Bioengineering Clinical Immersion

Week 6 Anesthesiology
Wednesday August 13th

How Products Get Bought

By complete serendipity we had an opportunity to observe a meeting of OR nurses. They happened to be reviewing a spreadsheet of which products they want to buy. The following is a lightly edited version of my notes I took down on Evernote:

Senior nurses sit together deciding what equipment they need. They are mid career people, experienced but also young enough to not be counting the days till retirement. 

Packaged deals get you a discount from Strykr. The hospital did not go with that option, unclear why.
Have to consider marginal costs (battery replacement, how cheap is to fix, how quickly do we need a replacement)
 
"How many times does this break...Has that effected patient care."

Doctor XYZ is complaining about ABC. The squeaky wheel got greased.  
At conferences world renown doctor lies to other doctors about having 3D vision microscope. 3D is not for patient care; it's for educational and research reasons. (Nurses discuss whose budget this device falls under.)

They use combined experience of how the office works, how devices get used. The third floor ORs will be remodeling in a few months. 

Excel spread sheet:
Service, ranking preferences for each category, Manufacture, Notes (links to brochures and pricing). 

Brochure links are ignored

Renting rectal probe for $1,000 per operation was considered a good deal. No need to buy. 

Synframe in spine curette tray removed from list while laughing. 

$3k for spine fusion is cheap. But they are not needed; enough are lying around. There is a department at the hospital that figures out how much inventory waste vs the cheap cost. 

Parts are out of date on some equipment in the OR. Once the device breaks "SOL"

Old device makes noise. "Is it supposed to do that?"

Device Blank is good for 5 years. We keep Device Blank for 7 years. 

The goal of the meeting was too rank preferences for each medical device requested by group LMNO in each category. And then send that out to QRS. 

 

Week 6 Immersion Review
Monday August 11th

Part One of Reviewing the Immersion Program

Three Weeks:

I think rotations lasting three weeks can seem long. However I found that I was not really able to appreciate the nuance of a medical specialty until I had adjusted to everything. On the first day of ophthalmology I showed up cold at the glaucoma department. I didn’t know the first thing about how to examine someone’s eyes, how to looking into a teaching side scope, or how to interact with patients and staff. By the end of the ophthalmology rotation I was able to diagnose people with cataracts in 2 seconds. And felt comfortable in my role as a suede medical student when interacting with staff and patients. Similarly in anesthesiology, I spent the first few days going: “that’s really cool”, “that’s really sad”, ‘that’s really disgusting”, and “those are a lot of words I don’t understand”. But after I got used to all of that stuff I was able to understand the typical workflow that an anesthesiologist goes through for each patient. Towards the end of both rotations I felt like I knew how to ask more relevant questions concerning what doctors would like from engineers and also what are their top worries were during a procedure.   



Week 5 Anesthesiology
Thursday August 7th

Pictures

This is a neuro-radiology room. In the foreground you can see the patients brain vascular on the screen in the monitoring room. In the other room you can see the anesthesiology monitoring equipment and in the background is the radiology machines. They are able to obtain a 3D view of a patient's vascular system. 



Week 5 Anesthesiology 

Wednesday August 6th

Pain Clinic
First procedure was an epideral to the back for leg pain. X-rays were used to find the correct placement in the spine. The patient was obese so the 9 cm needle was not quite long enough. The physian needed to press in an extra 0.5 cm to reach the correct location. Normally a needle can be left standing in a patients back, allowing the physican to have two free hands. But in this case the he needed to always keep a hand holding the needle. There is a 13cm needle option but physicans don't want to acciently push to far into the spine, so they avoid using the 13cm. Maybe a 10cm option should be made. (This might lead to miss readings, and hence spinal punctures for the smaller patients.)

Second procedure was an ultrasound aided heat injection. The location near the ribs was found using ultrasound. Heat was radially injected to cut off nerve sensation in the mid area of the body that was damaged in another procedure. The tempature was 80C. The patient was very in great pain during the enter procedure: finding the needle location, injecting a numbing agent, and having the hear treatment for 90 seconds. 

Third procedure: Another epidural injection. Using an X-ray device a physican can zoom in on an injection area after initial general location is established. This is done for two reasons1) to increase contrast on screen, which leads to better locating needle and vertebra anatomy and 2) to reduce radation exposer to everyone in the room. 






Week 5 Anesthesiology 

Wendsday August 6th

Residents Meeting

Oximetry
uses light monitoring(spectra), safer than leads that can shock; 

Causes of false readings:
methylene blue causes problems, xenon lamps, montion, nail polish

Beer-lambert law: 

Arterial Pressure
Small changes in artery diameter cause large pressure changes

Have to rest transducer everytime patient moves, bed with head up or down


Resperation:
Pulsus parox


Arterial catheter:
0.1 percent problem, invasive monitoring, 
CVP venous catheter:
What is it: volume status: volume of what: preload of heart, inter vascular volume, It is a ratio capacitance to volume assumeing capacitance stays the same, frank star lying curve
Makes a lot of assumptions, volume, nutrients 
Damage of tissue?


PA catheter (swan-ganz):
Cardiac output
Mixed venous oxygen partial pressures


Noninvasive cardiac output:
Impedance monitoring
Something
Stroke volume variation svv

Gas Analysis:
Ramon standard worse
Mass spectontor to big too expensive 
Photo acoustic spectrograph blueRay beta


Capnigraphs:
Safety in children?
Works in awake people
ETCO2

Hypothermia?: 36 degrees core, 

Brain function monitoring: 
Recall of surgery 1:500
Bis. awareness optimal monitoring 60
Asa on evidence: not required and not harmful
Disposable cost of $.5 billion annually
Is it really worth the extra cost?

Echocardiography:
Ultrasound, 
Trans a surgical echo 
Behind the heart, mostly benign, can damage small patients(Pedactrics), mostly not that bad
Askimiea monitoring? YES
Dopler, phase shift of blood movement BART blue is away red is towards

Evoked potentials:
Electrical responds to stimulus, response time, amplitude, 

Somatosensory evoked potentials: spine case, dorsal root, postal columns, up neck to sensory cortex. Most drugs that ano gives makes these things hard to measure for neuro monitoring. 

Finding baseline 

Motor evoked potentials 


Pain Clinic Post-Op surgery rounds
Ice bag rests on IV pump. 
Nurses personal bug is by the door, near foot peddles 

I am writing this in my iPhone's Evernote app. This is how I take notes as I shadow. I pull these notes into a word doc and then narrow it down to a few topics and make sentences. 


Week 5 Anesthesiology 

Tuesday August 5th

Vendors
For many operations vendors from outside companies are present. The vendors are easy to identify because they wear red hair nets, while everyone else wears blue hair nets. (Sidenote: because everyone has the same uniform in the OR suite its difficult at first glance to tell if someone is a world renown surgeon or a janitor.)

The outside vendors are not just sales people dropping off an implant for a surgeon. They provide mechanical sterilized tools to implant devices, in orthopedics. In neurosurgery a vendor took pre-op monitoring information from an electrical stimulus device, before a replacement surgery happened. He programed the reading device for the surgeon and prepared the new implant before it entered the sterile field. This vendor had a background in law.

Another vendor spend the day monitoring the use of his companies equipment in three operating rooms.  Still another vendor was a clinical medical worker. He did neuro-monitoring when people the hospital was understaffed. 

Except for the neuro-monitoring vendor none had degrees in  science or engineering; instead they had degrees in law, finance, and business. 


Week 4 Anesthesiology 

Tuesday July 29th

Brain Stuff
At 6:30 am there were two half hour meetings: one small group listened to a presentation on a neurological disease and a larger group went over titration. It was a resident student that gave the presentation on moyamoya disease. UIC sees a moyamoya case about twice a year, this makes UIC a high rate hospital for treatment of moyamoya. Most of the people in the room had more experience treating moyamoya than the resident giving the presentation had.

We observed two operating rooms and saw two and a half operations. From 7-730 people got ready for the day, meet the patient in the holding pen. One patient required a MRI before the operation, we saw them as they left for the MRI. Another patient was having a tumor then were pushing the patient to the or by 7:30. Preparing the tumor patient for the neurosurgeons took the anesthesiologist  over an hour. The anesthesiologist have to consider every thing from a patients medical history to their posture during the surgery to neurological interactions that could bother the neurosurgeons when treating the patient. It took the anesthesiologist about 40 minutes after the surgeons where finished to get the patient awake and prepared for recoveryThe patient didn't leave the operating room until 2:40pm. 

In the other operating room a patient was being treated for Parkinson's disease by injecting an electrode into the correct place within their brain. The patient only received local anesthesia. The anesthesiology resident mostly check vital signs.   

Alternative Careers
We meet a neuroengineering graduate student in one operating room; she was an intraoperative neurophysiology technician. She monitored the patient's nervous system throughout the operation. There are two in-house IONT at UIC. When they need a third an outside vendor. During the third operation of the day I meet an outside vendor. He was a biology pre-med student. While shadowing he discovered the IONT career. It's actually a prefect job someone with a neuroengineering background because the technician has to know when an 'odd thing' is the technology's failure or the patient is having a serious neurological issue.


Week 4 Anesthesiology 

Monday July 28th

Closing Time
In the morning the old groups went over the last three weeks of their accumulated knowledge. We then presented them to the class. We did this in order to prepare for our final presentation and report. It was a helpful exercise to unlock new information via information we all ready gathered. I particularly like the 2x2 matrix (side note: it should be called 'the Cartesian plain'). I broke matrix in to high tech vs low tech and common usage in a typical visit vs uncommon usage. This helped me frame the medical equipment in a new way. 

Knockout Introductions
We meet with our mentor at 1pm. He gave us more reading material, about the general history and categories of anesthesiology . Showed us the basics of surgery etiquette: how avoid nurses yelling at you. Showed how to get our scrubs in the day before we use them. 

Week 3 Ophthalmology

Wednesday July 23rd

Differential Tear Buckets The Saga Continues 
Current State
To much tear production due only to poor signaling in the nervous system is uncommon. 
However poor drainage is a problem. The current solution is to implant a plastic tube that starts at the bottom corner of a patient's eye and runs into the patient's noise. The problem with the eye to noise tear drainage is that the tube acts as a noise to eye snot pipe when a patient blows there noise. It is also uncomfortable. 

Dryness is sometimes caused by to much drainage. When this happens physicians insert a plastic plug; for some patients the plugs come out between visits. Another solution is to cauterize some of the drainage ducts. Cauterization usually requires a few treatment visits before it is effective.

Future Research
Dryness is sometimes caused by an inability to control the eye lid. Usually related to a damaged cranial nerve V. 
Things that have been tried but are not great solutions: springs to keep the eye shut, sewing the eye shut, sewing the eye almost all the way shut and then adding cream constantly, gold or platinum weights in eye lid. 

Observations 
Today I saw a topographical mapping of patient's eye. The patient had cornea transplantation surgery recently. The topographical map showed how tight the stitches in the cornea were. This helped the doctor know which stitches he should remove. 



Week 3 Ophthalmology

Tuesday July 22nd

Differential Tear Buckets
Eyes are buckets that hold tears. Tears come into the eye from one set of ducts and leave through another set of ducts. And the eye acts as a bucket that holds tears. 

Case 1: 
There is an ideal level of tear volume in the bucket, lets call this Videal. Nothing more to say about this.

Case 2: 
An individual with dry eyes has a tear volume that is less than ideal, Vdry < Videal. 
Cause 1: To much drainage from ducts. Solution: Block some ducts with plastic plugs.
Cause 2: Not enough tears coming in. A possible cause: stimulus system broken. The nervous system is not telling eyes to produce tears. Nervous system does not sense stimulus on cornea. Current Solution: Take eye drops every three hours. 

Case 3: 
Individual who cries (non-emotionally, no irritating object, etc) has a tear volume that is more than ideal, Vcry < Videal. 
Cause 1: To little drainage from ducts. Many possible reasons: inflation from infection causing skin problems... Solution: Depends on what the problem is. Treat inflammation with medication. Implant plastic tubes to open duct work. 
Cause 2: To much tear production. Possible cause: overly sensitive nervous system. 
Solution: Depends on what the problem is. 


The controlling the nervous system at some point in the response cycle  is one area for an engineering solution. 

Week 3 Ophthalmology

Monday July 21st

Cornea Clinic
I shadowed a cornea specialist in the afternoon. As part a patient's cornea visit they also examined her retina with an ultrasound machine. The doctor explained that the machine they have in the Cornea Clinic was the least refined ultrasound machine in use. 

Another patient was prescribed a few different medications. Some of the medications treated eye problems not related to the cornea. And other medications did not treat eye problems but caused side effects which damaged the patient's eyes. Additionally the patient was not using some of the eye mediations because the patients insurance was removing benefits randomly. The doctor had to write a letter for the patient. The doctor wrote the letter by calling a number and dictating the letter to a voice mail service. The dictation was done in front of the patient. All of this made a decision to preform cornea surgery on the patient's better eye harder.


To Cut or Not To Cut
In every department doctors go over risk-benefit evaluations several times before scheduling a surgery. Doctors try to avoid operating on a patients "good eye". If a doctor does not preform surgery they are even more wary to refer patients to an outside surgeon for fear of recommending a surgery that will damage the patient.

Doctors also make sure patients can fully articulate why not having surgery is damaging to the their quality of life. "Can you drive?" , "Do you drive?", "Where do you work?", "What do you do for fun?", "Theoretically could you live your life with just your left eye?", etc. 

Often doctors require second visits before even scheduling surgery for a patient. This is especially true in pediatric strabismus. In pediatrics doctors have to explain to patient's parents why not having surgery (or not keeping up with treatments at home) will negatively effect their child's quality of life. This is especially hard when parents do not speak English. 


Week 2 Ophthalmology

Sunday July 20th

Full Immersion
As I shadow ophthalmologist I wear glasses. On Tuesday a doctor correctly guessed my glass prescription just by looking at the glasses on my face. On Thursday I was in surgery with the same doctor. During an end of the day conversation she mention I should see a retina specialist. She explained that I have a long eye, which causes nearsightedness. My prescription is strong which means I have very long eye. The irregularity of the length of my eye is causing extra pressure and distortion my retina. This conversation took place in a hurdle that included a medical student, a fellow, and two fellow engineering immersion students. All of whom where making eye contact with me as I was getting a medical diagnosis. Mean while the doctor was throwing in words like myopic. So while I'm going through the emotional ride of suddenly being told I might go blind randomly at some point I am trying to remember strange words to look up later and I have to make eye contact with people that know more about my medical health then I do. In addition to all of that I'm asking myself when can I fit in an appointment, will my insurance cover such a visit, and can I get this all done before I have to switch insurance providers in a few months. And luckily I speak English naively and have some education in medicine and science unlike many patients I have seen.

I think the biggest take away from all of this is too have a friend or family member with you on your visit. The other interns where able to remember the medical terms for me. Someone who is not directly effected by the medical advice is in a better position to remember what exactly happened, what medical advice was given, and what next steps where given and implied. 

From a clinical observation perceptive I think it would be a good idea to give patients a hand out that explains their medical condition. I also think patients should leave writing down the diagnosis, next step, and where they are at within the overall diagnoses-treatment time line. Even within the Ophthalmology Department each specialist office and doctor have their own system. Some doctors walk the patients to the receptionist, say what the next step is to the receptionist with the patient present, and then leave. Others write down on a form all of that information and let the patient bring it to the receptionist. Still others verbally tell the patient what the next step is and hope that the patient can internalize the information and then communicate the next step to the receptionist

I see potential for an app would help organize, store, translate, and communicate patient information. The patient is currently responsible for knowing most of their medical history and diagnosis. Making it easer for them to carry this information would ease patients anxieties and allow for better medial care. However the patients who would most benefit from such an app seem like late adaptors to technology. I still think such an app would have value for the assertive-tech-savvy-native-English-speaking-science-educated individual


Week 2 Ophthalmology

Saturday July 19th

Instruments for testing eye pressure
There are many ways of testing eye pressure in a clinical setting. The most common way I saw in practice was to use a device called a Goldman tonometer. The Goldman tonometer is part of the split-lamp microscope set up, which is in every room. The Goldman tonometer is a lever. The working end of the lever touches the patient's cornea and the lever's fulcrum has a set level of tension or resistance. The tension is adjustable by the physician. The level of resistance is set based on the thickness of the cornea. The thickness of a patient's cornea is typically not known with great precision, leading to one cause of imprecise measurements. However this imprecision is not necessarily the leading cause of concern in this area of practice. If a reason seems out of bounds there are more pressure ways of measuring eye pressure. 

A patient's pressure is only measured during office hours. But eye pressure varies day to day and fluctuates over a single day. For patients with diabetes variability in eye pressure is particularly important. Currently researchers are testing contact lens tonometers (CLT). CLTs can be warn by patients through out the day allowing tests to occur at many times during a day without having to be in a clinic. Without CLTs there is no practical way to measure a patients eye pressure throughout the day. CLTs have been shown to have a high correlation (0.98) with Goldman tonometer readings (http://www.iovs.org/content/38/12/2447.full.pdf).


Week 1 Ophthalmology

Saturday July 12th

On Thursday we observed cornea and retina surgery. On Friday I observed contact lens in the morning and retina in the afternoon. 

The Building and Floor Plan
Patients have to take an elevator to get to the eye care departments on the second and third floor of the Eye and Ear Infirmity. 

The elevator on the second floor lands in a vacant hall way. On the third floor the elevator lands in the footpath of a waiting room. It is not obvious where to check in, often patients go to the cornea area to the left, instead of the general check-in area to the right. 

There has been little remodeling or maintenance for the specialty patient rooms in the Southwest of the third floor. For some reason there is a bathroom in each visiting room and the paint on the walls is from the Reagan Administration.

The Ophthalmology Department is spread out between the second and third floor of the Eye and Ear Infirmary and the first floor of a building next door.

Information Flow
Retina is the only clinic that has an exit form for the physician to fill out. This helps with organizing next apartments. 

Redundancy in patient interviews from physicians and nurses is efficient as the patient is more willing to reveal symptoms as the exam unfolds, especially if the different people are directing the interview.

Patients spend a lot of time sitting when they could be checking basic information, such as making sure their cell phone number is up to date. 

Patients rely on the color of eye drop caps in order to identify which medicine is which. Drop companies may want to invest in simpler names and unique cap colors (combination colors). The department may want to create a one-page-cheat sheet that identifies cap colors and medication. Possibly make individualized sheets for physicians and patients. 

Equipment
In clinic, physicians have to remove very fine and very short eye lashes with tweezers. Tweezers that have any dents or gaps fail to remove fine eye lashes. Basically, tweezers that have been used for many cycles are incapable of performing the job of eye lashes removal. Some times doctors go through three sanitized tweezers and many attempts before they can remove the eye lash. Each additional attempt is wasted time and another chance for the patients cornea to be damaged.

Week 1 Ophthalmology

Wednesday July 9th

rotated between four different subspecialties in the ophthalmology department the first two days. I spent time in glaucoma, cornea, pediatrics, and neuro ophthalmology. 

I notice problems or workarounds in three categories: communication, equipment, and floor plan. 

Communication
Each subspecialty has its own system for record keeping. Most of these centered around writing paper notes. In glaucoma and cornea scans of the notes are used during follow up. In pediatrics doctors are strictly paper for everything but ordering prescriptions. 

In neuro ophthalmology the resident and attending physician record notes on a continually updated Word Document on a Windows 98 laptop. The technician takes notes using a different computer and a specialized software. Finally all images from previous visits are stored on a UIC website system. These images are pulled up using Internet Explorer on a third computer.

I felt like sometimes patents did not understand the next step they were supposed to take. E.G. "Come back for a yearly check up. But you can't schedule an appointment a year in advance. Do it in 6 months." To someone who is elderly or with non-native-English skills that statement sounds like the patient should schedule an visit for 6 months from now.

Referrals from generalist can also be tricky. The patient is required to provide most of the information regarding their medical history and reason for being referred. This is because most information sent from the referring doctor is stored on multiple non-searchable PDFs. If patients are not familiar with the exact medical terminology this can lead to poor diagnosis and lost time. Patients bringing paper from their referring doctor helps, but seems demanding on patient and far from ideal for medical professionals in 2014.

Equipment
Two medical equipment related problems. 

1) Pulling eyelashes. Doctors have a hard time pulling tiny eyelashes. The tweezers used to pull eye lashes are sometimes not fine enough to attach to the eyelash. 

2) When testing peripheral vision on young people the Octopus 900 is great, however for the equipment refreshes to fast for the reaction time of old people. Old people use the Goldman Perimeter which requires a technician to operate. It seems like the Octopus just needs a simple software fix.

Floor Plan
The building was opened in 1965 and has major layout issues regarding the location and size of waiting rooms, reception desks, and patient rooms. I will tackle this in Episode 2 of Week 1.