Monday, December 22, 2008

33.5 Degrees of Hope

Last week, I visited UCSF's Neuro-Intensive Care Nursery. I had the opportunity to learn more about the Nursery and photograph the nursery for a feature article for the UCSF School of Medicine's website. Visiting the nursery with my camera was truly a unique opportunity. My essay and some photographs are included below. It can also be viewed at the following site:

Teddy bear wallpaper lines the top of the room. Large machines beep, and tubes are covering most of the crib that holds Baby E. Her small body is covered in plastic. Her face is just visible underneath the breathing tube. Her head is covered with white gauze, holding a series of green and red wires in place, which are connected to an EEG machine to monitor her brain wave activity. A camera records her movements. Despite the loud noises of the Neuro-Intensive Care Nursery (NICN), her eyes remain closed as if she were completely oblivious to her critical state of health.

The UCSF Neuro-Intensive Care Nursery (NICN) is located on the 15th floor of Moffitt Hospital. The front windows show a panoramic view of the city, from the ocean to downtown. Family members mill in and out of the nursery.

Dr. Tom Shimotake, Co-Director of the UCSF Neuro-Intensive Care Nursery, had given me a tour and introduced me to Baby E. Baby E had been transferred from another hospital and admitted to the NICN the previous night. Though being born full-term, she was in critical condition.

Since opening in April of 2008, the NICN has seen referrals of this type quadruple. UCSF's NICN represents one of the first nurseries in the United States that specializes in treating infants who have experienced brain damage during birth because of asphyxia, which prevents oxygen flow to a newborn’s brain and can lead to irreversible injury of neurons.

The NICN integrates multiple technological and treatment modalities along with clinical trials, to optimize the monitoring and care of critically ill infants who are at high risk for developing cerebral palsy, mental retardation and other cognitive problems later in life.

We were joined by Deidre Jarrell, Baby E's nurse, who has been with the NICN since its inception. She has specialized training to care for infants like Baby E who have suffered brain damage at birth. She works 12-hour shifts, attends to Baby E and provides updates to family members, who can call anytime for information about the baby's status.

As we surround Baby E's crib, the infant would periodically stir or kick her tiny feet. Bags of fluid were perched above her, dripping clear liquid into her system. She was sedated, and a machine was breathing for her. She was lying on top of a blue blanket that was set to maintain her temperature close to 33.5 degrees Celsius.

Baby E is receiving cooling therapy, which involves inducing a hypothermic state for 72 hours. According to Dr. Shimotake, the cooling therapy prevents further brain injury in babies born in a hypoxic (oxygen-deprived) state. Cooling needs to be started within the first six hours of birth after asphyxiation to have a benefit, and this therapy is only for babies born full-term.

After 72 hours of the cooling therapy, Baby E's body temperature will be slowly increased (0.5 degrees Celsius per hour) to her normal temperature. Her brain will then be imaged with an MRI to assess the primary injury, including the location and severity, to help develop a prognosis and determine the next steps in her long-term treatment.

Infants will spend an average of 10-14 days in the NICN. While in the NICN, they receive specialized care from a multidisciplinary team that includes neonatologists, pediatric neurologists, epileptologists, specialized NICN nurses, neuroradiologists and occupational and physical therapists. Social services, another integral component of the NICN services, are available to families and healthcare providers to help cope with the emotional stress that comes with caring for critically ill infants.

Dr. Shimotake believes families play a central role in making decisions, and healthcare providers must remain sensitive and open to each family's desires. "We deal with very sick babies here, so we participate in some of the most emotionally intense moments in these families' lives. In addition to specialized care for the babies, we provide important information to families that they may need to make difficult decisions. We don't make decisions alone."

In working with critically ill infants, healthcare providers are sometimes faced with the delicate balance between prolonging life and making decisions about palliative care. Some infants arrive at the NICN and are monitored, treated and discharged. Some will develop long-term neurological abnormalities, requiring lifelong specialized care. And some will have life support withdrawn due to an irreversible brain injury that shows no sign of recovery.

Those infants who are discharged from the NICN will visit their regular pediatrician and undergo ongoing physical therapy and follow-up with physicians at the high-risk neonatology clinic. They and their parents meet with a number of specialists, including neonatologists, developmental psychologists, physical therapists and nutritionists.

As I watch Baby E, I wonder about her prognosis and life after the NICN. Will she be among the patients that gets life support withdrawn? Or will she regain her strength and go home to her family? How is her family coping, not being able to hold their baby, who is covered in tubes and connected to so many machines? How are they processing the endless amount medical information presented by Baby E's medical team?


One week of vacation has gone by in a blink of an eye.

I spent the first few days in San Francisco taking care of business, tying some loose ends. I finally made my way to Union Square last week for some aimless shopping. And then left SF.

I arrived at my parent's house on Thursday. Since arriving, I've been spending time with my family, catching up and eating some delicious traditional Indian meals. In between, I have braved the chilling cold to fit some runs in my day. It's cold, but so much flatter in Davis, a welcome change from the hills of SF (although I do miss the views). I have been reintroduced to a concept three complete meals and eight hours of sleep. This is the life.

To sum up- vacation has been relaxing so far. I'm working on writing something insightful. For now, I'll enjoying the simplicity of life and the smells of fresh food without thinking too much.

Monday, December 15, 2008

The Endless "To do" List

M3 Mania has ended. I turned in my final today, proceeded to take the lung and prostate practical (almost mechanically). By now, tests have become a part of norm. We learn how to program our minds to ingest voluminous amounts of information in such short periods of time to answer question after question (and then we repeat the process). It's a well-oiled process for the most part. Except one big problem- retention. In the end, after an exam, you feel numb, knowing well that most of the information you meticulously hand wrote on multiple pieces of paper to committed to short term memory, will dissipate to a foregone memory. The reality of medical school.

When I walked out, I felt relieved but also unsure about what to do with myself. I have become so school-centric; my long to-do lists revolves around getting through material for small group or lecture, planning electives, preparing MSP sessions, etc. I can now attend to the growing list of things, some school-related (odds and ends), as well as a plethora of life things, namely shopping and social engagements.

The end of M3, which included cancer, blood disorders (leukemia, lymphoma and anemias) and epidemiology takes us to Christmas break. I am looking forward to spending time with my family. Outside of the cancer block, I was able to spend time in the pediatric intensive care unit in Oakland, working with a diverse spectrum of critically ill patients. I also had the pleasure and pure enjoyment of teaching cardiac anatomy and ischemic heart disease to first years during MSP sessions.

When we return from break sometime in January (not sure what date exactly) we start our last preclinical block (Life Cycle). A couple of weeks ago, our course directors sat us down and gave us that unwelcome talk about the "B" word, we have tried so hard to suppress. THE BOARDS have come upon us, infiltrating our subconscious and libraries with board review books. Not exactly sure when studying begins, just know it's going to be long, hard and epic. Overall, I'm apathetic to the exam. More concerned with getting it over with to move on to a "watershed moment" in our educational training- the wards. Hopefully, in the process I'll relearn all those important facts that have escaped.

Although we have become programmed professional information memorizes and test takers, I still can not believe how fast time has gone by. It was a year ago, when I finished my cardio exam and was preparing for clinical interlude. Now, I'm moving into uncharted study territory.

For now, I'll bask in being done. And with time, after some distraction (time to go shopping), I might actually look at the oh so endless "to do" list. I am hoping to reflect and write to process second year, looking at how I have changed and how far I have come.

From my year of medical school, I have learned that no matter how many things you have to do, you must always remember that you also have to live your life.

Monday, December 1, 2008

World AIDS Today

1 in 10 San Franciscans living with AIDS does not receive primary care.

December 1st marks World AIDS Day, a day to raise awareness about the AIDS epidemic. Today was the 20th anniversary. AIDS sprung to our attention in the 1980's as a mysterious disease affecting predominately gay men. With the emergence of the disease came discrimination and mistreatment due to lack of understanding. Today, we know more about the AIDS and the virus (HIV) that is transmitted by blood, sex and breastfeeding, which can lead to the development of AIDS. And over the last two decades, we have seen the face of AIDS (it affects everyone).

Over 60 million people have been infected with HIV, a number that continues to grow. And the death toll continues to rises.

There is so much that has to be done to understand the virus, decrease transmission, fund treatment and support those living and dying with HIV and AIDS.

Today, we gathered together, each donning sign with a statistic. With our signs and red ribbons, we made our way to Parnassus Avenue (right in front of the main hospital), where we stood in solidarity, remembering those who have lost the fight and those that are continuing the battle the disease each day.