Yogindra Week-1

Summer immersion started of great. I am matched with Dr. Mark Souwiedane, who is the director of Pediatric Neurosurgery at Weill Cornell and has appointments at MSKCC in Pediatric Neuro-Oncology. It was great finding out I was matched with a neurosurgeon. I was happy as it was a bit of a departure from what I work with in lab, a chance to learn something new. But when I found out the immersion was going to with Pediatric-Oncology, I was a bit ambivalent...those cancer kids advertisement automatically came to mind. However, after this week it seems that the cases we saw were mostly treatable.

From what I can tell, Dr. Souweidane spends his time split between the Craniofacial Clinic, Brain & Spine Center at Cornell-NYPH, the Operating room, MSKCC and his overseeing his lab. To handle all this he has his patient schedule mostly managed by his RN Coleen, and Charlotte. He has one Neurosurgery Fellow, Dr. Konstantine Margetis, who works primarily with him.

The first day was entirely a clinic day at the Brain and Spine center. As patients came in one by one the whole group started going thought notes, MRI’s, and CT scans. The usual logistics were Charlotte or Coleen had the original conversation/counsel after the patient has been referred to Dr. Souweidane. Then after a quick history and reason for visit refresher, the images are analyzed be the fellow plus resident and visiting med student. After a neuro work up/physical tests, the case is presented to Dr. Souweidane with all the finding and possible diagnosis/prognosis; where he revises all the images, makes a his conclusions, goes in with everyone and gives his medical opinion.

Day 1 (Brain and Spine center) we saw a total of 12 cases. Ranging from Craniosynostosis, where the infants cranial sutures fuse early lading to cranial deformity; to shunt revisions and Chiari malformation, where the cerebellum herniates from the foramen magnum.

Day 2 (OR day) where I observed two ventricular shunts being implanted into premature babies, that developed hydrocephalus. The way the head had swollen up, it seemed unreal. After the shunt was implanted to drain right under the scalp. After the shunt was implanted, the head radically shrunk down, and the babies’ head is turned to the other side every 3 hours, so they don’t form any deformities.  I also observed a shunt revision, where the shunt was not draining the ventricles, and the implanted was cleared with suction.

Day 3 (a lab day) Where I went to Dr. Souweidanes’ lab group meeting talked about lab project possibilities. Saw how they are working on their CED (Convection Enhanced Delivery) clinical study.

Day 4 (Cranial Facial Clinic Day) consulted 3 surgery cases dealing with Craniosynostosis, and talked about the possible clinical projects I could contribute on. After going to a Fellows case conference during lunch, we all went to Brain and Spine center. In the clinic a patient was consulted on a Chiari case, and since the surgery will be schedules for expedience, I might be able to observe this procedure.

Day 5 (OR day) Dr. Soueweidane and Dr. Grienfield lead the weekly morning Residents meeting, where they grill them on procedures and diagnostics. After that I was able to observe an endoscopic cyst removal. Then a cranioplasty of young girl with a synthetic machined bone that has been modeled from the patients CT scan. This case was super long, as there was soo much scar tissue, making in extremely hard to expand the scalp over the implant.

So needless to say, the first immersion week was pretty jam-packed. Hopefully, it will stay like this and I will share with you the highlights from now on.

Week 4 - Hannah

Though this week was a short one, I still managed to see and learn a lot.  The highlight of the week was when I received my clinical research project.  After weeks of feeling guilty and spinning my wheels as I sought in vain for a reasonable research project, I now have a specific task to accomplish: writing a literature review about xanthogranulomas versus craniopharyngiomas and other similar tumors.  Though this project has no relation to my PhD thesis or research interests, I am grateful for it, and it will be useful to practice writing a literature review.  Additionally, the knowledge I gain will be extremely beneficial the next time I attend a seminar on distinguishing factors in rare brain tumors. 

This week, I attended rounds in the OB ward.   It was nice to be in a part of the hospital where most patients were there for a positive reason.  Listening to the attending and residents on the round, I quickly realized that doing a bit of preliminary research on common abbreviations would have been helpful.  During my time spent shadowing Dr. Schwartz, one surgery stood out in particular because it emphasized the importance of robust engineering.  The surgery used a transphenoidal approach to remove a craniopharyngioma from a young patient and was a team effort between Dr. Schwartz and otolaryngologist Dr. Anand.  The surgery was complex and lasted over eight hours.  Near the start of the surgery, Dr. Schwartz noticed that the tip of one of the scalpel-like devices had broken off.  He was not sure if it had been like that before, or if it had broken off inside of the boy’s head.  It was necessary to have an x-ray taken to ensure that the piece was not lodged somewhere inside and in need of retrieval.  The x-ray ended up not taking place until the end of the surgery.  Fortunately, no metal shard was detected, meaning that the tool must have been broken from the beginning.  Several hours later, when Dr. Schwartz had reached the tumor and was slowly removing chunks of it, the vacuum that provided suction to his tools stopped working.  This meant that he could not see his workspace as well because it was filled with fluid and he had to progress at a much slower rate.  Meanwhile, nurses were trying to figure out why the pump was malfunctioning and calling the company to troubleshoot.  Eventually, they were able to retrieve a new pump from a different room, but it took a lot longer than I anticipated.  Once the new pump had been set up, the surgery was able to proceed as planned, and the remaining portion of the procedure went smoothly. 

Week 3 - Hannah

Week three has been a smorgasboard of shadowing experiences…resulting in further affirmation that entering a PhD program was the right choice for me.  Monday, I shadowed plastic surgeon Dr. Spector during his office hours.  It was quite the contrast to my previous clinic experience with neurosurgeon Dr. Schwartz.   MRI scans are the stars of neurosurgery clinics.   The patient and his/her entourage sit fully clothed in ordinary chairs; the obligate examination bed just an obstacle to weave around when entering the room.  Much of the conversation involves comparing various anatomies of the brain on the charts and demonstrating how they have changed.  The plastic surgery office hours are much more intimate.  Body parts are palpated and photographed.  Botox is injected, sutures are removed.  The atmosphere is a bit flashier, a bit less somber.   

Wednesday was another change of pace as I shadowed members of the pediatric intensive care unit (PICU) on their morning rounds.  Surprisingly, the PICU cares for children who are only a few months old all the way up to age 22.  This was my first time going on rounds and I wasn’t quite sure what to expect.  The attending and additional rounding personnel spoke softly in low voices when discussing patients, making it difficult to hear the discussion through the ambient white noises filling the room.  I was extremely grateful to one of the physician assistants for answering my perpetual questions and summarizing discussions for me.  One sad case demonstrated how fixing one problem can result in another being created.  A toddler with leukemia had received a bone marrow transplant.  Unfortunately, graft vs. host disease had developed and a small hole had formed in his intestine.  Fortunately, the hole had fixed itself, but not before bacteria had been released.  A healthy baby might have been able to fight it off, but he was on drugs to suppress his immune system because of the transplant.  Thus, he needed strong antibiotics.  All of the drugs then led to him having renal failure and kidney problems.  Despite these problems, the baby was in fairly stable condition when I saw him.   I want to continue to follow this case and hopefully see the baby make it out of the hospital.  As we shuffled from room to room, a large cart with a computer containing electronic medical records was dragged along as well.  While electronic records have many benefits, I witnessed the hassle they can present.  Residents scrolled through long lists of possible medical procedures, only to find the specific one they wanted to record wasn’t there.  The software seemed like it had a ways to go before it would make their lives easier.   

Thursday and Friday were ER days.  The first day I spent in the ‘A bay,’ which is where patients with the most immediate problems are triaged.  The A bay contains the A1 bed, which is where patients go when they are pulled off the ambulance and in need of intense medical assistance.   The day started off with a meeting that went over some cases and also contained a teaching component.  The topic was on acetaminophen (Tylenol) overdoses.  Once of the reasons that acetaminophen overdose is so deadly is because there is an intermediate phase where the patient feels fine, yet his/her liver is rapidly being destroyed.  One of the patients in the PICU was there due to a Tylenol OD, so it was interesting to learn more about the biochemistry behind the treatment.  I spent the remainder of the day following around a resident as he tended to several patients.  The whole ER was crammed with patients; many were without a room and lay in beds lining the hallway.   The C bay was even crazier than the A bay (partly because it was a Friday evening).  The patients in C were more elderly and tended to have chronic medical problems in addition to the acute one that brought them into the ER.  When making rounds, one of the attendings commented on how tough an elderly lady was; despite taking a bad fall in the night, the patient had waited until the next afternoon to come in.  “Tough?” the patient snorted, “Chicken is more like it—I’m scared of the ER.” Personally, I was rather inclined to agree with the patient.  Incredible as the medicine is performed in the ER is, I prefer the calmer neurosurgery clinic and operating room and am looking forward to returning there next week. 

Week 2 - Hannah

After seeing Dr. Schwartz at work in the clinic and operating room, I was curious to learn more about his lab.  Last week, I visited Dr. Schwartz’s lab and learned a bit about the research; however, only one of the members, Dr. Hongtao Ma, was there.  This week, I got to hear from Dr. Mingrui Zhao as well, who coincidentally had been up visiting Ithaca the previous week.  Despite being a research lab, the Schwartz Lab felt much less like the home-away-from-home I was anticipating.  Instead of having hoods and cabinets filled with chemicals, optical and electrical equipment crammed the room.  Soldering irons sat out on benches next to assorted pliers, wires, and glass probes.  It was not just the equipment and research that was different; the entire lab personnel structure was different from any lab I’d worked in previously.  As far as I could tell, the lab consisted of Dr. Schwartz  (who has an MD, but not a PhD), two assistant professors, Dr. Ma and Dr. Zhao, (who hold PhDs, but not MDs) and an assortment of summer students (such as myself).   It was interesting that despite being assistant professors, Dr. Ma and Dr. Zhao still spent a lot of time in the lab.  To me, one of the least appealing aspects of becoming a professor would be spending all day writing grants and going to meetings, instead of actually performing lab research, so it is good to know that post-doc-like professorships exist.   That being said, I do not think I would enjoy working in a hospital if I were not a doctor.  It is almost a bit like a caste system, with glamorous, life-saving MDs on top and mousy academics tucked away in their labs underneath.  Having no MD (nor burning desire to get one) makes me feel quite the outsider.    

Dr. Ma and Dr. Zhao study epilepsy by performing craniotomies on mice and recording the hemodynamic, metabolic, and electrical changes that occur immediately before, during, and after focal seizures.   By identifying the changes that occur before a seizure takes place, they hope to be able to predict, and eventually prevent, seizures.  Because there are only 5-ish weeks left in the program, and I have no knowledge or training in this field, it will be challenging to set up a complete research project.  However, I’m always up for a challenge, and I look forward to further shadowing Dr. Ma and Dr. Zhao.

My clinic experience was similar to last week.  There were many success stories of patients who initially had tumors who were now healthy and tumor free, as well as sad stories of tumors returned and surgical difficulties.  One case that stood out involved a young woman who had been involved in a car accident.  She had severely damaged one part of her skull, so a custom skull prosthetic had been used to repair that site.  The surgery had gone well, but the skin over the prosthetic had failed to heal; instead, it became necrotic, forming an eschar and losing all the hair on it.  This was extremely unusual and Dr. Schwartz postulated that it was possible that the skin had been stitched too tightly over the prosthetic, thus preventing sufficient blood flow to the tissue.   

One of my highlights this week was going to MRI training.  Though I had seen MRIs in pictures and pictures from MRIs, I had never operated one.  Thanks to fellow summer student, Amanda, prior summer student, Mitch, and phantom-extraordinaire, MR Plastic, I was able to perform an MRI.  Directly seeing the effects of varying parameters, such as repetition and echo times, helped me to better understand how MRIs work.  Now, I just have to work on learning to better interpret the images produced!

Hello. A description about the immersion course, as well as the syllabus can be found here:

http://weill.cornell.edu/mri/immersion/