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.