Clinical Immersion Experience

August 14, 2014

posted Aug 19, 2014, 10:02 AM by Unknown user

The last week of this rotation was spent at the ICU and the OR. There was nothing new this week at the ICU. I attended rounds, walked around the patient rooms, and talked to the doctors. The OR, on the other hand, was very interesting. I was able to finally see the Da Vinci in action. There were two procedures going on for a patient. The first procedure was a nephrectomy. The patient was donating her kidney to her mom. The Da Vinci has three main components: the surgical console, the actual robotic arms, and the monitors. During the surgery, the attending is at the surgical console. The surgeon looks into a screen and has controllers to control the robotic arms. The surgeon also has a mic, so he can talk to the other doctors and assistants. The robotic arms are over the patient and they are very big. The residents attached tools on each arm. It is very easy to put tools on and off each arm. Since the robot was really big, there was little room for the residents to help out. There were three monitors around the patient, so that the doctors and assistants can see what is going on.

   

I have really enjoyed the bioengineering clinical immersion. From my first day at the Orthopaedics department to the Transplant department, I have learned a lot about what kind of devices are needed in each environment. This experience also allowed me to learn about what current medical devices are being used and what flaws there are. I am glad that I was able to partake in this internship because now I have some future projects I want to work on.

August 7, 2014

posted Aug 10, 2014, 2:27 PM by Unknown user   [ updated Aug 19, 2014, 9:31 AM ]

Today, Haroon and I were finally at the OR. The first procedure was the removal of both kidneys. The kidneys were very large and looked deformed. After removing the kidneys, they were placed on a table. It was a profound scene. We then watched a fistula creation. It was a simple surgery where the surgeon made an incision by the brachial artery. They then use a cauterizer to continue cutting through the skin and stop small bleeders. The surgeon then used a retractor to keep the surgical hole open. The surgeon then cuts the cephalic vein and attaches it to the brachial artery with sutures. I noticed the surgeon had trouble keeping the surgical hole open with just one retractor, so he added another retractor that crossed the first retractor. It seemed like the surgeon had difficulty placing the two retractors, but he eventually got it. After attaching the vein to the artery, the surgeon closed up the patient. 

  

The next procedure I observed was a kidney transplant. The surgeon made an incision at the lower right side of the patient. She then used a big device called an omni retractor to keep the surgical hole open. The surgeon seemed like she was having difficulty setting up the omni retractor. She then made some incisions inside the patient, and then attached the new kidney to the patient.

  

August 6, 2014

posted Aug 9, 2014, 9:39 PM by Unknown user

The past few days have been very slow. There were no procedures at the OR, so Haroon and I were at the ICU and transplant clinic. We attended rounds in the morning as usual. Then we walked around the ICU, and observed the staff. There wasn't really anything interesting going on. The residents and medical students were taking notes and talking on the phone. They also just sat there and talked to each other about their days. Every now and then they would check up on their patients. Most of the cases there were also not interesting. They were mostly patients recovering from surgery. While walking around the ICU, I noticed a device that I wasn't familiar with, so I asked Dr. Tzvetanov what it does. The device was an Edwards Lifesciences Vigileo monitor. He explained that the device gives hemodynamic information to doctors. There is a catheter placed into a patient's artery, and then the device can display the volume of blood and oxygen saturation. Dr. Tzetanov was telling us that engineers build these deices, so that doctors can obtain more information about their patient and try to figure out what is wrong with their patient. He then told us that creating infusion pumps with pressure sensors have helped medicine. He said that doctors had to do calculations when using IV, so making a better infusion pump has made their lives easier. He then talked about how machines can be wrong, so a doctor needs to understand machines to verify if what is being displayed by the machine makes sense.


The patient that was hooked up to the Vigileo monitor was having many health problems after his surgery. He was continuously bleeding, and the doctors could not stop the bleeding. The patient was in need of blood, so the nurses got blood for him. However, the patient's name tag was not on the blood, so the nurse refused to give him blood until she was sure it was okay to give the patient the blood. The resident in charge was very calm about the situation, but the nurse was not calm. She did not want to give the patient blood because she was scared of losing her nursing license. Once the blood was verified, the nurse gave the blood to the patient.

August 1, 2014

posted Aug 3, 2014, 10:58 PM by Unknown user   [ updated Aug 19, 2014, 9:33 AM ]

Haroon and I went to the OR on Thursday and Friday. I saw a vendor from Applied Medical that I met a couple weeks before, and he asked us if we wanted to see his new trocars in action. We agreed and watched a hysterectomy. The surgery was interesting because the surgeon used a minimally invasive method to remove a whole organ (the uterus). The surgeon made a few holes over the patients stomach and pushed the trocars through the skin. What was special about these trocars is that they have a camera at the tip, so the surgeon can safely insert the trocar through the patients body without damaging any organs. Also, the trocar has a balloon, so the trocar doesn't move around. The trocar is important for minimally invasive surgery because it keeps the surgical hole open, and it allows surgeons to put tools inside the patient. The procedure took a while because the surgeon was carefully cutting away tissue with an Ethicon laproscopic tool. The tool was similar to a cauterizer but it's end looked like scissors. I was thinking that laproscopic surgery is great because it's minimally invasive and there is a less chance of developing infection, but it causes surgeries to take much longer. 

  Endoscopic Hand Instruments  

In the transplant department, there are a lot of surgeries related to the fistula. When Haroon and I were at the Transplant clinic, we saw many patients that had a fistula. A fistula is a substitute for a catheter for dialysis patients. Catheters are not great because they increase the chance of infection, so fistula's are recommended. The fistula is a pathway created by a surgeon. A fistula is needed because dialysis takes blood out of the body at a fast rate which causes veins to collapse. Thus, the fistula prevents the vein from collapsing. However, when the fistula does not work, then a graft is used. Haroon and I saw a procedure done in the OR, that inserted a HeRO graft into a patient. This was done by making an incision at the left shoulder and above the elbow. The graft is then tunneled through the skin using a device shaped like a hook.


July 30, 2014

posted Aug 3, 2014, 10:48 PM by Unknown user   [ updated Aug 8, 2014, 12:01 PM ]

The first few days with the transplant department were spent at the ICU. During the morning, the residents and medical students present the patients to Dr. Ivo Tsvetnov. The reason they do this is to make sure everyone is up to date with the patient, and so that everyone can discuss on what further actions can be done for the patient. One of the residents said they do this, so that they can figure out how to discharge the patients as fast as possible. The presentations or rounds take a few hours. I noticed most of the doctors talked in a low voice. I think they do this so that the patients can't hear what the doctors are saying about them. Since the doctors are discussing and making speculations, they probably don't want to scare the patients. However, it still seems uncomfortable for the patient because a group of residents, medical students, and pharmacists stand outside their room and talk about them. The patients look scared and curious of what the physicians are talking about. What I liked about the ICU was that there were a lot of medical devices. For example, there is a few Braun infusion pumps, a DVT pump, a GE patient monitor, urinary catheter, urine drainage bag, a glucose testing machine called the ACCU CHEK Inform II, an endotracheal tube, a ventilator, and many more. The ventilator was very interesting because the machine has many modes when assisting a patient. The ventilator can have full control and breathe for the patient. The machine basically pushes in air to the lungs. The volume and pressure can be adjusted by the physician. The person who sets up the ventilator is the respiratory therapist. We've also went to the Interventional Radiology (IR) room where minimally invasive procedures were done. The procedure that Haroon and I observed was the placement of a central line. The setting of the room where the procedure was performed was similar to an OR. Everything in the room was sterile. The patient was properly cleaned with iodine and had drapes over their bodies. The radiologist who performs the procedure also wears gloves and surgical aprons, but they also wear lead glasses, lead apron, and lead cuffs. The radiologist also used an ultrasound to see where to place the central line, and they also used an x-ray to see where the central line, which was coated with radiopaque, was when it was inside the patient. I've never heard of an IR so this was an interesting experience for me.


          

July 24, 2014

posted Jul 27, 2014, 6:29 PM by Unknown user

Today was the last day going to the OR for the orthopaedic department. It was a great day because there were a lot of surgeries scheduled today. One surgery in particular was very interesting. It was a total knee revision. The patient's knee replacement became infected, so she needed a new prosthesis. From the start, the surgery was a complicating surgery, but there were more complications during the surgery. One major complication was when the test for the femoral component wasn't working properly. Dr. Gonzalez tried to attach a piece to the test device, but the device was so worn out from being used multiple times that he wasn't able to properly attach the piece. This made him furious because he was spending a lot of time trying to fix the test device and also the implant may not fit correctly. Since he wasn't able to properly screw the piece to the test device, he just put them together without screwing them together and placed it into the knee. He then continued the surgery. One thing that was interesting was that the surgeons and the scrub nurse had to wear special gloves since the patient had HIV and hepatitis C. The gloves were to protect the surgeons and scrub nurse from getting infected. I thought this was interesting because they are already wearing layers of gloves, so I wondered how also wearing this special glove can make such an impact. I then remembered my gloves breaking many times when I worked at Northwestern. I also looked up why layers of gloves are needed, and it is because there is a a lot of defects in gloves.

July 23 2014

posted Jul 27, 2014, 6:09 PM by Unknown user

The past few days, Ryan and I were at the UIC clinic and the downtown clinic. At the UIC clinic, I sparked a conversation with Dr. Schmell and the other residents about their opinion on Orthalign. They were saying that the system is very precise, but there wasn't any proven fact that patients do better. They were talking about a study on Orthalign and that the patients who had the Orthalign system used on them actually had a worse recovery than patients who didn't use Orthalign. The reason is because there isn't a good ligament balance when using Orthalign. Another problem with the device is that it causes the operation to be longer. I noticed that orthopaedic surgeons like things quick and easy, so the device increasing the time of the operation is not great. However, Dr. Schmell said that the device does work in getting the correct angle or tibial resection. Dr. Schmell doesn't use the device at all during surgery, but Dr. Gonzalez uses it for the tibial resection. I asked Dr. Gonzalez for his opinion on Orthalign, and he said the same thing. It is good for tibial resection and that is why he uses it. He said he would like to use the device for the second part of the surgery, but the device isn't effective then. I found this orthalign issue interesting. At the UIC clinic, we saw patient and physician conflict for the first time. One issue was that a patient was behaving immaturely and made the doctors feel uncomfortable and think their lives were in danger. The patient's behavior led her to be kicked out of the spine clinic. Dr. Gonzalez talked to the patient and told her that their are rules in the clinic and the patient's behavior was unacceptable for the clinic and in general. Since he knew the patient for a while, he did not throw her out from the orthopaedic clinic. Later that day, there was another patient-physician conflict. A patient was very mad that she could not have surgery. Dr. Gonzalez kept telling her that there is an increase risk of infection and blood cots if the patient had the surgery done because she was overweight. The patient could not let this go and things escalated. The two kept yelling at each other until Dr. Gonzalez couldn't take it anymore and called security to kick her out the clinic. I've never seen patients and doctors getting into serious conflicts to the point that a patient is banished from the clinic. I never knew a patient could even be banished. I noticed that all of the residents and medical students talked about what happened in a low voice when Dr. Gonzalez wasn't around, but they didn't mention the situation when he was around. This was a very strange experience for me.

July 17, 2014

posted Jul 21, 2014, 5:21 AM by Unknown user   [ updated Aug 10, 2014, 1:34 PM ]

Today was another day at the OR. This time we were able to watch a total knee replacement from start to end. This made it much easier to understand what was going on. The first thing that happened when the patient entered the OR was putting the patient to sleep. This job was done by the anesthesiologist. Then the patient had a urinary catheter inserted. The patient was also hooked up to a Zimmer automatic tourniquet machine. The tourniquet is important because it controls bleeding. Then, the surgeons applied iodine and alcohol pad all over the patients leg to get rid of any bacteria on the surface of the skin. Then, the patient's whole body except one of his or her leg was covered by blue sterile drapes. This was done to prevent the spread of infection. If a surgeon touches skin that isn't properly cleaned and then touches the surgical area, then bacteria can go inside the patient and cause infection. The drapes also prevents the patient from getting blood all over their body. Next, a bandage was tightly wounded around the leg and then removed to decrease blood flow. Then they put an orange film over to prevent bacteria to go into the body. I also noticed that a DVT pump was used. It was cool seeing the DVT pumps in surgery because I was familiar with them. I had to repair them a lot at Northwestern. The surgeons and scrub nurse go outside the OR and properly wash their hands. Then they return wearing a helmet called the Stryker T5. The helmet is light and has a fan at the back for airflow. Then they put on their "spacesuits" and layers of gloves with the assistance of the scrub nurse and the circulating nurse. Once it was time to make an incision, the circulating nurse called timeout and stated the patient's name, age, operation, and any allergies. The first thing the surgeons did was cut through the skin until they reached the kneecap using a scalpel. They also used retractors to keep the surgical wound open, and they also used suction to get rid of any fluid. Then a tool was placed on the joint of the femur. It was secured on the joint by having pins hammered into it. There are slots in the tool, so a sagittal saw can be used to shave off bone. Next, the Orthalign system was being used. The system was placed over the shin, and pins were used again to keep the device in place. The surgeon followed the instructions on the screen of the device. This allowed precise tibial resection. The orthalign system was then removed and put aside. Another device was placed over the joint of the femur. It also had slots, so that a sagittal saw can be used to shave off bone. The joint was sculpted, so that the prosthesis would fit. There were test prosthesis, so that the surgeon can keep checking if the final prosthesis will fit nicely. Once the sculpting was done, the surgeon made cement and applied it to the joint. Then the prosthesis was hammered into the patient. Now the surgeon was ready to close up the knee.

         

July 16, 2014

posted Jul 20, 2014, 8:45 PM by Unknown user   [ updated Jul 20, 2014, 9:39 PM ]

So far this week, we haven't been to the OR. On Monday, we were at the clinic, and saw a lot of patients. When a doctor sees a green flag, they go to the patient's door and pulls out the patient's papers from the door. The papers tell the doctor the patient's history and the reason for their visit. Before entering the room, the doctor puts the red flag up so that both green and red flags are up. When the doctor enters the room, they greet the patient and sit close to the patient. They try to get the patient comfortable before actually evaluating them. When a doctor sees a patient with hand pain, I noticed the doctors use the same tests to evaluate the hand. They tell the patient to squeeze their hand to test the patients strength. They also touch the tip of the patients fingers to see if the patient has any tingling sensation. They then tell the patient to spread their fingers and try to resist when the doctor tries to squeeze them together. They also tell the patient to bend their hand forward and backward to see the joints mobility. If the patients never had surgery before and their problem isn't too bad, then the doctor would advise physical therapy. If the patient has severe pain, then they would give the patient an injection of steroids. The injection is performed first by applying iodine and alcohol pad. Then they inject the needle. Patients have a lot of pain when they get the injection, so the doctors sometimes apply a spray while giving the injection. The spray is supposed to ease the pain. If the injections and physical therapy don't work then the doctor advises surgery. Another thing I noticed is that the doctors didn't really use many tools. One tool they use is a goniometer, and it is used to measure angles such as the angle when someone bends their hands. Another device they use is an x-ray which is really important when evaluating a patient. We also saw patients who needed their cast removed. Normally people who work at the cast room would remove the cast, but when we were there the medical students wanted to remove the cast. They used a cast remover to remove the cast. The device has an oscillating blade that only cuts through hard material. It can't cut through skin because the skin moves with the oscillating blade. A hard object like the cast doesn't move with the blade, so the blade can cut through it. The clinic at the UIC medical center is usually busy, and the doctors don't really have a break. The clinic downtown is totally different. It is more like an office environment with a great view of Millennium park. The layout of the clinic was different too. The doctor's office was far away from the patient's room. The center of the clinic was the x-ray machine and the cast room. I think the clinic was designed this way because there is not a lot of patients at the clinic at one time, so the doctors don;t really need to rush over to the patients. The downtown clinic also had flags, but they weren't used often. I also think it's because there is not a lot of patients to see at one time. I noticed there wasn't any hand sanitizer dispensers anywhere. There was only one anti-septic container in the hallway. They were also in every patient room. One thing that was interesting was that there was a room that was latex free. I don't think there was a room like this at the UIC medical center. The patients were also different. All of the patients downtown were all Caucasian and seemed pretty wealthy. They also took care of themselves, so there cases weren't that serious. The UIC medical center had a lot of minorities and poorer people. They did not really take care of themselves and were normally overweight. I think it was great going to the clinic downtown because we can compare the two clinics.
      
 

July 10, 2014

posted Jul 20, 2014, 5:35 PM by Unknown user   [ updated Jul 20, 2014, 7:19 PM ]

Today was another day at the OR. The first surgery we watched was a total knee replacement. The surgeons were wearing a big suit that covered there entire body. It looked like a space suit. The suits were needed to protect the surgeons from bone and tissue fragments. We arrived in the middle of the surgery, so it was a little confusing what was going on. I saw a metal cap on top of the knee, and the surgeons were using a sagittal saw to cut the bone. After cutting, they removed the metal cap. Then there was a plastic object that they kept inserting into the knee. I think they were trying to make sure the plastic object fits nicely in the knee. It seemed like the plastic piece wasn't fitting nicely, so they continued to use the sagittal saw. Once the adjustments were made, the surgeon made a white cement by mixing a liquid and a powder together. The cement had a very strong smell. They then put the cement on the knee and hammered the prosthesis to the knee. There was a vendor from Orthalign named John. He took us outside to explain the device that was being used in the surgery before me and Ryan came. It was a device used to make sure the surgeons were correctly placing the prosthesis. The device works by using an accelerometer. There was also a LCD on the device that gave the surgeon simple instructions on what to do. The device was only used for the first part of the surgery because the surgeon wanted to use his way for the second part. Next, Ryan and I watched a total hip replacement. This time we couldn't see anything except a huge hole, so the experience was not that great. We tried getting a better view, but we didn't have any luck. The surgery was over two hours, so we were really tired of standing for so long.

     

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