Neurological Surgery
I also have been working on my clinical research project evaluating effectiveness of two different treatments for aneurysms, and have obtained some interesting results. I will be presenting my research project in the seminar meeting in
Overall, I gained a lot from this experience, especially in terms of realizing that there are many areas that still need technological improvements. I would like to thank my clinician mentor, Dr. Riina, and also Dr. Gobin and Dr. Chapple.
Finally, I convinced myself to watch at least one open heart surgery. I was surprised at how invasive the whole procedure was. The doctors’ basically sedated the patient, sliced his chest open, and then pulled his ribs apart using their bare hands or a crude mechanical device. It was almost like watching a scene out of a movie with hygienic zombies in scrubs trying to carefully eat the victim’s heart. Okay, maybe that’s an exaggeration. What followed was a bit more impressive. They bypassed the patient’s arteries, immobilized the heart using high concentration of potassium chloride, and then made an incision in the heart in order to replace the mitral valve. The following picture is borrowed from its.med.yale.edu. It depicts a mitral valve replacement.
Apparently, this particular patient had mitral valve regurgitation. This was evident from his transesophogeal echocardiogram or the ultrasound measurements. One could see that the oxygenated blood that entered the left ventricle through the mitral valve periodically reentered the left atrium. In most cases, a patient’s valve is irreversibly compromised due to either ischemia, stenosis, or infection. These problems are usually onset due to coronary artery disease, age, or rheumatic fever, respectively. However, congenital defects are not rare.
In the patient’s case, the problem was caused by ischemia through coronary artery disease. As a result, the doctor had decided to replace his valve with a bovine valve - the reasons for choosing a bovine valve or a mechanical valve were explained previously by Dickinson. It seemed as though the stitching of the valve required great dexterity. One of the more skilled residents tried to stitch the valve but it seemed as though he could not make the more difficult 10-12 o’clock stitches. As a result, the primary surgeon took over and showed him how it should be done.
One could definitely make it easier for these doctors by developing an innovative device for sewing. In fact, I don’t really know why a big hospital like NYP still uses open heart surgery for such cases. There are hospitals that are performing these types of procedures percutaneously using the da Vinci surgical system. I think that’s the way to go. If not, the least one should do is make something that replaces the “needle and string.”
Generally, an incision is made around the nipple and the nipple is then removed and a new nipple relocation is added to raise the nipple site to fit with the new smaller breast. Tissue is removed along with skin and then brought in downward to close over and shape the new breast. Scars will remain around the nipple, extended to the crease, and through the crease as seen in the pictures. Later that day, a patient came to office hours to be consulted for a breast reduction. Mistakes were also discussed where the reduction produced breasts that were very asymmetric and occasionally with nipples that were misplaced. Many of these complications arise because the doctor works with an assistant on one side or because of shifts from laying on teh operating bed to getting up. This really brought the talk together because I went from the academic discussion to the patient doctor interactions. During this week I was able to observe a few more surgeries and attend a few more rounds. I was luckily able to scrub into another tracheaesophageal fistula. The patient was two days old and had a type C fistula which consists of an upper esophagus ending in a blind pouch and a connection between trachea and fistula. Dr. Spigland was able to occlude the fistula and connect the esophagus back together.
However, during the esophageoesophagus connection the patient’s lung did not infant. The lung appear very deflated and small. A code blue was called and within 1-2 minutes a barrage of nurses, residents, and attendings came to help out. They ran into the room with concern expressions and eagerness to help out. The attendees quickly got the patient to start breathing again using manual ventilation. There was a pediatric cart in the room in case the use of a defiberator was needed. In actuality, most of the people who rushed in for the code blue just stood around watching while 1-2 attendees did all the work. But it’s a good sign when over a dozen people rush into the room minutes after a code was called.
I was able to make progress on my research and conclude some aspects of the project. I will continue to collaborate with Dr. Spigland on the research project dealing with esophageal atresia and hopefully write something up in the near future.
Maybe it is better in a certain way that I will not be collecting scores using VCAR. According to my mentor, although the software is more advanced than Smart Score, it is just as tedious to use. If you recall, the Smart Score software forced one to highlight the calcium in transverse CTA slices. It, thereby, was able to deduce a calcium score based on just volume (volumetric score) or area and average Hounsfield value (agatson number) for the overall calcium in the arteries. VCAR calculates the score in a similar fashion, but it does not need the user to highlight the calcium. Instead, it is designed to automatically segment the calcium in the arteries. However, before the algorithm is capable of doing this, one must click along the centerline of an artery so that the algorithm can basically fit a curve to the selected points and subsequently subtract it from the image to straighten out the artery. Then it presents the artery of interest in a longitudinal format so that one is better able to view the calcium deposits (figure). I’m not certain why this step is necessary. Nevertheless, the software seems very user friendly so I think it would have been fun to work with.
