Vivienne Tam ’15, Swedish Neuroscience Institute

I applied to this Princeternship at Swedish Neuroscience Institute expecting to see how research and medical practice intersected. It ended up being a face-to-face encounter with life and death – a story of the struggle for hope and a battle for survival all in a short three days of a neurosurgeon.

Tam 2Monday

It started off with a tumor board where doctors in scrubs congregate at 7:30 a.m. around Starbucks cups and fMRI projections. A brain image would go up and after giving a short description of the patient, the group of surgeons and radiologists would proceed to comment and dialogue about potential treatment. It was hard to believe that every single blotchy black and white blob on the screen belonged to an actual person – with a story, a family – a life. Sometimes, it was very easy to forget that in the jargon of ‘necrotic tissue’ and ‘intertemporal medial lobe’. Dr. Charles Cobbs ‘85 started to speak of a woman in a comatose state; and in that moment, it was no longer tissue, the case had a face and a name. She had 3 kids, was divorced, addicted to narcotics and still young – only 34 years old. The gentleness and compassion with which he spoke moved me. This is where medicine touched real lives. They were going to have to pull the plug on her pretty soon, it seemed was the verdict. A procedure to implant a shunt was scheduled later that afternoon as a last-ditch measure to keep her alive.

Without taking off the doctor-cap, we immediately switched gears to talking about research at his lab meeting. By applying his experience with brain cancer patients to his time beside the lab bench, Dr. Cobbs is able to generate the most cutting-edge research as it pertains to brain cancer. He discovered, for example, that cytomegalovirus is behind glioblastoma, the most deadly form of malignant brain tumors and this has led him to design vaccines to cure brain cancer which currently has no cure. This was groundbreaking.

As the newly recruited director of the Ivy Institute, Dr. Cobbs’ job also takes on an administrative role. An advisor counselled him on how to make Swedish the most competitive in the space, so that those with brain tumors will see it as a place that has ‘got it right’. We also talked about how to cut down on extraneous costs.

Back in the office, Dr. Cobbs receives a call from the comatose woman’s mother requesting they cancel the surgery and remove life-support.

I step outside the hospital doors. One more person has just crossed the line from life to death. I can’t imagine every day being like this. Seeing lives pass through your fingers, but like gripping sand you can’t do anything to stop it. I ponder about eternity as I board the bus back home.

Tuesday

After a rather somber end to the first day, I was ready to meet the hopeful cases – the patients who had gone through surgery and were coming to see Dr. Cobbs for a post-op follow up visit, and also those who were contemplating a potential surgery. He had eight patients lined up back to back without a lunch break and with persevering dedication, he powered through all of them – going into a room, meeting patients, going back to his office and dictating notes, then back to another room again.

If I could use one word to describe Dr. Cobbs as he met his patients, it would be humble. As a very accomplished neurosurgeon, he probably knows all there is to know about the brain. Yet, with each patient, he broke the concepts down to a very basic level and patiently walked them through enigmatic grey-and-white brain scans.

A couple of scenes stick out in my mind: Dr. Cobbs holding an elderly man as he got out of a wheelchair, his arms reassuring the man as he stood wobbling; Dr. Cobbs gingerly pulling back a woman’s hair to clean up the scar tissue beside her ear and apologizing when he hit some raw tissue; him very gently breaking the news to a visibly distressed elderly lady of the need for surgery as soon as possible to remove a malignant tumor. Even though he has only been at Swedish for a couple of months, he is much respected by his patients and it was such an honor seeing such a display of genuine caring. This world needs more doctors like that.

I was also amazed at the hopefulness Dr. Cobbs carried in the face of such a menacing disease. I can’t even imagine the frustration of months of hard work only to have the patient pass away. How do you stay sufficiently emotionally detached so that each inevitable loss is not devastating, yet continue fighting this amorphous monster to the last breath? Perhaps it is the way Dr. Cobbs doesn’t take himself too seriously that gives him the grace to carry on this kind of environment.

“Thanks for answering all of my questions doctor,” a patient pipes up after an intense interrogation.

“Oh, it was tough,” Dr. Cobbs responds with a twinkle in his eye.

Wednesday

The first day I saw death, the second, life and now I was to stand at the brink of life and death. It was surgery day.

After sending my parents a quick email to please pray for me so I don’t faint, I donned my scrubs and entered the already-buzzing operating room at 7 in the morning. Today’s was a “cranie,” in other words the removal of a cancerous tumor in the brain.

It was my first surgery so I had to look awayTam 1 as the anesthesiologist stuck an IV into the patient’s neck. I never was a big fan of needles. Unfortunately, I didn’t look away fast enough to miss the other surgeon nonchalantly screwing a U-shaped fixture with long sharp needles on either end into the man’s head.

Dr. Cobbs took me and another observing student into the back room to show us where the tumor was located using an fMRI. This man’s tumor was huge and he would probably have to remove about a quarter of the brain to get it all out.

Being careful to stay 3 feet away from all the blue sterile stuff lest I get kicked out of the OR, I made my way to the front of the bed where the surgery was proceeding like clockwork. The skin was cut through, holes were drilled in the bone, dura peeled back and finally brain revealed. I gasped quietly in awe at the first sight of the brain.

However, the recognizable folds of the brain were quickly dismembered under the skillful scalpel of Dr. Cobbs. Soon, he was burrowing deep into the brain, sucking out pieces of brain to the tune of Adele in the background.

All of a sudden, Dr. Cobbs’ voice turned terse, “He is showing a lot of swelling, also hyperventilating. I need an ultrasound.” It is an emergency situation. The lights turn down and I pray under my breath for a man I do not even know. “Shut the music,” he orders. No one moves as they stare intently at the screens displaying the man’s vitals. I walk over and press ‘mute’.

The silence hangs heavy in the room as Dr. Cobbs works fast to save his life. I watch with abated breath, in disbelief that I was observing what he was later to describe as one of the scariest experiences he has had in a long time doing surgeries. This literally was the brink of life and death. A couple of tense moments later, Dr. Cobbs had removed the problematic tissue and the patient was back in the ‘safe zone.’ I remain amazed at how calm he was. Later on, he confided that the challenging cases were actually his favorite part of his job because it gets him to think on the spot. No wonder he’s a neurosurgeon.

The second surgery – a spine decompression – was simpler, though it involved the correction of major errors made by the previous surgery, one of which included leaving the patient’s major spinal nerve protruding from her spinal cord. After the surgeries, we went to visit the patients recovering in the ICU. It was so encouraging to see them responding well, and I was actually quite surprised to see the man being able to obey commands without a large part of his brain.

I am now on the plane returning to Princeton and to finals awaiting me. Usually, I would be approaching this season with much fear, but after what I have been through these past few days, finals seem so insignificant. We complain about receiving a bad grade on an exam, when people receive news of having an incurable glioblastoma leaving them about 1-2 years to live. Honestly, I feel so blessed just to be alive – and with brain cancer that could affect anyone with no known reason, that is definitely not something to be taken for granted.

To anyone who is thinking about doing a Princeternship – go. You only have one life; live it to the fullest. Who knows, you might even get to see a human brain (I definitely wasn’t expecting to!).

To Dr. Cobbs – what can I say.  You inspire me. I can’t believe I had the amazing privilege of following you around – it was surreal. You’ve shown me what it means to do a job with genuine passion, pursued excellence and real love. Thank you.

Mina Park ’17, Swedish Neuroscience Institute

Mina-ParkAs this was my first time doing some type of shadowing in the medical field, I was very excited to go to the Swedish Neuroscience Institute in Seattle, Washington to shadow Dr. Charles Cobbs ‘85 for the next three days. I was able to gain so much through this Princeternship and the three days I shadowed Dr. Cobbs definitely made my Spring Break memorable.

On the first day of the Princeternship, the other Princetern, Hope Xu, and I changed into scrubs and went to the OR with Dr. Cobbs. In the OR, we got to observe Dr. Cobbs take out a tumor in one of his patients. Before he started, he told us that if we felt light-headed or dizzy from the smell of blood or seeing it for the first time, we could lie down near the corner or leave the room for a little bit.  I did not realize that people could react to blood in this way, so after he said this, I started getting worried about how my body would react to blood. Would I faint? Would I need to leave the room? Would this mean that I would have to rethink about whether or not I wanted to be a surgeon? Thoughts started circulating in my head before the operation even started. When Dr. Cobbs started the surgery, however, I was very surprised because my body did not react in the way I thought it would. Fortunately, I did not feel dizzy or light-headed, and observed the whole surgery in awe.  I was unable to remove my eyes off the big screen, which magnified the surgery that he was performing on the patient.

The second day was also spent shadowing Dr. Cobbs, who let us see MRI scans of patients’ brains so we could see where he was going to cut into the brain to take out the tumor. It was really interesting seeing these MRI scans because the places where the tumors sat in the brain were different for each patient. In each case, Dr. Cobbs would explain to us how he was going to take out a tumor and told us which places he had to be extremely careful of so that the patient would not be impaired in some way when he or she woke up after the surgery was finished. Dr. Cobbs then went in the OR room, where we observed the surgeries. After each surgery was finished, Dr. Cobbs went to the lobby and explained to the patient’s family about how the surgery went. It was really inspiring seeing Dr. Cobbs in the surgery room for these two days, and this experience was unforgettable.

On the final day, Dr. Cobbs let us attend the 5th annual Swedish Neuroscience Institute Brain Anatomy course, where other doctors from around the country came in to talk about the specific surgeries they performed on their patients. This course was a really interesting experience, as I got to sit in a room with many other acclaimed doctors, and I learned about new types of surgeries that could be performed on the brain.

This Princeternship gave me such a wonderful opportunity, where I got to listen to lectures and observe surgeries. This experience has given me determination to stay on the pre-health track and go into the medical field in the future. I thank Dr. Charles Cobbs, his assistant Davida Pennington, and all the residents, nurses, and staff at the Swedish Neuroscience Department. Thank you for such an unforgettable experience!

Hope Xu ’15, Swedish Neuroscience Institute

Hope-XuDay 1: Wednesday, March 19

At 6:00 am, I took the public bus from the University of Washington to the Swedish Neuroscience Institute at Cherry Hill, where I met for the first time with our host, Dr. Charles Cobbs ‘85, and my fellow Princetern, Mina Park. Before we even headed for the OR, we ran into the family of a middle-aged woman scheduled for an operation that very morning. Dr. Cobbs patiently reassured the patient’s mother, and I exchanged a few friendly smiles and waves with the patient’s daughter before we headed upstairs. In the ICU, we quickly visited another recovering patient, who had had a brain tumor the size of a baseball removed the previous day. With a single surgery, he had improved from a state of complete confusion and motor incapacity to sipping coffee and joking with the nurses.

The first case of the day involved the removal of a recurring glioblastoma tumor that was putting pressure on the patient’s delicate brain stem regions. An assistant in the corner monitored the patient’s neurological stimulations throughout the procedure to ensure that Dr. Cobbs didn’t damage any crucial nerves, and an anesthesiologist injected a variety of drugs and anesthetics into the patient’s IV’s to maintain vitals. From time to time, Dr. Cobbs would explain each step of the process and point out anatomical layers of tissue and different cranial nerves. Because the patient had already had a similar surgery a year ago, Dr. Cobbs had to navigate through massive amounts of scar tissue, making it very difficult to remove the entire tumor. After excising about 50-80% of the tumor, Dr. Cobbs replaced the missing part of her skull bone with a titanium mesh that would prevent the swollen cerebrum from bulging out of the hole.

In the afternoon, Dr. Cobbs Xu 2gave us a quick tour of his private lab, which has been researching the role of viruses in brain tumor development, particularly cytomegalovirus in blastomas, using tumor samples removed from previous patients. Afterwards, he let us shadow his colleague, Dr. Newell, who was in the middle of removing an overgrown vertebral disc that had begun pressing into the patient’s spinal cord, causing enormous amounts of pain. The missing disc was replaced with a small, white installment containing some of the patient’s original bone, which would encourage the neighboring vertebrae to grow back together once it was bolted into the patient’s spine. Dr. Newell’s next case involved a cranial artery bypass for a patient suffering from Moyamoya disease, caused by the constriction of crucial arteries in the brain. After carefully isolating the extracranial artery that had been blocked off, Dr. Newell proceeded to suture it together with a large artery within the brain. He allowed us to look at the arteries in his surgical microscope and with our naked eye—you couldn’t help but marvel at the incredibly miniscule size of the blood vessels being meticulously sewn together with near-invisible threads.

Day 2: Thursday, March 20

First thing in the morning, Dr. Cobbs invited us to listen to a lecture by the influential researcher, Eric Holland, who presented his groundbreaking research on the possible role of radiation therapy in encouraging the growth of malignant, recurring tumors in blastoma patients.

Afterwards, Dr. Cobbs operated on a patient with a malignant meningioma that had spread and invaded multiple regions along the top and frontal regions of the brain. We were allowed to touch a small piece of tumor tissue with our own hands, and Dr. Cobbs indicated the textural difference between tumors, which are like “hard rubber balls,” and actual brain tissue, which is “soft like butter.” Using a surgical tool similar to a small spatula, Dr. Cobbs carefully separated and removed four enormous tumors with the help of an infrared navigation system that tracked his progress on the patient’s MRI. To avoid infection, Dr. Cobbs irrigated the gaping hole in the patient’s now tumor-free brain with multiple saline washes before covering the open brain with bovine pericardium, patching up the skull with a titanium mesh covered in calcium paste, and suturing the patient’s scalp back together. Before the patient was wheeled away to recovery, we saw his eyelashes begin to flutter as he started to wake up, much to the relief of his family and friends in the lobby who clung to the doctor’s every word after the operation.

We stopped for a quick lunch in the cafeteria, where Dr. Cobbs regaled us with incredibly amusing anecdotes of his days back in Princeton as a freshman, with Michelle Obama (then Michelle Robinson) living in the room next door. The afternoon featured a more routine removal of a benign meningioma in an elderly man, and the last surgery of the day was a quick shunt revision in a cancer patient who was suffering accumulation of blood in the brain ventricles.

Day 3: Friday, March 2

Every year, the Swedish Neuroscience Institute holds an annual conference inviting residents and fellows from all across the country to discuss and learn about the latest technology and equipment related to neurosurgery. We were lucky enough to have our Princeternship coincide with the first day of this conference, and got to sit in on a full day of lectures from leading neurosurgeons who talked about deep brain stimulation, epilepsy, frame and frameless navigation, neural pacemakers, etc. The entire afternoon featured live demos of new techniques on cadavers, and we even got to wear 3D glasses during anatomy lectures and watch the speaker point to popped-out images of the hippocampus and corpus callosum.

Unfortunately, our Xu 3short time with Dr. Cobbs and the Swedish Neuroscience Institute came to an end with the conclusion of this conference, but these three days were packed with tons of new knowledge and experiences. Even though I have done a neurosurgery Princeternship previously, I learned so much more about the wonderful partnership that can exist between research and applied medicine from Dr. Cobb’s example. With determination and a commitment to change, a normal doctor doesn’t have to sit back and can actively engage in the pursuit of scientific progress. I have found both Dr. Cobbs and my time in Seattle to be truly inspiring, and I thank everyone at the Swedish Neuroscience Institute and those involved with the Princeternship Program for this incredible opportunity!