Final Day: Maternal Fetal Medicine (Newton Wellesley Hospital)

"Medicine is not just a science, but an art."

I had made this observation after my first experience in the Emergency Department at Tufts Medical, but then it was reinforced by the absolutely wonderful doctor I shadowed today at the Maternal Fetal Medicine Department at Newton Wellesley Hospital. The excitement the doctor's face showed whenever he got to explain the rarities (and normalcies) of his specialty (twins) made me love his work all the more. "Look at that hand! Isn't that wild?" he would say to nearly every patient, truly in awe of what he was seeing (although he had been doing it for years). 

Let's begin with the basics about twins:

Zygocity-

A Zygote is a fertilized egg. Twins can happen for one of two reasons: 

1. The mother's ovaries aren't working as well (because of age or another factor) and the ovary releases two eggs instead of one. Two eggs are fertilized and this is like two different pregnancies at once, resulting in two different babies in two different placentas (dichorionic; just keep reading...). This is referred to as dizygous (two babies).  

2. The eggs splits after fertilization. This is essentially one pregnancy, because you have (genetically) the same zygote twice. Depending on when the zygote splits, there are different scenarios in which the baby can develop. This is where Chorionicity comes in. This is referred to as monozygous (one baby).

Chorionocity-

The chorion is the outermost membrane around the embryo (together with the endometrium, or the uterine tissue, it froms the placenta). 

In a dizygous pregnancy, the babies are dichorionic. Meaning that because they are two babies, they develop in two different placentas. This is alway true. 

On the other hand, in a monozygous pregnancy, a babies will be dichorionic or monochorionic. And it can also be monochorionic-diamniotic, or monochorionic-monoamniotic. 

Let's break it down:

a) If the egg splits within four days of fertilization, each one will have its own placenta; therefore two chorions, making it dichorionic. (now we have two ways of having two placentas: 1. two genetically different babies or 2. two genetically identical babies). 

b) If the egg splits between the 4th and the 8th day after fertilization, the babies will be monochorionic, within the same placenta. However, there will be a thin membrane separating the two babies (amnion). So these babies are developing in the same placenta but separated in their own spaces. This is monochorionic-diamniotic (one placenta, two spaces). 

c) If the eggs splits between the 8th and 13th day after fertilization, the babies will develop not only in the same placenta, but also in the same amnion. These are monochorionic-monoamniotic twins (one placenta, one space). 

d) If the egg splits between the 13th and the 15th day after fertilization, the babies will end up being in the same placenta, the same amnion, and will be conjoined. In other words: "siamese" twins. 

When a mother is having twins, the first things that done are figuring out the zygocity and chorionicty. This helps the docotors be prepared for the pregnancy. 
All twin pregnancies have a risk of pre-term labor (delivering before 37 weeks). However, the last couple of scenarios (2: mono-di, 3: mono-mono, 4: conjoined) increase the risk of a problem in the pregnancy. 

When the babies are in different placentas, they will both receive enough nutrients for each to develop. However, when they are in the same placenta one twin can be receiving more nutrients than the other. This will cause the other baby to die from undernourishment, and the other twin will then be left will all the blood and the nutrients of the other. This causes extra work for the baby's heart, and this baby will also end up dead. If the babies happen to be in the same placentas AND the same amnion (mono-mono) then the babies umbilical cords can become tangled, which end up in the babies' asphyxiation. Conjoined twins have health problems when born. 

While I was at Tufts I was able to see a mono-mono pregnancy. The woman was most likely going to have to go into pre-term labor to ensure the survival of both babies. 

While I was at Newton Wellesley I was able to see both a dizygous and dichorionic pregnancy as well as monozygous monochorionic-diamniotic pregnancy. The pregnancy with the dizygous dichorionic twins had one very clear difference from the monozygous monochorionic ones in the ultrasound: the the thickness of the membrane separating the babies. Because the dizygous, dichorionic twins had both the chorion and the amnion around them, there were essentially four layers of membranes separating them. These four membranes made a very clear, thick line between both twins. The monozygous, monochorionic twins had only two membranes separating them (the amnions surrounding each one), so the line was much fainter in this ultrasound.

Another very interesting thing the doctor on call taught me was how to [make an educated] guess the baby's sex before they developed the organs. Its very tricky in the beginning because both males and females have the same structure very early on. However, the tissue that turns into the clitoris or the penis in the baby looks slightly different in girls and boys. In girls it is sometimes larger and usually flatter, while in the boys is angled upward. The doctor told me that he is 93% accurate in his guesses. The mistakes are made with girls he thinks are boys. 

One very interesting thing is that dizygous pregnancies can yield a boy and a girl, because they are two different eggs, but monozygous pregnancies are supposed to yield same-sex babies. However, there have been cases (about or so 10 in the world...ever) where, because of the way the egg splits, that a monozygous pregnancy can yield a genetically identical boy and girl. 

There are many more things I learned, but I think this post already has too much information. Special thanks to Dr. Robinson for teaching/showing me all this. An even more special thanks to Dr. Wolfberg who set me up with all the doctors in these hospitals and Cassan who made my schedule and helped me get everywhere. 


THANK YOU SO MUCH! (I wont forget about you when I become a famous doctor) :)

   

Day 11: Pulmonary Clinic

It never ceases to amaze me how many different specialties medicine includes. Yesterday I had the chance to shadow a doctor in a Pulmonary Clinic, and was reminded how essential it is to be able to breathe. Most patients I saw had narrow tracheae which caused them to collapse at night when there was more pressure on the throat and the muscles relaxed. The collapsing of the trachea then caused the patient problems breathing, because the air simply could not get in and out. There was really no way of solving this, so most patients walked around with oxygen tanks on wheels and tubes to deliver the oxygen to the nose. They came in to test how their lungs were working and come in for a routine check in to make sure things were not worsening. 

Other patients I saw were complaining of having trouble breathing. Their problems were not as bad as the patients who had needed oxygen tanks, but they came in to prevent problems in their lungs. Some of them complained of dizziness and fatigue. Others were prone to having Pneumonia. These patients had to have tests done and then  would come back in for diagnosis and treatment. 

I was also able to see an X-ray of a patients lungs and was explained how X-rays were evaluated. Firstly, the patient's name is confirmed, to make sure the correct X-ray is being looked at. Then the angle the X-ray was taken from is determined, because depending on if the rays were coming from the front or the back of the patient, different things can be seen. Next the bones are checked to make sure there are no fractures, then the angle of the bottom of the lungs and the heart, to make sure all is healthy. If there was fluid in the lungs, or something was wrong with the lung tissue, it would show up as a white mass in the lungs. I was able to see lungs with an abnormality which was most likely fluid. If something abnormal is spotted, the patient is further examined to make an accurate diagnosis and then figure out how to treat the problem. 

I was astonished at the number of pills each patient took. There were pills to induce urination (diuretics) so that there is less fluid in the body for the heart to pump, pills for allergies, pills for lupus, pills for this, pills for that. Every time I see such unfortunate cases I become more grateful for my health and want to take more steps to keep it up.        

Day 9 and 10 : Neurology and Epilepsy; Physical Therapy

I have to say that my favorite hospital has to be Children's Hospital. Maybe I am biased, because I absolutely love children, but every experience I have had there has been extremely rewarding. In Neurology and Epilepsy I got the chance to entertain children while they waited in a tiny cramped room while their sibling was being attended, and I got to smile at little babies who weren't even aware that they were at risk of having seizures. 


I learned that based on brain activity, the doctor can tell whether someone is at risk of having seizures. They can also look at brain x-rays and depending on the color of the tissue they can tell whether there are abnormalities that may contribute to the patient's health. Based on the "spikes" in the brain activity levels, patients received certain doses of medicine to bring the levels back to normal and reduce or eliminate their chances of seizures. After the levels get back to normal, which may take years, then the patient is slowly weaned off the medicine and will most likely be "cured". 


Later that same week, I was at Children's Hospital again, but this time in the Occupational and Physical Therapy department. This time, I was following the doctor who was working with inpatients, or patients that had been staying in the hospital for a period of time after a surgery. I was able to meet a young boy from Chile, who had a surgery to biopsy a part of his brain that was lesioned. Unfortunately, he had a brain hemorrhage and lost a lot of blood after the surgery. Because he was in bed for so long and the surgery involved removing a part of his brain, his muscles, his brain, and his eyes, were not functioning together and needed to be trained to return back to normal activity. This was done through lots of rest, walking around the hospital, pushing elevator buttons, reading signs around the hospital and playing basketball. 


I also had the pleasure to meet a young girl who had had a heart transplant. She was being monitored to make sure her heart was assimilating to her body and functioning properly. What she was working on with the Physical Therapist was everyday functions like brushing teeth, brushing hair, and taking showers. This she did very well. I got to sit in and watch her heart ultrasound, or echo cardiogram, which showed the pressure of the blood in the heart to make sure blood was not being backed up in the heart and creating pressure.  


Both these patients had such positive attitudes, that one forgot that they had suffered from such serious complications. This was possibly the most rewarding part: seeing such innocent people benefiting so greatly from such subtle activities. I think this is the best part of medicine, being able to make a difference in a person's life, especially one who's life is barely beginning.

Day 8: Acute Waiting Emergency Department

11:00pm- Admit intoxicated people to the hospital 


11:30pm- "Release" previously intoxicated people from the waiting room


12:00pm- See patient complaining of knee pain


12:15pm- Admit intoxicated woman with big bump on her head


12:30pm- Question woman: "Do you know where you are?" "Um... beverly?" "Close, but no, you're at Tufts Medical... Do you know what day it is?" "Um... Friday?" "Again, close, but no, its Sunday... who's the president?" "um... I don't know?" "that's ok"


1:00am- Look at knee x-ray, drain patient's knee of fluid.

1:30am- Hold down little boy getting an iv. 


2:00am- Stitch up patient's eye brow after having fallen in a David Guetta concert.


3:00am- Waiting for patients to come in


4:00am- Talk to patient having elbow pains


4:15am- Waiting for patients to come in


5:00am- Begins waking up intoxicated patients


5:30am- Question recently awoken intoxicated patient: "Why did you drink so much?" "Because, the world is ending. Am I in heaven?" "No sir, you are not... What is your name?" "Guess..." "Sir..."


6:00am- Release intoxicated patients


6:30am- Waiting for patients to come in


6:45am- "Well, looks like there won't be anything exciting happening between now and 7 am, so you're free to go"

Day 7: Children's Hospital PT and OT

Shelves, closets, even drawers full of toys, silly putty, bikes, PLUS really nice doctors... The Physical Therapy and Occupational Therapy Department at Children's Hospital was kid heaven. Again, I was struck by the importance of this kind of rehabilitation, where the muscles and the brain need to be taught to work together. This department was very special, because it did so through play.


The first patient I saw was a little Asian boy (probably around 4 years old) who had had a stroke when he was baby and had lost some of the function on the left side of his body. He was being taught to use his left hand to hold on to things again. The simplest of tasks were difficult for him to do, and he relied heavily on his right hand for everything. But the doctor brought out the toys and made him use his left hand to play. Although he was a little testy, he started using his left hand, and began "pinching" things between his thumb and index finger in order to hold them. His favorite and most difficult activity was playing with rubber toys in water. The way they got him to pinch was to allow him to fill the toys up with water with his right hand, but ask him to squirt the water out with his left. In order for the water to come out, he had to apply force, which he didn't have quite yet, but he was getting more comfortable using his hand (which the doctor told me a year ago he wouldn't use AT ALL).


Another patient I saw was this charming little 16 month old toddler who had severe low muscle tone (his muscles were very weak). The doctor told me the aim was to get him to stand on his own for about 4-5 seconds, which he did very well. Again, this was done while playing. His toys were put on a little bench, which forced him to prop himself up and keep his balance using his legs muscles. I noticed he was very, very good at crawling, and the doctor told me that was a very big improvement, because normally kids with such weak muscles tend to just slide on their butts to get to where they need to. But this strong little baby (who also had some vertebrae missing in his neck) didn't let anything stop him. He propped himself up, spun around, sat down to rest, stumbled to his mama, and played for about 45 minutes. And when it was time to go he flopped his wrist up and down and flashed a huge smile to say goodbye.


I really liked being in Children's simply because I loved interacting with kids. It was amazing to learn how much the children had improved and how much the therapy was helping with their day-to-day lives. It was also very inspiring to see these children with such wonderful personalities work through their struggles. Next time I feel like saying "I can't" ill try to remember that if these children can regain their abilities, I can also work to get better.  

Days 4, 5, and 6

5:30 pm, 8 lbs. 12.5 oz., female. 


The last time I was scheduled for labor and delivery all the women were either pre-term or postpartum. I was sent home having seen only the circumcision of a little 2 day old baby boy. Then, on Tuesday I was scheduled to be in urology. Although I saw pictures of prolapsed uterus, I didn't get to see any in person. There were only two patients being seen, and neither of them had any serious complications (although I did get to see an elderly woman's bladder and a biopsy of the inside of her labia minora, and another woman who had mild prolapse). 
I was beginning to think I had a calming aura... 


My 12 hours of labor and delivery were rescheduled for today (Wednesday). I showed up at tufts medical, second floor in Proger, and again, there were only pre-term mothers. Just as I was starting to feel unlucky, a woman, 40 weeks pregnant, came in to be induced. She had had 3 other pregnancies, so this baby would be delivered more easily. 


I stuck with her through almost every procedure, from inducement medicine injection, to contractions, to epidural, to cervix dilations, to water breakage, to more pressure, to delivery, to umbilical cord draining, to placenta removal. I was very impressed by the woman's ability to keep her good humor during the contractions in which she did not have an epidural to help. 
It was absolutely mind blowing to see the little head of the baby protrude more and more with each push. Soon her head was in the nurse's hand, and the shoulders were wiggled free until, finally the rest of the baby's body came smoothly out (along with some other things). Then dad then cut the umbilical cord and the baby was then taken to its own spot in the room to be cleaned and evaluated. However, there was still more going on with mom. 


The umbilical cord (containing special stem cells) was still attached to the placenta which was still in the mother. The blood was drained from the cord (much the same way blood is drawn for your arm) and then the cord was used to gently pull the placenta out. The placenta was examined to make sure there were no other part of it still in the mother, and when all was well, she was cleaned up and able to meet her newborn.


All this happened in the span of about 6 (or more) hours. Although it was a long time to sit around and wait, I was so grateful to have had a chance to see a live delivery. Because the mom's delivery went so smoothly and quickly, I was released from the hospital two hours early and was able to take a nap before starting my 8:45 capoeira class at Brookline Ballet. 

Day 3: Emergency Department

Whenever I go to the hospital, I regard the people wearing scrubs as gods, and today I finally got to be one of those people. However, I quickly realized how far from being “God” these people really are. I learned that the doctors in the Emergency Department can’t really do much for a patient that does not have a problem as obvious as broken bone or an open wound. Unless the patient is in critical condition and needs surgery, the doctor can only recommend sleep, ibuprofen, painkillers, or antibiotics. After that, the patient leaves as he or she came, in the hopes that in a couple of days his or her health will return back to normal.

In the Emergency Department I was able to see a many different patients complaining about a spectrum of different things. The smaller, more insignificant injuries came to the side of the department I was in (express waiting). Things like people having sinus infections, ear infections, coughs etc. were quickly dismissed with a recommendation of medicine and rest. Then there were some patients with broken bones. One young man came in with a fractured fifth metatarsal (a bone in the foot that attaches to the pinky toe), and another man came with a fractured bone in his leg which had happened four weeks earlier in Vietnam. Again, not much could be done for these people, since the body would do the healing on its own. One little girl came in with strange skin lesions and an abscess in the ear. The abscess was drained, and the doctors did not know the cause of her lesions so she was sent to dermatology to have it figured out. That is where her story in the Emergency Department ended. Another young man came in with a cut on his chin. He was given the necessary analgesic and then stitched up, and on he went. Another man complained about pain in his eyes due to sparks. The doctor put a dye in his eye that reacted with his cornea and where the cornea was damaged the dye would turn green instead of purple. The man did have some damage to his cornea, but he was told that the it was the fastest healing part of the body and then released. These doctors knew what they were doing, but there wasn’t really anything that they could do with these patients that their bodies would not do on their own.  

What I learned from being in the ED is that we have to take care of our bodies. It’s the only one we are going to get, and what we put in it to nourish it and what we do to it in everyday life can have a consequence that we will have to deal with for the rest of our lives. Doctors can give you medicine to lessen the pain, but the problem may never go away. Unlike the other departments I was in where the doctors specialize in their patient’s care, these doctors attend to an umbrella of problems and have to discern whether the patient needs to go into another department for special care or simply go home. They don’t know the backstory of the patients nor what will happen next.  

Day 2: Pediatrics Physical Therapy and Rehabilitation

Normally when I think of Botox I think of women (very much like those in Desperate Housewives) who want to somehow reverse the traces of time and maintain their youth. After my visit to Pediatrics Physical Therapy and Rehabilitation, I realized that Botox serves a purpose much more important than the superficial beautifying one we know of.

Firstly, what  is  Botox? It is Botulinum toxin produced by certain bacteria. This toxin blocks neuromuscular transmission through decreased acetylcholine release. In other words, it blocks the signals from brain and nerves to muscle. How could it possibly be useful to block signals to the muscles? 

Patients with Cerebral Palsy have cognitive deficits. The part of their brain that controls motor functions is damaged, and so signals that make their muscles contract are sent out unwillingly. These patients come in and have Botox injected into the nerves and muscles in their legs, arms, and even necks, to relax their muscles so that they may be more comfortable in their everyday lives. The procedure to inject the problematic nerve sending out the signals was very interesting. The doctor would first use electro-stimulation to locate the nerve or the muscle. And then he would inject the saline-Botox solution into the nerve. If he didn't get the appropriate impulse response from the nerve, he would move the needle around until he found the right spot. 

This procedure was most likely uncomfortable, if not painful. It was heartbreaking to hear the patients whimpering and seeing them flinching, but I was told that the doctor used a sedative, “Versed”, that acted as a relaxant and, in addition, made the patients forget what they had just gone through. Although the procedure seemed painful, the lifelong muscle stiffness seemed much worse. Leading a life with constant muscle spasm is much worse than the 35 second discomfort for each leg. 

It was amazing to see how long some of the patients live, a testament to how effective modern medicine has become. One patient, with muscular dystrophy, was 28 years old. A doctor explained that the reason he has to come in to see a pediatrician is because most patients do not live to be adults, so adult doctors are not specialized to treat patients like these. I was also amazed to learn that one of the patients with cerebral palsy was graduating from high school and going on to college to be a video game programmer. Although his motor skills were severely affected by his CP, his brain was completely functioning, and he had the capacity to learn and think the way a person without any deficiency could.  

Again, my second day was wonderful: I learned a lot, and laughed a lot. I learned a bit about the manifestations of the effects of extra copies of chromosomes, which I had read about in my first day at obstetrics. I was able to see a small child with a very rare disease, Edwards Syndrome, caused by an extra copy of the 18th chromosome (we normally have 2, one from mom and one from dad). The syndrome has a very low rate of survival, resulting from heart abnormalities, kidney malformations, and other internal organ disorders. However sad the disease of each patient, the doctors still had a very keen sense of humor, jesting about my having gotten into a “small community college in Cambridge” and laughing when getting kicked by a patient. It seems to me that the patients at Tufts Medical are in very good hands.  

Day 1: Obstetrics

   To the untrained eye, the black and white image that appears in an ultrasound is simply an outline of a little baby’s head, hands, body, and feet. However, after flipping through a book of obstetrics ultrasounds, the other seemingly amorphous spots on the screen became more identifiable—a stomach, kidney, heart, and gallbladder were all visible. The doctors I shadowed today, my first day at Tufts Medical, are specialists in identifying problems in fetuses. After I followed the doctor into the patient’s room, I quickly saw the outline of the baby, a heartbeat, and then a circle, within a circle, within a circle. Although most of it was black and gray, some white was visible. Not too soon after did I hear the words echogenic and cysts being thrown around. What did these things mean?


   The definition of echogenicity is the ability for something to generate or reflect sound waves, which in this case, are captured in an ultrasound. I found out that if something, like a fetus’ little kidney, is echogenic, then the image appears whiter on the ultrasound. This warns the doctor that the kidney is damaged or not functioning properly.  Other signs of a fetus having abnormalities can be determined by sampling the mother’s blood to check for a balance in hormones. I learned that the doctor can tell whether a baby is at high risk of being born with Down syndrome depending on the balance of the hormones. The baby can then be tested for Down syndrome by amniocentesis. What is amniocentesis?


   The baby develops in a sac called the placenta, which is inside a woman’s uterus. Inside the placenta is a fluid which contains an amniotic fluid rich with nutrients to help the baby grow.  As the baby develops, it actually swallows the fluid and urinates it back into the placenta, so that the amniotic fluid becomes the baby’s urine (and not water as I thought it was). The fluid actually contains fetal tissue, which is why, if extracted, can help more accurately determine if a baby has any genetic abnormalities. When a doctor performs amniocentesis, he penetrates the mother’s belly and the baby’s sac in order to obtain some of the fluid which will yield the baby’s karyotype (a “chart” of the baby’s chromosomes), and therefore uncover any genetic abnormalities. 


   These are two of the things I learned today shadowing at Tufts. The doctors were very patient with me, answering all my questions ranging from “Why would a pregnant woman bleed, and where does the blood come from?” to “If the baby’s kidney is failing and the amniotic fluid is low, why can’t some artificial fluid be injected into the sac?” to “What happens if a woman has complications but no insurance?” I definitely enjoyed walking around and seeing patients in different stages of pregnancy because the image of the baby was different every time. I am very excited to come back and see the babies outside of the womb. Overall, I had a great first day.