Emily Avery ’17, Swedish Medical Center

Emily-AveryDay One

The first day of my Princeternship I met my host, Dr. Charles Cobbs ’85. who explained to me that the day would begin with a weekly tumor board conference at 7:30 am. During this meeting, about twenty neurosurgeons and medical professionals concerned with brain tumor patients gathered to discuss current patients and their progress throughout the past week. Stories of successful recoveries were shared, and especially challenging cases were discussed. Collaboration was a key component of this meeting, and many doctors exchanged advice concerning treatment and surgical methods. Dr. Cobbs, for example, described a recent patient with a tumor that was especially difficult to remove because of major blood vessels running through and around it. Dr. Cobbs explained his conscious decision to leave remnants of the tumor rather than take extreme risks to remove it entirely, and it was generally agreed that this was the most appropriate choice.

As the conference ended, Dr. Cobbs was informed that he was needed in the ICU, as one of his patients had experienced a complication while in recovery from his surgery and was now in a coma. I was able to accompany Dr. Cobbs to the ICU and observed as he explained the situation to one of the patient’s family members. While there, we visited another patient of Dr. Cobbs whose cerebrospinal fluid was not draining properly after his surgery to remove a tumor in his third ventricle. With a colleague, Dr. Cobbs discussed the probability of needing to perform another operation to give the patient a shunt that would assist in cerebrospinal fluid flow (This was an operation that I was able to observe during the third day of the Princeternship!).

Next, we returned to the Neuroscience Institute for a weekly lab meeting with the team of researchers at the Ben and Catherine Ivy Center within the Swedish Neuroscience Institute. During this meeting, the researchers shared the progress they had made throughout the past week while also discussing the potential flaws in their methods to ensure that their results will be clear and indisputable. During the meeting, Dr. Cobbs took the time to explain his research and findings to me in more detail. In short, I learned that he and his lab members have developed a treatment that would double the survival time of patients with glioblastoma, and they are working to set up a clinical trial for the new treatment. This was such an exciting discussion for me to listen to, and, in case there was any doubt, it proved to me that the biology I’m learning now has powerful applications!

Following the lab meeting, I accompanied Dr. Cobbs to a CyberKnife treatment. This form of robotic radiation to combat tumors was one I was not familiar with, and Dr. Cobbs explained the procedure to me in detail. I was blown away by the extreme precision of the equipment! Next, we returned to Dr. Cobbs’s office for a small meeting with his secretary, Davida Pennington, and a marketing advisor to discuss the Swedish Neuroscience Institute’s website and future plans to spread awareness about the high level of both the institute and its neurosurgeons. This was an interesting reminder that even medical professionals must make use of social media, which was not something I had previously thought much about. Once this meeting came to a close, I accompanied Dr. Cobbs as he visited a new patient with neurofibromatosis. Before meeting in person, Dr. Cobbs examined the patient’s scans and the brain tumors they revealed while also explaining to me the biological basis of neurofibromatosis. Next, we went to see the patient in a small exam room, and I observed as Dr. Cobbs described the necessity of determining the exact type of tumors present in the patient’s brain. A surgery to remove some tumor and perform a biopsy was tentatively scheduled. I was surprised to see this scheduling process happen so quickly.

After a quick lunch, we Avery 1returned to Dr. Cobbs’s office in time for him to make two conference calls. These calls mainly concerned the organization of a clinical trial for the treatment he is developing, and I enjoyed getting to hear about the complex logistics of such trials. Later we visited some more patients. The first had recently undergone surgery to remove a tumor near his brain stem. Dr. Cobbs explained to me that this tumor had been present since childhood, so the patient’s brain had developed to accommodate it. I was amazed to see how well the patient was functioning; it was a great illustration of the brain’s ability to adapt. The next patient we saw had a temporal lobe tumor, and I watched as Dr. Cobbs examined two sets of her scans, taken weeks apart, to try to determine if the tumor was growing. No clear consensus could be made, as the differences between the scans were subtle, and this allowed me to see how difficult it can be for neurosurgeons, and doctors in general, to make important decisions about a patient based on minimal information.

After we left this patient, I observed Dr. Cobbs make a few short phone calls, and the workday came to an end at about 5:00 pm. Dr. Cobbs informed me that, by lucky coincidence, there was a Princeton alumni event happening at the Four Seasons hotel downtown that night! I was able to accompany him to this event, and there I got to meet many alumni, including some of my classmates’ parents, recent graduates, and even President Eisgruber! Being able to connect with so many wonderful people made me feel very lucky to be a part of the Princeton community. This event was an unexpected and wonderful way for me to learn more about Princeton, and I am so thankful that Dr. Cobbs was able to include me.

Day Two

On the morning of my second day, I shadowed Dr. Cobbs’ colleague, a neurologist and radiologist. He took me to a morning conference focused on patients who had suffered strokes, and, like the tumor board meeting I attended the day before, it included much collaboration. Doctors presented specific cases one at a time, and members of the crowd of about thirty discussed the most appropriate ways to treat each patient. Disagreement concerning the best treatment often centered on a patient’s lifestyle and occupation and how certain procedures or medications would affect the patient in these regards. I was intrigued to learn how many factors, directly related to illness or not, are involved in treatment decisions.

After the meeting the doctor gave us an overview of his responsibilities as a neuroradiologist. focused mostly on the interpretation of MR images, whichallowed me to develop a feel for what neuroradiology is all about.

After that I returned to Dr. Cobbs’s office in time to observe some more patient visits. The first patient had recently hit her head in a fall, and Dr. Cobbs pulled up scan images to assess any brain damage this could have caused. The scans showed some bruising, but there were no indications of damage to the brain. I watched as Dr. Cobbs delivered this reassuring news to the patient, and it was fun for me to see such a positive visit. The next patient we saw had also recently suffered a fall, and Dr. Cobbs made a similar assessment after pulling up this person’s scans. Next, at Dr. Cobbs and I took some time for lunch at the medical center’s cafeteria. This break was a great opportunity for me to get to hear more about his experiences as a neurosurgeon and also as a Princeton student!

We then returned to Dr. Cobbs’s office and I observed another round of patient visits. The first patient, Dr. Cobbs explained, had recently undergone surgery to remove a tumor near the pituitary gland and was now experiencing side effects, such as difficulty in shifting his glance upwards and trouble focusing in some areas of his visual field. Dr. Cobbs explained to the patient why this was occurring, and I listened as they discussed the possibility of taking action, potentially through surgery, to correct these visual difficulties. The next patient we visited was one I was particularly excited to see because Dr. Cobbs had described this person’s challenging tumor removal at yesterday’s tumor board meeting. Thankfully, the patient was doing extremely well. Because of her tumor’s precarious proximity to major arteries, this good recovery had not been entirely guaranteed, and Dr. Cobbs noted that he was very pleased with the results of this patient’s surgery so far. The patient also expressed her gratitude, and her successful story showed me just how rewarding a neurosurgeon’s work can be.

Day Three

The third day of my Princeternship was a very exciting day for me because I got to spend most of it observing surgeries in the operating room! As this was my first chance to observe surgery of any kind, I was feeling both nervous and excited as I made my way to the medical center that morning. Though he would not be performing surgery until later on that morning, Dr. Cobbs took me down to the OR at around 8:45 am to observe some of his colleagues at work. After putting on scrubs, I followed Dr. Cobbs into the room where his colleague, with the help of other residents and fellows, was carrying out an aneurysm clipping surgery. Both doctors helped explain the surgery to me in greater detail while the residents worked to fold back the dura and access the brain. Once this was accomplished, the patient’s brain was visible and the doctor allowed me to step in close as he pointed out structures such as the optic nerve or temporal lobe. After learning much about these structures in lectures this fall, it was amazing for me to get to see them in the brain of a living human! Once the doctor finished this quick overview, he began the actual task of placing a clip around the aneurysm. This procedure would have been impossible for me to see clearly by simply observing, but, thankfully, it was projected onto numerous screens within the OR. This allowed me to see the procedure in much greater detail, which I greatly appreciated.

Once the aneurysm was clipped and the residents began working to close the dura and replace the bone flap, Dr. Cobbs showed me to another operating room where I got to see an operation on a patient suffering from trigeminal neuralgia. Carrying out a microvascular decompression procedure, the doctors inserted a piece of Teflon felt between the trigeminal nerve and the blood vessel compressing it. By the time I arrived, the felt had already been inserted, and I got to look through the microscope to see this accomplishment up close. Once again, I was hugely excited to see aspects of the surgery up close.

The third surgery I observed was performed by Dr. Cobbs on one of the patients we had visited in the ICU on the first day of the Princeternship, and the background knowledge I had of this patient made the surgery even more interesting for me to observe. The operation concerned the insertion of a shunt to help drain the patient’s cerebrospinal fluid. Due to specific challenges of the patient’s unusual body type, a general surgeon was also present to assist Dr. Cobbs in making the necessary incision on the patient’s abdomen. This surgery was unlike the two I had previously observed because it involved work on areas outside of the brain. I had not expected the chance to see structures like intestines, but I found it very cool to see and was glad to have a small demonstration of surgery outside of the brain as well.

In the fourth and final surgery I observed, the doctor performed a deep brain stimulation procedure. This involved the implantation of electrodes in the brain of a patient who was, in this case, suffering from essential tremor. After a DBS surgery is complete, these electrodes help to reduce tremor symptoms by blocking the nerve signals that cause tremors. Of all the surgeries I observed, I found this one to be the most fascinating. This was largely due to the fact that the patient was awake during part of the surgery, and I got to witness the immediate effects the electrode implantation had for him. Once awake, the patient was instructed to perform various tasks while the doctor turned the electrodes on or off or changed their intensity. For example, the patient attempted to draw a smooth spiral on a piece of notepaper, bring an empty cup to his lips, or hold a half filled water bottle horizontally and keep it as still as possible. It was amazing for me to observe the patient’s increased success. At a certain intensity, however, the electrodes interrupted the patient’s ability to speak clearly. To find this point of intensity, Dr. Nora instructed the patient to say ‘Methodist Episcopal,’ and the difficulty of this task for the patient was clear at a higher intensity.

To finish up, the doctors used wires to connect the electrodes to a stimulator that they inserted into the patient’s chest. They then stitched the patient up, and I left the OR to take off my scrubs and return to Dr. Cobbs’s office. There, I was able to listen to one more discussion about his research methods and clinical trial logistics. Next, Dr. Cobbs showed me the scan images of his newest patients and described the surgeries he would perform tomorrow to remove their tumors. We left the Medical Center at around 5:00 pm, and, after having dinner and saying goodbye to Dr. Cobbs, I returned to the airport to fly back to the East Coast.


As my summary conveys, I was able to see, observe, and learn a huge amount throughout the course of my Princeternship. My time in the operating room, especially, allowed me to realize just how fascinated I am by neurosurgery and what it can accomplish. After ending my OR observations by seeing the DBS procedure and its clear, positive effects for the patient, I had a sort of ‘light-bulb moment’ and realized that my Princeternship experience as a whole had inspired me to pursue a career in neurosurgery. In addition to all I learned about medicine, research, and neurosurgery by shadowing Dr. Cobbs, my time in Seattle also taught me a lot about being a part of the Princeton community. Dr. Cobbs’s openness to me, as well as the welcoming attitudes of the alumni I met at Monday night’s alumni event, showed me how lucky I am to be a student here and how much I have to look forward to in the years to come.