Carry On My Wayward Son

posted Aug 15, 2014, 6:26 PM by Unknown user

Ophthalmology

    My time in the ophthalmology department has been a rewarding and constant learning experience. I am truly grateful to all the doctors who took the time to incorporate us bioengineers into their challenging daily routines. Being able to rotate into different specialties within the department allowed me to gain a deeper appreciation for the wide range of medical devices utilized to examine and treat vision deficiencies. The clinical setting allowed me to understand how doctors and patients perceive different medical devices to address the various needs. Not all medical equipment is new and state-of-the-art, and as a result, doctors and patients must function as a team. To persevere past these obstacles, a balance needs to be established between device usage and patient service. I envision to design medical devices that strengthen such a delicate balance. One approach would be to research Possible design projects include advancing keratoprostheses, advancing multifocal and accommodative intraocular lenses, and developing smart contact lenses that monitor physiological properties such as blood sugar and intraocular pressure. As biomedical imaging and optical technology advance, ophthalmologists will be better equipped to treat patients in a more effective and accurate manner. As an aspiring bioengineer, I plan to be apart of that mission.

Anesthesiology

My experience in the anesthesiology department has been nothing less than spectacular. Everyday we were faced with new opportunities for advancement. Before my rotation in anesthesiology, I believed that anesthesiologists only had to view a monitor and inject medication into a patient at various stages during a procedure. How wrong I was to imagine such a simple and calm environment for anesthesiologists. These specialists are essentially engineers in the sense that they must analyze various inputs and constraints in order to determine the most optimal treatment for their patients in real-time. In addition, they must be proficient in comprehending and utilizing a wide array of sophisticated medical devices in chaotic and congested environments. Current technological advancements aim to reduce the risk an anesthesiologist experiences during surgery, but fail to integrate seamlessly into existing procedures and work areas. As a result, anesthesiologists require additional training, and are forced to love the addition of cables and tubes. This immersion helped me understand that physicians need to be able to do more with less. I envision to design medical devices that are multi-dimensional in terms of functionality and efficiency. Possible design projects include wireless telemetry systems that integrate various physiological sensors and communicate the data to external peripheral devices, as well as a syringe auto-injector for constant pressure IV injections.


Thank you Dr. Sugar, Dr. Edelman, the Ophthalmology department, the Anesthesiology department, and last but definitely not least, Dr. Kotche and Professor Sterling, all of which have made this immersion experience a once in a lifetime opportunity that I won’t soon forget! 

Mission Aborted (Case Studies: Pt. 3)

posted Aug 8, 2014, 3:55 PM by Unknown user

During a robotic airway laryngeal tumor operation, the attending anesthesiologist expected the operation to last for several hours and so, front loaded the patient with large doses of anesthetics, which is a common tactic for long operations. The anesthesiologist then proceeded to attach all the various physiological monitoring sensors and then intubated the patient. In this procedure, the endotracheal tube was wrapped with a laser absorbent tape. The tape served to protect the tube from catching fire from a laser that was going to be used during the operation. As an additional safety precaution, a special dye was injected into the tube. If the dye was seen during the operation, the surgeon knows that the tube had been breached by the laser. During intubation, the anesthesiologist had difficulty inserting the tube into the trachea, a red flag. After 20 minutes or so, once everything was prepped and the sterile field was up, the surgeons approached the patient and proceeded to examine the patient’s throat. After examining the throat for less than a minute, they knew the operation was in peril for the tumor had progressed to the back of the throat. The case was cancelled, all the prep work and open instruments had gone to waste. However, a war was then raging between the anesthesiologist and the extubation process. The anesthesiologist had to extubate the patient hours ahead of time after a heavy preload. The anesthesiologist needed to reverse muscle paralysis, relax the muscles and reactivate the respiratory system. The whole crisis could have been adverted if the surgeons just glanced at the throat to begin with. Instead, the patient’s health was at risk, money went down the drain, and valuable time was wasted.

Pain is a highly subjective topic. On a scale of 1 to 10, how much pain are you in? Has your pain decreased or increased overnight? What more can we do for you? These questions are often asked by the pain clinic anesthesiologists who administer various narcotics to patients for pain management. When not administering narcotics from IV pumps, the anesthesiologists treat pain by burning nerves inside a patient. In a lumbar pineal shunt case, after applying anesthetics to the nerves, a needle that emits radiofrequency is guided via ultrasound to the area. Ultrasound is utilized instead of X-rays because X-rays can’t show depth. However, while ultrasound can show depth, it cannot show detailed anatomic structures. For example, a rib is a rib, but which rib is it? An experienced anesthesiologist who is familiar with the ultrasound can navigate such difficult paths. In addition, the anesthesiologist does not have binocular vision and can’t look at the ultrasound monitor while guiding the needle at the same time. Instead, the anesthesiologist relies on tactile feedback while looking at the monitor. Furthermore, the anesthesiologist cannot modify the ultrasound machine by himself/herself when inserting the needle. Once positioned properly, the needle emits radiofrequency to burn the sensory nerves. During this process, the patient experiences painful heating sensations. In addition, the pain relief generally lasts from 3 months to a year.

Terminator: Rise of the Robots (Case Studies: Pt.2)

posted Aug 6, 2014, 3:44 PM by Martin Strama

    Robotic devices are fully functional and operational in the OR. More specifically, the da Vinci robotic system is the dominant robotic platform. Such procedures that utilize the da Vinci Surgical System include laparoscopic cholecystectomies, gastric bypass surgeries and laryngectomies. Robotic platforms offer smaller incisions for major surgeries, more precision, and faster recovery times. In these operations, miniature wristed instruments along with a HD 3D camera are inserted and controlled externally by the surgeon at a console. The surgeon’s hand capabilities are expanded into micromovements of the wristed instruments. Although an incredible step forward, the wristed instruments of the da Vinci Surgical System lack tactile feedback. The incorporation of tactile feedback would allow surgeons to better assess their surroundings inside the patient, increase precision, and minimize errors in severing tissues. To address this issue, haptic technology should be implanted into robotic platforms. In addition, robotic platforms have no indication for which cables are which and where the cables are connected. For such a sophisticated system, there are no indications for malfunctioning equipment, which prolongs the troubleshooting procedures.

 

Anesthesiologists’ Complaints

    Patient-controlled analgesia (PCA) infusion pumps allow a patient to self-administer opiates at the click of a button for pain relief. Patients feel empowered and experience immediate results. However, one main problem is monitoring and recording the injections. Most of the time, someone other than the patient administer the pain medication in a situation known as PCA by proxy. PCAs are programmed to reject additional injections requested by patients who are oversedated. However, such safety features are overridden in PCA by proxy. Thus, physicians need to be able to monitor when the injections are occurring as well as who is facilitating such injections. Such information needs to be recorded electronically to EMRs so physicians can have immediate access to such information from their office.

    Currently used infusion pumps are bulky, brick-like, and not emergency-friendly. The pumps are stacked on top of each other on a pole and can be easily dislodged from position. The interface for the pumps are difficult to navigate and exhibit delayed response times. Many times, the IV pumps are unplugged and replugged for a quick restart. The drug library for each pump varies for each department. As such, the selection process becomes a hassle and causes delays. Infusions need to be seamlessly integrated into one system to drive IV standardization. Infusion pumps need to be compact, lightweight, and infuse a wide range of fluids. The pumps should include dose rate calculators, convenient drug libraries, and perform titrations of drugs. In addition, the exterior should feature a user-friendly interface with durable buttons. Furthermore, IV injections should be barcoded and scanned directly into EMRs with dosage.

Jackpot (Case Studies: Pt. 1)

posted Aug 1, 2014, 7:08 PM by Unknown user

    The best part of being in the anesthesiology rotation is that I am not confined to a single department in the OR. Anesthesiologist are everywhere. Thus, I am exposed to many different surgeries, and consequently, many different medical devices! How amazing. This is a jackpot for any bioengineer. As a result, I will be posting many different case studies along with significant medical devices utilized by both anesthesiologists and the surgeons.  

Deep Brain Stimulation to treat Parkinson’s

    In DBS, the patient was awake and under local anesthetics. The surgeon targeted the subthalamic nucleus with electrodes. These electrodes emit a radio frequency that correlate to the brain activity at their positioned location. Essentially, the radio frequency mimics brain responses and the brain waves are picked up on a monitor. The patient is awake in order for the neurologist to examine the patient during stimulation. The neurologist directs the patients with verbal and physical cues. For example, the neurologist would move the patient’s arm and listen for the electrode response. In addition, the surgeon would increase the current in the electrode to assess the maximum pain threshold the patient can perceive before muscle spasms occur.

Spine Lumbar Laminectomy

    In this operation, the anesthesiologists were concerned about the patient’s blood pressure because the patient had a weak heart. The two main medical devices/instruments utilized were an echocardiogram and a pulmonary artery catheter. The echocardiogram is positioned in the esophagus and uses Doppler ultrasound to produce images of the back of the heart. The images allow the anesthesiologist to assess the heart muscle, valves, contractility, pumping capacity, and tissue damage. The pulmonary artery catheter is used to monitor pressures in the heart chambers. To insert the catheter, the anesthesiologist created a central line across the patient’s chest using ultrasound. The anesthesiologist then looks at the EKG to make sure there is no irregular heartbeat as a result of the central line. The central line is then sutured to the patient’s skin for stability. During the operation, anesthesiologists are also concerned with cardiac output and cardiac index parameters. To obtain these parameters, a separate machine performs calculations on the EKG trace to obtain the cardiac output, and another requires the patient’s height and weight in order to obtain the patient’s body surface area, which is required to calculate the cardiac index. Thus, machines do the math for the anesthesiologists, which makes sense since they should be more focused on the patient instead of calculations.

Right Ventriculoperitoneal Shunt

    In this procedure, a small hole is drilled into the skull to allow a catheter to pass into a ventricle in the brain. The surgeon used an infrared pen to position and guide the catheter to the ventricle. Another catheter was guided in a similar manner down the neck, chest, and into the belly area. Excess cerebrospinal fluid drains down this catheter network in order to reduce intracranial pressure.

 

Anesthesiologists’ Complaints

During my lunch break in the anesthesiology break room, I engaged with some anesthesiologists to inquire if they experienced any problems with the medical devices. One anesthesiologist enthusiastically wanted all medical devices to be like a car in the sense that one would not have to read a user manual in order to operate the device. In essence, devices should be more intuitive with simple knobs and no icons. Make signals be straight to the point with words. Another anesthesiologist mentioned that placing the various EKG leads onto patients takes too much time. Additionally, the leads are attached to cables that clump together and create a mess.

Wires and the Concept of Breathing

posted Jul 30, 2014, 6:03 PM by Unknown user   [ updated Aug 8, 2014, 3:59 PM ]

    This week I began my exciting adventure in Anesthesiology under Dr. Edelman. When I first met Dr. Edelman, I could immediately tell that he was going to be a great mentor from his Squidward sticker ID badge. Dr. Edelman stated that no individual really knows what anesthesiology is because no one has completely identified the chemical pathways triggered by anesthetics. As a result, there is no standard protocol for anesthesiologists. Instead, there are suggestive studies that indicate ranges of anesthetics for given operations. Thus, each patient receives individualized care based on their medical background. In essence, anesthesiologists are the jack of all trades. There are neural anesthesiologists, cardio, ophtho, etc. Each area requires specialization and has their own constraints regarding anesthetics. Right off the bat I was immersed into two highly specialized neurosurgical procedures: a craniectomy involving the removal of a brain tumor in the pineal body (the center of the head) and a deep brain stimulation (DBS) operation to treat Parkinson’s. In the craniectomy operation, Dr. Edelman explained that the patient was put under local anesthesia as opposed to inhaled anesthesia so that the intraoperative neurophysiological monitoring technician could acquire meaningful invoked signals. These technicians monitor the neural integrity of sensory and motor functions. This is another example of how an anesthesiologist must consider all aspects of a given operation, from the staff to the actual procedure. It definitely feels like the weight of the world is on their shoulders at the beginning of any operation. To make matters worse, the patient was oriented in a sitting position. When under anesthetics, positioning of the patient is a critical consideration. Since the brainstem goes to sleep, a patient loses hemodynamic abilities resulting in lower blood pressure. Thus, a war wages on to keep blood pressure up to normal ranges. In addition, nerves need to be padded and tissues need to be relaxed. All the things sentient humans take for granted are what anesthesiologists need to monitor/regulate.

    When a patient enters the OR room, the anesthesiology team springs into action. They attach a pulse oximeter to a finger to monitor oxygen concentration; a blood pressure cuff on the bicep to monitor blood pressure; electrodes on the chest to monitor heart rate (EKG), an endotracheal tube via CCD video endoscope to allow respiratory functions and monitor CO2, and a bispectral index (BIS) strip on the forehead to monitor neural activity (analyzes an EEG and EMG signal and returns a number). The electrodes are oriented across the chest and transversely across the body. The CCD cable serves as a guidewire for the endotracheal tube and is utilized for patients with stiff necks or for patients with spine injuries. The cable is equipped with an oxygen port to blast away barriers and a camera that produces colored video onto a monitor. The anesthesiologist slips the tube onto the cable and tapes the end of the tube onto the cable. The anesthesiologist then proceeds to navigate the cable into the trachea via handheld controller by looking at a monitor. The CCD allows the anesthesiologist to look around corners. Once the cable has reached the desired position, as indicated by the markings on the cable, the anesthesiologist detaches the tube and manually shoves the tube along the cable. The BIS strip is based on an imperfect science where a number between 40-60 is usually accepted as indicating that a patient is under general anesthesia. In more fragile cases, real-time blood pressure monitoring is utilized via IV catheter. Thus, the anesthesiologist does not have to wait for the blood pressure cuff. To insert the IV catheter, the anesthesiologist has to locate a radial artery by palpating the artery. In essence, the anesthesiologist is blindly poking around until blood leaks.  

    Each sensor is attached via cable to a machine with analyzers for the various physiological parameters. One popular machine located in many of the ORs is the Dragus-Fabius Tiro. In addition, the machine contains ventilators and vaporizers. The monitors on the machine are touch-sensitive. In addition, the machine can be programmed to emit audible alerts for a given physiological variable. Thus, during the operation the anesthesiologist does not have to look at the screen to know which parameter needs attention because the alerts can be customized to emit different sounds. Based on the sound heard, the anesthesiologist knows which parameter needs attention.

    Given the amount of physiological parameters an anesthesiologist needs to monitor, one could guess that a lot of cables are involved. Indeed, a labyrinth of cables is formed on the floor. Everyone in the OR needs to watch their step at all times and navigate their way through this complex labyrinth. One would think that these connections would be wireless in this day of age given wi-fi, Bluetooth, or IR technology. I must say, the labyrinth is quite deadly.

Variables

posted Jul 25, 2014, 2:36 PM by Unknown user   [ updated Aug 1, 2014, 5:12 PM ]

    In a sense, doctors function as MISO (multiple input, single output) control systems. For a given patient, the doctor must extract vital information and piece the inputs together in order to form a coherent diagnosis. The information can be obtained verbally from a patient, electronically via EMRs, or physically from several different examinations. Patients are not alike, and so, the inputs vary from patient to patient. As a result, the constraints differ from patient to patient too. Furthermore, a trial-and-error process in often taken to refine the diagnosis, similar to a negative feedback loop. The process a doctor undertakes is almost analogous to the process an engineer takes when solving a problem. However, doctors can’t change their inputs while engineers can’t change their constraints.

    In addition, disturbances are dispersed throughout the system. One prominent disturbance is scheduling. Typically, the front desk schedules 50 consultations for a given day. However, the doctor can usually handle 35 consultations. Of the 50 scheduled consultations, approximately only 25 actually show up. Doctors have no control over such disturbances. If a patient does not show up, the doctor stands idle. Another prominent disturbance is language. A large portion of the patient clientele is Hispanic and speak Spanish. If the doctor doesn’t speak the patient’s native language, the doctor tries to overcome this disturbance by seeking the help of office employees who do. A translator hotline service is available, but doctors prefer in-person translations. The in-person translations allow the doctor to display hand and facial gestures to the patients while speaking to the translator. Thus, the patient observes the doctor’s gestures while listening to the translator.

    Medical instruments/equipment pose another disturbance for doctors. Doctors operate the phoropter and slit lamp in the dark or very dim light. Doctors must read and interpret the data from these instruments in the dark. A majority of the equipment is loose and hand-held. While performing retinoscopy, doctors manually maneuver a light torch horizontally and vertically. In addition, doctors must be familiar with many different instruments that cross different specialties. Children pose another disturbance for doctors. When observing children in pediatrics, a majority of children are uncooperative. To overcome this disturbance, the doctor asks the child’s mom/dad to sit in the chair with them and constrain them. Children get bored easily and have short attention spans. As a result, performing thorough eye examinations is very difficult. In addition, checking a child’s eye pressure is nearly impossible. Children who receive drops become scared of the doctor and environment. In essence, the child becomes emotionally disturbed. In such cases, the disturbances disrupt the system entirely.

    Today wraps up my rotation in the Ophthalmology department. I can’t believe it’s already the third week. Time is flying! I learned so much about eye care, anatomy, and the medical instruments currently utilized by the doctors to keep vision alive. This has been a rewarding experience. I am definitely looking forward to my next rotation in Anesthesiology!

A Balancing Act

posted Jul 23, 2014, 6:17 PM by Unknown user   [ updated Aug 1, 2014, 5:12 PM ]

    Patients are verbally summoned and guided from the waiting area to a patient room by a technician/resident. During the trip, the technician communicates with the patient on a personal level in order to provide a sense of comfort to the patient. The patient is then guided into an illuminated room. Upon entry, a patient always encounters a chair that is located towards the end of the room. Attached to the chair are the phoropter and slip lamp. These two instruments are relatively large and can be intimidating to children and adults alike. When not in use, these instruments hover to the side and often get in the doctor’s way during visual examinations. The chair also contains a foot pedal that repositions the patient to a comfortable level prior to using the phoropter or slit lamp. The foot pedal is often mistakenly utilized by the patients before sitting down. When the patient takes a seat, they look right and left for a place to put their personal belongings. Often the patients put their personal belongings on the floor, in their lap, on the phoropter arm, or on a chair located on the other side of the room. Furthermore, patients often have to get up and walk over to their personal belongings to get their glasses, medications, or documents. Rising from the patient chair and walking across the room may seem like a trivial task but it can be dangerous given the design of the patient chair. The patient chair contains a foot holder, which many patients forget about when standing up. As a result, many patients seem to “slip” off the foot rest.

    The whole introductory process could be streamlined with technology to better manage traffic flow, but would such technology be necessary? For instance, at Panera Bread, a buzzer is given to a customer after placing an order. The patient then finds an available seat in the “waiting area.” Next, the buzzer goes off when the food is ready to be picked up. This type of system can be easily implemented into the hospital setting, but instead of the buzzer going off, the buzzer would indicate to the patient that they are ready to be seen and could direct the patient to their room by displaying a room number. If such a system were to be implemented, personal interaction between patient and technician/doctor would be delayed. As a result, the patient could feel isolated, nervous, or even scared. In contrast, the technician/doctor could utilize the additional time to better acquaint themselves with the patient file to better communicate with the patient.

    After the patient is seated, the technician/doctor goes over their medical history. The patient file is either in electronic or paper format. Electronic medical records (EMR) are convenient for accessing a patient’s medical history, but lack flexibility in regards to data/figure entry. In contrast, paper records are convenient for data/figure entry, but lack the ability to view the patient’s entire medical history. Furthermore, both methods take time for the technician/doctor. Usually the technician/doctor asks a patient a question and writes/types the response. During this time, the technician/doctor has their back to the patient and silence fills the room. Instead of waiting until the technician/doctor sees the patient to ask basic questions regarding their medical history, patients should be proactive in the waiting room. Patients could be handed a tablet containing forms/documents that help gather necessary data regarding their personal and medical history. The data could then be instantly linked to the technician/doctor at their office to review before visiting the patient. This would give the technician/doctor an opportunity to personalize patient care beforehand. Furthermore, the technician/doctor could then directly communicate with the patient right off the bat. Patients prefer to see the technician’s/doctor’s eyes instead of their backs. Thus, technicians/doctors could be equipped with tablets to record examination results, etc. while keeping their faces visible to their patients. Since tablets allow the use of a pen, technicians/doctors do not need a keyboard and can “write” their notes directly into electronic format. Again, the question arises whether such technology is needed?

    I feel as doctors try to maintain a balance between technology and personal contact with patients. Many of the instruments utilized by ophthalmologists call for patient cooperation and patient contact such as light torches and loose lenses. However, such instruments require manual operation. As a result, the doctor’s hands often get tired. Nevertheless, patients are engaged in their examinations and are not just visitors.

    This post was mainly to address the balance between technology and personal care in regards to servicing a patient. My next post will try to be more geared towards observations relating to pathologies/conditions.

Second Week Down

posted Jul 18, 2014, 2:55 PM by Unknown user

    On Thursday, I had the privilege of observing Dr. Azar in the OR. The OR room was different compared to the other rooms in terms of layout and equipment. Upon entry, one could tell the room was grounded to prevent electric shock hazards. Various cables terminated into the walls from doors and windows around the room. Towards the bottom of the room were green and red outlets. Anything plugged into the red outlets will be powered by a back-up generator in case the power goes out. Thus, the operation would continue and the equipment would still maintain functionality. The OR room had no three-head microscope or a visual monitor to view the procedure. I was a little discouraged by the lack of a visual monitor because I thought I wouldn't be able to observe the operations in detail. I soon found out that a monitor wasn't needed because the operations were macroscopic when compared to cornea/retina surgeries. In other words, one didn't have to utilize a microscope in order to view the extraocular muscles around the eye.  Instead, Dr. Azar and Dr. Namavari utilized magnifying headsets. In addition, fiber optic headlights were utilized in order to increase the intensity of light around the eye; the lighting required varied from operation to operation. The room temperature was manually controlled and was often deceased to temperatures in the fifties. As a result, lots of blankets were wrapped around the patients in order to maintain normal body temperatures. The operations always began by cleaning the eye areas, especially the eyelashes since they carry the most bacteria. After cleaning, the eyes were isolated with transparent sheets from 3M. During the operation, swabs were often utilized to absorb blood from the vessels. Visualization is critical for any operation. Except for the use of the cauterizer, the operations were manually performed by hand. When in use, the cauterizer generated loud noise pulsations. Frequently, chunks of fat/tissue would stay on the forceps and were dislodged manually by hand. The doctors manually twisted suture threads to create square knots. The best part was hearing Dr. Azar sing to the Pandora radio playing on the computer in the background.

    On Friday, I had the opportunity to observe a visual field test. The test can be electronically or manually administered depending on the severity of the condition of the patient. The technician informed me that the manual visual test is administered to patients who need a more thorough examination or who cannot react quickly to the visual cues. In a manual visual field test, a patient uses a buzzer to signal that he/she saw a light at a particular location. The examiner then records the location where the patient had buzzed in. The buzzer is loud, frequent, and annoying. Furthermore, most of the equipment squeak loudly when positioning/moving them.

    Two-thirds done with my rotation in ophthalmology. I have learned so much about anatomy and physiology of the eye. I only have one problem. I might be considering an MD, PhD. Oh. My. Goodness.

Fire the Laser!

posted Jul 16, 2014, 7:41 PM by Unknown user   [ updated Aug 1, 2014, 5:13 PM ]

    I began the week observing doctor/patient encounters and patient testing in more detail. When conducting the basic visual examinations, many of the technicians and doctors had to squint their eyes to read the small numbers on the phoropter. The difficulty of reading the numbers increased when the lighting was dimmed to perform a visual acuity test - a test to determine the smallest letters a patient can read from a standardized chart given a certain distance. The visual acuity tests were performed on electronic monitors or displayed on a wall/door. The electronic monitors are controlled via remote or tablet. When using the remote, many of the doctors selected the wrong option because they could not read the font on the remote in the dark. When using the tablet, the screen would go to sleep due to inactivity and would have to be woken up constantly. At times, the phoropter had to be adjusted several times for a given patient because the patient was leaning forward and not making use of the chair.  Before the patient is positioned into the phoropter or slit lamp, the head/chin rests are sanitized. Some doctors use the paper sheets on the chin rest to sanitize. In addition, only the chin rest of the slit lamp can be adjusted for patient comfort, not the headrest. Adults are usually able to comprehend and follow the doctor's instructions when positioned into these instruments. In contrast, doctors use visual aids on children to get their attention such as stickers, movies, and hand-held devices. I saw a sticker attached to an indirect ophthalmoscope to help a child focus their attention onto the doctor during a retina examination. After the examinations, the doctor would give verbal instructions to the patient / patient's parents regarding treatment procedures and medication usage. Some doctors utilized a "Return Appointment Form" that contained the patient's barcode. On that note, each patient receives a sheet of sticker barcodes in their file. The barcodes are peeled and placed onto various forms that relate to the patient. The barcodes help organize patient data electronically. The electronic cloud service/software contains various tabs that help categorize vital information including chief complaints, illness history, health status, symptoms, and physical examinations. Although the service organizes patient data, the service is limited by human input. Recent tests and examinations on patients were not readily available to doctors because the files were not scanned into the system over the week period.
    
    I never realized how much physical contact ophthalmologists had with their patients. The doctors have to almost always physically pull their patient's eyelids apart. The doctors also position their patient's head into a certain orientation/direction. Furthermore, doctors often have to hold loose lenses in one hand while holding a torch light in another. The doctor would place their fingers on the patient's forehead to stabilize the lens to a desired position. This also occurred when using loose lenses with the slit lamp.

    Towards the middle of the week I observed several retinal detachment and vitrectomy procedures performed by Dr. Lim. These procedures utilized a more complex aspirator/visual system that powered a laser to patch the retina. The system was color-coded in order to correctly attach various tubes to the machine. In addition, the machine verbally confirmed any modifications performed by the surgical technician. Furthermore, these operations came with their own tray that contained the necessary instruments for the procedure. The tray also included the labels for the instruments and provided the technician with an overview of the required instruments/medication for the operation. Dr. Sugar mentioned that some of the microscopes contain a light source defect that only supply 20% of the light from the source to a head. Ideally, all three of the microscope heads would have full illumination and stereopsis/depth perception in case the doctor required additional help during surgery. In addition, Dr. Dela Cruz demonstrated a laser surgery using a LenSx Laser System. The system was the first femtosecond laser cleared for cataract surgery. Essentially, the doctor creates a template on a monitor, follows a series of steps to modify settings and ensure safety, and clicks a button. The laser makes the desired incisions, and the doctor aspirates the left-overs. The technology is so advanced that the hospital actually loses money when using the machine on most patients (approx. $300 per use of the docking station and $50,000 per contract)! On the bright side, the surgery time is drastically shortened. I love to see bioengineering at work! I just wish it could be more affordable to the general public.

    As a side note, younger doctors seemed to use more newer technologies when performing visual examinations as opposed to senior doctors who preferred the more traditional technologies.

Surgical Connections

posted Jul 13, 2014, 7:23 PM by Unknown user   [ updated Jul 13, 2014, 8:08 PM ]

    The operating room, the OR, or the panic room is a daunting place for anyone who has never set foot in the place. As I entered the main OR entrance, I noticed that everyone had hair nets on, foot slippers, and scrubs. It was like being inside an ant hill, except the ants were trained OR personnel. Each person had their own job, was rushing about, and seemed overworked. Before entering the OR, I had to put a mouth mask on for sterilization purposes. I looked great! Entering the OR room, I encountered the main staff: a circulating nurse, an anesthesiologist, and a surgical technician. This trio was prepping the room for the upcoming operation to music played from an iHome docking station. Each person had their own corner workstation in a sense. The room seemed cluttered with equipment and loose, unlabeled cables/tubes. The surgical technician sterilizes the room by placing sterile, blue sheets onto medical equipment and instrument trays. These areas are considered sterile and cannot be touched by unauthorized personnel. The surgical technician told me that everything used in the operation is labeled with a pre-printed label prior to the operation. If a label is missing, the technician must hand-write a label with a marker that can smudge. Also, the technician and nurse must exchange verbal confirmations before exchanging fluids/medication between each other. The technician also mentioned that the chairs utilized by the doctors are uncomfortable. After sterilizing the room, the patient was wheeled in on a stretcher and placed in the center of the room. Upon entry, the patient was exposed to bright lights and a chaotic atmosphere. When positioned in the center of the room, everyone cluttered around the patient. I was beginning to feel claustrophobic for the patient. In addition, the patient was not put to sleep and was able to communicate with the doctors and personnel. The team performed a quick verbal debrief before starting the operation. The patient’s file was placed beneath the patient’s feet on the stretcher. There was no dedicated place for personal items or desk space for paperwork. I observed Dr. Tu, a cornea specialist, perform multiple cataract surgeries and corneal transplants. Observing the beginning, middle, and ending of these surgeries was a great experience. I saw how the donor corneas were packaged, extracted, and modified for the patients. While trying to find weak points in these surgeries, I could not. These surgeries were so elegantly performed and averaged half an hour. I asked Dr. Sugar if he knew of any weak points, or places that can be improved upon. Dr. Sugar told me that there is no standard protocol/procedure for these operations. It was up to the doctor to use whichever technique he pleased. Furthermore, Dr. Sugar told me that the standards for these operations would be changing soon to techniques that are currently used in Europe. Currently, an aspirator and image inverting microscope with two teaching scopes are the two main instruments used by the doctor to perform the surgical procedures. The aspirator contains several functions that sculpt and irrigate the eye during the operation. Dr. Sugar said that the current medical equipment utilized are outdated, but do not constrain the operations in any significant way. New instruments utilize a cloud-like service that allow the doctors to prep for the operation in their offices beforehand. The doctor must be comfortable using two feet pedals at the same time to operate these machines while performing the operation. I got to operate the foot pedal for the inverting microscope, and it was extremely difficult. Dr. Sugar pointed out that most doctors wear only socks to operate the foot pedal because they need the freedom of motion. The skill needed to be comfortable using these foot pedals while operating is unbelievable. Aside, I was astonished to see how steady the doctor’s hands were when performing these operations. In addition, there was no place for the doctor’s hands to rest. Furthermore, the patient’s chest was utilized to hold medical sponges and forceps. Also, folded sheets were used to comfort the patient’s neck. In addition, a holding sac was creating by the side of the patients head to hold the liquid oozing out of the patient's eye. After the operation, the patient was comforted and taken away into the ant hill. The OR was then turned over for the next patient, and the process repeated. After four operations, I could only image how tired Dr. Tu’s arms were. I definitely enjoyed the thrill and rush of being in the OR.

    Furthermore, on Friday I got to shadow Dr. Shorter in Contact Lenses and Dr. Chau in Retina. In Contact Lenses, I learned that the PROSE contact lenses are like a six month long surgery. The patients need to constantly make appointments to come back and refit/reshape their contact lenses for comfort or for more refractive power. In Retina, an indirect ophthalmoscope is used in conjunction with magnifying lens to view the retina. Another machine emits ultrasound wavelengths from a probe onto the patient's eyelid. This instrument is non-invasive, provides high resolution pictures and videos of the retina. In addition, optical coherence tomography (OCT) is another method used to get the cross-section of the retina to view gross cell layers. Both of these services utilize drops to treat the patients. Patients primarily identify their medication using the cap color of the bottle if they do not recall the name of their medication. Patients are also asked the same questions by the nurse and doctor regarding their medical history. This redundancy allows the patient to extend his/her responses, but may not always be to the doctor. When interviewing the patients, the doctor asks the patient for personal contact information to update their records so that the patient can receive messages from the doctor's office. The patient could be updating their personal information/medical history while waiting for the doctor in the waiting room instead of sitting idly by doing nothing productive. I underestimated how much a barrier information flow is in a clinical setting.

    
    All in all, an awesome, eventful week. I am looking forward to learning more in the coming two weeks!

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