Bioengineering Clinical Immersion Program


Welcome

This blog will serve as a detailed account of my experiences within the UIC Bioengineering Clinical Immersion Program. I will spend 6 weeks immersed in the clinical environments of the University of Illinois Medical Center. The first 3 weeks, I will observe the Transplant Surgery department. The last 3 weeks, I will observe the anesthesiology department. Through careful observation of these environments, I hope to grasp a better understanding of how the medical devices and protocols, largley implemented by engineers, impact the clinical atmosphere they are immersed in. By taking a step back from the typical "problem solving" mentality of an engineer, I will simply observe to establish what problems there are, if any.


Saying Goodbye to Anesthesiology

posted Aug 24, 2014, 5:50 PM by Nadia Crawley

I loved this department. I truly enjoyed Dr. Edelman, the entire department, and the awesome people we got to meet along the way. What I took away from shadowing the anesthesiologists was sheer respect for what they do. Their job far exceeds what I ever thought. They hold one of the most important positions in the hospital. They allow for surgery to take place. They assess a patient's status to determine what drugs are appropriate. They alleviate pain. They consult the patient before and after surgery. They serve as doctors, confidants, and therapists. And though they carry so much responsibility, their working situations are less than ideal.  While their technology is advanced, they still lack many advancements, namely wireless connections, which could really alleviate the stress of their jobs. However, even with all of the stress, the staff still welcomed us with open arms and were happy to teach. 

Dr. Edelman took so much time to explain to us procedures, tools, devices, doctors, etc. He allowed us the opportunity to see multiple types of procedures. We traveled to other departments and labs. And we sat it on daily workshops for the residents. This was more than an immersion, but a dynamic educational experience. The staff that he introduced us to were also very welcoming. We were able to shadow doctors in the pain clinic, the IR department, and travel to an anesthesiology lab. No question was a stupid question! And in the end, I wanted to stay longer! I hope that next year Dr. Edelman will do this program again and that other students will be fortunate enough to experience what we got to experience.

This program was truly a blessing. I can never thank Dr. Kotche and Susan enough for choosing me to be apart of this wonderful immersion program. The lessons that I learned could not be taught in the classroom. I have so many ideas flowing for my upcoming senior design class and I can't wait to tell my peers of the opportunity I was awarded. 

Interventional Radiology (IR)

posted Aug 24, 2014, 5:22 PM by Nadia Crawley

I really enjoyed going to the IR department. I must admit I was a bit biased, because my mother is an IR nurse. So I was very intrigued to finally the devices and procedures I heard her speak of so often. On this particular day I witnessed a biliary tube exchange. A man suffering from cancer of the bile duct had to come in every 6-8 weeks to have the tubes in the bile duct replaced. The tubes hung outside of his body, on the side of his abdomen. After so long, the tubes become obstructed due to the thickness of the bile, which causes build up. The procedure was very straight forward. Guide wires were placed inside the old tubes as place holders. The old tubes were removed and the new tubes were inserted where guide wires were. The procedure took all of thirty minutes. But I wondered if there was a way to prolong the life of the tubes a bit longer than just the 6-8 weeks. I thought of different tubing material or a better porting system to drain the bile, but keep the tubes intact. But there already seemed to be a plethora of devices in the IR department. In fact, it resembled a grocery store in the main hall. I noticed tons of catheter systems and tubing from Abbott, Boston Scientific, Kimberly-Clark, Cook Medical, etc. The number of different medical device manufactures in the department was astonishing. I did not have nearly enough time to try and distinguish between the multiple devices to determine their difference. Nonetheless, it seemed each tool had a purpose and was there for a reason.

Unfortunately, there weren't any "interesting" cases to view in the IR department, other than the biliary tube exchange, which the attending referred to as their "bread and butter" cases. But it was an enjoyable experience. The department seemed to use a large amount of medical devices and imaging tools. It would be awesome for there to be an IR rotation next year. 

Blog Posts and Saving Lives...

posted Aug 24, 2014, 4:46 PM by Nadia Crawley

My immersion in the Anesthesiology department really made me think of how I budget my own time and priorities. I seemed to really struggle with updating my blog regularly. I always felt that by the time I got home from a long work day and an even longer commute, that I was way too tired to write a blog post. I would push the blog to the next day, then the next day, and then before I knew it...it was Sunday night. I must admit, initially I felt quite justified in my excuse for not completing my required posts. But I soon became rather disgusted with myself for two reasons. 

1) My excuse for not keeping up with my blog posts was just that, an excuse. 

2) The doctors I had the pleasure of shadowing were working 3x harder and longer than I was, yet still had to arrive at work at the same hour every morning because people's lives depended on them. They couldn't forget a patient just because they had a long day/night. 

Some anesthesiologists had to spread their weeks between multiple departments. One such doctor was Dr. Rakic, who also worked in the Pain Clinic. So not only did he work in the OR, but on certain days, he had to make rounds within multiple departs to check on the pain of recovering patients and then go to the Pain Clinic to consult with outpatients. I got to witness the treatment of a misplaced epidural pump, nerve burning, and simple one-on-one doctor patient consultations. The most interesting part, however, had to be the nerve burning procedures.

The nerve burning procedures, or Medium Branch Block, are performed on patients who are experiencing pain due to damaged nerves. An ultrasound is used to locate the area, and then a needle with radio-frequency capabilities at the tip is inserted into the patient's skin and the nerves are burned. The pain can remain gone anywhere between 3 months to 1 year. The procedure is relatively quick, yet it was very painful for the patient. 

One thing to note was the use of the ultrasound during the procedure. It seemed as though Dr. Rakic had a love-hate relationship with the device. While the ultrasound is dynamic, it shows only a small portion of the image. Therefore, every time you replace the probe on the skin, you have to start from square one to find your position again. In contrast, the X-ray shows a much larger image.The con of the X-ray, however, is that it is only 2-D. It would be very beneficial is the ultrasound could display a larger image. I'm not sure if that would mean a probe with a larger surface area, or not. But it seemed like a larger radius could be to the benefit of the doctor and the patient. 

What do Anesthesiologists Want

posted Aug 3, 2014, 8:56 PM by Nadia Crawley

My first week of Anesthesiology has been absolutely amazing. I've seen multiple neuro cases, lumbar back cases, robotic gastric bypass, laryngectomy cases, and the list goes on and on. I've gotten so used to the procedures that seeing blood and guts doesn't even phase me anymore. I find myself asking soon afterwards, "So when's lunch?" But although each case may be completely different, with different body parts and surgeons and complications; there are a few universal problems that I've found in all operating rooms. 

1) Too many cords/tubes!!!

I was quite shocked when I saw the amount of clutter. Each and every operating room deals with this large amount of tangled tubes. The anesthesiologists use 4 types of drugs, and each drug has its own PCA pump and tubes. There is also a tube for pain medication. Other tubes included are breathing tubes, gas tubes, IV's, EKG leads, etc. All of these tubes have to be hooked up to the patient in some way, yet there is no product to consolidate the tubes. Such a clutter poses serious risks! How can the doctors know which cord is which if it needs to be changed immediately? If the patient's position needs to be altered in the procedure, how could they? What if someone tripped over these tubes? The questions are endless. And anesthesiologists aren't very happy with the set up either. This issue seemed to be the number one problems for many doctors.












2) Equipment like a "car" 
New technology appears in hospitals through a revolving door. While tons of new equipment comes in, medical staff have to be re-trained to use them. This appears to cause some frustration with the anesthesiologists. They desired equipment that was all intuitive. They compared their ideas to that of renting a new car or buying a new phone. You don't have to re-learn how to use a new or different car; they all work the same. The similar though process goes for buying a new phone. All the devices function the same, despite their different brand or model. So doctors desire equipment that functions on the same principle. With that idea in mind, time and money could be cut down and medical staff could effectively use the equipment without of fear of misusing a new device. 



Anesthesiology!!! July 29th, 2014

posted Aug 3, 2014, 8:20 PM by Nadia Crawley   [ updated Aug 3, 2014, 8:37 PM ]

Can I just start off by saying that I love the anesthesiology department! Not only is this rotation much more organized; but our doctor is amazing and the number of engineering related applications in this department help me better conceptualize the true purpose of this program. On our second day, but first day in the OR, we saw two neuro cases: a brain tumor resection and deep brain stimulation for Parkinson's disease. 

1) Brain tumor resection:
This case was extremely interesting to watch. We were able to see this case from start to finish. When the patient was initially put to sleep, the resident anesthesiologist was searching for her radial vein to place the A-line (fig. A). However, he had difficulty finding it. He was essentially "poking blindly". After some time, he decided to go for a central line instead. The central line also proved to be difficult. The attending anesthesiologist, our Dr. Edelman, was also frustrated because he believed the patient should have had an x-ray beforehand to avoid all of the hassle. He explained that trying to place a central line is also "poking blindly" because they have to find the subclavian vein. Often times an ultrasound can be used to look for veins, however the subclavian vein is hard to detect because it lies under the clavicle. That means the deeper the vein, the lower ultrasound resolution because of the lower frequency. If advanced technology were developed to overcome such obstacles, prep time for surgery could be cut down significantly. And ultimately, the well being of the patient, so doctors aren't "poking blindly."

Something very interesting about this procedure was the patient's posture. Due to the nature of her tumor, she was placed in an upright position (fig. B). Her tumor was located directly in the center of her head (fig. C). So the surgeon had to enter her brain behind her ear in the suboccipital region of her head. This position posed a major risk, as it increased the chance of air traveling into the vessels and causing an embolism. Additional precaution was given to avoid such a tragedy. 

Ultimately, the procedure was a success. We were able to see the procedure clearly due cameras being used for the procedure. The operation took our entire shift, however we saw the patient wake up. And while she rather disoriented, she seemed to be ok. 

                                                                        
            fig. A                                                               fig. B                                                                       fig. C         


2) Deep Brain Stimulation for Parkinson's Disease
The true gift of anesthesia was personified in this case, as the patient was wide awake as micro-electrodes was placed into her brain! A small part of her scalp removed and a whole was drilled into her skull, all the while she was cognitive on the other side of the plastic drape (fig. A). Since the procedure was to examine her brain activity in terms of muscle movement related to her disease, she couldn't be under full anesthetic, as those drugs impact neural activity. 

So electrodes were placed in her brain and we were able to see muscle activity and movement through a signal wave on a DBS monitor: Alpha Omega (radio frequency). After the signal was established, her neurologist moved her muscles to test brain activity. She was also asked to repeat certain words from him. It was amazing to watch her speak and be fully conscious through this procedure. The device showed certain movements resulted in a high and rhythmic amplitude. 

                                                                               
                                                                                            fig. A

The use of different medical devices in this single day proved to me to advantages of engineering concepts in the medical field. And it has already got the wheels in my brain turning of certain improvements. Little did I know the amount of work that went into an anesthesiologist's job, nor how engineering intensive these operations are. But I'm excited for the rest of this rotation.

Goodbye Transplant July 25th, 2014

posted Jul 27, 2014, 1:18 PM by Nadia Crawley   [ updated Jul 27, 2014, 1:19 PM ]

It was bittersweet Friday afternoon. While I was, and still am, excited to go to Anesthesiology to experience a new department, I was sad to leave the Transplant unit. The doctors were amazing, the surgeries we saw in OR were amazing, and my partner was amazing. In just three short weeks we had developed relationships with the attending doctors, the residents, even the nurses in the OR. We had asked them tons of questions, followed them around everywhere, and still they always made us feel welcome. So, because of the amazing generosity of the Transplant Department, we decided to give them thank you cards. 

We got cards for the two residents that helped us out the most and allowed to ask them anything and everything. At times, they even encouraged us to ask questions. We also got cards for Dr. Jeon, our shadow doctor, and Dr. Garcia-Roca. I truly feel that Dr. Garcia-Roca's card was the most important one of all. She turned out be our favorite doctor and she is not even apart of this program. She allowed us to follow her incessantly. If anything, she was more helpful than our shadow doctor during the last 2 weeks of this rotation. And for her generosity, I will always be grateful. 

In terms of our last day in transplant, I must say it was pretty eventful. We watched a bloody procedure in which doctors were assessing a graft in a woman's arm. Part of the arm was infected, which made it difficult to determine how and in what direction the doctors would have to loop the tube. The infected mass on her arm had dark tissue inside, but was full of blood. So Dr. Garcia-Roca continued to drain it using the suction tube. And many times the doctors just pushed down on the mass to push out the blood. It was apparent that the doctors were getting frustrated, so another attending was called to get his opinion on what should be done. After he scrubbed in, he forcefully removed as much of the tube out of her arm as he could. That was pretty gross to watch. But it seemed to remedy the situation, at least somewhat. 

                      

All in all, I really enjoyed my time in transplant. I feel I have obtained a better understanding of the clinical environment. I was able to identify common issues within the hospital, in terms of medical devices, that need further development. I gained a very strong sense of empathy for the patients that need these medical devices or procedures done. I also gained a sense of empathy for the users of the devices, such as the medical staff. I believe that I now have the first-hand knowledge and experience to explore better options, to explain was obstacles within a clinical environments, and the motivation to be apart of the advancement of medical practice. Although I will miss the Transplant unit deeply, I'm looking forward to see what lies ahead in Anesthesiology. 

Pancreas Transplant July 22th - July 23rd

posted Jul 23, 2014, 10:58 AM by Nadia Crawley   [ updated Jul 23, 2014, 10:58 AM ]

During our last week in the transplant department, Nada and I have decided to commit as much time in the OR as possible. While it seemed apparent that the doctor we intended to shadow no longer had a desire to accommodate us, we used our resources and cordial relationships with the other attending physicians and residents to our benefit. We were able to see one of our favorite doctors, Dr. Garcia-Roca, dissect a cadaver pancreas that was shipped from Texas, in preparation for transplantation of a 68-year old patient. We watched as she inspected the work that had already been done on it, and then began to cut away some of the fat and remove the spleen. While she was doing this, three medical students were present in the room, so she took the time to thoroughly explain the process, the pancreas, and educate us on issues regarding why someone would need a pancreas. Our conversation delved into the world of islet transplantation, instead of the entire pancreas. It was very interesting to hear because I have some knowledge of that process from taking BioE 455: Intro to Cell & Tissue Engineering. While she was discussing the process of islet transplantation, I asked her opinion of placing the islets in biocompatible capsules to prevent rejection, an idea we had previously discussed with Dr. Jeon. She expressed that experimentation is very premature, but it would be interesting to see what results from it in the future.
 
A second attending physician, Dr. Ivo (can't remember how to spell his last name) came to assist Dr. Garcia-Roca in preparing the pancreas. Both doctors would be performing the actual procedure. Watching them work together was awesome. In contrast to Dr. Garcia-Roca working with a third-year medical student thirty minutes prior, the cohesiveness and fluidity of the two attendings showed not only their skill, but also their years of working together. There was an accompanying vessel that needed to be attached to the organ, so both Dr. Ivo and Dr. Garcia attached the vessel. Once everything was connected, what I thought to be saline was pumped through the organ to check that there weren't any leaks in the pancreas and that the water was flowing all the way through. Once that was confirmed, the doctors called for the patient.
 
When the patient came in, the doctors were still working on the pancreas. But there was still a lot of chaos and foot traffic in the room as nurses prepped the patient and anesthesiologists began to monitor him and put him to sleep. Once sleep, we watched a medical student insert a Foley catheter, which proved to be a lot quicker and simpler than I had ever imagined. Once the patient was sedated and prepped, Dr. Ivo and Dr. Ying (resident) began the procedure by making a large incision down his stomach. The cut was much larger than I had expected for such a small organ. They then had to cut through all of the fascia to get to the abdomen. One thing that was kind of hard for me to watch was the placing of the clamps on the exterior walls. They use metal rods and clamps to pull back the open skin to provide a large cavity to be able to work within the body. While I know it's necessary, seeing the doctors yank, pull, and tug and the skin was sort of....creepy. Anyway, once everything was in place the doctors began to work. But because the work was being down so deep into the stomach, we weren't able to see much.
 
Not too long into the procedure, Dr. Garcia-Roca came and began to take over for Dr. Ying. Time was ticking down, in terms of our work shift, but I was able to stay long enough to witness them place the pancreas inside the patient. Although I didn't finish the procedure, I was able to see the patient this morning in the Transplant/ICU unit during rounds. He seemed ok, but there looked to be excessive bleeding, which may cause clots. So he's been brought back to the OR to find the source of the bleeding.
 
Something that stood out to me about this case was the impact of transplantation. Unlike the kidney, no living human being can donate an entire pancreas. A live donor can give a pancreas segment. However, if it's full pancreas, then that means that the donor is dead. And in this case, that donor was a 10 year old. I don't know the full details of the story, however the resident briefly told us the sad story of how that young boy came to become a donor so early in his life. Despite that boy's unfortunate death, his organ is now sustaining the life of a 68-year old man. Interestingly enough, when the patient was first brought into the OR, I overheard him asking the nurse how he could become a donor. He wanted to donate his body to science. Since I've been in transplant, that's the second time I've heard of that request. But this man was asking it on the operation table! It's an amazing thing: the process of transplantation. And the recipients of organs seem to not only appreciate what they're being given, but want to contribute. Even if their health doesn't allow them to donate to other people, they want to donate their bodies to science. I think that shows the power of medicine and the power of surgery.

Week 2 Concerns July 14th - July 18th, 2014

posted Jul 21, 2014, 6:54 AM by Nadia Crawley

While some great things happened this past week, a few things concerned me. Our doctor was very much absent and non-responsive to us. When were attempting to locate him or figure out where to go next, we were pretty much left to our own devices. We took the initiative, at times, to speak with the residents and nurses. However, we were also aware that this is a busy running hospital with busy employees. So sometimes there wasn't an opportunity to "bother" anyone at the moment. We did our best to quietly observe or shadow, but there was often downtime when were wondering what we should do or where we should go. We know it is not the responsibility of the nurses or residents to accommodate us, but we were shocked with the great distinction we discovered in our doctor from the first week to this one.

We've discovered that our favorite place is the OR. And so on this last week, we will attempt to spend more time there as it seems some of the other doctors recognize us and are a bit more comfortable with our presence in the OR. While the time spent in the clinic is good and it impacts our empathy towards the patients who use the devices, we would like to see more use of the devices.

Week 2 Recap July 14th - July 18th, 2014

posted Jul 21, 2014, 6:48 AM by Nadia Crawley

Some really great things happened this past week! First, I noticed that I felt more comfortable coming into this second week of Transplant Surgery. I knew my way around the hospital more, I had developed a nice relationship with the fellows, and I was really excited to see more surgery. On Monday, while there was no procedures going on to observe, I was able to play with the Da Vinci surgical robot! In a cold and sterile "large animal procedure room," I experience, first hand, what it felt like to use a device as an extension of my own hands. It turned out that the device was quite easy to use. After speaking with Dr. Jeon, I grew to understand the benefits and disadvantages of the robot. While it is great to use on overweight patients, there are a few factors that could be improved. The arms could be a bit slimmer as to not bump in each other when multiple arms are being used. And the robot lacks tactile feedback. So there were times when I gripped the testing board too hard. Had that been human tissue or flesh, that could have been very painful. The only issue with designing improvements to the device, or any device for that matter, is patent laws. We learned, to the irritation of our doctor, that improvements or ideas are no longer based solely on the advancement of medicine and science, but business. And so the company that makes the Da Vinci robot and patented so much of the technology that they use, that it would almost impossible to design an improvement to the device without selling it to them. That was very interesting to hear.

Tuesday was beneficial because after our morning rounds, I was able to speak with a number a nurses about their experiences in the hospital, with the equipment, and with patient care. They were very opinionated and had a lot to say about the PCA pumps that are heavy and the lack of consideration for nurses in terms of room design. The following day, I was able to shadow a nurse for about 15 minutes to see how he interacts with the equipment. Wednesday and Friday were the typical clinic days.

But Thursday was amazing! I was able to see an actual kidney transplant. In the first room, I witnessed Dr. Garcia use the Da Vinci robot to remove a kidney from a live donor. Afterwards, I followed her to another operating room where Dr. Jeon placed the kidney in the recipient. It was an awesome procedure to witness. Right after that procedure, there was a fistula case which I saw the beginning stages of. Overall, I was very pleased with this week.

Friday July 11th, 2014

posted Jul 13, 2014, 8:39 PM by Nadia Crawley

At the end of the first week I was relieved and exhausted, but most importantly, I was excited for the coming week. I really didn't know what to expect, but the experiences that I've had in just  short days were incredible. I was able to see surgery, in which a HERO catheter was placed in a man's arm. I also shadowed a doctor as she did her rounds in the Transplant Clinic. Most of my time last week was spent in the clinic, and while it was interesting to hear patient's stories, it was also very sad. I wasn't really prepared to hear of patient's tumultuous health history, their struggles as they wait to be put on the "list", a patient being notified he may have cancer, and the list goes on and on. Those type of encounters were pretty tough to hear, and it made me more aware of my own mortality. Many patients were diabetic and suffering from kidney failure. Many patients were on dialysis, and the toll it takes on the human body was exposed through each pair of enlarged veins I witnessed. It made me wonder, in what ways could the process be improved to not damage the human body in such a manner; or further more, in what ways can we develop practices in which we prevent the use of dialysis machines?

While the patient interactions were memorable, I'm still yearning for a chance to get more acquainted with the equipment in the hospital rooms and OR. I had very littler interaction with the actual hospital rooms. However, I spoke with a nurse who will allow my partner and I to interview the other nurses and potentially follow them around the Transplant/ICU unit, so we can gain a better understanding of how the equipment works, how it impacts the environment and users, and potential obstacles, if any, when using the equipment. I'm also looking forward to seeing more surgeries. My favorite part of this experience so far has to be my time spent in the OR. Watching live surgery is amazing, and it gives me an opportunity to see many devices in use. 


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