`Medical Elective – India                          (01st February – 20th March, 2011)     Figure1. Neuro O.T – Experiencin...
Index:Introduction-----------------------------------------------------------------------Page 3& 4The Elective------------...
Introduction                                      Somewhere along the way,                         You may lose something ...
Fig3. Faculty of Neurosurgery, Neurology and Interventional Neuroradiology departments after a Friday meeting.The highly s...
The ElectiveThe Elective attachment seemed like a much effective way to explore and discover my interests. Pre-vious exper...
Fig5. (Left)Dr. Sunandan Basu during a surgery, (Right) Dr. Ratul Bose demonstrating central venous catheteriza- tion, wit...
Learning experienceIn course of my elective, I came across some really tough moments, which I was able to learn fromover t...
Stirring momentsAlthough during the course of elective, there were several miraculous moments, where we were as-tonished b...
 Understanding and learning the application CT Scan and MRI in Diagnostic decision making.     Gaining skills of Clinica...
 Tracheostomy V.P Shunt and Cranioplasty. Ventriculoperitoneal (V.P) Shunt insertion.22-24    *Some procedures were obs...
   ORIF: Open Reduction and Internal Fixation      PD: Parkinson’s Disease      SAH: Subarachnoid Hemorrhage      SLR:...
8. Bernard Karnath. Subdural hematoma, Presentation and management in older adults. Geria-     trics, 2004; 59: 18-24.    ...
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Medical Elective - India

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Medical Elective - India

  1. 1. `Medical Elective – India (01st February – 20th March, 2011) Figure1. Neuro O.T – Experiencing the unique opportunity of observing a live Cranioto- my, through the Carl Zeiss OPMI Pentero microscope.Medica Superspecialty Hospital−“Neuroradiology and Neurosurgery” - By Harsh Sethia medminus9@gmail.com 1
  2. 2. Index:Introduction-----------------------------------------------------------------------Page 3& 4The Elective-----------------------------------------------------------------------Page 5& 6Missing help!----------------------------------------------------------------------Page 6Learning experiences-------------------------------------------------------------Page7String of moments-----------------------------------------------------------------Page 8Future learning---------------------------------------------------------------------Page 8Appendix I---------------Elective approval letter---------------------------------Page 8Appendix II--------------Elective learning objectives-----------------------------Page 8& 9Appendix III-------------Time table------------------------------------------------Page 9Appendix IV-------------Observed surgical procedures--------------------------Page 9& 10Appendix V--------------Commonly used abbreviations--------------------------Page 10& 11Appendix VI-------------Seminars, Workshops and Conferences----------------Page 11References----------------------------------------------------------------------------Page 11& 12 2
  3. 3. Introduction Somewhere along the way, You may lose something you thought was important. But everything you need to fulfill yourself, Is inside you or right in front of your eyes. You just have to reach. It often may not be easy, But it will always be a great adventure. ~AnonymousI was fortunate to be accepted for an elective attachment at Medica Superspecialty Hospital, India,attached for 7 weeks to the department of Neuroradiology and Neurosurgery.Fig2. Medica Superspecialty Hospital, Kolkata (India)Medica Superspecialty Hospital is a tertiary care hospital with 500 beds, established in the city ofKolkata. It was the first green hospital in the Country and serves as a hub to the smaller hospitals es-tablished by Medica Synergie Pvt. Ltd. in Asansol, Siliguri, and various other North-Eastern parts ofIndia. The Department for Neurological Diseases (MIND) at Medica, is considered one among thepremiere Neuroscience Departments in the Country. Built by the dedicated efforts of many stalwarts,the department draws patients from different corners of India and Abroad. 3
  4. 4. Fig3. Faculty of Neurosurgery, Neurology and Interventional Neuroradiology departments after a Friday meeting.The highly specialized faculty at MIND embodies the following sub departments:  Neurosurgery:  Dr. L.N. Tripathy (Director and Vice-Chairman at Medica)  Dr. Sunandan Basu (Elective Supervisor)  Dr. Harsh Jain  Dr. Kaushik Sil  Neurology:  Dr. Amlan Mandal  Dr. Ashish Das  Neuroanesthesiology:  Dr. Kallol Deb  Dr. Ratul Bose  Dr. Rakhi Mittal  Interventional Neuroradiology:  Dr. Aditi Chandra Sen (Elective Supervisor)  Dr. Ejaz Ahmad Bari  Dr. Arif Faizan  Neuropathology:  Dr. Sudipta Roy  Dr. Vinay Shankar  Co-ordiantor: Karabi Ghosh 4
  5. 5. The ElectiveThe Elective attachment seemed like a much effective way to explore and discover my interests. Pre-vious experience from my attachment at NUS, Singapore, as an Undergraduate Research Assistanthelped me appreciate how I could productively accomplish this Hospital attachment to gain a bettersense of the direction of my future research interests.For the most part my role was that of an observer, as it would have been unethical on the Hospital’spart to allow a 3rd year student to carry out medical procedures. In the MRI/CT Core Laboratory Iwas allowed to navigate through the different medical scans of patients to develop and improve skillsof Diagnostic decision making.During the ward rounds my supervisors, Dr Sunandan Basu, Dr Kaushik Sil and Dr Harsh Jain usedto explain, each case to me. Adopting the American style of learning, I use to do a follow-up readingon the cases for the consecutive days. This used to help me, in understanding the Management andTreatment approaches being adopted by the Sr. Doctors and also used to help me during the processof gathering Clinical history and Physical examination of the patient.Fig4. From left to right: CUSA Excel Ultrasonic Aspirator, Aestiva 5 Anesthesia Machine, Brainlab Kolibri naviga-tion system, Carl Zeiss OPMI Pentero Neurosurgical Microscope.In the Operation Theater, being a novice I learnt about the various instruments, like the OPMI Pente-ro Neurosurgical Microscope, CUSA Excel Ultrasonic Surgical Aspirator, Bipolar Coagulator toname a few. During the pre-incision term, Sr. Neuroanesthesiologist Dr. Kallol Deb and Dr. RatulBose used to demonstrate Tracheal intubation,1,2 Central venous catheterization3,4 and other minimal-ly invasive procedures and taught me how to monitor the patient’s condition using Aestiva 5 Anes-thesia machine, while carrying out these procedures. They also taught me some basics about the dif-ferent Anesthetic agents, N-M blockers and Narcotics and their doses used. 5
  6. 6. Fig5. (Left)Dr. Sunandan Basu during a surgery, (Right) Dr. Ratul Bose demonstrating central venous catheteriza- tion, with Dr. Kallol Deb and Dr. Rakhi Mittal in the rear.During the O.T sessions the neurosurgeon also demonstrated the usage and application of Brainlabimage-guided surgery platforms, which allows them to wirelessly navigate during surgical proce-dures. Several times prior to Surgery, the Neurosurgeon also took the initiative to discuss with me theClinical Neuroanatomy and the basics of Surgery, necessary to understand the surgical procedure thatto be carried out. At times, I was even fortunate enough to receive an entire demonstration of theSurgery video clip by the Neurosurgeon himself or at times by the assistant Surgeon.Every Friday morning, we used to have a Neuroradiology meeting, during which the entire MINDTeam used to discuss Radiological scans and images of all the important cases. These meetings usedto be among my favorite hours, especially due to two reasons. Firstly, there used to be so much foodfor my brain. And secondly, the sumptuous breakfast and coffee served. The meetings used to be ad-dressed by Dr. L.N. Tripathy himself and tracking his wisdom and experience through his opinionsand insights used to give a wonderful feeling, which I don’t have words to explain. Missing help! Although, Hospital attachment at Medica was a remarkable experience, yet I badly missed thepresence of other students. Being the only elective was a bit tough for the first few days, as at times,boredom used to take the best of me. I also used to regret, not having the option of discussions andcollaborative learning. There was also lack of e-learning facilities and library resources in the hospital, which I was able toovercome with the help of Dr. Ejaz and Dr. Arif who suggested some very interesting websites offer-ing useful e-resources. Dr. Aditi also contributed to the situation by lending her Scott’s Atlas. 6
  7. 7. Learning experienceIn course of my elective, I came across some really tough moments, which I was able to learn fromover time. On the second day of the elective, my Elective Supervisor asked me if I wanted to ex-amine a patient. The difficulty here was that the patient was unconscious, and as a medical student Iwas never trained to examine an unconscious patient. Having learnt examining an unconscious pa-tient, that day was a memorable experience.In the following days, I was allotted the job of collecting patients’ history, subsequent to the wardrounds. In spite of having knowledge of Hindi, English and Bengali, I still faced problems in collect-ing patient’s history and in demonstrating the first few cases to my elective supervisor and had to re-visit the patient, at times in order to collect some missing details. I guess that’s how my supervisorwanted to train me, for perfection. Fig6. CT Scan room: (Left to Right) Dr. Ejaz, Harsh Sethia(me), Dr. Arif(in blue) and other staff members.Another difficulty I faced during the course of the Hospital attachment was in understanding the vastnumber of abbreviations used by the Doctors and other staff members in their conversations and lite-rature. A small list of abbreviations regularly used by Doctors, have been listed in Appendix V. 7
  8. 8. Stirring momentsAlthough during the course of elective, there were several miraculous moments, where we were as-tonished by looking at the surprising recovery of the patient, there were some cases where the prog-nosis itself wasn’t that good, and there wasn’t much we could do to help the patient, other than man-agement and pain alleviation. But, the most disconsolate moment during the entire attachment waswhen a 7yr old girl was confirmed with the diagnosis of Medulloblastoma.5,6 The 7yr old was asmall, cute and playful girl, who was enjoying her stay, even at the Hospital by capering around. Shewas even curious to see her MRI results after having gone through the scanner, to have a glimpse ofhow beautiful she was looking, as the nurse mentioned to her, that she would be taking pictures ofher (in order to keep her still within the scanner).These are the moments when even Doctors feel helpless; as yet, they haven’t been equipped withsuch resources that they can completely cure these little angels for a much better life, and many moresmiles, which they deserved. Future learningThis elective gave me a more holistic view of Neurosurgeries, as I saw the patients from pre-operative assessment right through to the recovery room. It also helped me gain comprehensiveknowledge of MRI and CT scan, as I went through the scans of hundreds of patients and tried to un-derstand and learn the process of diagnostic decision making.Based on my achievements and lessons gained from this attachment, I decided future learning objec-tives for myself. As I couldn’t gain knowledge on fMRI from this attachment, I decided to look intothe literature for fMRI and to get hands-on information on fMRI through correspondence with Sr.Neuro-radiologists at my home university. I also decided to utilize and improve my knowledge inNeurosurgery by sharing my experiences with my university fellow mates, as having discussionswould help me gain a better understanding of the subject. Appendix I: Elective approval letterThe link to the Elective approval letter is attached below. The Elective approval form was receivedfrom Sudhanshu Roy, VP-Operations at Medica Superspecialty Hospital.https://acrobat.com/#d=rpHUSaVmOjWnobmO1Uf6LA*The PPE certificate obtained from the home university was submitted along with the application. Appendix II: Elective learning objectives  History taking and Interview techniques.  Physical examination. 8
  9. 9.  Understanding and learning the application CT Scan and MRI in Diagnostic decision making.  Gaining skills of Clinical problem solving and Treatment approaches.  Seeking knowledge on various surgical procedures and techniques. Appendix III: Time table am/pm: Routine 9am Ward rounds 10:30am Operation Theatre 2:00/3:00pm MRI/CT Core Laboratory 5:30pm Ward rounds*The time-table mentioned above was for Mondays-Fridays. Appendix IV: Observed surgical procedures  Anterior cervical discectomy and fusion (ACDF).7  B/L drainage of subdural haematoma.8,9  Bone marrow aspiration for stem cell therapy.  Brainlab biopsy.10,11,12  Brainlab guided craniotomy and excision of cavernoma.13  Burr Hole Drainage.14  Cervical laminectomy and excision of tumor.  Craniotomy and aneurysm clipping.  Craniotomy and removal of meningioma.15  Craniotomy and removal of tumor.13,15  External ventricular drain (E.V.D): Right side.16,17  Extra-abdominal reposition and trans-abdominal fixation.  L4-L5 discectomy.  Laminectomy and screw fixation.  Lumbar decompression.  Lumbar-peritoneal (L.P) Shunt.18,19  Open Reduction, Internal Fixation (ORIF) of Frontal bone.20,21  Pedicular screw fixation.  Re-exploration and nerve repair of Right arm.  Revision of V.P Shunt.22,24  Stem cell insertion.  Thoractomy and removal of disc. 9
  10. 10.  Tracheostomy V.P Shunt and Cranioplasty. Ventriculoperitoneal (V.P) Shunt insertion.22-24 *Some procedures were observed numerous times, in different patients. Appendix V: Commonly used abbreviations ACDF: Anterior cervical discectomy and fusion AD: Alzheimer’s Disease ADA: Adenosine Deaminase AF: Atrial Flutter APTT: Activated partial thromboplastin time ART: Anti-retroviral treatment AT: Antithrombin ATT/AKT: Anti-tubercular treatment AVM: Arterio-Venous Malformation B/L: Bilateral BT: Bleeding time C/S: Culture sensitivity CAA: Cerebral Amyloid Angiopathy CRP: C-reactive protein CSDH: Chronic Subdural Hematoma CSOM: Chronic suppurative otitis media CT ratio: Cardio-thoracic ratio CT: Clotting time DAI: Diffused axonal injury DC/DLC: Differential Lymphocyte Count DLB: Dementia with Lewy bodies DNS: Deviated nasal septum ETV: Endoscopic Third Ventriculostomy EVD: External ventricular drain FBS: Fasting Blood Sugar FLAIR: Fluid attenuated iversion recovery (A type of MRI) GCS: Glasgow Coma Scale HOB: Head of bed ICH: Intracerebral Hemorrhage ICP: Intracranial Pressure LFT: Liver function test MCI: Mild cognitive impairment NCCT: Non-contrast CT-scan NF+: Neurofibromatosis NPH: Normal Pressure Hydrocephalus OPLL: Ossified Posterior Longitudinal Ligament 10
  11. 11.  ORIF: Open Reduction and Internal Fixation  PD: Parkinson’s Disease  SAH: Subarachnoid Hemorrhage  SLR: Straight leg raising  SOL: Space occupied lesion  SOS: If needed/ If necessary  TBI: Traumatic Brain Injury  TC/TLC: Total Lymphocyte Count  TDS: Three times daily  TOF: Tetralogy of Fallot  Urine R/E: Urine routine examination  US: Unremarkable Strategy  WNL: Within normal limits Appendix VI: Seminars, Workshops and ConferencesThe Hospital attachment also brought me the benefit of attending some worthy events:  Workshop and Seminar on “Hand-washing and Advanced sterilization techniques.”  Conference on “Advanced treatments for gastrointestinal cancer.”  Seminar on “Poison control and management”  INFOCOM Conference and Exhibition, 2010-11. References: 1. D O’Flaherty, A P Adams. Endotracheal intubation skills of medical students. Journal of the Royal Society of Medicine, 1992; 85: 603-04. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293685/pdf/jrsocmed00106-0017.pdf 2. C. Michael Dunham, et al. Guidelines for emergency tracheal intubation immediately follow- ing traumatic injury. An EAST Practice Management Guidelines Workgroup. http://www.east.org/tpg/intubation.pdf 3. Central Venous Catheterization. http://www.surgicalcriticalcare.net/Guidelines/intravascular catheters 2009.pdf 4. Roberto E Kusminsky, et al. Complications of Central Venous Catheterization. American College of Surgeons, 2007: 680-96. http://www.surgicalpatientsafety.facs.org/research/kusminsky.pdf 5. Medulloblastoma. American Brain Tumor Association (ABTA) http://www.abta.org/sitefiles/sitePages/D3A2C571CD0CDE16C0FFE57607F22A65.pdf 6. Kevin Lai, Mandy Tam, Sharon Karackattu. Differential Gene Expression in Metastatic Me- dulloblastoma. http://www.psrg.lcs.mit.edu/6892/01presentations/medulloblastoma.pdf 7. Anterior Cervical Discectomy and Fusion (ACDF). Michelson Technology at work, 2005. http://www.sofamordanek.com/spineline/ACDF.pdf 11
  12. 12. 8. Bernard Karnath. Subdural hematoma, Presentation and management in older adults. Geria- trics, 2004; 59: 18-24. http://www.sbn-neurocirurgia.com.br/site/download/artigos/article.pdf 9. Thomas M Keller, Martin C Holland. Chronic subdural haematoma, an unusual injury from playing basketball. Br J Sports Med 1998;32:338–345 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1756123/pdf/v032p00338.pdf10. Kaiser Permanente. Stereotactic Brain Biopsy. Neurosurgery department, Redwood City. http://www.permanente.net/kaiser/pdf/64084.pdf11. Sajid Nazir Bhatti, et al. Computerized stereotactic brain biopsies: An experience of 15 pa- tients at Ayub teaching Hospital. J Ayub Med Coll Abbottabad 2005;17(3) http://www.ayubmed.edu.pk/JAMC/PAST/17-3/SajidNazir.pdf 12. Carlos Augusto Ferreira Lobão, et al. Comparison between frame-based stereotaxy and neu- ronavigation in an oncology center. Arq Neuropsiquiatr 2009;67(3-B):876-881 http://www.scielo.br/pdf/anp/v67n3b/18.pdf 13. Juri Kivelev. Brain and Spinal Cavernomas – Helsinki Experience. Töölö Hospital https://helda.helsinki.fi/bitstream/handle/10138/22947/brainand.pdf?sequence=1 14. NK Khadka, et al. Single burr-hole drainage for chronic subdural haematoma. Nepal Med Coll J 2008; 10(4): 254-257 http://www.nmcth.edu/nmcj_articles_pdf/volume_wise/nmcj_no4_vol10_december_2008/nk_khadka.pdf15. Focusing on Tumors: Meningioma. American Brain Tumor Association. http://www.abta.org/siteFiles/SitePages/BC633774088193FEFBB0303C852478BD.pdf16. External Ventricular Drain. Western Sydney Health Services 2003. http://intensivecare.hsnet.nsw.gov.au/five/doc/evd_S_n_swahs.pdf17. Management of External Ventricular Drains. NTICU, Memorial Hermann Hospital. http://www.uth.tmc.edu/schools/med/neurosurg/Assets/pdf/residency/management_of_extern al_ventricular_drains.pdf18. Lumbo-peritoneal (LP) Shunt. Melbourne Neurosurgery. http://www.neurosurgery.com.au/pdfs/OPERATION/LPSHUNTOP.pdf19. Leonard R., et al. Epidural Blood Patch for Headache After Lumboperitoneal Shunt Place- ment. Anesth Analg 2005;101:1497–8 http://www.stratmannlab.com/publications/Razzu Almond epidural blood patch for PDPH.pdf20. Maj MG Venugopal, et al. Fractures in the Maxillofacial Region: A Four Year Retrospective Study. MJAFI, Vol. 66, No. 1, 2010 http://medind.nic.in/maa/t10/i1/maat10i1p14.pdf21. Facial Trauma. Dr. F. Ling’s notes. http://drfling.hyperphp.com/Notes/Bony Facial Trauma.pdf22. Matthew J, et al. Risk Factors for Pediatric Ventriculoperitoneal Shunt Infection and Predic- tors of Infectious Pathogens. Clinical Infectious Diseases (CID) 2003:36. http://dicon.mc.duke.edu/wysiwyg/downloads/M9McGirt_et_al._Risk_factors_for_pediatric_ve ntriculoperitoneal.pdf23. Ravi Kanojia, et al. Unusual Ventriculoperitoneal Shunt Extrusion: Experience with 5 Cases and review of the literature. Pediatric Neurosurgery 2006 http://drravikanojia.tripod.com/sitebuildercontent/sitebuilderfiles/pne977.pdf24. Cindy Julius Simpkins. Ventriculoperitoneal Shunt Infections in Patients with Hydrocepha- lus. PEDIATRIC NURSING/November-December 2005/Vol. 31/No. 6 http://www.pediatricnursing.net/ce/2007/article12457469.pdf 12

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