Ryan - Week 2

This week I got off to a better start than last week. I started off watching an endoscopy for the resection of a pituitary adenoma. The surgery went well and Dr. Boockvar and Dr. Huang, an ENT surgeon, worked quickly and efficiently to cut through and remove a portion of the septum to open up the nasal cavity. Then they drilled through the sphenoid bone much more easily than the last endoscopy I saw and removed the adenoma. They used some fat tissue from the belly button area to fill the void and recreated the septum and closed up. While closing up, Dr. Huang and I were talking about my adenoidectomy from a few years ago and he showed me on the patient where the adenoids are, which I thought was very cool. Towards the end of the surgery, Liz came in from the next OR room over. Since our surgery was done and it was a little while until the next one for Dr. Boockvar, I went with Liz to the next room to meet Dr. Greenfield and watch him perform an occipital craniectomy through the foramen magnum on a little girl for a Chiari malformation. I was able to see Dr. Greenfield cut in through the back of the neck and dissected the cervical vertebrae before I left to go to Dr. Boockvar’s next surgery. His next case was a craniotomy resection of a right, frontal lobe meningioma. The surgery went much the same as the last craniotomy that I saw except that this tumor was much larger, about the size of a walnut, and was removed a little quicker since the tumor was largely solid and therefore easy to remove. The surgeons told me a good analogy: brain tumor resection is like removing gum from a wool sweater, you have to remove all of the gum while preserving as much of the sweater as possible even though it’s extremely messy. Once the surgery was over and the patient was all closed up and stapled, Dr. Boockvar told me to scrub in and get gloves on so that I could hold a compress to the patient’s head while he was coming out of anesthesia. My job was to press lightly on the patient’s coronal incision to stop the bleeding and also to keep the patient from touching it while waking up. It was very cool to get to do something to help out with the case and I’m glad that Dr. Boockvar trusted me to participate. The last case was an anterior cervical discectomy and fusion for a disc herniation in an old man. Basically, the patient’s intervertebral disc had degenerated and now the vertebrae were rubbing on each other and causing the spinal cord to kink. To regain the level of separation necessary to restore spinal cord extension and cease the vertebral grating, Dr. Boockvar inserted a bioengineered surgical device that works much like an anchor for a wall screw would. This device will hold the vertebrae apart while an osteogenic solution injected between the vertebrae induces bone growth and fusion of the two vertebrae. This is a superior method to using screws and wires because it allows for a smaller incision and shorter surgery but also it is less bulky and allows for more normal swallowing ability.

Aside from watching Dr. Boockvar operate, I shadowed Dr. Greenfield, another neurosurgeon for a day, in the OR. The first case was a baby girl who had a tethered cord and dermoid cyst. Dr. Greenfield operated on the little girl’s lower spine to alleviate these conditions and help the baby develop as close to normal as possible. This was my first baby case and it was very interesting to watch how this case differed from that of an adult case, for instance, all of the surgical equipment was the same but the operation support on which the baby laid for the surgery was much smaller and all the tubes and leads attached to the baby made the field of operation seem much more crowded. Later in the afternoon, Dr. Greenfield worked with Dr. Schwartz on a very fascinating case where an 18 year old boy was suffering from multiple seizures (3-5 per day). Last week, the surgeons performed a craniotomy and implanted this very cool bioengineered electrode net sub-cranially with wires coming out of his skull at the end of the operation. Via these wires and a numbering system for the electrodes in the net, neurologists monitored the boy for the past week and deduced that the seizures were originating from a region near the hippocampus. With this location mapped on the monitors in the operating room today, the surgeons opened up the boy’s head again, removing a skull plate about a third of the size of his skull, took out the electrode net, and resected a walnut-sized piece of brain matter from the temporal lobe. One thing that the surgeons kept mentioning throughout surgery was that the boy’s brain had irregularly deep clefts, resulting in an abnormal anatomy. This irregularity is likely responsible for the boy’s cognitive developmental disabilities, and having seen a lot of young kids with such disabilities in my life because my mom is a pediatric physical therapist, I thought it was amazing to get to see such a brain up close. During the surgery, I got to chat with the OR nurses and fellows about what it’s like to work in the OR and life in general working at Weill Cornell Medical Hospital. They all seemed to sincerely love working here and had plenty of interesting and funny stories to share about their first days, their most memorable cases, and just how dramatic the social life is in the hospital. One of the OR nurses said that the tv show “Scrubs” is the most accurate depiction of what life is really like working in a hospital.

Also this week, I officially have my own white lab coat, which I’m very excited to finally have. I look so official! Hahaha. I needed it for shadowing Dr. Boockvar during clinic consultations. This week Dr. Boockvar met with a lot of post-operation patients who were all mainly content with the results of their operations. However, there was one middle aged male patient who had a spinal cord tumor in his lumbar spine resected by Dr. Boockvar. He was not happy with the fact that although he had surgery, the symptoms had not disappeared and, in fact, he now had new ones, such as stiffness in his neck, increasing weakness in his legs, loss of muscle tone in his upper body, etc. I thought this patient was incredibly rude and impatient with Dr. Boockvar and I’m impressed with the way that he patiently dealt with the patient, going through all of his symptoms and explaining what could be connected to his spinal cord tumor and what isn’t. Dr. Boockvar clearly, and in a straightforward manner, told the patient that due to the size of the tumor and the placement, the compressive damage done does not look like it will heal. For instance, his leg strength may never fully recover but that doesn’t mean that he should give up on doing physical therapy and training to help stretch and regain what functionality he can. Unfortunately, the patient didn’t want to hear any of this and declared that he was going to go get second opinions and further expressed his discomfort and dissatisfaction with Dr. Boockvar’s work. Once the patient had gone, Dr. Boockvar told me that this patient had been trouble from the beginning and that the patient had seen several other neurologists and neurosurgeons prior to him who all told the patient they wouldn’t help him due to his demeanor. I personally don’t understand why Dr. Boockvar took on this case then, but I guess he’s the professional and saw something in the case worth doing. Also while in the clinic, Dr. Boockvar and I got around to talking about the positives and negatives of being a surgeon since he has to go to meet with a lawyer this week to discuss a lawsuit filed against him by a patient. Apparently the patient was on blood thinners and was advised to cease taking them for 2 weeks prior and 2 weeks after surgery, which is standard safety procedure. About a week after surgery , the patient came in to visit complaining of pain/discomfort and he met with Sherese, Dr. Boockvar's head nurse, since Dr. Boockvar wasn’t available. That weekend though, he had a heart attack and so now he’s suing Dr. Boockvar. I, personally, think that this is a crazy scenario and that this is not Dr. Boockvar’s fault but Dr. Boockvar seems to think that the case will settle and the patient will get compensation for work time lost and discomfort.

This weeks meetings consisted of the weekly Multidisciplinary Brain Tumor Conference, where Andrew and I sat in to listen to the more challenging cases the neurosurgeons were working on. Then I went to the PS-OC brainstorming club meeting, where we discussed organizing tumor metastasis into an electrical circuit analogy over pizza. At our summer immersion weekly update meeting with Dr. Wang and Dr. Frayer, we again all went around the conference room and shared our most interesting experiences for the week and how our projects are going. Since last week, I’ve been in contact with another student working with Dr. Boockvar, named Mark, and I’ll be working with him for my summer immersion project. In one of the pituitary adenoma endoscopy surgeries, we learned that the surgeons identify healthy pituitary tissue from tumor based on color. The tumor appears to have a more bruised, yellow tint to it than the healthy tissue. So Mark and I got to talking about the possibility of developing and incorporating an endoscope band-limit filter to the preexisting endoscopes that would exaggerate the discoloration contrast between the two tissues. Using this technology, the surgeons could more easily distinguish between healthy and tumor tissue and therefore more effectively ensure that they have resected all of the tumor tissue while maximizing the amount of healthy tissue saved. This week we’ve been working on the paperwork to get this project going and we’re hoping to start proof-of-concept testing as soon as next week. After our meeting, some of us went to the gym for a little bit and then we went out to “For Pete’s Sake” for some more karaoke. Almost everyone showed up, including Mike again from Ithaca to visit for the weekend, and we had a great time making fools of ourselves well into the night.

One cool thing to note that I did this week was participate in a study for a post-doc. from Columbia University, Dr. Moreno, who works in fMRI research. This cognitive study is a language mapping experiment with patients that have disorders of consciousness. As she explained, many of these patients are unresponsive but their brains seem to retain basic language capacities that Dr. Moreno is trying to map. By this, Dr. Moreno seems to think that by looking at the residual cognitive functions of these patients, they can better understand the possibility that these patients may be more aware of their surroundings than previously thought. My involvement in this study as a volunteer is that of a control. So what she had me do was lie down in the MRI machine while looking at images on a screen and she imaged my brain. When an image would pop up on the screen I had to, in my mind only, shout the name of that image over and over again until the image changed. Then, there was another part where I had to rap my fingers on my dominant hand whenever a checkerboard appeared on the screen. Also, there were parts where I just had to lie as still as possible and try not to fall asleep, which wasn’t easy because I was told to try to think of nothing in particular while doing this and I became bored quickly. The MRI machine was really noisy but they gave me earplugs and the study only took 45 minutes. I was able to get a CD of images of my brain, which I think are so cool to look at and I'd like to have Dr. Boockvar check my images out to see what he thinks of my brain!