3-7-24 MSC Perspectives on Medicine - Charles Duncan

March 08, 2024

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00:00Once again, thank you everyone for joining
00:02in on our Perspectives on Medicine series.
00:06That's our last one for the school year.
00:09Very excited to introduce our guest
00:11speaker for today, Doctor Duncan.
00:13Doctor Charles Duncan is a
00:16Senior Research Scientist,
00:17Professor of Neurosurgery and Pediatrics
00:19at the Yale School of Medicine.
00:22He has been a neurosurgeon
00:23at Yale since 1997 or 1977,
00:25where he became the Chief
00:27of Pediatric Neurosurgery,
00:28and has also established the first pediatric
00:31neurosurgery program in Connecticut.
00:32He also served as the Program
00:34Director for the Yale Neurosurgery
00:36Residency Program for 18 years.
00:38Doctor Duncan's research focuses
00:39on the prevent focus on the
00:41prevention of intraventricular
00:43hemorrhage and premature infants.
00:45He's developed the cerebral blood
00:47flow measurement systems for
00:48the immature brain by positron
00:51emission tomography and adaptation
00:52to developing brain to injury.
00:54His Endomethicine Project for
00:56Prevention of Intraventricular
00:58Hemorrhage in Preterm Infants has
01:00adopted has been adopted in over
01:0275 countries and his work have led
01:05over 100 peer reviewed publications.
01:07Dr.
01:07Duncan is also very deeply committed
01:09to medical education.
01:10He and his colleagues,
01:11Doctor Bill Stewart and Shanta Kapadia,
01:13have developed online resources on
01:15human anatomy and the Coursera platform.
01:18They've also developed a human
01:20anatomy video project,
01:21a series of iBooks on human anatomy,
01:23and the Apple Bookstore.
01:25Doctor Duncan completed his Bachelor's
01:27at Vanderbilt University and his MD in
01:30residency training and neurosurgery
01:31at the Duke University School of Medicine.
01:34We're very excited to have Doctor Duncan
01:36join us today for his talk titled Pitfalls,
01:39Clinical Research,
01:40Education Life.
01:41Doctor Duncan,
01:43again,
01:43thank you so much for joining with
01:46us today and we will turn it over to
01:48you whenever you're ready to begin.
01:51Thank you. Thank you Wilton
01:53and and thank thank you,
01:55the Medical Student Council and
01:58Doctor Mint for inviting me.
02:01This is a real pleasure.
02:08Make sure I get the sharing going.
02:23This is just a bit of a soundtrack.
02:27Barbara Watt Barb Watts. They reset
02:31this so that it actually hear hear this
02:38maybe you know what it is and
02:41whom bird learned the song and
02:44which might have learned it.
02:45But if you don't know,
02:46it's a Bob White quail.
02:50And they learned this from
02:52their father before they hatch.
03:00So I don't know if you ever feel
03:04like you're tracking up Everest in a
03:08long line or if you might feel like
03:11you're just being tossed in a pond.
03:13Or maybe sometimes you feel like both.
03:19Mr. Mr. Jones. I'm doctor Anderson.
03:21I'm the neurosurgeon.
03:22The paediatricians called me
03:24because Jimmy had an MRI scan,
03:26and it looks like the MRI
03:29scan shows a brain tumor.
03:31I looked at it myself and it
03:33shows a lesion in the cerebellum,
03:35tumor in the cerebellum that
03:37we're going to have to deal with.
03:40So we've checked out my OR schedule
03:42on the way up here and it looks like
03:43Tuesday afternoon we can do a surgery.
03:45Are you sure you were
03:47talking about the right?
03:49Yeah, a little.
03:50Jimmy, about four years old.
03:50I walked by his bed when
03:51I was coming up here.
03:52He was still just coming
03:53out of the MRI scanner,
03:54but but he we, we thought he had the flu.
03:58I mean, he's just had some nausea
04:00and and some headaches. Sometimes
04:02these brain tumors can push on the
04:03back of the brain and where they
04:05push can cause nausea and vomiting.
04:07And sometimes it mimics well, no,
04:10it's not the flu, It's a brain tumor.
04:12So we set up the surgery for Tuesday.
04:16The pediatricians will come in and
04:18tell you what Betty's going to.
04:19I don't know what Betty's going to yet.
04:20We're going to keep him in
04:22the hospital till Tuesday.
04:23Surgery looks like it'll be in the afternoon.
04:27Any other questions? We
04:31didn't see him
04:32in. He'll be up here in a little while.
04:34I don't know. I didn't see him.
04:35I just saw him laying in the bed.
04:36The the the nurses are
04:38taking care of him. But
04:43any other questions,
04:45I just can't leave it, but
04:49we may have some time to talk before
04:50the surgery on Tuesday. All right.
04:56All right. Well, the pediatricians
04:56will be in, in a little bit. OK.
05:06Well, that's one perspective on medicine.
05:12I thought we talked today about
05:13some some of the pitfalls that
05:18I've encountered you may
05:21encounter and it and falls into
05:24just about everything we do.
05:27I don't have any conflicts.
05:28I do receive royalties from Coursera.
05:31They're not very much.
05:35There was a man named Charles Drake and very,
05:41very prominent vascular neurosurgeon
05:46from London ON he he he didn't
05:51tout all of his successes.
05:53He would, he would talk about
05:55the problems he had and the
05:59disappointments and the the the the
06:02times when it was just a disaster
06:07after after he was gone.
06:10This is the the the fish named
06:13Charlie that's at the the
06:18entrance to that that area in in the
06:23Medical Center in the University
06:25Hospital at his Medical Center.
06:33So as you as you heard, I I did my
06:35residency at Duke and it's been a while.
06:39Two of my Co residents had been in Vietnam.
06:42One was a General Medical officer and he
06:46was dropped out of a helicopter and a wire.
06:49The other was a major and
06:52then later became a general.
06:54So what do you think that most chief
06:57residents might do right after they finish?
07:00Well, he went to Ranger School.
07:03He was certainly a great guy to have around.
07:06When disputes arose.
07:09The one who dropped out of was
07:12dropped out of helicopters,
07:14came back straight out of Tim O'Brien's.
07:18The the thing they things they carried.
07:22Another resident went on to become a
07:25chicken farmer in his in his off hours.
07:27So I think everybody needs a distraction.
07:31This guy on the on the right is a
07:36weekend warrior at that time and
07:42mostly took care of cuts and scratches
07:45for people who were training in
07:47the occasional lightning injury.
07:52We worked every other night for six years.
07:55The tough ones were in medicine, though.
07:57They worked five out of seven.
08:00Pediatrics had Sam Katz,
08:02who brought measles vaccine to us.
08:06OBGYN had Charles Hammond to help
08:09develop cures for trophoblasts.
08:11Plastic disease, well,
08:13Surgery had David Savaston,
08:15who was one of the great figures
08:18of American surgery and medicine,
08:20was led by Jim Weingarten,
08:22who later had the LED the NIH.
08:24The top left was was Main Chief Guy,
08:28Guy Odom and Barnes.
08:32Woodall was the the former chief
08:35and still still an active person.
08:38He went went on to be Dean of the medical
08:42school and then president of the university.
08:46It was a great turmoil
08:48over the war in Vietnam.
08:49On many campuses,
08:51including including New Haven,
08:56Doctor Woodall would operate when
08:57he's president of the university.
08:59He'd operate in the morning and
09:02then he'd walk out to the so-called
09:06quadrangle at at Duke and then sit
09:09with the students in the grass
09:12or on a wall and listen to them.
09:15Just listen to them for as
09:17long as they wanted to,
09:18wanted to speak in the evening.
09:21He did whatever university presidents do.
09:26Bill Anlian was the Dean
09:28of of the medical school,
09:29and in the top right is John Anlian.
09:32He's the person for for whom
09:37the Anlian Center is named.
09:39Here he's pictured with with his wife,
09:41Betty. He he was a general
09:45surgeon in San Francisco.
09:48He and Bill Anlian
09:52came to Yale, immigrating from Egypt to
09:56Yale College and then went on to the
09:58Yale Medical School and and remained
10:01very devoted to the institution.
10:03I think most of you have been
10:05in our our labs or somebody's
10:07lab in in the Anlian Center.
10:10Alan Friedman was my junior resident
10:12when I was chief and and I think
10:15there's always a particularly fine
10:17relationship between between residents
10:20and particularly between the the chief
10:23resident and his and his junior resident.
10:26There were some memorable lessons
10:30from mentors across this time.
10:36Doctor Odom informed us that
10:39Medicare would wreck medicine.
10:41Doctor Woodall was about 5
10:43feet two inches on a good day.
10:45You know, he always stood at a
10:48stool when we operated together
10:50so I wouldn't need to bend over.
10:53Doctor Odom fired me week
10:54after week after he found out
10:57I'd voted for Jimmy Carter,
11:01and on some occasion I managed
11:04to annoy him or make some
11:07grievous error in his estimation.
11:09And he did tell me that I was
11:12chief resident at the time and
11:15planned to come to New Haven.
11:17He told me that he was going to
11:18send me to Pittsburgh instead
11:19of Yale if I did that again.
11:32I I love being a resident.
11:33I'm sure I I hurt a number of
11:36people when I was learning
11:37and probably still have,
11:42but I hope I helped some in
11:45a in a reasonable number.
11:48Try to imagine taking care of folks
11:52without computerized imaging,
11:55without CT, without MRI.
12:00You know, we became an awful lot
12:04smarter with the introduction
12:06of computerized imaging.
12:08Before you see on the left a
12:11pneumoencephalogram where air was
12:13injected with a lumbar puncture
12:16on the right and arteriogram.
12:17We did direct stick carotid arteriograms,
12:26but now we're a whole lot smarter. I hope
12:31these are the original
12:33devices in in New Haven,
12:34the CT scanner that had a water bag
12:37around it instead of being a big circle.
12:41And I came in the early 70s and
12:44then in the mid 80s we we got our
12:48first first magnet and this is that
12:51magnet the devices you see now or
12:54considerably more sophisticated.
12:58The left is ACT scanner and the mid as
13:02a mid one is a Siemens 3 Tesla MRI device.
13:06And then one of the rights the the
13:10pediatric magnet which has been
13:12decorated like a little castle.
13:16This is what we have in our operating
13:20room in Smilo so-called Emer system,
13:24where there's a magnet on a
13:26overhead railroad that can
13:29travel into two operating rooms.
13:31Does men mean that we we have,
13:35we're happy to have a very compulsive
13:38staff in the operating room to make
13:40sure we haven't left needles or
13:43instruments anywhere near the my field.
13:53My first came to Yale,
13:57or actually it was my second
13:59visit in 1977 on July 9th.
14:02First time I'd been was to A to
14:05a meeting and my my second visit
14:08was for a faculty interview.
14:10Well, I had a cold a fever Coraza.
14:13There was 9 inches of snow that fell
14:16that day and they sent me to the
14:19VA for more interviews on a bus.
14:23I'm sure you recognize some
14:26of these places and a lovely
14:28photograph of our Medical Center.
14:33When I was 29, I joined the Yale faculty.
14:37Nevertheless, this has been my only job.
14:40I was an electrician's assistant, an orderly.
14:44I thought medical school would
14:46be less work, and a glass washer
14:49and microbiology during college.
14:51Otherwise, I've been here.
14:56Once I arrived, it took me a while to
14:59realize that my chief Doctor Collins
15:02had divided his office in half for me.
15:07While this place can seem harsh,
15:11there are aspects that divine it,
15:13that define it. Why did you choose it?
15:17And why did I just decide to stay?
15:21Well, we all have obligations.
15:23You perhaps to study medicine.
15:25And while I'm sure I've still
15:27been learning and needed to take
15:29care of patients, write grants,
15:31do research teach published papers,
15:34the usual things.
15:37The critical piece I thought and I
15:39and I still believe is that our role
15:44and my role was to think sounds right
15:50until you appreciate the incredible
15:53environment in the opportunities we have.
16:01Clinically
16:04we have lots of obligations and
16:06lots of patients that need care.
16:08This is in early days,
16:12the young man with a with a
16:15tumor that's bulging out of the
16:18craniotomy side on the left and
16:20on the right after it's out.
16:24This was in our operating rooms
16:30and what was then called the the
16:33New Haven Pavilion on the right
16:35by Tompkins for her offices are
16:37now and now the actual location
16:40of the neurosurgery labs.
16:41We had 10 operating rooms and we
16:44operated in room one of the 10
16:51and after taking out the tumor,
16:56this little white spider just
16:59shot down on the little little
17:03spinneret on the on the thread right
17:07onto the brain and then crawled
17:09under the dura and disappeared.
17:11Well, we irrigated a lot
17:15and hopefully we washed out.
17:16This creature
17:21patient did well,
17:22never seemed to have any problems.
17:25Some not too long after that
17:27we did move to the new,
17:28newer operating rooms in
17:31the in the South pavilion.
17:33And then later came the smile O ours
17:58This is a preview of the
18:01Neurobiology 500B course.
18:03With apologies to the 1966
18:06film Fantastic Voyage.
18:08We'll talk about some anatomy,
18:10Physiology and pathology.
18:12Then Alina Hopkins will tell us
18:15her experiences with hydrocephalus.
18:18Finally, you'll do endoscopic
18:20surgery on green and red
18:22Peppers to retrieve their seeds.
18:25I hope you enjoy it.
18:27Let me give you a preview.
18:31In the lateral ventricle,
18:33you'll see the septum, pellucidum,
18:37choroplexis, foramen and Monroe.
18:42The frame of the foramen is the fornix.
18:48That is the pipeline that lays down memory,
18:51all new memory.
18:53In the third ventricle you see
18:56the mammary bodies at 6:00,
19:00the posterior optic chiasm at 12:00.
19:04Just below is the infundibular
19:08recess or the top of the pituitary
19:12stalk In the center billowing up is
19:17the floor of the third ventricle.
19:19Maybe you can see a red hint below
19:22it That is the basilar artery.
19:24In the next frame you see the
19:27basilar artery itself below this
19:29billowing membrane that is the
19:31floor of the third ventricle.
19:33The goal of this operation is
19:36to create a passageway for CSF,
19:39flow from the third ventricle to
19:42basler cisterns and bypass the
19:45aqueduct and the outlets of the 4th
19:48ventricle to treat hydrocephalus.
19:53To get there, we need to plan an
19:56operation. The approach is right
19:58frontal along the trajectory
20:00you see on the MRI.
20:05Access is from a scalp incision and a
20:08hole in the skull called a Burr hole.
20:11In the lower frame you see the endoscope
20:14you will use on Peppers in January.
20:18Are you ready? Watch out for the
20:20basal artery and the big fat
20:22veins on the appendable surface.
20:24They can ruin your day.
20:28We are descending through a 6mm
20:32tube into the ventricular system.
20:35The septum pellucidum is waving on our left
20:44and we follow the cori plexus
20:45to the frame of Monroe.
20:50Remember, the door frame is the fornix
21:05as we enter the third ventricle.
21:07Orient yourself, mammary bodies,
21:13optic chiasm,
21:16infundibular recess. Walls
21:20of the third ventricle
21:22are the hypothalamus.
21:25Now we're going to score the floor of
21:27the third ventricle with a YAG laser.
21:30The heat at the tip is very focal.
21:32The laser tip is .8mm.
21:35Notice how the floor of the
21:37third ventricle shrinks.
21:41Now we need to perforate the
21:42floor of the third ventricle
21:44and widen the opening.
21:46For this we're using steel forceps.
21:50The summit of the basilar
21:52artery is just below us.
21:59Now we need to look through our
22:01opening to make sure we are
22:03in a subarachnoid location.
22:04The basal artery is very apparent.
22:11We're done. This should treat the
22:14hydrocephalus. Enjoy the course.
22:20Some of you may recall trying
22:21this out with the Peppers,
22:27but how did we get there?
22:30The image in the upper left
22:32is A pediatric cystoscope.
22:36The urologist would look at the
22:43bladder with the with their eye right
22:46right against that black eyepiece.
22:49Well, we tried that a
22:50couple of times with brain,
22:52but it just gave us too much
22:58risk for for sterility.
23:00Then along came the camera that
23:04would fit directly onto the scope
23:11and the image On the right are some
23:15of our later in the scopes for the
23:19third ventriculostomy for for example,
23:25we didn't have any of this
23:27equipment in in neurosurgery.
23:28The urologist used it,
23:35but it took a group of people to be
23:38able to bring this into neurosurgery.
23:41Now it's commonplace, almost all
23:44operations are done laparoscopically,
23:46endoscopically, but this,
23:49this was in many instances developed
23:55by a small Group, A small group here
24:01in the left and then the blue jacket.
24:03You see Ina Williams,
24:06I couldn't find a photograph of Reuben
24:10Perea and there's Joe Warshaw who
24:13as Chair of Pediatrics at the time,
24:15you might wonder his contribution
24:20Mr. Perea built an endoscope for us
24:26or the the endoscope tower that held
24:30all the electronics for materials
24:32that were in the discard area in
24:36the lower levels of the hospital.
24:40We we we still needed some funds
24:44and while there was some reluctance
24:47to provide funds for something
24:49new like this in in neurosurgery,
24:52when this was I was borrowing
24:55things from the urologist
24:59Joe Warshaw
25:02used to hold court in the in the hallways
25:08asked me what I was doing what what were
25:11we accomplishing which was typical for him.
25:14And I explained to him about how we were
25:17trying to bring endoscopy, ventriculoscopy
25:23into neurosurgery and he he Pediatrics
25:28has never had that much money.
25:30He offered to to contribute for
25:33whatever it would take to make
25:35this viable and available for
25:38kids in the Children's Hospital.
25:41Fortunately the hospital came
25:43through on the right hand of Huggins.
25:46Many of you have met when you've
25:49worked with the Peppers has been
25:51very instrumental in keeping this
25:53effort ongoing and and Anna Williams
25:57who I wrote papers with when she was
26:00a young nurse pictured in our our
26:04scrubs is now the the the senior vice
26:08president in nursing for the for our
26:11institution and was very instrumental
26:13in having the the hospital bring
26:17bring this into forefront for us.
26:26The endoscope really has revolutionized
26:28the treatment of hydrocephalus.
26:30Before, we would treat children with
26:34shunts and continue to in many instances.
26:38But shunts have a high infection rate.
26:42They aren't but so durable.
26:47However, an endoscopic third ventriculostomy
26:50has a high high rate of success.
26:55However, if we think back about Doctor Drake,
27:00it may seem safe to say,
27:02oh, point 4% have a serious
27:07intracerebral hemorrhage.
27:08That means that every couple of
27:10years somebody's going to have
27:11a severe injury from us just
27:13passing that tube in their brain.
27:18I don't. I don't know how to eliminate that.
27:24I've been very fortunate to be involved
27:28in a number of investigative and research
27:32projects through my through my time.
27:36Once once a week for about 5 years,
27:41I I commuted to Brookhaven
27:44National Laboratory to work
27:46on positron emitting tracers.
27:50This is during the time of the
27:52development of auto antipyrine
27:55and fluorodeoxyglucose for
28:00positron emission tomography.
28:03Now they're far more
28:06complex emitters available.
28:08I worked on the DRG Revision project
28:13at the School of Management. Dr.
28:16GS are the way hospitals are paid
28:21and I managed to be a bit player
28:24in the IBH prevention studies.
28:30The big question was how does
28:33developing brain adapt to injury.
28:36Doctor Mint let let all of these
28:39projects in here photographed or some
28:41of the the key people who were involved.
28:46Doctor Mint, Doctor Stewart, Dolores Montoya.
28:53There there many talents around this place.
28:57Dolores Montoya was one of the great
29:02masters in small animal surgery.
29:06We see Doctor Mint with some of her staff.
29:10Carol Katz who did Biostatistics.
29:13Karen Schneider,
29:14who was really the major domo through
29:17many projects and more janely,
29:20who incredibly kept patients
29:25involved in our studies for years.
29:36So how did this happen?
29:40We
29:43I went, I went to a meeting in Saint
29:47Louis the cerebral brain metabolism
29:49cerebral blood flow and metabolism
29:52meeting and there was a a short talk
29:55about maybe in the in the methicine is
29:58influential to developing blood vessels.
30:02As Doctor Min and I spoke,
30:03we thought about how how this might
30:08translate into something useful for babies
30:11and the methicine was already used for
30:14for treating a patent ductus arteriosus.
30:19So how do you bring something
30:21that's an idea into the clinic?
30:25This meant developing an animal model.
30:28This meant thinking about what influences
30:31and finding out what influences
30:37in the medicine might have on newborns,
30:41on preemies and when when did infants,
30:47premature infants actually have
30:52intraventricular hemorrhage.
31:01We we carried out studies to show
31:05that in the methicine prevented
31:08hemorrhage in a large proportion of
31:11the of the and of the animal models
31:14and compare it to the thameslate and
31:17superoxide dismutase as well as in
31:20the methicine in the in the nursery.
31:24With Bob Lang we were able to determine
31:28cerebral blood flow changes through
31:30stable xenon studies in infants
31:35and timing of hemorrhage which
31:38occurred in the first three days.
31:42This meant that a large number of people
31:47were involved to from the nursery,
31:50from ultrasound technicians,
31:53we Doctor Mint organized that.
31:57Babies would have ultrasounds every six
32:00hours for the first three days of life.
32:03This meant consenting the parents,
32:05making sure that what we were
32:07doing was acceptable to the IRB,
32:11to the nursery,
32:13and as as well as to ourselves.
32:17This ultimately led to a multicentermer
32:20randomized trial that showed the
32:24advantage in these and with the the help
32:29of the the people I'd shown earlier,
32:35we were able to follow these
32:38children into young adulthood.
32:42And while many drugs we we read about are
32:47extraordinarily expensive, for example, the
32:52drug Surfanta to help mature preemies
32:56lungs is over $1000 a dose and
33:00the medicine remained dirt cheap,
33:03about 1000, about a dollar per dose.
33:07So it was usable by any country that could
33:11actually maintain premature infants.
33:20Well, what I didn't know or
33:24hadn't thought about was that
33:26surgery has a time stamp on it.
33:29So after a lot of cases and a lot of
33:32brain tumors and and leading this
33:37leading pediatric neurosurgery and
33:39the residency for quite a while,
33:44the time came to change direction.
33:47You may or may not want an old president,
33:50but I don't think anyone wants
33:53wants an old surgeon.
33:57Fortunately, we have a an
34:00institution that has such such
34:03depth that there are many,
34:05many things for us to do.
34:06I mean the residency program,
34:11teaching, neurobiology,
34:15professional responsibility,
34:16ILCE for a few years.
34:19That's the bottom left with
34:20Linda Honan and the group,
34:22and now most of you have
34:24seen me through anatomy.
34:32As we looked at anatomy
34:34and how times changed,
34:37we developed what we call the
34:39Human Anatomy Video Project.
34:41In the top left you see
34:45Doctor Kapadia, who is now retired.
34:49In the lower left you see Levi Squire,
34:53who's kindly letting us paint,
34:55paint his chest for surface landmarks.
34:59We we embarked on a project
35:04to video record and video
35:07the whole dissection cycle.
35:09This took us two years.
35:12You see in the right frame,
35:16Doctor Capatia with the
35:18with the camera in place,
35:23we had a lot of help and a lot
35:28of funding to make this happen.
35:31And many of these names,
35:33you know, Lei Wang and Kelly
35:36Perry are from the library.
35:38We had two librarians for the
35:41first year of the the project.
35:43Ray Hill, who you may or
35:45may not have ever met,
35:47is responsible for the
35:49Guided Anatomy website.
35:52But the the Caplow family,
35:55the Rossetti family
35:58provided almost all the funding
36:02with some help from the Office of
36:06Education in the Poor View Center.
36:09We weren't the first ones to do this.
36:22In part A
36:23of the section #4, the anterior thoracic wall
36:25is reflected and bound
36:27down to the head. This allows
36:30a complete study.
36:31The internal thoracic vessels,
36:33the artery arising from the subclavian
36:35and the venicomatons draining
36:38into the brachiocephalic anterior
36:41intercostal branches should be exposed
36:43as well as parasternal lymph nodes.
36:46And the transverse asthorsis muscle
36:48is to be slit and reflected to
36:51show how the vessels pass to the
36:55abdomen and they change. A view
36:59will show a reflection
37:00of the cost of margin where the
37:02vessels internal thoracic vessels
37:04terminate as a lateral branch,
37:06they're reflecting the
37:08transversus thoracis muscle,
37:09they're the lateral branch.
37:10The musculophrenic going along
37:12with the diaphragm attaches
37:13to the cost of margin and
37:15they're the superior epigastric
37:17passing into the rectus sheath.
37:22Now if you'll just help hold that down.
37:26That's right. Put it in.
37:27That's a good boy. Thank you.
37:32Doctor Creeland would would probably need
37:36to revise some of his language today.
37:40This was recorded in pneumatic
37:42and we thought that the all
37:45these videotapes had been lost,
37:48but we were able to recover them, find.
37:51We found a company in Pennsylvania that
37:55was able to digitize them for us and
37:58now they're in the library archive.
38:01Back in Doctor Creelin's time,
38:04he was the predecessor to Doctor Stewart.
38:09All the students would sit and watch these
38:13small televisions. You'll notice
38:17that he wasn't wearing gloves.
38:19I think that we're all a lot happier
38:22that we have nitrile gloves. For us.
38:27We we started with the videos,
38:31putting them on panopto,
38:32and then moved to a series of iBooks.
38:36Apple and its wisdom or finance
38:42did not support these so much.
38:44And then we moved to
38:48guided anatomy and and I I think
38:50this has been the the most
38:52successful and the most flexible for
38:57as a primary resource.
39:00We also have Coursera courses,
39:03we have several Coursera courses.
39:05This is the one on the trunk.
39:07Overall, we have approximately 135,000
39:12learners through through Coursera.
39:20There there there's life.
39:22I I will tell you if the the
39:25bottom left has circles around
39:27our our children and then you
39:29see them at different points,
39:31on on the right of the left is a
39:34school that a number of them went to.
39:36I must tell you, going back to Doctor Drake,
39:40that there was only one occasion
39:42that I brought them to school
39:45one morning and left them
39:49to find out later that
39:52school was closed that day.
39:55Fortunately their grandparents lived
39:58a short walking distance away.
40:03I was sent out with the kids periodically.
40:06The bottom left is what we would call
40:09the cousins camping trip the other.
40:11People in the photograph or are a
40:17large cadre of their of their cousins,
40:20and this is in the White Mountains.
40:22But I was periodically sent
40:25out with the with the kids.
40:30Some people in the household thought I
40:32spent too much time in the operating room.
40:39You know, life around here tends to be hard,
40:43fast, and unforgiving, Unforgiving.
40:49Claire Forscolo, I'm sure most of
40:54you know about Claire's cornucopia,
40:55but she's the she's the lady who
40:59started that business in the mid 70s.
41:02She was a nurse or she still is a nurse,
41:04but that's her business and
41:08this is this is her new cup.
41:11She told me last week that a philosophy
41:16professor came in and said that he had
41:20used an image of her cup in his lecture,
41:23so I thought I'd do that as well.
41:27Below are some of some of our friends,
41:29so it can be a tough place.
41:31But we need to to think about how
41:34we can make it better for everyone.
41:41If you haven't read your New
41:43England Journal for the week,
41:45you might put a pen on Lisa
41:49Rosenbaum's editorial from last week.
41:56This should be fun.
42:01Hi, Mr. Misses Jones. I'm Doctor Anderson,
42:03the neurosurgeon. It's nice to meet you.
42:06Can you tell me a little bit about
42:08what's been going on with Jimmy? Well,
42:12he's, he was sick last week,
42:14just all this week having, you know,
42:17throwing up and headaches and
42:19just really intensely sick and
42:22just not kicking it. Yeah, so.
42:24And we know there's a flu going around,
42:26so we just wanted to make sure
42:28it wasn't anything more serious.
42:29And then they wanted to give him an MRI here.
42:33So yeah, just they said to roll things out,
42:36but he's been gone for four hours
42:38now. We've been waiting.
42:40So, so you've he's been sick for about
42:43a week and throwing up and headaches,
42:46and I know you've been waiting a long time,
42:48and I'm sorry about that.
42:49They have to, they have to sedate
42:51him a little bit to get him to
42:53hold still for the MRI scan.
42:53Is he scared? Is he OK? He's OK.
42:54I just saw him and I was.
42:56He was basically like
42:57waking up from a long nap.
42:59So he's moving around and he looks fine.
43:01He's opened his eyes, but he's still
43:03not kind of back to his normal self yet.
43:05The nurses are watching him really
43:08closely and everything's fine with him.
43:10I looked at the MRI scan and I'm
43:12afraid I have some bad news for you.
43:14Looks like he's got a brain tumor.
43:27Are you sure? Yeah. I checked
43:29very carefully the scan and him,
43:31and it fits with the symptoms he's having.
43:34And he's got a small brain tumor back here
43:36in his cerebellum on the right side. I
43:48just thought he had the,
43:49you know, he just thought it was.
43:51I mean we just,
43:51we thought it was kind of silly.
43:53We even came in today
43:56sometimes. These present that way people,
43:58the the little kids are sick and
44:00they're nausea and vomiting.
44:01But it turns out it's actually
44:02pressure on the back of the brain
44:04that's causing him to have the
44:05headaches and that kind of thing.
44:13This is really a shock.
44:14I just don't just.
44:17I'm so just done.
44:19Didn't even know why they
44:20wanted to get him an MRI.
44:21Where? Oh my God.
44:24I know this must be really
44:25hard news to hear. Is
44:30he going to be OK?
44:31He's going to be OK. We're going to
44:32be with you every step of the way.
44:34Would you mind if I tell you a little
44:36bit about what the plan's going to be,
44:37what we're going to,
44:38what the next step is so we can
44:40keep taking good care of him? Yeah.
44:42So that I can tell you one thing and
44:45looking at the MRI scan sometimes
44:46these you can tell whether they're
44:48more slow growing benign tumors or
44:50more fast growing aggressive tumors.
44:51And the good news is it's the more
44:54small growing benign type tumor.
44:55It looks like we won't know
44:57for sure till we take it out,
44:58but we're going to have to do
45:00surgery to get it out and try to
45:02cure him from this brain tumor.
45:04So it's just a benign 1.
45:06If you think it's, we
45:07hope so. We'll know once we
45:08look at it under the microscope.
45:10But looking at the MRI scan,
45:11that's that would be the the
45:13more likely scenario. That's
45:14what it looks like. You're not,
45:15it's not just that you're going
45:16to rule out. I mean, it's,
45:18it's probably benign then. So where
45:20it's located, it looks like that, Yes.
45:22OK. So, so we've looked at the schedule
45:24and we want to admit him to the hospital
45:26tonight and we'll keep him here over
45:29tomorrow and give him some steroids to get
45:31the swelling down so he'll feel better.
45:34And then Tuesday morning,
45:35we'll do the surgery and the
45:36surgery will last about 3 hours.
45:38A couple days. Yeah.
45:47So can we see you Missy? Yeah, he's
45:50going to be right up by the nurses
45:51were just about ready to, you know,
45:52they were getting him already in
45:54the bed and he was like I said,
45:55waking up from like a long nap.
45:56And he's going to be up here
45:58in about 5 minutes. And
46:02I know that's a lot to take in,
46:03but what questions do you have?
46:06I know I'm just so floored right now.
46:08I just do you, how long do
46:12you think he's going to be in,
46:13in the hospital after the surgery?
46:14If things go, things
46:16go well. He should be
46:17able to go home by next weekend.
46:18So tonight, Sunday nights,
46:19have surgery, Tuesday,
46:20should be able to go home by,
46:21you know, Friday, Saturday, he's
46:23going, he's going to be OK.
46:24We just, he's going to be OK. We're
46:26going to be with him every
46:27step of the way with you guys.
46:29And if you want to, I'll come back
46:31in a little bit and we can talk.
46:32You know, once you've got a chance to kind
46:34of process a little bit of this stuff,
46:35we can talk and with him and tell
46:37him he's going to have to have,
46:38you know, a little surgery on Tuesday.
46:41Yeah, that would.
46:41I think that would be helpful. Yeah.
46:44Yeah. I'm not sure what helps.
46:45Yeah. I don't know.
46:49Your job just to be mom and dad.
46:51Well, we'll be the neurosurgeons, OK?
46:53We'll take good care of them. All right.
46:55Thanks. All right. Take care.
47:03Well, you might not do brain surgery,
47:06but they're going to be plenty of
47:08tough issues you'll encounter.
47:09So I I need to apologize to Tim
47:12O'Brien for the things they carried.
47:16I come to this Yale School of Medicine,
47:20a quiet, thoughtful sort of person.
47:23A college grad, Phi Beta Kappa,
47:25summa *** laude.
47:26All the credentials.
47:27But after seven months in class,
47:30in the lab, on the floors and the clinic,
47:34the Ed, the, OR the delivery room,
47:38I realized those high,
47:41civilized trappings had somehow
47:43been crushed under the weight
47:45of simple daily realities.
47:48I'd turn mean inside.
47:56I want to thank Michael Haglund
47:59for sharing those videos.
48:01Wilton Son, the Medical Student
48:03Council and Doctor Mint.
48:21Awesome. Thank you so much, Doctor Duncan.
48:23That was a really great talk.
48:26If anyone has any questions,
48:29there should be AQ and a box for you
48:31to type them in and we'll just go by
48:34them by the order that were received
48:35with the last few minutes that we have.
49:05Well, if questions occur
49:06to you, we come to the lab.
49:15We just have one comment,
49:17just thanking you for the talk.
49:20I guess while other people are typing
49:22their questions or thinking of questions,
49:24sort of one small question that I had with,
49:27you know, some of the things, oh,
49:29actually we do have one question.
49:32So this attending says that attendee
49:34says that they are pursuing a post
49:36baccalaureate and very much at the beginning
49:38of their Med school journey For you,
49:41you know, did you always know what
49:43specialty you were aiming for when
49:44you were going through, you know,
49:46the the training process and education?
49:50I didn't. And I think it's a a
49:52fascinating question when people decide.
49:53I mean I think they're plenty of
49:56people who come to medical school.
49:58Sure they're going to be whatever,
50:02but the the part of the beauty of
50:04medical school is being able to try
50:07out so many different different areas
50:09that particularly in the clerkships
50:11for example that you get to put on a
50:14a hat that says you're a cardiologist
50:16for a while or a pediatrician and
50:20everyone has interesting problems.
50:23I worry that if a team is too friendly,
50:27that might push you to in that direction,
50:30or if a team is unfriendly,
50:32that might push you away. So.
50:35But the the, the, the, the,
50:38the times that people spend learning
50:43about specialties certainly seems
50:45to be the most decisive factor.
50:48And don't be afraid to change your mind.
50:57Yeah.
51:18So I guess some more you know
51:19technical question that I
51:20had you know regarding some of the
51:22stuff that you know you had done with
51:24Indomethacin for intra ventricular
51:25hemorrhage is you know did you were
51:27there any sort of risk factors or
51:30prognostic factors that that you've
51:32noticed you know throughout the project
51:35that made it you know more efficacious
51:37in certain you know patients or was it
51:39you know just wanted to kind of hear
51:41a little bit more thoughts about that
51:43if there were any resistance or non
51:45responsiveness to the endomethacin.
51:48Well since hemorrhages occur so early
51:53we tried giving in the methicine
51:56early and and quickly we're reminded
51:58and learned an awful lot about
52:03renal blood flow after transition. So
52:10renal blood flow increasing
52:12post natally post delivery is
52:16is prostaglandin dependent.
52:19So we and and dose dependent.
52:21So our early trials were adjusting
52:28dose and adjusting timing
52:35and we would want to see
52:40child, child is born prematurely.
52:43Everyone's anxious before we can do anything.
52:46We have to consent the mom and make
52:51sure they understand what we're up to.
52:53Do an ultrasound and have a a baseline
52:57for whether there's a hemorrhage or not.
53:00If there's a hemorrhage,
53:02there's we we we didn't do a
53:05study to prevent progression.
53:10So these were there,
53:11there there you you plan plan a
53:14project and there are always lots of
53:16confounding factors to move along with.
53:17But we wound up with over 500 children
53:22in our multi center randomized trial.
53:25The NIH had a looked at the the 10
53:33most significant clinical trials
53:35over a period of time and in in the
53:40methicine was at the top in terms of
53:44reducing morbidity and morbidity
53:47mortality, morbidity of any
53:52any just about anything else.
53:55Oh this is this is thanks to Doctor
53:58Min a huge huge achievement.
53:59Like I said I I enjoy being
54:02more of a bit player.
54:08Awesome. The next question for you,
54:10just wanted to hear your thoughts
54:12on what do you think is next
54:14in pediatric nerve surgery.
54:17Well, boy, I I think that whether
54:24nanoparticles are going to be able to
54:26deliver drugs to to tumors what other
54:32other therapies we can devise. Certainly
54:38endoscopy has come come to the head.
54:42What are There's plenty of
54:44smart people in your class.
54:46It seems to me instead of having a
54:49fiber optic tube to look down that
54:52we could develop the engineers in the
54:56crowd to where they the the the chip
55:01would be at the end of a flexible rod
55:03and and provide a lot more flexibility.
55:08You look at the, the camera on your
55:11iPhone or your Android, It's tiny.
55:16Yeah.
55:18Next question, wanted to hear, you know,
55:21if you if you went through sort of
55:23a midlife crisis and if you did,
55:24you know, what did you do about it
55:26and did you sort of reinvent yourself?
55:30I I hope that we're all reinventing
55:33ourselves more frequently than midlife.
55:37I mean, we all have complicated times.
55:41I think that it sure helps to have a a
55:45family and a support system of of some sort
55:52and you know we we all have
55:54our our ups and downs.
55:55I think that you know no no matter
55:59how how tough can things can be.
56:02You know, in in my business,
56:04you could win big or you can lose
56:07big when you're operating on kids
56:12and you have to be able to to talk
56:15to people about this. You know,
56:20I decided marathon running wasn't for me,
56:24That I like fly fishing better.
56:29Awesome. Well, it looks like
56:30we're just running out of time.
56:32Want to thank everyone again for
56:34joining us on this talk today.
56:36And thank you so much again,
56:38Doctor Duncan, for your time and for
56:41sharing a little bit more about your
56:43life and you know what you've done.
56:46And thank you for those of you
56:47who've joined in all our talks
56:49throughout the school year.
56:50So thank you, Doctor Duncan once again.
56:52And thank you everyone,
56:54and have a good weekend.
56:56Thank, thank you, Wilton. Thank you.