes in structure. The gene therefore supports the hemodynamic model, rather than a genetic model for the defect formation, or rather as researchers are coming to learn, the two are not mutually exclusive. There are no gene mutations currently linked to interrupted aortic arch. It was satisfying to see how my research really fits into their work here and know that at some pt we’ll help lead to better treatment of these illnesses.

Emily - Week 6

Monday:
I used my new skills to sack some mice, dissect out the lungs, digest the cells (no trivial task – I think I have blisters from all the pipetting), and plate them in media.
Tuesday:
I was in the ER for the morning, which included going to “morning report” in which I learned about the different kinds of anesthesia. The ER residents and fellows discussed and quizzed each other about the effects of the different levels (minimal, moderate, deep, general) on patient response, respiration, and cardiovascular function.
After morning report we all headed back to the Emergency Department, only to be greeted with, “We have a trauma case, everyone, incoming trauma. Prep for trauma.” A middle-aged woman had been hit by a car, throwing her through a storefront window. The whole process was intense, from when the EMTs arrived with the victim, through all the ER teams merging together in one chaotic, life-saving organism, to the CT scan that confirmed the locations of her various femoral and pelvic fractures.
The rest of the morning was House – style medicine, with fellows and residents taking patients’ history and vitals and reporting back to the attending. The attending would walk them through the logic of diagnosis, encouraging them to think outside the box, to consider all possibilities, and in all cases, assume illicit drug use until proven otherwise. That last was a bit of an exaggeration, but they have to be really careful due to potential pharmaceutical interaction effects.
In the afternoon I imaged my lung tissue sections for epithelial and mesenchymal staining, checked on my cells, and came back after dinner to start another round of the same.
Wednesday: I headed out to the Bronx to meet with a collaborator at Albert Einstein Hospital who is working on an endothelial cell isolation process that is similar to the one I use in Ithaca. I enjoyed dialoguing with the students in the lab, as we’ve experienced may of the same challenges and frustrations. In the afternoon I “met with” my Ithaca PI via skype, finished my staining, and rushed out of lab to meet a long-lost friend for dinner on the West side.
Thursday:
I finally got to watch a pediatric “cath”, which means they insert a long tube into the patient’s femoral artery (or was it a vein…?), feed it all the way up into the heart, and in this case apply a ventricular septal defect repair device to close off a stent. The case history was really complex, but essentially it was a follow-up surgery for a little boy that was born with Tetralogy of Fallot and was doing well enough to have his “pulmonary escape hatch” closed off so he could erly entirely on his own circulation.
In the afternoon I imaged my fluorescent lung tissue, fixed my cells, and attended the immersion meeting.
Friday:
Watched an aortic valve replacement/coronary artery bypass graft surgery in the morning. This surgery was great, because there were very few students in the room and the anesthesiologists were really nice about letting us stand at the patient’s head to watch. I had a great view – the coolest part was when they attached the homograft coronary artery to the patient’s heart – the delicacy and precision of the procedure was incredible. I felt bad for the patient, though… His whole heart was calcified, it seemed like. This surgery will keep him going for awhile, but he’ll probably need to be re-opped.
In the afternoon I focused on assembling my PCR plate, double-checking the concentrations and protein contamination levels, via spectrophotometry, and filling 360 tiny wells with master mix, primer, and cDNA. Tedious, but rewarding based on the sheer volume of data that results.

Week 6 - Joseph

On my second-to-last week here at Weill Medical College, I mostly continued my previous week's experience: lots of lab work for my research project, with a little bit of clinical experience to make the whole time slightly more applicable to the goal of immersion for the term (if I had wanted to do all lab work all the time, I would have stayed home in Ithaca!). In the lab, I continued pursuing my relatively straightforward goal for my project: 1) make a series of mutations to the AAV genome that would ablate native tropism and retarget the virus to the blood brain barrier, 2) grow the virus in mammalian cell culture, and 3) test to ensure the virus formed was functional and normal, aside from the changed tropism. This past week was focused on step #1, so it was just continuation from the previous week concerning mutating plasmid DNA, growing bacteria, harvesting DNA, analyzing it, and moving on to the next mutation. Nothing more to really say on it, other than thankfully everything has been successful, I have the final plasmid construct with all desired mutations, and hopefully next week we can quickly grow the virus and run some initial tests just to see what we've got.

The major clinical experience I had this past week was a visit to the Emergency Department (ED). I went in the afternoon on Friday and was there from 3:00 pm to 11:30 pm... and let me assure you, it was one long night. As soon as I came in and managed to find the attending (the reins were in the middle of being passed off at the time to Dr. Senturia, a fellow Texan), we were launched into a mixture of constantly rounding on the ~40 beds in our wing of the ED and dealing with the critical emergencies that would come in via ambulance. For the latter, the heat certainly made things crazy; we had several cases of critical heat stroke, with people coming in with body temperatures ranging up to 107 F (!) and suffering from all sorts of dehydration and delirium. We also had a couple motorcycle injuries. Thankfully none of them were fatal, but I liked how the EMTs brought the helmets into the critical care room to show the patients just how dead they would have been without them (the helmets looked like someone had taken a jack-hammer to them). When it came to the critical emergencies, I was thoroughly impressed at how the residents instantly snapped into action as a team, assigning a leader and various necessary roles and being ready to act at a moment's notice when the EMTs came rolling through the back door. When it came to normal patients, I was impressed to see the level of empathy the attending and residents managed to convey time and time again, something I had seen surgeons struggle with when they only needed to see several patients a day. There are many little details I could comment on - seeing the usefulness of multilingual talent for a doctor working in an ED, learning how to assign likely diagnoses for chest pain and headaches based on statistical data compiled solely on age and history, learning that fixing a posterior shoulder dislocation is as simple as "picking an apple" - but what impressed me the most was the stamina these doctors showed in the face of their unrelenting job. The pace of the ED was physically draining, the need for constantly drawing on a diverse reservoir of clinical knowledge was clearly mentally draining, and the need for ping-ponging empathy between dozens of stressed out patients simultaneously was even more emotionally draining. This was in no way an easy job... honestly, at the end of it I was exhausted purely from the physical and emotional drain, and that was merely as an observer! And on top of all of this, I'd finally like to comment on something from the viewpoint as an observer who personally has been to the ED several times as a patient and have had a 100% frustrating experience every time. This team and this hospital's particular ED experience, even though it clearly made a number of patients far from satisfied, was truly a cut above the hospitals I had been to before. These doctors cared, were professional, and got the job done as fast as possible. They represented NYP very well in my eyes, and it was very meaningful for me to stand on the other side of the ED experience and see how one of the harder jobs in the hospital was supposed to be handled.

Week 6 - Sara

Summer Immersion is slowly reaching its end. Thinking bad, this experience was definitely one of the most worthwhile and it has definitely achieved its purpose in giving a perspective in clinical aspects by allowing us to shadow surgeons and clinicians in their daily activities (most of which we wouldn't have known about).

As the immersion comes to an end, I spent most of this week preparing and running experiments to wrap up my project. I ran another flow cytometry experiment to check for tissue factor (TF) expressions in prostate cancer cell line. Expanding on the list of cell line, I tested C4-2 (metastatic prostate cancer LNCap cells planted into castrated mice host and removed after week 4 twice), RWPE (benign prostate epithelial cells) and MDA-MB-231 cells (metastatic breast cancer cell from Ithaca to be used as a control) in addition to PC3 cells (metastatic prostate cancer cells) which I tested last time. Unfortunately, C4-2 was negative for TF expression, while PC3 was once again weakly positive. RWPE cells were positive, however, much to my disbelief. This is most likely the fact that they are epithelial cells, not benign non-metastatic cancer cells. TF can be expressed in subendothelial cells to form blood clots in the case of blood vessel damage. I had thought that RWPE cells were non-metastatic cancer cells, so they can give some differences with PC3 cells as TF is typically only expressed on metastatic cancer cells.

In a second experiment, I spiked PC3 cells into blood from a non-cancerous person to see if TF can be used to identified the cancer cells. The PC3 cells were pre-stained with a live dye before spiking to distinguish it from other cells from the blood donor. The blood was processed with Ficoll and the buffy layer with the PC3 cells and mononuclear (PBMC) cells were separated and further stained with TF antibodies for flow cytometry. Compared to blood controls, the spiked controls has two populations - PBMC cells and PC3 cells. However, the TF expression in the PC3 cell population was not that high. Compared to mouse IgG antibody control, the number of events positive for TF was increased from 196 to 210. The small difference could be because most of the cells detected were PBMC cells. If I had increased the number of events further, the difference may be more significant. However, given how weak TF expression is in the cell line, TF may not be the best marker for prostate cancer cells.

In terms of clinic, I went to PICU twice this week to shadow each of the two teams. The residents, fellows and attending were all very friendly and have taken the chance and opportunity to explain many of the cases and details to me. Some of the people were there post-op, others were preparing for operations. There was a cardio and a neuro team. In the cardio team, most of the babies have congenital cardiac defects in which the heart did not develop properly, and a surgery is necessary to fix it. One of the baby I saw in delivery had an aortic arch that stopped at the end, so then the surgeon must connect the arch back to the heart. In the neuro team, some of the babies have tumor in neural tissue. Other babies have recurrent tumor in the brain, and little can be done to treat the babies.

I always spent a few hours in radiation oncology to see what radiation therapy is and the procedure used to treat patients. In general, a consultation session is needed in which a CAT scan is taken of the region to be treated of the patient. The radiation oncologist then planned the treatment (i.e. the dose, type of radiation, where to shoot) with dosimetrist and physicist to come up with a plan. Then, the patient goes through the treatment daily from Monday to Friday for weeks. This treatment is usually used for local tumors, but is also used to palliate bone pain and to prevent new bone growth after hip implant.

I only went to see one surgery this week. I was originally in another surgery, but then I heard about an emergency surgery that required bypass instantly across the hall. The circulating nurse pulled me aside and told me to go to that room and it would be definitely worthwhile. So I went into the room which was in a state of chaos with 30 surgeons, anthesiologist, nurses, students, residents and fellows running around. A surgeon was performing heart compression, while surgeons are attempting to perform a bypass through the femoral vein, the anesthesiologists working their magic and the rest of the room prepping him for surgery. Before further describing the procedure, it is probably better to explain the conditions. All in all, I don't exactly know what happen was most of the nurses and surgeons don't either and I didn't want to get into the way for a good chunk of the surgery. What happened was that the patient had a Nissen procedure to connect the stomach to the esophagus to prevent acid reflux. The procedure was successful and the patient was wheeled back to his room when suddenly he crashed. They suspect that he had a embolus in the femoral vein from lying too long on the table, and the change in pressure in the abdomen caused it to dislodge and caused his heart to stop functioning. There was also a mention of arrhythmia which may be caused the conditions. Back to the surgery - they then opened the heart, and also accessed the femoral vein from the other leg to put a balloon in to regulate the blood flow. Further operation was performed on the heart (which I can't see). After awhile, they tried to remove bypass, but cannot after multiple tries as the blood pressure was really low (40s/30s). In the end, they transferred him to a VAD (mobile bypass unit) and he was to be kept on bypass and wheeled back to ICU in that manner. Brain damage may also be a problem for the patient as he may have accumulation of CO2 in his brain.

Ryan - Week 6

Hey everyone, I'm sorry this is a late post but I've been very busy this past week, especially since my girlfriend, Jess, came to visit for the weekend. My mentor, Dr. Boockvar, was gone this past week on vacation so I took advantage of the opportunity to shadow as many other departments in the hospital as I could. I started off the week shadowing the obstetrics and gynecology residents and nurses in the delivery room. When I arrived, I met Dr. Maheshwari, who helped me acquire the specific blue scrubs with the baby delivery logo on the chest necessary to shadow Cesarean sections (C-sections) in the labor OR. She then took me to my first surgery: a middle-aged woman who gave birth to a 6 lbs 9 ounces baby girl. When we got into the room, the patient was receiving an epidural. Then they draped her and made several slow incision cuts to get down to and isolate the uterus. The surgeons had to remove scar tissue from previous C-sections, too. Once there, they carefully cut through the uterus, which resulted in a gush of amniotic fluid. Dr. Maheshwari then reached into the incision to grab the baby’s head while her assisting surgeon pushed on the woman’s abdomen to force the baby out. Slowly the baby came out and then a nurse took the baby and cleared out its airways and cleaned it off before wrapping it up in blankets and showing her to mom. The surgeons then proceeded to perform a tubal ligation, or having the fallopian tubes tied. Next the mom was sutured shut, layer by layer, and the baby was taken to the nursery. All the babies there were super cute, pink, and either whiny or asleep, so basically it all was pretty typical of a nursery. On my way back to the OR, the head nurse from the prior surgery told me I could come into the OR with him and help him with setting up for the next C-section for twins. We chatted for a while, just the two of us, and he had me doing little odd jobs to help him with his surgery prep. The next lady came in and the C-section went the same as the first one but this woman had a tattoo along her waist, so Dr. Waterstone was able to avoid cutting through the patient’s tattoo to operate. The two baby boys were pretty big, both being around 7 lbs, and one was perfectly healthy but one had breathing problems so they put him under close observation.

Next, I shadowed in the Emergency Room (ER), Dr. Balsari, the attending, and two of the residents, Dr.s Madhok and Piracha, who all were very friendly and allowed me to follow them to see the many different patients coming through the ER. One of the more interesting ones, a woman who was suffering from aphasia, meaning she could understand what we said to her but when she went to respond, she thought she was saying the right words but what she actually said was just jumbled random words that didn't make any sense. After an x-ray computed tomography (CT) scan, the radiologists discovered many lesions along the central fissure of the brain, deep inside near the brain stem. These lesions were hemorrhaging (bleeding) and the increased pressure in the skull was forcing the brain down the base of the skull and pinching the brain stem. Since this patient had a kidney transplant and is fighting graft-versus-host disease (GVHD), the prognosis does not look good, especially since the lesions are so deep within the brain and so close to the brainstem that surgery is really dangerous. The ER admitted this patient to neurosurgery to see if they could get someone to operate and help the patient, but they aren't very optimistic that she’ll survive this visit. Another interesting patient was a man who had a hugely distended abdomen, to the point where he looked pregnant. The ER doctors deduced that the patient is retaining fluid and while they aren't sure what exactly is causing this (the chemical workup on the patient showed relatively regular levels of everything except for his glucose, which was explained by his diabetes), they want to look further to investigate liver and kidney function while removing as much of the fluid as possible.

Sara and I shadowing the Pediatric Intensive Care Unit (PICU) during their clinical rounds. Dr. Traube, the pediatrics attending, and Dr. Dayton, the pediatric cardiology attending, walked around with the group to each patient and heard from the residents and fellows about each patient case. Then they discussed and set the plan of patient care to follow. The majority of the cases were cardiology complications, such as interrupted aortic arch (IAA), where there’s a discontinuation or absence of a portion of the aortic arch, causing oxygen-rich blood from the left ventricle of the heart to not be able to reach all areas of the body. One way to compensate this condition is the development of patent ductus arteriosus (PDA), where the extra arterial connection (the ductus arteriosus) necessary in utero for baby survival prior to using its lungs for blood oxygenation fails to close, which is what should normally happen following childbirth. When this complication does not close on its own, the oxygenated blood and the deoxygenated blood mix in the ventricles, which decreases the overall oxygenated blood delivery efficiency. Therefore, surgery is required to close the PDA and also complete the IAA so that the heart pumps blood as it normally should. One patient, a teenage boy, has recurrent anaplastic ependymoma (brain tumor) in his ventricles by his brain stem. This is causing him to experience paralysis symptoms similar to “locked in” syndrome, where he can only communicate via blinking. He’s already undergone craniotomy and tumor resection surgery, radiotherapy, and intra-arterial chemotherapy but nothing has worked to keep his tumor growth under control, so the best the hospital staff can do now is make him comfortable and talk with the parents about whether they would like to take their son home with a hospice care nurse or stay in the hospital until their son succumbs to the cancer. This is a particularly sad case because he was a happy, normal teenager up until a few months ago, when the tumor initially grew to a size large enough to start impinging on normal function and was noticed.

In the Neonatal Intensive Care Unit (NICU) with Stephanie, we shadowed Dr. Frayer and his team during their rounds. There were a lot of cute babies there, most of which had complications with their heart and lung development. A lot of the mothers were present during the rounds and it was sad to see the concern and wear on them. It was refreshing to see a set of happy parents take their twins home who were premature at birth and were healthy except for the fact of being underdeveloped. So they stayed in the NICU under careful watch to make sure that they grew and developed appropriately. Then Dr. Frayer, Stephanie, and I sat down in the office to chat about what we had seen on rounds, as well as how our summer immersion was going and how satisfied with the whole experience we are. When I brought up my summer immersion project, Dr. Frayer helped me by calling Dr. Pochapin, a gastroenterologist and close friend, who was more than willing to help me with bringing a narrow-band imaging (NBI) endoscope to Dr. Schwartz. On a side note, Dr. Pochapin was Kate Couric’s gastroenterologist for her colonoscopy a few years ago. When all four of us met together, Dr. Pochapin offered to let Stephanie and me shadow a colonoscopy of an old man to show us how the NBI scope works. It was amazing to actually see the scope in action in person. As Dr. Pochapin performed the procedure, he talked us through what he was doing and pointed out all of the polyps prior to removing them. The endoscope had an attachment where a cauterizing loop/lasso came out and ensnared the polyps, burned them, and sucked them through the tubing and into a collection chamber. After pulling out a total of six polyps, one of which was thought to be potentially cancerous, thereby making this procedure lifesaving for the patient, Dr. Pochapin showed us the opening to the small intestines. Since they looked a lot like a sea anemone, he mentioned how this could be viewed as proof that we evolved from sea dwelling creatures and this feature stuck with us over the generations. After the procedure ended, Dr. Pochapin was kind enough to let us have pictures from the procedure illustrating the drastic difference between white light and NBI blue light in illuminating the vasculature.

John - Week 6 - ED & Labor

ED:


Rounding with the emergency department (ED) had a much different feel. Unlike in the specialized units, patients here have a wide variety of ailments, with some significantly more serious than others. Some less life-threatening conditions include severe migraines, or chest pains. One patient even had a stiletto wound to his left flank. Other patients had more pressing medical needs.

One in particular was a patient with Crohn's disease. He came into the ED with a fistula on his left groin that was emitting pus, as well as a painful swelling of his left buttock. He had developed a fever two days before, and had been taking tylenol to alleviate it. Although his latest temperature reading indicated he was afebrile, the two doctors who evaluated him indicated that he was warm to touch. He had also not eaten for the past two days because eating caused him to have severe diarrhea. This patient had been treated previously for leukemia, which was presently in remission. He also had surgery previously to remove portions of his small intestine. The attending doctor suspected that the fistula on the patient's left groin was connected to the swelling in the patient's left buttock. She recommended a CT scan of his abdomen, but due to numerous CT scans in the patient's history, changed her recommendation to an MRI at the patient's request. It was likely that the patient needed to undergo surgery to drain the pus-filled fistulas.

Despite the severity of this patient's problems, things were rather calm in the ED until it was about time for the next change of shift. A geriatric male patient had just been admitted into the ED. Though alert and responsive, he had a heart rate of 40 beats per minute and an electrocardiograph with the P and QRS waves out of sync, leading the attending doctor to activate the emergency cardiology team. Within minutes, a crowd of doctors had gathered. They scrutinized the ECG printouts, evaluated the patient's condition, and concluded that a pacemaker was in order.

Labor:

During our rounds in the Labor and Delivery unit, two very kind mothers allowed us to observe their delivery. 

The first case was a vaginal delivery, and the baby was full term. Throughout the labor, the frequency and intensity of the contractions, as well as the baby's heart rate, were monitored and recorded. During the initial phase of delivery, despite the mother's contractions getting stronger and more frequent, there seemed to be little progress in terms of the baby moving out of the birth canal. The resident placed her hand in the mother's vagina to feel for the baby, and commented that the baby's head was slightly tilted upwards, which would make the delivery a little harder, but not cause any problems. The resident did try to turn the baby's head a little, but did not manage to alter its position.

Due to the pain from the contractions, the mother then requested for an epidural administration of an analgesic. 8% bupivacaine was used because it is longer-acting than lidocaine. The drug was injected into the epidural space (between dura and bone)) between vertebral discs L3 & L4 (L1 to S2 are involved in labor) to locally numb the sensory nerves of the lower body. In the administration of local anesthesia into the spine, the cerebrospinal fluid (CSF) has to be avoided, otherwise the drug will travel together with the CSF throughout the central nervous system, causing general numbness that can affect breathing instead. If given intravascularly, the analgesic could affect the heart. 

To ensure that the needle is not in the cerebrospinal fluid, the anesthesiologist attempted to push and pull air into the space. If the plunger barely moved, it would mean that the needle was not deep enough. If cerebrospinal fluid entered the needle, it would mean that the needle was too deep. A catheter was left in place, so as to allow subsequent boluses of analgesics were the labor to last a long time (i.e. > 2 hours). The epidural alleviated the pain from the contractions, but it also reduced the frequency and intensity of the contractions. As such, the mother was given oxytocin, a brain neuromodulator released in large amounts during labor, to counteract this effect and increase the frequency and intensity of the contractions. Not long after, the baby was born. 

The mother's girlfriend had the honor of cutting the umbilical chord after the doctor had tied a tourniquet on both sides surrounding the planned incision site, so as to prevent excessive bleeding from the mother and the child. After the infant had been delivered, the mother still had to wait for the placenta to be expelled. After that, the doctor ensured that there was no serious tissue tears that needed to be treated.

The next case observed was a cesarean section (c-section). The mother had a previous c-section, and thus needed a c-section this time round as well, since having a c-section once renders the womb and the surrounding tissues more susceptible to rupture if the baby were delivered naturally. It was not apparent whether there were other complications that necessitated a c-section.

While the anesthetic was also administered via a lumbar puncture, this was done to the depth of the intrathecal space (between arachnoid and pial layers), so that the anesthetic is able to mix with the CSF and numb most of the body. After the mother had laid down on the operating table, a blue sheet was placed vertically above the mother's chest to separate the sterile area where the surgeons would work, as well as to block the mother's view of the operation itself, since she remained conscious during the procedure with her husband by her side.

During the procedure, the surgeons first removed the scar from the mother's prior c-section before proceeding to cut through the fascia. The left and right rectus abdominis were spread apart for access to the womb, which was then cut to reach the baby. Because of the position of the opening in relation to the baby, the surgeons had some difficulty removing the infant. Apparently, once the womb has been cut, there are only a few minutes to remove the baby. Potential problems include the baby not having enough blood supply, that the umbilical cord may strangle the baby, and that the baby may choke on the blood from the c-section. As such, the time elapsed since the womb was incised was closely monitored and frequently reported. As the seconds went by, the tension in the operating room began building up. When the three-minute mark was reached, the medical team went into emergency mode. The experienced nurse practitioner who had been explaining the procedure to us moved over to assist the residents, while another nurse paged for the Labor fellow to intervene immediately. Thankfully, as the fellow rushed in mere seconds later, the residents successfully removed the baby. A team of pediatricians and nurses immediately suctioned fluid from the baby's mouth, performed a blood test, and cleaned the baby up simultaneously.

Meanwhile, the residents sutured the womb back up. It was interesting seeing the womb, as it was visually a large and highly-vascularized organ that would shrink significantly in size over the next couple of months. The womb was replaced into the mother's abdominal cavity, and the fascia, and finally the skin were sutured back up. 

The blood test indicated that the baby was hypoglycemic, which may have been due to the birthing process. Regardless, the baby was brought to the NICU for monitoring. 

Week 6 - Jawad: "Patient is not the only victim"

This week I continued following Dr. Gauthier in the clinics.

There was a senior citizen, quadriplegic patient of Multiple Sclerosis for a long time, with almost no mobility in his left side. He had a cather for 12 years, and though it was never comfortable according to him, recently it had become painful! His hystroscopy showed stones in the kidney, though he said they weren't causing any pain to him. However Dr. Gauthier recommend him to stay away from surgery just yet. His lung function was down to 33% of the normal. He uses IPPB to help with respiration, but he finds them uncomfortable. However, even with all this (stuck on a wheel chair, and all the other problems) he was very cheerful. He had two very nice and helpful caretakers (probably were his family). I couldn't help but contrast him with the case I saw earlier where a patient in much better physical shape, almost perfect ambulatory function, had given up to the disease. Support from family and friends goes a long way toward ensuring emotional stability. His caretaker mentioned that he loves going to Indian restaurants and have spicy food!

When he was leaving, he wished me good luck with my school, and told me something that is probably the quote of this entire summer immersion experience: "Always remeber - patient is not the only victim". Amen to that, sir!

Another, very interesting case that I came across this week exposed me to some other, previously not encountered clinical experience: dealing with the 'adverse effects of access to information' ! A person came to see Dr. Gauthier and said that Dr. Gauthier was the fourth neurologist this person saw. There were MRI scans of her brain and spinal chord from the last 1 and half years. All were clear, and showed no lesions. However, the patient(?) insisted that they were having symptoms that were typical for MS, and had changed neurologist after neurologist when they wouldn't agree! Though a spinal tap hadn't been done, it wasn't recommended by Dr. Gauthier, just yet. This whole episode reminded me of the adage, ignorance is a bliss! People shouldn't really get an MRI of their for no reason. That reminds me, I'm volunteering for a brain MRI scan myself this week! sheeeesh!!!

Another important case was of a person who was JC positive, yet was on Tysabri! Yikes! The person was very nice and sweet, and looked to be in fairly good shape. He works full time. And he was full of praises for Tysabri, even so much that he was prepared to swear by it. I was told that there currently are 120 such patients that WCMC has, which are on Tysabri and are JC positive. Dr. Gauthier was briefing him about the risks that he was being subjected too, but it seemed to me that his earlier treatment (Copaxon) must have been really unpleasant for him to deal with, as he appeared to be very comfortable with Tysabri. I learnt that according to most recent data obtained by Biogen, 145 cases out of a total of 90,000 patients have developed PML after being on Tysabri. However the risk seemed to peak at about 2 years of administration, whereas this patient had been on Tysabri for almost 3 years now!

This week I coregistered several other patient's T2 relaxometry images with their DTI images. Though the results obtained aren't that great. I've been tweaking certain parameter values to see if it helps, but doesn't help much. However, it's known that FLIRT doesn't work that well with T2 spiral. I'll go on to exploring the non-linear coregistration next week, and wrap up the project too. Hopefully, the results will be good.

Finally, I volunteered for a brain MRI scan of my own for research! It was a fun experience. I came to know that one: I am not claustrophobic, and two: I don't have a perfectly healthy brain! How reassuring!

Week 5 - Jawad

This week instead of following Dr. Gauthier, I shadowed Dr. Freyer in his clinic rounds, observing several babies of different ages. There were a few interesting cases that I got to observe.

A 62 days old baby boy who had more spinal fluid than normal. A mass in the cerebrum showed up in the MRI scan. An extraventricular drain was to be put in shortly (next day) to drain the excessive fluid. After the shunt has been placed, the baby will have to lie in bed all day, causing discomfort though. The baby exhibited multiple instances of low heart beat during the day. I was told that this could be an indication of increased pressure in the head.

A 36 days old boy, who required PPD when he was delivered, and then the heart started responding. He had elevated enzymes level, which could possibly mean that liver was damaged or not functioning well. His brain EEG was also continuously being monitored, and a spinal tap was scheduled for the next day to look for markers of infection. The baby though looked fairly comfortable and otherwise healthy to me.

There was a baby girl who was developing gigantic abscesses in different parts of her body. I was told that the size of these were totally disproportionate compared to the rest of her body. There was one on the side of her neck, which was drained a few days earlier and was still 'open', however the girl had developed another one the wrist of her right hand. The puss from that was to be drained the next day. The cause of these abscesses was currently unknown, and I would like to follow up to find more about her in the coming weeks.

Finally there was a 46 weeks old baby girl who had tracheoesophageal fistula and she also had thick maconium. This led to difficulty in feeding her through the mouth, and growing/developing. A case for surgery to connect her esophagus to her buccal cavity was under consideration.

There were several cases of premature delivery, and I couldn't help but ask Dr. Freyer if these babies would survive. The answer was a plain yes, and also that they grow up to become healthy adults. This was fascinating to know!

On the project front, now I am working on image coregistration. We are trying to see how well the T2 relaxometry (both pre and post-processed) images coregister to DTI one's. Most of this week was again spent trying to automate the process. However, the first results using just linear coregistration (FLIRT routine from FSL library) were encouraging. I hope to have more on this next week.

Week 4 - Jawad

This week I continued on with shadowing Dr. Gauthier in her clinical rounds. This time around though, I observed residents attending the patients and then briefing Dr. Gauthier about the patients. It was interesting to observe the 'protege-guru' kind of a relationship, with the residents doing a fairly good job of attending to patients, obtaining the required information and then suggesting to Dr. Gauthier about the treatment plans. Most of the times, their suggestions were acceptable without any major alterations to Dr. Gauthier.

Although I've been observing this for several weeks now, but this time around the emotional aspect of dealing with Multiple Sclerosis (MS) was more and more apparent. I could also appreciate the importance and relevance of the support structure, or lack thereof, afforded by the society to the MS patients. While most of the patients have friends and family to lean on for support, and it certainly gives them the will-power to continue on with their lives and be (economically) productive and functional for the most part. I witnessed that in the lack of such support system, a patient can experience simply a total emotional break down and become reclusive, when in fact they are in much better shape than some of the other patients who still work full-time and go hiking and trekking! "I could detect the screams in the smiles" was a remark made by a resident toward one such patient, who unfortunately had no family and friends to make her feel warm, and take care of her.

Other than the clinics, I've been working on the project. The automation of code to process the T2-Spiral images is now complete. And now it's just a matter of collecting all the patient's dicom images in one folder and passing the path of that folder as a parameter and pressing enter. The results will take a while (4 hours per patient) to compile, but no user intervention is required so one can attend to other tasks. Hopefully some nice results will be obtained!

Week 6 – Joyce

There were no surgeries in this week, but I saw several patients with Dr. Lipkin. Some of them have colorectal cancers (CRC) with inflammation bowel diseases (IBD). IBD, often characterized by conditions such as ulcerative colitis and Chron's disease, increases the risk of developing colorectal cancer. (However, ulcerative colitis increases risk more than Chron's disease.)In general, the longer a person has had IBD, the greater his or her chance of developing colorectal cancer. This is because inflamed areas of the colon can give rise to abnormally-developed cells, which in time, can give rise to cancer cells. We had one patient of CRC & IBD registered for CRC surgery and I am curious to get the tumor tissues for histological analysis and primary culture.

Research project goes slowly but progressively. I use the primary CRC lines for small molecule screening and identified some KRAS targeting components. While the KRAS mutation sequencing results are not good due to the bad DNA sample qualities. I will repeat DNA exaction to improve the quality by more PCR production and gel elution. In the other hand, we consult gene sequencing / expression expert, Dr. Zeynep Gumus about the whole genome / exon sequencing for these highly metastatic primary CRC lines.

Week 6 Liz Babies have Amazing Skull Bones

I am convinced, babies have awesome skull bones. In clinic a two-day old baby fell to the brain and fractured her skull. It will grow back and no harm will be done from the break.

What I learned in all cases is that a child's skull is able to grow quickly, since it grows develops to fit the shape of the growing brain. Surgeons prefer doing surgery (such as for the removal of a dermoid cyst) on a young baby because the skull bone will simply grow back. The brain's most dramatic growth occurs from birth up to two years of age. In clinic, I observed Dr. Greenfield and nurse Maria Rust use this knowledge when they questioned patients. They monitor the growth of the babies head, checking to see if it was in the proper growth curve. If the child is not growing along their expected growth curve, then they investigate for deeper issues. During an exam, doctors perform a hand examination to feel the sutures in the brain and to make sure the fontenelle or soft spot on the babies skull is still soft. Essentially, during the first months to two years it is vital for the baby to grow uninhibited, the brain must have space to grow and the skull must also growth with the brain.

I also I saw a lot of cases concerning the development of the skull and its growth in babies. In particular, there were two cases of Plagiocephaly or "the flat head syndrome." Plagiocephaly cases have increased since the 1990s campaign on "back to sleep", making babies sleep on their back to reduce the occurrence of SIDS, even though babies natural prefer to sleep on their bellies. (As a sidenote, it was interesting to see how some practices which not all doctors consider effective are still done because of public health advertising. Interesting dynamic.)

Besides he "wow" factor, it was initially hard for me to appreciate how shadowing a doctor in clinic would inform my career as a PhD-trained scientist. But now, I think these experiences will allow me to be a better scientist because I have a practical understanding of how the data/information I collect can be put into practice by doctors. It will also help with the language/interest barrier between doctors and scientists. Now that I have been around the hospital I understand how they process information from a patient and turn that into a diagnosis and treatment plan.

Week 6 - Karin

Aside from working on my research project, I shadowed a PA, Laurie Yin, that worked with Dr. Alex Swistel. I observed Laurie's meeting with the patients: going over their medical history, going through what exactly brought the patients there, the patient's physical exam (I also had the opportunity to palpate a breast tumor mass ~3cm in length), and looking through their diagnostic images.

I shadowed the Burn unit with Young-Hye and observed the attending doctor (Dr. Yurt) go through rounds with the residents, PAs, nurses, technicians, and pharmacist to assess the healing and status of these patients (two of which were toddlers). We watched a resident sterilely perform an arterial line replacement (has to be changed weekly) in the patient's room.

I was also in the ER this week, or rather ED, with Dr. Matt O'Neil. The ER was very fast-paced with all types of patients. One patient was in a few severe accidents in the past and had gotten addicted to pain narcotics. The patient was trying to overcome his addiction, but with the anxiety attacks he has (for which he has to take Valium) it has been difficult. He came into the ER because his wife was worried he had overdosed on narcotic and anti-anxiety medication. These medications may have a synergistic effect that could cause respiratory suppression. Additionally, the medications he has may also have Tylenol; if he had an overdose of Tylenol, there is a chance of liver failure.

Another unit I shadowed was MICU. This unit gets a variety of cases (e.g.: patients with respiratory or liver failure, bone marrow transplants, etc.). A 55 year old patient in this unit had gotten orthopaedic surgery and because of the chance of clots that could cause pulmonary embolism, he went down to radiology to get a CT scan. He complained of chest pain and shortness of breath (indications of a heart attack) during his scan, so they brought him back up to MICU. He lost his pulse when his arrived back in MICU, causing most of the unit to congregate to his room to aid in his immediate life-saving care. Nurses and residents took turns compressing his heart and taking his pulse; doctors, nurses, residents, and technicians gave him numerous intravenous injections of sodium bicarbonate and epinephrin. He regained his pulse once, but ultimately passed away.

Week 6 - Young Hye

This week I shadowed Burn ICU. Early in the morning, residents and fellow went through pre-rounding, going over the list of patients to be covered in the afternoon rounding. Then saw arterial line replacement. Then afternoon rounding. Contrary to what I've expected, this rounding consisted of doctors, nurses, PAs, and even pharmacist talking outside of the patients room and discussing patients conditions. It seemed to me that while residents and fellow were more focused on vital signs and the medications that have been administered to, the doctor asked questions on the status of burn. I was surprised to see fellow and residents not knowing the answer to the surgeon's question on the status of patients' burns. There were babies with hand, arm burns. They were placed in hydrotherapy rooms. It was painful to watch babies crying with the burns.

I also watched Dr Schwartz's surgery; it was a left cerebral tumor resection of a breast cancer patient with bone mets. Brachytherapy inserted. It felt good to be back in the OR. I think I'm going to miss watching the surgeries when I go back to Ithaca.

As for the project, I briefly met up with Dr Vahdat on Friday morning to discuss how to end the project, etc. Contrary to what I've worried about my project, I think I'll be able to get a substantial amount of data. I also set up another experiment at Vivek's lab, which didn't work well since the surface treatment of the microwells wore off and the collagen didn't stay on microwells.

James Week 6

7/18/2011 –

I joined the neurovascular rounds this morning. There was an interesting case of aphasia which was very hard to determine. At first when talking to the patient he seemed normal, nothing was bothering him and he thought everything he said was normal. He made a few subtle mistakes like where we were, it was hard for him to find the word hospital, but I did not notice anything major. Then we gave him a flashcard with a lot of pictured and had him name them. The first was a glove which he got correct but for the other five pictures he kept saying they were gloves, and it was just repeating glove, he would look for a while and then say “It looks like a glove”, or of the like. It was very interesting; the only other aphasia I have seen was global aphasia which you could tell had a profound effect on the language. After rounds I went with Dr. Leifer to the stroke conference with all the heads of neurology/neurosurgery/radiology/cardiology. The cases were not very interesting to me, most were post surgery patients that the surgeons needed the neurologists help on. I am still awaiting access to the patient charts for my project.

7/19/2011-

I went with the consult team today. There were a lot of new patients, so it took a while to go through everyone. Two patients were labor patients, one having a very depressing and abusive history. Most of the cases were spine related and we were just checking to make sure that the overall neural network was still intact. This was my first time seeing the pin prick technique for numbness. Normally we just ask and see if touching them feels different, but there is a new attending this week and he used a safety pin to tap on the patient’s skin and then asked. I have yet to receive permission to access patient charts for my project.

7/20/2011-

Today I observed cardiovascular surgery, in particular a bypass surgery. The patient walked into the room emotionally unstable, and had to be asked questions about the surgery making sure she knows what is going to happen. Once the patient was under general anesthesia an ultrasound device was placed down her trachea. Her carotid artery was also opened for and life sign indicators were placed through it. After more tubes were placed in her and a urine catheter she was patted down with iodine and ready for surgery. The surgery entailed sawing open the sternum and then dissecting out the mammary artery. Then the pericardium for the heart was breached and the heart lung machine was connected. After the machine was up and running the heart was arrested and the mammary artery was attached. Then the heart was resuscitated and the chest was closed back up. Titanium wire was used to close the ribcage and three sets of sutures were used to close the fat up to the derma.

7/21/2011 –

Nothing of great interest happened today. Mostly I was taking tests for access to Epic. I also discussed a new project idea with Dr. Frayer.

Week 5 - Natalie

In research this week, I performed the reverse transcription step (turning RNA into cDNA) for the RT-PCR protocol. I did this on E10 Mouse embryo RNA that was purchased, rather than on samples from the mouse fracture study, since all of that RNA has been converted. This E10 mouse embryo cDNA will be used for quality control plates in the future, in order to test the primers of interest for the mouse fracture study. This analysis of the primers will be my main contribution to the study for the summer. To begin this process, I ran a quality control plate for the SFRP1 primer. This plate is used to determine the optimal annealing temperature for the primer. The 96-well plate is set up so that each column is subjected to a different temperature, ranging from 50C to 60C, and each row has a different concentration of the E10 cDNA sample. The goal is to find the temperature where the efficiency is highest at all concentrations. This will then be the temperature used for this primer when the PCR on the actual samples is performed.

I have seen operations in the OR and have gone to the clinic to see patients but I had not yet experienced rounds on patients after surgery. Since the adult reconstruction and joint replacement service is quite busy, one of the residents suggested I shadow in the pediatric orthopedic service instead. I went early one morning to round on two children who had undergone orthopedic procedures. The first patient was an eight year old boy who had a Achilles tendon lengthening procedure. This was performed because the boy was walking on his toes due to the shortness of his Achilles tendon. In this procedure, the tendon is cut in a “Z” pattern, the two pieces are slid relative to one another, and then they are sutured together in the overlapping region. The patient was doing well, although had used his self-administered pain killers a lot during the night. His mother was with him, and was concerned about his pain, but the doctor reassured her that this was normal. The second patient was a fourteen year old girl who had an ACL reconstruction. She was with her mother as well, and was recovering very well, with very little pain. Each visit with the patients was only about 5-10 minutes long, which was a little surprising to me. It was still good to see this other aspect of the clinical experience.

I also attended grand rounds for the adult reconstruction and joint replacement service, as usual. The speaker this week was Dr. Carl Imhauser, from the biomechanics research group. He discussed the planning and early results of an upcoming study on the kinematics of unicondylar knee implants. This study will examine cadaveric human knees on a six degree of freedom mechanical testing robot in the intact case, and then with a unicondylar knee implanted. This study was a great example of a collaborative study between engineers and surgeons. Dr. Imhauser was working closely with Dr. Westrich, an orthopedic surgeon who will perform all of the cadaver surgeries in order for this study to be performed.

Next week will involve more quality control plates for other primers, and hopefully shadowing at New York Presbyterian.

Week 6 - Stevenson T

Imaging of ex vivo specimen: This week I was lucky enough to track the trajectory of patient involved in my clinical study from admittance to surgery and further analysis. The patient in question was selected for the study due to his high grade gleason score and change in PSA expression levels over six months. The patient was injected with Indium-111 labeled J591, an antibody specific to the prostate specific membrane antigen (PSMA). In principal, the J591 would localize to large-volume, high-grade lesions, at worst allowing for localization of the disease within the organ and at best revealing metastases throughout the body after the patient was imaged using SPECT. An interesting addition to this protocol was ex vivo imaging of the prostate specimen after it was removed. Interestingly, a clinical SPECT camera was used as the dept. doesn't have access to a µSPECT. As a result, the imaging results were of very low resolution. In an attempt to increase the signal to noise ratio, we tried to move the specimen closer to the scanner. Due to technical difficulties, I had to improvise a way to hold the prostate in place between the scanners which were waaaaay out of their normal alignment. The result: prostate on a stick. A better explanation and visual representation of this" "highly innovative" method will be on my poster in about a week.

Meeting with “Collaborating Company”: I'll have to give a very spotty description of this meeting due to IP issues. Basically, I was witness to the interactions between industry, medicine, and academia. For instance, in some cases, a much better imaging agent from a scientific and medical point of view (say carbon 11 radiolabelled peptides) gets looked over by the company due to market conditions. SPECT, though lower resolution than PET is much more widely used and the radionuclides required for it are much easier to obtain.

Week 5- Brandon

Week 5 was interesting, the research projects are going in full effect. The most slowly moving of the projects is the intradiscal pressure project. We have a few rat surgeries coming up during week 6, so we will be taking pressure measurements then. A concern we have for this week is whether or not the equipment will work in the necessary capacity. Since the setup is used primarily for arterial pressure measurements, we are unsure as to what range the transducer is capable of. Also, we are anticipating a somewhat dynamic load regime throughout testing, rather than the cyclic continuous loading of arterial function. I am excited to see if the system works, since having this system will allows us to add another metric of mechanical analysis to our intervertebral disc analysis. The literature review on cracking joints has yielded interesting results. Curiosity about the cracking joint phenomenon came about during clinical visits where patients would notice the cracking. There was a direct link between this project and clinical observations and experiences. I am looking forward to continuing my research on the topic. The MRI vs X-Ray validation study is moving along well, I am taking my time with it since is fairly straightforward and I want to make sure I see as many surgeries as possible before leaving and get as far as I can with the pressure transducer work. I went to both days of clinic again this week, it is becoming my favorite time during the week because the diagnostic process is interesting, and free food is fun too. I am getting better at reading films and recognizing spinal problems which is exciting. I got an MRI of my lumbar spine which, in my expert opinion, looks pretty good. No herniated discs or stenosis but possibly some bulging. It was blurry, most likely because I moved too much breathing.

Earlier during the week we had a conference call with my lab in Ithaca to discuss the upcoming rat surgeries and a few other projects. This was good for me since it put the disc height study in context and set up expectations for the upcoming week. It was also nice to hear from everyone again. I am looking forward to the next few weeks, not because the program is ending, but because there is a great deal going on in my research and possibly some interesting surgical cases.

Week 5 .....Poornima

This week was as usual as it could be. I met Dr.Frayer again at the beginning of the week for rounds in the NICU. It was interesting again to observe the health of the babies I saw on the previous Friday. Some of them were doing really good and about to go home; it was nice to see some very pleased parents. I continued on my long experiments for almost every afternoon this week and made some good progress with data collection. This week also allowed me to see a wide range of surgeries. One patient underwent a resection of a glioblastoma multiforme, since GBM’s have undefined boundaries there is a possibility of tumor revival. This does point towards a need for better imaging or dyes that would make tumor boundaries more prominent. Another patient had an operation for shunt in the left temporal and right frontal lobe. But due to glitches on the software, they could insert only one shunt. For this surgery, the patient has the shunting tube inserted from the peritoneal cavity all the way upto the brain and into the ventricle to drain the excess CSF. Another surgery involved a patient undergoing laparoscopic rectopexy and intraoperative colonoscopy. Moreover, I observed a plastic surgery too. It certainly did stand out from all the surgeries I have seen earlier. It was a facial reconstruction surgery for small boy with burn injuries. I finally got to see the silicon tissue expander. It was inserted into the neck that allowed the tissue to expand over a period of two months, enough to cover the face of the patient.

Later during the week, I attended clinic with Dr Schwartz. Saw a lot of patients in different stages of their treatment. I learnt a lot more about disease and symptom progression in the case of lesions, malignant and benign tumors.

week 6 Goff

This week was different from other weeks. Instead of sticking with just one specialty, I jumped around a bit. I went to rounds, surgeries and as always research.

I went to rounds in the ER, Labor and Cardiovascular surgery.

In the ER, I saw a patient with possible COPD and another with fibromyalgia. I learned that many doctors don't believe in fibromyalgia since there isn't a way to measure the levels of pain.

In Labor, I saw a vaginal birth, c-section, and a 3-D ultra sound. The c-section and vaginal births were interesting to watch because I got to see the two main methods that women can give birth. In both procedures, the doctors and nurses were nice enough to give us a blow by blow explanation of what was happening at why. It is very important to correctly pass and remove the placenta from their explanations. There are two methods that you can pass the placenta: "spontaneous" and "manual". The manual method involves putting your hand inside and removing the placenta while the spontaneous version just has the woman push it out. The 3-D ultra sound wasn't as impressive as I was hoping. They use two planes of view to recreate a third plane that they cannot image normally. I was expecting to see depth with the imaging technique due to the name.

I saw a cardiac surgery this week. During the surgery, the patient underwent and avr a bi-pass and an aortic replacement. I couldn't see the process very well due to the location of the surgeons and the large number of people in the room. I did get to see the heart once during the surgery and it was amazing. It was intersting to see how they chilled his head and blood before they stopped his heart to do the bi-pass.

My research is going well. I am working on my second project and I have almost completed the first fixture that will be necessary for the experiment. Next week I hope to discuss with my mentor the study and flush out the idea further.