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"