Final Blog --- Friday, August 15th, 2014

posted Aug 15, 2014, 8:02 PM by Unknown user   [ updated Aug 18, 2014, 12:45 AM ]

Whirlwind, experiential, unbelievable, beautiful, and downright fun. Those adjectives barely begin to describe the Clinical Immersion Internship under the guidance of Professor Sterling, and Dr. Kotche. The purpose of this internship was to guide students toward empathizing, and understanding the feelings of both patients, and clinicians in a healthcare setting. This experience was truly eye-opening. 

I began my first day at the internship by nearly passing out in the middle of a routine colonoscopy in the UIC Hospital G.I. Lab. I remember the tunnel vision forming around my eyes, the sounds of the G.I. lab becoming more and more distant, and the sudden shock of an ice pack hitting the back my neck and bringing me back to reality. Thankfully, a nurse had been paying attention to me and made sure to sit me down in a bathroom and talk me through the frightening experience I was undergoing. This experience showed me the kind of care that nurses and doctors provide in the hospital; despite the enormous amount of bureaucratic shuffling they do, and filing of papers, at the end of the day they are there to take care of people. 

Past the human standpoint, I went to analyze the tools/layout/procedures of the physicians in order to identify some sort of need. Now that leads one to question, what exactly is a need? A need is something that must be had, or something that is essential. The essentials that I witnessed were: extra training for colonoscopies, a more intuitive colonoscope, and a colonoscope with a larger visual field. My general experience in the G.I. Lab was that of EGDs (esophagogastroduodenoscopy) and colonoscopies. Though these procedures were typically outpatient, and not difficult in a skilled hand, new fellows and medical students would have difficulties in maneuvering and obtaining the correct positioning without causing some ramming of the intestinal wall. This observation founded my interest in extra training for G.I. fellows/students. Furthermore, the colonoscope has an incredible number of functions which range from taking HD pictures, clamping polyps for biopsies, deploying a net, spraying air or water, suction of air/water, and even cauterizing biopsied areas. It's no wonder that 2 people, the attending physician and nurse, are required to operate the numerous different functions of the colonoscope by using a footpedal, a controller, and by literally pushing and pulling the colonoscope in and out of the colon. A more intuitive colonoscope would hopefully give all the control to 1 person, as well as be easily manageable in control by centralizing controls. In addition to this, I noticed that the colonoscope had to take several different camera angle shots, many of which required tricky maneuvering and extensive pushing and pulling of the scope for proper bending. Perhaps additional cameras with a wider scope/visual field would reduce the necessity of all these movements. In essence, these solutions seek to streamline the colonoscopy/EDG procedures because ultimately they are embarrassing, sometimes painful, and somewhat of a hassle (though they are HIGHLY necessary). 

Next, I found myself in the Transplant Surgery rotation in the hospital. The main areas I frequented were the transplant ICU, the transplant clinic, and the OR. Between these three areas, the OR happened to have much of the advanced technology and techniques for surgical operations. For example, the da vinci robot for minimally invasive transplant surgeries is a tool that empowers surgeons to make incisions and cuts with higher precision and maneuverability than a human can normally do. While the transplant ICU featured ventilators, ultrasound equipment, infusion pumps, and ECG machines. Much of the equipment used in the ICU was typical in most ICUs in the hospital. The clinic on the other hand had little to no technology, for the most part it was meeting space for patients and physicians. Furthermore, the clinic was rather cramped and little adornment; the walls were largely blank and dull. Ultimately, many of the proposed improvements in technology for Transplant would be involved with the ICU. This is because the largest problems are not exactly health related, rather they are centered on the ergonomics of patient comfort. For example, infusion pumps are sometimes stack upon each other, up to 5, in case a patient needs multiple different intravenous medicines at once. This can lead to very heavy IV poles, and decreased patient mobility. Another issue noted was that the beds and infusion pump had no point of attachment. Some solutions for these issues would revolve around having 1 infusion pump do multiple medicines at once, rather than separate infusion pumps for each medicine. Also, the infusion pump device could be incorporated into the bed for increased mobility, or even a backpack apparatus for increased portability among younger patients/older patients. 

What was most surprising about the Transplant surgical rotation was the human aspect. I learned that Transplant surgery was much more stressful than I anticipated. The rotation had medical students and residents working around the clock for 10+ hours for multiple days, and many of them were running on minimal sleep. Between deciding medications and conducting surgeries that would determine the difference between life and death, the sleep deprived surgeons seem to have adapted to this high stress environment. In response to that conjecture, I feel that it would be highly appropriate to design tools that are easy to use at all times, and require little forethought before putting them into operation. I have reconsidered my interest in being a surgeon, as it calls for a greater sacrifice of personal time and life than I might want to give. I believe in living a balanced life, and in some ways the lives that are lived by the people I saw were undoubtedly one-sided (though I believe their work is necessary and incredibly important). 

Once again, I would like to thank Dr. Kotche and Professor Sterling for allowing me to foray into these once alien subspecialties in medicine. I have learned incalculably important information, and I feel like I have developed a new design + engineering mindset that will allow me to approach bioengineering problems in a new light. 

Entry 10: Week of 8/03/2014

posted Aug 11, 2014, 12:57 AM by Unknown user   [ updated Aug 15, 2014, 7:32 PM ]

My final week in transplant was bittersweet, but packed with unforgettable experiences. The second half of my week encompassed a few major operations and in-depth rounds. Furthermore, I got the experience to talk with Jurgis, a medical student, and a resident, Dr. Arun, about what I saw, heard, and felt. 

A sobering and humbling experience in medicine is the inevitability of death. Despite the best efforts of the transplant physicians on staff and nurses, patients can die. The patient mentioned in blog post 9 passed away. His passing was chosen by his family, because he had reached a critical state where he would only survive with the constant infusion of blood, IV fluids, and oxygen. When I had last seen this patient he was gasping for air, hooked up to 6+ infusion pumps, and had a heart rate above 120 consistently. In all honesty, I feel slightly relieved that the patient’s suffering did not continue. At the same time, I was dissatisfied with the technology that the man relied on, as it did not heal him but only just kept him alive. I was also musing that the patient’s family’s perception of the number of infusion pumps, IVs and monitoring equipment hooked up to the patient could have influenced their decision in removing the aforementioned systems. Although I have my own fascination with medicine, life, and healing the enormity of death will always oppose the efforts of physicians.

The major operation that I was privy to see was a nephrectomy; the surgical removal of the kidneys. This operation is only done when the kidneys become non-functional and are a detriment to a patient’s well-being. The patient in question had kidneys that had become non-functional and filled with cysts. The left kidney had broken through the peritoneum and had deformed the small bowel. The procedure required the kidneys to be tied off and removed surgically. The major tools used were scissors, a clamp to open up the cavity, and a cauterizer. Though these were relatively simple tools to conduct the surgery, it was done successfully. Prior to the surgical procedure, the patient was undergoing constant pain, and did not have a high quality of life. The surgery was a step towards restoring this patient back to health, and presumably a life with less pain. Ultimately, the patient will undergo dialysis 2 times per week until they can receive a transplanted organ. 

These two experiences showed me vastly different sides of medicine. The human aspects as well as the technological aspects that we were meant to focus on. From this I now place more importance in human perception of healthcare along side the efficacy of the involved technologies. Between these two ideas design can emerge and create a common point of intersection that understands the issues of both a physicians and a patient with an engineering edge. 

Entry 9: Week of 8/03/14

posted Aug 7, 2014, 10:36 PM by Unknown user

Slow. That is really the only way I can describe the first half of this week at Transplant. I slowly grew to realize that much of the residents and medical student's work is waiting, watching, and writing notes. Once again my days began with rounds roughly at 7:30 in the morning to 10:30 am, and we went bedside to bedside listening to medical students and residents present cases on patients while Dr. Ivo added his recommendations. The rest of the day was dominated by note taking and reception/recording of patient tests by physicians. In addition, there weren't very many surgeries at the beginning of the week. 

In the meanwhile the attention of the transplant unit was turned to patients in their ICU. The transplant unit had several patients who were currently healing, one of which had taken a turn for the worse. This patient had GI tract bleeding, a blood infection, his transplanted kidney was failing and he had atrial fibrillation. Between these conditions his body was dying, it was a painful state for the patient who was receiving platelets, blood and various medicines. Unfortunately, all of these fluids were not helping much to increase blood pressure. Surprisingly, the nurse and the doctor were undaunted despite the grim nature of the situation. 

When asked about the different measurement devices in the room Dr. Ivo gave an in-depth explanation of their various uses and the theory behind them. The devices according to him made it possible to perfectly deliver a certain concentration of a drug over time. I noticed that the room he was in was filled with IV poles and infusion pumps which made it increasingly difficult to maneuver around. Furthermore, it looked confusing to identify the several different bags of medicine and IV fluids around the patient. 

Entry 8: Week of 7/28/2014

posted Aug 3, 2014, 8:42 AM by Unknown user

At the instruction of residents and the medical students Justin and I spent time in the OR and the Transplant clinic in the Eye and Ear infirmary for the remainder of the week.

The OR lies at the heart of the hospital, with many important surgical procedures taking place there. In order to be in the OR you must obtain a set of scrubs, a hair net and shoe covers. Actual procedures require you to wear a face mask at all times. The first procedure that was seen was a hysterectomy; not a transplant procedure but one to see while waiting for a Transplant surgery to start. A hysterectomy is the surgical removal of the uterus. The surgery requires several trocar, a scope for viewing, and sets of scissors and cauterizers. The procedure was slow and took a long time as cutting through every muscle fiber was tedious and inefficient. I posited that a scissor-cauterizer combination could speed up the procedure greatly instead of having each physician snip and cauterize cyclically.  The setup for the procedure was highly interesting where a set of 3 monitors were placed in a configuration that allowed you turn in any direction to see the progress of the procedure. Furthermore, the arrangement of each nurse was to improve efficiency and sterility. This is evidenced by the circulating nurse who prevented any contamination, and watched the team from outside of the procedure. Despite this, it would be rather easy for any incoming bystanders to brush up against the sterile cart holding tools, therefore better signage or brighter colors than blue could be used to signify the difference between each cart. 

Next, I went on to witness the removal of a fistula for a patient. A fistula is an abnormal connection from a vessel to another part of the body. Transplant surgery deals with many fistulas due to the fact that kidney transplant patients often need to undergo dialysis, and a fistula can occur due to regular connection to a blood vessel which experiences a flow that is too large. The fistula was found in the upper forearm of the patient, and it was removed by first opening up the patient's arm. The fistula was excised from the blood vessel to prevent the formation of clots, and to keep the patient safe. The primary tools for this operation were blades, a cauterizer, and sutures. The operation was relatively simple, although the patient continually complained of pain from their central line until they received enough medication to put them to sleep.

The Transplant clinic in the Ear and Eye Infirmary was also explored. The clinic is a simple area where patients are met in extremely small rooms, and are given a diagnosis and explanation of their treatment. The resident nurse, Carl, discussed the various cases that come in ranging from fistulas to kidney and liver transplants. Furthermore, Dr. Ivo talked about laminar flow rate in a fistula and why it is problematic. According to him, a fistula causes turbulent flow in a blood vessel which is often too fast which can cause damage and platelet accumulation. These two factors combined are dangerous for a blood vessel as a blockage could happen at any point and cause patient mortality. Though the clinic was cramped and small it did bring all the physicians together to discuss patients, and had a homely feel (an odd thing for a physician's clinic).

Entry 7: Week of 7/28/2014

posted Aug 3, 2014, 7:58 AM by Unknown user

This week Justin and I rotated into Transplant Surgery under Dr. Ivo Tsvetnov. We found ourselves on the 7th Floor of the Hospital where many patients in the Transplant unit are in critical care. 

Each morning on the 7th floor extensive rounds are conducted under the tutelage of Dr. Ivo from 7:30 AM to 10:00 AM. Medical students, residents, and a pharmacist present various cases, and discuss the current stage of each patient in a comprehensive manner. The discourse includes methods of treatment, and Dr. Ivo's startling revelations regarding each case. In one particularly interesting account, Dr. Ivo mentioned that he preferred a patient to be hypertensive rather than hypotensive. His rationale was that it was much easier to lower blood pressure with 20 or so medications available, but not easy to raise it. Another bit of info he talked about was that when a line was contaminated, a whole new line/pathway into the body must be done due to bacteremia. This was in response to a resident who simply tried to change the line. Additionally, Dr. Ivo discussed the difference between peripheral and central lines, where only certain concentrations of medication can be used. A peripheral line can infuse up to 10% of a medication before toxicity happens in the body, while a central line in the venous system has higher flow and greater dilution that can handle a medicine concentration greater than 10%. Rounds act as an essential part of the students medical education as Dr. Ivo is able to easily impart his experience and regularly test students on their knowledge. 

Despite the fact that rounds does in fact manage to address the needs of every patient there were noticeable problems. For instance, during rounds was that handwashing/hand sanitizer use had less than 50% compliance for every room visited. Although it would be inefficient to wash hands at every juncture before and after meeting a patient, somehow a system should be developed to counter the accidental spread of pathogens. Interestingly, rounds have an air of intimidation towards patients, because the doctor is discussing them a few feet away to the medical students. I can imagine it would be unnerving to see a doctor and a large gaggle of medical students gawking at me if I were a patient. Another issue that occurred was a patient shouting for help repeatedly with no immediate response. Justin and I stood waiting for somebody to acknowledge a patient who was in pain for whatever reason. It turns out that the patient into question was actually just complaining and had no real issue, but the fact stands that sometimes the patients are simply not believed. 

After observations, some of the technology and design in the Transplant Unit was phenomenal. For example, a room had a special pulmonary ventilator that supplied oxygen to a sedated patient. The ventilator has a variety of options ranging from pressure, volume, and duration ventilation. Yet, the ventilator acts dynamically to measure how much more oxygen it should pass to the lungs in a way to prevent the patient on being wholly dependent on the machine. The patient rooms themselves had clear sliding doors equipped with blinds. This simple bit of design is efficient in that it provides a glimpse of the patient while being able to block out sounds to aid their rest. Other novel bit of design was to place an electronic chart displaying all the physiological signals of patients in the middle of the resident's desk. This type of design is optimized to quickly understand when patients are in trouble, and get them the appropriate care. 

Unfortunately on Monday, Tuesday and much of Wednesday were marked with no cases in the ER.

Entry 6: Week of 7/21/2014

posted Jul 23, 2014, 4:28 PM by Unknown user   [ updated Jul 26, 2014, 2:44 PM ]

The final week in G.I. has concluded, and many valuable observations and insights have been made. These last few days were marked with a couple of unusual cases, and disdain from the a anesthesiology department. 

I was lucky enough to witness 3 unusual cases in GI which push the abilities and often patience of the attending physicians. The first case was an ERCP/EUS procedure which was done to access the bile duct. Unfortunately, the procedure was NOT successful because of the difficulty in maneuvering a thin piece of wire from an artificial hole in the colon. The patient was older and under anesthesia during the procedure, additionally  an X-ray machine was in use during the procedure with a high contrast dye. Though the visualization and equipment was sufficient, the difficulty of the procedure was high. The second case was an EDG patient with no stomach. Essentially, the esophagus was connected to the small bowel with a suture. According to Vineel, the stomach does do a small portion of protein breakdown, but the small intestines do the majority. Therefore, the stomach is really only necessary for acid degradation prior to the intestines.   The endoscope could not go far enough during this procedure, and there was difficulty in locating a specific component for the operation. The component was a foreign body scissor, which was only found when Dr. Boulay lay physically went to search for it during the procedure. When the component was retrieved Dr. Boulay snipped a small piece of offending suture which had not degraded in the body. The final procedure was a routine colonoscopy done by Dr.Carrol, a senior attending physician. Though it was a routine check it was not possible to reach the cecum, and the patient was in extreme discomfort. This was because of the patient's obesity coupled with a sharp turn around the first bend of the colon. Ultimately, these cases showcase that despite superior technology and technique there are shortcomings and each can only be met with a personal solution.

Interestingly, the anesthesiology department for the last two days were slightly critical of the GI department. In the first case, the anesthetists equipment had a hard time fitting through the doors in the GI lab, and the anesthesiology nurse complained loudly to Dr. Halline about how awful the conditions (room size and layout) were. He quickly explained he understood, but made to return to the procedure at once. Subsequently, an attending physician from anesthesiology gathered the GI staff and loudly complained that the patient ought not be late, and that waiting for them say past the time appointment time was not okay. Despite the bittersweet ending of that situation, the GI physicians and nurses were unfazed and continued onwards to improve the lot of their patients. 

Entry 5: Week of 7/21/2014

posted Jul 23, 2014, 4:26 PM by Unknown user

My week at the G.I. Clinic came to a close, and I moved to working with Dr. Sugir and my partner in G.I. Matt Dela Cruz back at the G.I. Lab :) The purpose of the next bit of shadowing is to see inpatient consults, and get a better sense for what happens on rounds. Interestingly, rounds don't seem to have a set schedule and happen at irregular time intervals.

My first few days back in the lab were marked with the hectic hustle and bustle of a newly implemented Doctor's note taking system, Provation 5.0. Staff, including doctors and nurses, were in the middle of getting trained by software engineers within the hospital for this new system. The reason for the switch is for an upgrade, and to prevent unauthorized personnel from accessing patient information/files. The change causes doctors to log in for every patient that they see, rather than leaving the computer logged in all day (which is against the law, and much more efficient). The second day in the week, the engineers were still available post-op to help with inputting doctor's notes and other vital information. Though the new software seems to be slightly inefficient, the software engineers tout its reliability and work hard to teach the doctors how to use the system.

Matt and I ventured onwards to watch a very different procedure on a patient with a colostomy bag. We spectated an ileostomy, a procedure where an endoscope is inserted where a colostomy back is to visualize the small intestine. I noted that the colostomy bag was removed, and the patient had a hole on their side. The endoscope was inserted, not delicately, into the stoma. Despite previous sterilization procedures, the endoscope could've easily transferred a large number of foreign microbes into the body. The doctor took various biopsies to be sent to pathology. The biopsies according to the physician looked fairly healthy, and displayed large villi.

Today, Matt and I watched a procedure called a bronchoscopy. Though similar in procedure to a colonoscopy, a bronchoscopy is much harder on the patient and requires great skill as a physician. The preparation for the procedure is as follows; the patient recieves a lidocane wash for their mouth, and is required to inhale lidocane in order to permeate the numbing effects throughout the trachea. In addition, patients are given fentanyl to reduce discomfort. Simply the degree of anaesthetic used in this procedure speaks volumes on how uncomfortable it is.  The premise of the procedure is to visualize the lungs with a bronchoscope that is inserted down the nasal cavity in order to obtain biopsies and rule out other abnormalities. The scope continues and goes in between the vocal chords (a highly unpleasant feeling that induces intermittent coughing). The scope explores the bronchus, and some larger bronchioles but predictably cannot fit into alveoli. In order to obtain biopsies of the lungs a clamp is extended to the chest wall, then retracted 2 cm and extended 1 cm, the biopsy is then collected. The purpose of these seemingly random steps is to prevent puncture of the lungs. That is a terrifying outcome. The risk that is incurred from this procedure is heavy, and any miscalculations could have dire consequences for the patient. Thankfully an x-ray machine is used to supplement the camera on the bronchoscope to make sure the scope never pierces through the chest wall. 

Lives are truly held in the hands of physicians who rely on bio-instruments. 

Entry 4: Week of 7/14/2014

posted Jul 18, 2014, 7:50 PM by Unknown user

My next few days in the clinic were enlightening as I saw numerous different patients, and the method of interaction that physicians engaged in. The usual procedure I saw for each patient is as follows: 

1. A patient history is submitted to the physician and they look it over.
2. The patient's previous medical reports and seen by the physician.
3. A general purpose for the clinic visit is developed.
4. The doctor and patient meet, and the history is reviewed again with the patient in order to identify anything incorrect, or to further update information.
5. The doctor asks a patient a series of questions about their chief complaints.
6. The doctor delivers the principal idea they have on the patient, and communicates it using pictures/diagrams.
7. They ask if the patient has any questions and understands their diagnosis.

A few notable patients I saw were detailed below:

Patient 1: Caucasian Male, older gentleman
He was diagnosed with inflammation of the pancreas and had a high degree of bruising. Non-compliant with stopping alcohol use for several months. Was asked to undergo the EUG procedure. 

The patient was quiet and seemed overwhelmed by the number of people in the room. He understood that his health issues were critical, and was told by Dr. Halline he needed to make sure that he would not continue his alcohol use. The patient understood, and said that he stopped drinking for 2 months. The atmosphere was intense, and the patient knew that he was not doing his best in getting better. 

Patient 2: African American woman, middle-aged
The patient came in to schedule a screening for a colonoscopy after significant weight loss. She was previously diagnosed with seizures and was under disability. She expressed her living situation was not ideal, and did not have a home/occupation. She also previously expressed having suicidal thoughts. 

Dr. Carroll began the patient meeting by taking notes about family history, and noted that the patient did not look at the history form. He later told me that it is possible she could not read. The doctor was primarily concerned with her living situation and wanted to make sure that she had access to a bathroom in order to properly prep and flush out her colon. He also thought that the weight loss could be due to poor dietary habits rather than any colon cancer issues. Despite this, he did note that her family of 14 brothers/sisters had several cases of cancer. Dr. Carroll also made sure to inform her of the various homeless shelters nearby, and made an appointment for her to a social worker. 

Dr. Carroll informed me that many cases of weight loss and stomach pain are due to living conditions rather than disease. The actual problem lies in economic/social hardship. 

Patient 3: Caucasian female (older)

This patient came in to discuss her throat stricture and pain she is experiencing daily. Her demeanor was stoic, yet upbeat and hopeful. Dr. Stewart was the attending physician in this case. Of all the clinicians I have met, she is the most understanding, empathetic, and listens the most. She works with her patients rather than "on" them. She rarely used the computer during the visit, and made it a habit to hold out her hand to her patient in order to emphasize that she is there for them. Dr. Stewart also made an effort in keeping me in the loop while explaining the issues that the patient was undergoing. 

The principal problem was that the patient could not eat without experiencing mild to severe pain. She previously had a dilation of her esophagus which allowed her to eat, but the stricture in her throat made it difficult for even liquids to pass. In the past, Dr. Stewart was unable to prescribe a powder form of the medication that was only in capsule form because the patient could not swallow solids. This situation produced a work around where both physician and patient worked together and came up with an ingenious solution. The patient opened the pill capsule and put the powder in yogurt and ate it. The idea worked marvelously and the patient recovered some of her weight. 

In the end, Dr. Stewart decided that another ct scan was necessary and comforted her, she told her that she would do everything she could to reduce the pain. The experience seeing this clinician-patient interaction was exceptionally moving. 

In reference to the common problems I saw in the clinic I will propose some solutions. 
First I will start with the edification of patients on their own liver and GI system in general. The posters kept in the room should be moved away their location, and perhaps placed behind the door. So a doctor can stand up and actively teach the patient about the liver and the progression of Hep C. Furthermore, the computer system in each room should be entirely removed and replaced. A tablet note taking system would promote higher interaction with the patient and efficiently allow the physician to get every detail. I would also posit that a large lcd screen could be placed on the wall which would display relevant information about the patient's health. I noticed that many patients felt distant and uninformed about their own health information. Perhaps in the future providing a patient with their information would speed up treatment and give them a better understanding at what their doctor is trying to do. 

Alternatively, if a patient does have access to their labs it could cause a patient to self-diagnose and come to incorrect conclusions about their own health. Some sort of compromise must be reached with holding patient information, and granting them access to it.  

Entry 3: Week of 7/14/2014

posted Jul 16, 2014, 8:40 PM by Unknown user

My week in the GI lab had come to a close, and I transitioned on to the G.I. and Liver clinic. Though I moved forward to a new department, I felt like I moved a step back in the clinical process. I moved to the point in time where I saw the diagnosis that lead to the procedures I witnessed last week. I gained a greater appreciation of the process that doctors use to treat their patients.

The attending physician was Dr. Halline, and I was his shadow. Before walking into patient consultation rooms he stopped outside, explained the patients' history and informed me of his ideas and plunged in. He systematically approached each case with a collected demeanor that was assuring. His process was to describe what he knows about his patient, verify the info with them and then asks about their complaint. He listens and notes down anything important, then he offers treatment options and explains his views. He leaves the decisions entirely with his patient after giving his advice. He works quickly and patients trust him. Despite his ability for medicine, he does have a weak point so to speak. He is not fond of typing out large quantities of information, and this can sometimes occupy much of his thought especially when attending with a patient. Unbeknownst to him he might miss a vital part of a patients question or be unable to answer due to his occupation with typing out some bit of info. As a result, he uses pen and paper with most patients and keeps vigilant air of attention in order to obtain each piece of information in order to process it. 

Something else I would like to discuss is not the human environment, but the physical environment itself. The actual clinic is separated into an interior office, and surrounding hallways that have patient consultation rooms. Each room is box like and small, 3 people can be crowding in the room, and there is almost no space to move without bumping into anyone. Additionally, the diagram of the liver is right above the patients head when they sit in the room, thus preventing them from reading important information. Even though each room is equipped with a computer, it is pointed in a direction that makes it hard for the patient to see. It would help if a patient could see what a doctor is seeing on screen to better understand what is happening. The very layout of the room impedes patients from becoming more knowledgeable about their health. It can be noted that the very aesthetics of the room are plain and uninviting.   

In my next blog post I will detail some interactions I saw with patients and possible work arounds for the problems mentioned. 

Entry 2: Week of 7/07/2014

posted Jul 9, 2014, 8:41 PM by Unknown user   [ updated Jul 12, 2014, 9:24 AM ]

The length of the following post is directly related to how much information I learned in my week in the GI Lab. There is much more raw data that I observed but could find no spot in the post. 

My next few days in the GI Lab were fairly routine, I watched several different procedures and observed the lab in 2 different aspects. I rotated between technical descriptions/problems, and humanistic occurrences and problems. 

The main problem faced by people in this lab was organizational chaos. Each day it grew more apparent that the system of organization was not well understood. I determined that the information for patients came from the UI Health online system, which is organized, advanced and usually up to date. But this information is transferred to paper for easier accessibility and then transcribed onto a white board to further disseminate information. Though the system appears to be working, at times it is not understood why certain hiccups occur. These include when a certain "Dr. ?" is assigned to cases and at times this simply means the nearest attending physician. It is worrying that patients care can so easily be mismanaged simply from a lack of knowing which Doctor is assigned to what patient. Furthermore, there are times when the OR simply arrives at a standstill with patients waiting for their turn and all of the operating rooms open. These intermittent stops increase the odds that every single day is behind schedule, and increase patient stays in the hospital. Although routine colonoscopy or EDG procedures are outpatient, these wait times cause a 8:00 am patient to wait until 8:45 or even later, simply waiting for a procedure to begin. 

Though these sort of problems happen frequently they are dismissed by staff, and are usually expected. Everyone shrugs when it comes down to organization claiming whoever is at the top clearly doesn't know what is happening. Additionally, most residents seem to carry around sheafs of paper and notebooks during their rounds to take notes. Often these can be seen as a large cluttered mess sitting around in their pocket which grows larger each day. I'm sure a more profoundly simple system for note taking could be used to eliminate the bundles of paper they carry. Disorganization of information is not something new here, and it has been adapted by the system and several work arounds exist that somehow get the right papers to the right room, and the right procedure on the correct patient (thankfully).

Another issue that I was privy to was the endoscopy prep. Every colonoscopy patient is to undergo a preparation which involves drinking a large amount of laxatives the night before and day of the operation. This would flush out the colon and make it easier to visualize the colon walls and excise any abnormal growths. Usually, some patients would neglect to prep themselves properly and in turn would have stool/liquid stool in their bowels. This ultimately makes the colonoscopy harder, as the scope would need to navigate through this in order to make to the end. Somehow a way to improve prep adherence might be beneficial to the staff as well as the patients. 

It is also worth noting that the physicians and nurses frequently wash their hands. Although they do wash hands pre and post operation, the older physicians tend to make mistakes such as touching the faucet's handle, or doing procedures without wearing a mask/gown due to seniority.  Also, hand washing is not prompted when a gloved and gowned nurse who participated in the procedure would hand a pen and paper to the physician who might not have been gloved, and the physician does not wash their hands afterwards. This sort of culture is prevalent here because GI work hardly involves risk of infection here in the lab, and I fear that someday that the laxity could cause a patient more discomfort. 

Now that I've explored a little bit of the human side of the GI Lab, I will enter a discussion of the more technical aspects. The two major procedures that occur in the GI lab are colonoscopy and EDGs which is for the upper digestive tract. Both procedures are done using a colonoscope which can illuminate, move up/down and torque left/right, it can spray water, air, and suction air and water, it can also deploy a clamp and take high resolution images with 17x magnification. The manufacturer is Pentax and the GI department has a good relationship with them. These devices, in a trained hand, can navigate the colon or upper digestive tract and take images, biopsies, and diagnose illnesses. It not a intuitive device, but can be learned and requires experience to improve. Though when it is in a untrained hand, it is possible to damage walls of the colon or stomach through repeated hits which is incidentally referred to as "skidding". Though the damage is very minimal, it could be a potentially threatening problem in some cases. It was explained during patient consent that less than 1/1000 patients end up with a perforated colon due to this procedure, which is still large number of patients. I mused that a simulation of an endoscopy might be worthwhile to improve skills without lengthening colonoscopys with new trainees. 

The operative spaces themselves are equipped with high tech monitors and visualization devices. For example, there are monitors that display the colonoscopes pictures in high definition on a main screen for the physicians. Furthermore, there is a computer in every room for documentation, and to record duration of each operation. However, it is common that the recording times are rather haphazardly kept and sometimes completely made up. This could be solved with a reminder system or by incorporating this job more fervently to the nurses (as if they didn't have enough work). Another issue that caught my attention were the piles of wire in every room. All though the GI lab is touted to have state of the art equipment, the electrical wires for equipment run all over the floor and posit a hazard to anyone who isn't looking directly at them. The possible consequences of this would include stopping the procedure, and stopping data collection if any wires specific to the colonoscope/computer were pulled. This could be handled by creating a casing for the wires, or by looking into wireless devices that could replace current equipment. Additionally, the operative spaces are rather cramped, and the position of the door has a high probability of hitting anyone near it. It would be worthwhile to look into light doors that would swing with less force, and they could be equipped with a blind+window to improve communication outside of the room. Another point I would like to make is that the GI lab does not have dedicated stethoscopes for each operation space. This should be corrected, and more stethoscopes should be introduced to further drive down chances for infection.

The non-operative spaces on the other hand are spacious, and conveniently located near all sorts of device that are necessary. For example, thermometers are simply steps away, there are cavi wipes next to beds, gloves next to beds and handsanitizer dispensers in every direction 10 ft or less away. There is an easily drawn curtain that goes around the beds, and the location of the beds is a few feet away from the nurses desk, so it is likely that any patients in distress would be noticed. Each bed has disposal for bio hazardous waste, and linens roughly 5 feet away with a foot pedal to avoid touching anything. 

In conclusion, regarding the GI lab, it is a working environment with state of the art equipment and highly trained attending physicians, bubbly hardworking nurses,  and capable (but tired) fellows. Each person has their role and does it to the best of their ability using their skills. 

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