Chapter 3: Week 4

It has been a busy week, as my mentor’s schedule has picked up in both the OR and research world. This week I attended several surgeries, the most interesting of which was an operation to remove a tumor from a pediatric patient’s brain. In the OR a large microscope was used to broadcast the interior of the brain onto a digital screen, which made it easier for both myself and other observing students to visualize and understand the procedure. During clinical hours this week, I learned how a shunt can be used to treat children with hydrocephalus caused by cysts, and some of the surgical mechanisms by which Chiari malformations can be corrected. In research this week, I obtained more data from the medical students I am currently working with. I spent a large portion of the week writing an algorithm that will quantify drug distribution parameters from PET images.

I was able to attend a conference this week for the Cancer Moonshot initiative. Speakers included surgeons and clinicians specialized in neurological surgery and leukemia from Weill Cornell Medical College and New York Presbyterian Hospital. One of the main topics of the meeting was to discuss potential reasons, from a clinician’s perspective, as to why patients do not participate in clinical trials. One of the speakers expressed a great point: that the paperwork and jargon associated with clinical trials, compared to the limited documentation associated with traditional yet inadequate radiation and/or chemotherapies, can scare patients away. Specifically, the speaker noted that up to 50 pages of complex documentation can be given to a patient to read before clinical treatment. The speaker implied that if we explain clinical treatments and the associated risks and benefits better to patients, they may be more inclined to partake. I was personally very glad to hear so many clinicians suggest that multidisciplinary collaborations between healthcare workers, clinicians, researchers, and engineers are 100% necessary for the development of adequate cancer therapies. Vice President Joe Biden attended the meeting on a conference call and further reinforced the idea that cancer treatment will not be possible without multidisciplinary collaborations across multiple funding agencies.

Per usual, I had some great food this week in New York City. I would recommend the Buttermilk Buffalo chicken sandwich from Bareburger. Last weekend we also explored the Met.

Week 4

This week I made progress on both my individual research project and the review paper I am working on with the other summer medical research students. Monday I presented the patient cases to Dr. Kennedy and the group for the surgeries they would be doing that day. This involved me collecting patients intake forms, their diagnosis, all relevant radiographic images, and explaining the plan for each surgery. It was interesting that most surgeries involved more than one procedure, and I was able to learn more about different surgical techniques. Afterwards I met with Dr. Deyer in radiology to discuss and outline what I needed from the MR images for my study. This was a very productive meeting, and I was able to get access to the East River PACS system to help with organizing patient information. This will make it easier for Dr. Deyer to collect the information and also for me to analyze it once collected. I finished working on the spreadsheets and then outline the research proposal with specific aims and hypotheses that we will be testing. I kept in touch with Dr. Deyer throughout the week, and will meet with them on Friday morning to go over the radiographs. This way I can also learn how to score the radiographs and I can score the images myself to allow for intra-observer error to be calculated.

For the review paper, we finished narrowing down the list of studies we will investigate, and developed a modified Horn's method for evaluating the quality of evidence presented in the in vitro and in vivo studies. Now we will go through the papers, evaluate them with the modified Horn scale, and also start collecting the main findings. This way next week we will be able to organize the outline of the paper and the main sub headings that we will focus on.

I was able to be in the clinic twice this week, and get much more experience with the intake process of new patients. I'm really enjoying both the clinic and the operating room, I already feel as if I have learned so much. This immersion program has made me realize how great it is to work with clinicians and I think that collaborations between clinicians and engineers would only benefit the research community.

Week Pho

This past week was somewhat of a bummer, as I caught a cold and had to miss some interesting cases in the operating room.  While this week was not quite as exciting as the previous three, getting sick staying out of the OR and clinic helped me focus on research and establishing a stronger literature background for my projects.

One interesting case I was able to observe while I was healthy was a craniotomy for a tumor resection.  While I have seen craniotomies in the past for the resection of meningiomas, this case was novel to me, as the patient had a growth just behind their right orbit.  The surgeons removed parts of the frontal and sphenoid bones, as well as others composing the right orbit in order to get access to the tumor and relieve pressure on the eyeball.  While parts of the operation were performed without aid, most of the surgery was guided by an endoscope.  This made the operation much more exciting, as the view of the endoscope was projected on multiple screens throughout the OR.  I was concerned for the patient due to the precarious incisions and retraction around the eyeball, however the surgeons appeared confident that they could operate with minimal risks to the patient.  I did not stay to see the patient wake up from anesthesia, however I have good faith they will recover well.

A few new undergraduate students and fellows joined Dr. Hartl's group this past week, which gave me a boost of confidence as I was no longer the bottom of the totem pole in our office.  I also realized that being here the past three weeks has infinitely increased my clinical knowledge of a variety of spinal surgeries, as I was talking undergraduates through each step of an ACDF (anterior cervical discectomy and fusion) while Dr. Hartl operated.  At weekly spine conferences where all of the spine neurosurgeons get together to discuss particularly difficult cases and present imaging studies, I understand 90% of the surgical terminology and can "diagnose" deformities, degeneration, and areas of stenosis with reasonable accuracy.

On the topic of my blog post's title this week, I tried out pho at a vietnamese restaurant close to Olin.  As with most food in NYC, it was great.

Week 3: An adventure

By working in a seizure-focused lab, I had many chances to observe drug-induced seizure in different types of animal models and this week was zebra fish. I have always been wondering, since mice and rat brain surgeries are difficult enough, how to manipulate a fish's brain that's only few millimeter in diameter. It turned out that the single fish that we were doing experiments with would be anesthetized and mounted in agar gel. While observing the zebra fish under a microscope, it looked almost transparent and the blood vessels were so tiny that I could see individual red blood cells flowing. The heartbeat also became the single source to confirm the fish's wellbeing throughout the experiment and every detail of the heart could be seen through that thin transparent layer of skin.  Then the electrodes would be carefully stuck into the fish's brain and with drugs that opens calcium channel, the fish would experience seizure and the neuron activities could be recorded.  Even though it might seem cruel,  I thought the waves of neurons were really beautiful and I could wonder what the zebra fish was thinking when there were interesting-looking shapes.

With the time not in lab or library, we spent a lot of time enjoying ballet performance or learning swing dance in Lincoln Center. On weekends, I went for my regular horse riding lesson and cantered across the park with the coach, then we hopped on jetskis in long island and spent an hour chasing the waves and the wind.

Week 3: Going Down for the Third Time

Events this week provided an impetus for some introspection on my part. I am not exactly sure what will come of it, but I hope it is beneficial. This post will be a bit shorter than usual. Anyway, onto the immersion experience!

I discussed in my first blog post about how patient compliance was of vital importance to successful outcomes post transplantation. This issue presented itself once again this week in one of the meetings with the entire transplant team. It was noted that cases of patient noncompliance to medication regimens appear to happen more frequently in younger patients, and at this point there are no real mechanisms to track these patients more closely once they reach months after transplantation and their time between clinic visits becomes greater and greater. Another consideration for these patients is at what point should their noncompliance affect their eligibility to receive another transplant? These ethical considerations are just one part of how priority on the organ transplant list is determined, and I look forward to Dave’s conclusions regarding the performance under the new revised system.

New York Themed Music Selection of the Week: The Rolling Stones - Shattered

Week 2: Sophomore Slump or Comeback of the Year

Coming from a family where many members are employed in healthcare and related fields, I was always encouraged from a young age to consider becoming a doctor. In fact, at almost every holiday party or large family function from high school through undergrad, I was met with constant conversations about when will I take the MCAT, what kind of medicine do I want to go into, and so on. I would joke that the only position I could ever see myself in would be in a medical examiner’s office, mostly due to my obsession with Law & Order: SVU and my desire for patients not to talk back to me.

This second week of clinical immersion has definitely changed my outlook on the doctor-patient relationship. Interacting with the patients on the floor on a day to day basis as they progress from in some cases a very poor state of health from complications of transplantation or from the routine recovery following their surgery to a much improved outcome as they are discharged gives one a great sense of satisfaction. Every patient seems like a new puzzle to be solved, with their symptoms and lab results as clues, and while not every piece seems to fit perfectly at times, more often than not the picture becomes clear by the end. Furthermore, patients aren’t simply a name, age, and sex on chart; they all have their own character and charm. The unique personalities that come through the floor have really humanized my view of medicine in this sense.

If the multiverse theory is to be believed, then there exists a universe where I am world-renowned clinical expert. There is also another where I am a perfectly adequate one. I think I would be perfectly happy in either of those universes.

New York Themed Music Selection of the Week: Sufjan Stevens - The BQE

Immersion week 3: Jam Packed

Summary: Week three was jam packed. I was able to see more surgeries, observe and shadow breast imaging procedures, visit the ED and shadow an ER doctor, and finally spent the weekend in Boston with Marianne and Matt, presenting a poster at the AACR meeting on Engineering and Physical Sciences in Oncology.

I started the week in radiology and Dr. Drotman was able to place me with her senior resident who I shadowed for the day. I was able to observe several mammograms and I must say that I was honestly shocked by how aggressive the procedure it. The technician explained that they have to apply up to 20lbs of force onto the breast to compress it enough to acquire the resolution necessary to correctly identify potential cancers. Continuing the week, spent time in ambulatory medicine with Dr. Talmor and was able to observe two breast reconstructions. The first patient was a previous survivor of breast cancer who underwent a nipple preserving double mastectomy and had silicone implant placed to reconstruct the breast. Well several years later the woman had a recurrence in her left breast and had radiation therapy performed. The radiation caused hardening of the left breast tissue and caused a visual defect in the appearance of the woman’s breast. So, to correct this, Dr. Talmor purposely tightened the skin of the opposite breast and resized the woman’s breast. After the procedure, the woman was left with much more symmetrical breasts.  The second procedure was a breast reduction for a young woman who has suffered with back and shoulder pain for much of her adult life. I found it quite interesting how subjective breast shape and size were for everyone in the OR. After the patient had nearly two and half pounds of tissue removed, the surgeon sat the patient up and conversation was had on the best shape and size for the reconstructed breasts that would meet the patient’s wants and needs. After the procedure the patient had went down three cups sizes and should hopefully be able to live a much more comfortable life. The last procedure was a lower leg tumor resection. I was able to see the nuclear med team inject a radioactive solution into the patient and observe the surgeon use a Geiger counter to find the sentinel node. That was a very interesting procedure and the surgeon was able to remove the cancerous mass. Lastly, I was able to observe Dr. Peter Steel in the ED. In the short time I was in the ED I was able to observe a great deal. I saw two emergencies and was able be in the room as the ED team rushed to stabilize the patients. It was a different world than that off the OR with this impeccable sterility and calm demeanor. In the ED it is a free for all and the attending doctor had to do all he could to wrangle the 20-30 people racing to save the patients. I would recommend observing ED medicine to all the immersion students who want to get a feel for practical medicine.

The oncology conference was a great experience and I got to listen to several of my scientific heroes talk about their research. People like Jain, Langer, Mooney, Schartwz, and Austin, all authors of BME cornerstone papers. My poster was well received and had a lot of good comments. For the following week I hope to spend some time in pathology, seeing patients with Dr. Vahdat, and shadowing Dr. Simmons in the OR. 

Week 3

This week, I continued with much of the same activities as last week: attending breast sign-out in the mornings and following residents into the gross room to watch them prepare frozen sections or gross samples. Even though some of the terminology has become more familiar and I am more easily able to follow along in discussions concerning diagnosis, there is so much patient-to-patient variability in the tissue samples that each case continues to be interesting and engaging. Apart from this all, I also shadowed a resident performing autopsies for the week. The very first autopsy I observed was a fetal autopsy, and I worried beforehand about how it would affect me. In the end, I had no trouble watching the procedure; I just felt sad about the circumstances. I was able to follow along as the resident meticulously performed each step, more easily as I was given a sheet detailing the protocol, and take notes for her as she removed and examined each organ. She explained everything that she did to make sure I was able to follow, discussing her findings and whether or not they were typical, and provided more information on the organ systems I was less familiar with. I was also able to provide some assistance, holding the body steady for some of the trickier parts as well as assisting in measuring and weighing the organs. I was also able to watch another resident dissect a brain and prepare the sections for proper analysis later on, a vastly different procedure as the brain was present without its body.

Aside from clinical work, I attended the AACR conference on Engineering and Physical Sciences in Oncology in Boston this weekend and presented a poster along with Adam and Matt. I enjoyed my time at the conference and believe it went well, though I would have liked to spend more time in the city, as it's been a while since I've been back.  Next week I hope to explore my options outside of surgical pathology; hopefully, I'll get the chance to enter the OR and attend surgeries. I also plan to explore my research project in more detail and advance in my work.

Week 3

This week I was able to scrub into two joint replacement surgeries in the OR.  First, I watched a total hip replacement.  This was a fascinating surgery to watch as both the head of the femur and acetabulum were removed and replaced.  It was interesting to see how severely degraded the cartilage was on the removed femoral head and how the new parts were fitted specifically to the patients size.  Next, I was able to watch a total knee replacement.  This was also a very interesting surgery as both the femoral condyles and the tibial plateaus were replaced.  This patient had a severely valgus one.  When the tibial condyle was removed the cartilage had been completely worn on the lateral side while it look quite good on the medial side as a result of the unequal distribution of load.  Both of these surgeries were incredible to watch and the entire process could best be compared to carpentry.  It was awesome to be able to scrub into these surgeries and even participate in a little by helping operate the device which sucks the excess blood and synovial fluid from the surgical area.  Finally, a big takeaway from these surgeries was the intense care that was given to keeping to room sterile.  All people scrubbed into the surgery wore an additional sterile layer over their scrubs, two paris of sterile glove, and a helmet with a sterile visor cover.  Implant infection is one of the primary modes of implant failure so it makes sense that keeping a completely sterile surgical area is critical to the surgery's success.  Overall, watching these surgeries was an amazing experience and I can't wait to do it again!

Additionally, I was able to start a little lab work this week as well.  I helped with the analysis of some microCT data and finding image threshold values using Matlab.  This data was part of one of the implant infection studies in the lab that utilized a mouse tibial implant model.  This is a very interesting project and it was nice to be helpful to other people in the lab while still determining exactly what my summer research work will be focused on.

Week 3

This week on the clinical side, I had an interesting experience shadowing Dr. Vielemeyer, who is an infectious disease and travel medicine specialist.  I was quite surprised at the fact that the majority of the patients we saw had non-communicable infections arising from surgical implant procedures (such as hip replacement, stent insertion).  Due to their material properties, implant surfaces often act as anchor sites for bacteria and fungi to adhere, which can subsequently cause problematic infections to develop at the implantation site.  To make matters worse, infections contracted in a hospital setting are often times highly drug resistant and difficult to treat.  This is clearly an unmet clinical need that can be addressed by biomedical engineers through the development of novel antimicrobial biomaterials. 

Research wise, I am continuing to make progress on the Plasmodium falciparum project.  I started my third batch of parasite cultures early in the week and performed DNA and RNA extraction on my culture from last week.  Using extracted genomic DNA, we are continuing to test the primers we designed for amplification of beta subunits 1, 2, 3, and 5 of the proteasome.  Amplified products are sent in for Sanger sequencing to allow for genomic comparisons between wild type and drug resistant strains of falciparum parasites.  In beta subunit 1, we identified a missense mutation in the resistant strain genome, which is quite exciting.  More work is definitely required to elucidate the impact of this amino acid change.  Later in the week I had the chance to learn about a flow cytometry method for analyzing percentage of parasite infected red blood cells.

Third Entry: Home and Belonging; a man without a Home

When were those lost? The first drips of the sense of belonging I had built all of my life, among peers back in my hometown, Abidjan, economic capital of Ivory Coast, a west African country bordering the Atlantic ocean.  When were those lost? The peaceful moments when I had not to think about the color of my skin, the accent of my speech and the making of my hair. When were those lost? The infallible conversation starters which were not the last ditch efforts of a man who tirelessly ruminated the last few pop culture items on the American menu before making his way over to a gathering. When were those moments lost?

When did it start? Intensely watching my tongue for fear to enunciate words which would damn me permanently to be remembered by the color of my skin and the vulgarity synonym with the making of a race of long lost distant cousins who are racially profiled everyday. When did it start?  Cowardly avoiding to raise my voice an octave higher feeling anxious that I will be categorized as one of the so known and stereo-typically called "loud ones". When did it start? Externally laughing yet internally contemplating will I ever find it easy to fit in. When did it start? Avoiding making eye contact on the street in fear of being thought of as aggressive and violent, words which have come to describe the largest minority in this country. When did it start? Denying myself access to stores, restaurants, bars and specific gatherings, for fear of standing out as the only black individual in the crowd and specifically tracked on a monitor screen to "catch me in the act". When did these thoughts start occupying my mind?

Was it after coming to New York City or did I always had them buried in my subconscious yet growing by the day? The answer is unassailably ambiguous at best. While I have been in the United States for now a total of five years, having lived mostly on a college campus, I always and strongly identified myself as an international student, African or Ivorian ( a term denoting a citizen of Ivory Coast); a term which, in my mind, signified pride, scholarship and "goodness of character". Although undeniably black, I had reservations about being grouped with African Americans for reasons which were unbeknownst to me for some time. I came to later found out that my fear of being called an African American rather than an international student, resided in what I held as "goodness of character". In fact, subconsciously I had come to accept that being called an African American meant a lack in character, whether it be as a result of poor education, manners, and/or willingness to do good. 

Indeed, this willingness to do good always became a motto. If I was good in the eyes of others (whether white Americans or not), I would differentiate myself from the African American fellow who despite his best intentions would always be reprimanded for an action he undertook with good intentions which ended in a poor result. In fact, who was to believed he could ever be good at heart? Nonetheless, after doing good by others and for others, I never came to belong. Strangely enough, riding the NYC subway while on the Upper east side (a predominantly white neighborhood) I never felt like I belonged among the majorly white populated wagons. Likewise, I never felt like I belonged riding the subway towards Queens or Harlem with predominantly black Hispanic and African Americans.   

While life in the hospital has been marked with a serious step forward, following the start of my project assessing the performance of the new Kidney allocation system used by the OPTN (Organ Procurement and Transplantation Network), I have come to face the fact that without my work, I have yet to find a place I belong. Thanks to the wonderful friends in the BME program, I have had the easiest time putting away my restlessness failing to renew my sense of belonging before the time I spent in NYC brought it all back. It has truly been a battle and will continue being a battle because like others of my diaspora sharing my fate, returning home would feel even more heartbreaking since we now do not belong there anymore, having "missed out". Thus, undoubtedly, I am a man without a Home.