Week 4 - Joseph

This week was shortened but eventful, a mix of familiar and new hospital experiences. On the familiar end of the spectrum, I attended additional craniotomies for tumor resection in the OR with my mentor (by my estimation, I’ve seen just about every possible surgical approach to cutting into the skull except perhaps a biparietal one, which I’m not sure even exists) and continued work on my project. The project is going well – I’ve developed a good set of mutagenic insertion sites tested for thermodynamic stability within a folded AAV capsid structure. The next step is to convince Dr. Kaplitt that what I want to put into those sites to target the AAV to the blood brain barrier (a mixture of substrate-derived and viral peptides) is feasible enough to be worth pursuing in the lab. Time will tell, therefore, whether I am in fact very close to finishing my project or if I have several more weeks of work to go.

Several new surgical experiences helped continue to enhance my immersion in neurological surgery. I observed my first glioblastoma multiforme resection, which was an interesting mix of success and a feeling of helplessness. Glioblastomas are some of the most prevalent, yet most deadly, brain tumors, and they are rarely easy to fully remove surgically. They stem from mutated glial cells, support cells in the brain with a variety of functions, ranging from chemical environment modulation to phagocytic immunity, and possessing the crucial capacity for division and mitotic replication. And as we all know, a cell with the capacity for replication has the capacity for cancerous mutation, particularly if it is a cell that is programmed to respond aggressively to permutations and deviations in the neuron microenvironment. All of this aside, the tumor seemed not unlike most other tumor I had seen resected over the past few weeks. It was near the surface of the brain, composed of a more pudding-like material than normal brain matter, and its removal was a simple matter of thorough “vacuuming” via suction with the guidance of the BrainLab imaging instrumentation and software. The main difference was what a completely successful surgery (which, to the surgeons’ great credit, this was) meant for the patient. Removal of a contained meningioma, as a counter-example, was a valid correction of a problem that meant the person could likely continue to live their life as normal; the removal of a glioblastoma merely meant the person could expect to live their next 1-2 years in a little more comfort before the cancer killed them anyway. This wasn’t corrective surgery; this was quality of life surgery. A successful surgery meant the following: congratulations, you can live your last year of life with a little bit less of a headache. I don’t mean to belittle the science or art of the surgery; I merely wanted to highlight how frustrated it made me feel that by the time this tumor was apparent enough to remove it was already too late. Seeing the reality of the medical fact in the OR, with the patient’s brain opened up on the table in front of me, really drove home just why the concept of a “cure for cancer” can never really encompass just how hard the challenge is in many instances of the disease.

In addition to that more depressing surgical experience, I also saw a relatively rare correction of a chiari malformation in a mid-aged woman. This is a rarity not in the sense that the disorder, which involves a certain development of hydrocephalus that results in the herniation of the cerebellum down through the base of the skull, is rare, but in the fact that most often this disorder is identified and surgically corrected shortly after birth. Seeing it in an older patient made it interesting and ultimately made it easier to visualize for a student observing the procedure taking place on the table. As with a lot of surgeries, the solution was conceptually simple but practically a little more difficult. The goal was to decompress the spinal fluid surrounding the herniated tissue and get the cerebellum back into the cranium where it belonged. To accomplish this, the approach was a little less straight forward – decompression was achieved by laminectomy of C1 (that’s right, they sawed off a piece of the woman’s spine to fix a brain hernia) and implantation of a shunt to manage the CSF flow, and a little dura-graft padding closed up the hole in the brain a little bit which was causing the problems. While it was admittedly a little odd to see the brain residing in the spinal column and rubbing up against the spinal cord itself, I was assured that it really wasn’t going to be a problem after the surgery. It’s amazing the crazy things these surgeons see every day and are apparently unphased by.

I also saw a da Vinci-assisted radical prostatectomy, which was truly a marvel of biomedical instrumentation to behold. Without having to open the central body cavity, surgeons were able to precisely insert robotic arms into the patient’s abdomen, open the bladder, carefully cut out the prostate in its entirety, suck it out, and suture up all the wounds without ever requiring a hand being placed inside the patient. The robot-assisted technique made the procedure clean and simplified, and apparently the patient is out of the hospital a whole day quicker and recovers within a decreased amount of time upon returning home. It was a fantastic experience as a PhD student, and inspirational in terms of seeing what our hard work has the potential to accomplish in changing the face of modern surgery.

On the clinical side of my experience, I did something very different this week by attending neonatal intensive care unit rounds with Dr. Frayer. Though similar in format to when I went on neurology rounds for a day, the subject matter was of course completely divergent from what I had been seeing in the OR. We rounded with the nurses in the NICU, moving quickly from patient to patient, summarizing changes in condition and treatment options/modifications. I was amazed at how every aspect of the newborn’s biological function was precisely controlled, like they were a flow diagram out of an engineering problem from an undergraduate engineering class. Caloric intake, respiration, ambient light absorption, heart rate, fluid intake, circulation, temperature… the list went on. And it made sense, too: most of the babies were weeks premature, and thus their environments had to be controlled as the placenta’s environment would have precisely controlled it. The instrumentation was quite sophisticated, and it was amazing how these babies, who shouldn’t even have been alive in the world yet, were being kept so by cutting-edge technology that made the sure thing of a premature baby’s death a much less likely scenario than them going home happy and healthy with their parents. Stepping away from being an engineer for a moment, it’s also worth commenting on how the tone of the operation was different due to the presence of at least one parent at each of the babies’ stations. I was impressed at how the rounding team included the parents, sought their input concerning how the baby was doing, and made sure that all comments concerning treatment and outlook were tempered for their benefit. The ICU is certainly not a low stress place, and the inclusion of tired, emotionally-drained non-medical professionals certainly cannot help; yet the team managed to handle every station professionally and effectively, and just about every parent seemed satisfied and happy when they left. Such ability really emphasized for me the importance of the clinical side of the hospital’s operations, and reminded me of how even when the medical treatment is almost 100% governed by precisely engineered machines, a hospital is a far cry from the lab.